Enhanced Care Coordination Leads to Lower Hospitalization Rates
A study of four programs that were successful in reducing hospitalizations of patients who were at high risk of near-term hospitalizations found that the majority had used one or more of six approaches for improving care to achieve reductions ranging from 8 percent to 33 percent. These were: telephone calls and frequent in-person meetings with patients, in-person meetings between patients and providers, the use of care coordinators, evidence-based education to patients; medication management; and transitional care after hospitalizations. The four programs, implemented as part of the Medicare Coordinated Care Demonstration, were essentially cost-neutral after payment of care management fees, suggesting these approaches would save money only if care coordination fees were modest and organizations found efficient ways of delivering interventions. R. S. Brown, D. Peikes, G. Peterson et al., "Features of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions of High-Risk Patients," Health Affairs, June 2012 31(6):1156–66.
Avoidable Hospital Admissions Higher Among Patients Using Home- and Community-Based Services
A study of Medicaid members found those using home- and community-based services were particularly vulnerable to avoidable hospital admissions compared with the full Medicaid and U.S. population. Two-thirds of the 2.2 million users of these services—such as personal care, adult day care, and home health care—were dual eligibles. The rate of avoidable hospitalizations in this population was 60 percent higher than in the general Medicaid population, resulting in almost $3 billion in annual Medicare and Medicaid expenditures. The authors suggest that efforts aimed at increasing coordination of care and decreasing fragmentation of financing and may help to offset the problem. R. T. Konetzka, S. L. Karon, and D. E. B. Potter, "Users of Medicaid Home and Community-Based Services Are Especially Vulnerable to Costly Avoidable Hospital Admissions," Health Affairs, June 2012 31(6):1167–75.
Medicare Innovations Collaborative Speeds Adoption of New Models of Geriatric Care
Interviews with health care organizations participating in the Medicare Innovations Collaborative, a program that promoted the adoption of new models of care for Medicare beneficiaries with multiple chronic conditions, found the organizations managed to adopt multiple complex care models within a year. Many used or adapted one or more of the following approaches: The Nursing Improving Care to Healthsystem Elders model, the Acute Care for Elders Model, the Hospital Elder Life Program, the palliative care consultation model, the Care Transitions Intervention, and the Hospital at Home model. Five of the six organizations named the perceived prestige of participating in the program and the ability to participate in the learning exchange as the most important factors for success. B. Leff, L. H. Spragens, B. Morano et al., "Rapid Reengineering of Acute Medical Care for Medicare Beneficiaries: The Medicare Innovations Collaborative," Health Affairs, June 2012 31(6):1204–15.
High-Touch Approaches to Care Management and a Focus on High-Risk Patients Superior to Telephone-Based Programs for Medicare Beneficiaries
After redesigning its care management program for Medicare beneficiaries—from a model that relied on phone communication from out-of-state care managers to one that provided phone contact and occasional in-person visits from local care managers—Washington University School of Medicine in St. Louis reduced hospitalizations by 12 percent and monthly Medicare spending by $217 per enrollee, exceeding the program's monthly care management fee of $151. The new model also focused more intently on patients at risk for hospitalization and provided stronger transition planning and medication reconciliation services. The previous model had not only not reduced hospitalizations or Medicare spending; it increased spending by 12 percent. D. Peikes, G. Peterson, R. S. Brown et al., "How Changes in Washington University's Medicare Coordinated Care Demonstration Pilot Ultimately Achieved Savings," Health Affairs, June 2012 31(6):1216–26.
Admissions to Observation Units Increase While Hospital Admissions Decline
Using Medicare enrollment and claims data nationwide, researchers documented a rising trend in the delivery and duration of hospital observation services in the fee-for-service Medicare population. They also found that during the study period (2007–09) there was a corresponding decline in inpatient admissions. During this period, the ratio of observation stays to inpatient admissions increased 34 percent, from 86.9 observation stay events per 1,000 inpatient admissions per month on average in 2007 to 116.6 in 2009. Because admission to an observation unit is considered an outpatient service, these patients are at risk of greater out-of-pocket expenses if they are subsequently admitted to a skilled nursing facility. The authors speculate that several Medicare policy changes may have contributed to these trends, including those that put hospitals at risk for retroactive payment denial when an inpatient stay is deemed not medically necessary. They also suggest penalties for higher-than-expected readmission rates may exacerbate the problem. Z. Feng, B. Wright, and V. Mor, "Sharp Rise in Medicare Enrollees Being Held in Hospitals for Observation Raises Concerns About Causes And Consequences," Health Affairs, June 2012 31(6):1251–59.
A Call for Monitoring the Impact of Readmissions and Payment Reform Policies on Older Adults
The authors of this article identify some possible unintended consequences of three federal programs to cut readmissions and/or introduce payment reform. The first, the Hospital Readmissions Reduction Program, which penalizes hospitals with excessive readmissions of Medicare beneficiaries within 30 days of discharge, may prompt hospitals to discourage or limit admissions of frail, elderly patients. The National Pilot Program on payment bundling, which offers providers a set amount for each episode of care, excludes long-term care services giving long-term care providers little incentive to coordinate care. And finally, the Community-Based Care Transitions Program, which provides $500 million in funding to enable community-based organizations to improve care transitions, excludes patients who are not hospitalized and those with low risk scores but high functional impairment. The authors recommend that policymakers anticipate such unintended consequences and advance payment policies that integrate care. They also recommend providing additional assistance to providers to implement evidence-based transitional care practices, recraft strategic and operational plans, develop educational and other resources for frail older adults and their family caregivers, and integrate measurement and reporting requirements into performance systems. M. D. Naylor, E. T. Kurtzman, D. C. Grabowski et al., "Unintended Consequences of Steps to Cut Readmissions and Reform Payment May Threaten Care of Vulnerable Older Adults," Health Affairs, June 2012 31(6): 1623–32.
Alternative Quality Contract Slows Spending in Second Year
Physician groups participating in the second year of Blue Cross and Blue Shield of Massachusetts' Alternative Quality Contract reduced the growth rate in health care spending among their patients by 3.3 percent that year—up from 1.9 percent the first year, resulting in a 2.8 percent spending reduction over two years. The quality of chronic care management, adult preventive care, and pediatric care in organizations participating in the global risk-sharing agreement also improved more in year two than in year one, suggesting the payment model may be an effective tool for controlling costs and improving quality. Z. Song, D. G. Safran, B. E. Landon et al., "The 'Alternative Quality Contract,' Based on a Global Budget, Lowered Medical Spending and Improved Quality," Health Affairs, Aug. 2012 31(8):1885–e94.
Drawing a Distinction Between Patient-Centered Care and Patient Satisfaction
The authors of this commentary draw distinctions between patient-centered care and patient satisfaction, noting patient-centered care involves health literacy, care coordination, physical and emotional comfort, and shared decision-making, while the latter is a measure of whether a service meets customers' expectations. The authors urge caution in using patient satisfaction measures as a primary standard for success and suggest additional work is necessary to implement objective and subjective measures that address quality of care. J. M. Kupfer and E. U. Bond, "Patient Satisfaction and Patient-Centered Care Necessary But Not Equal," Journal of the American Medical Association, July 2012 308(2):139–40.
Integration of ACOs and Patient-Centered Medical Homes Urged
In an editorial, two physicians from Group Health Research Institute in Seattle, Wash., argue that accountable care organizations—particularly those run by hospital systems— should develop strategies for investing in and integrating practices that establish patient-centered medical homes. They also stress the importance of linking these practices, including federally funded community health centers, with specialist and hospitals. R. J. Reid and E. B. Larson, "Financial Implications of the Patient-Centered Medical Home," Journal of the American Medical Association, July 2012 308(1):83–4.
Patients with Mental Health Diagnoses Have Higher Ambulatory Care-Sensitive Admissions in VHA System
A study of patients who receive primary care from the Veterans Health Affairs system found the rate of the hospital admissions and emergency department use for ambulatory care-sensitive conditions (ACSC) was higher among patients with mental diagnoses—particularly depression and drug abuse disorder. The rate of ACSC admissions was 31.7 admissions per 1,000 patients with mental health diagnoses compared with 21.0 admissions per 1,000 patients without. The ACSC-associated emergency department visit rate was also significantly higher. Higher medication use and lower medication regimen complexity were significantly associated with decreased risk for ACSC events. The results suggest patients with mental health conditions may need additional support in managing their conditions. "Reducing Costs of Acute Care for Ambulatory Care–Sensitive Medical Conditions: The Central Roles of Comorbid Mental Illness," Medical Care, Aug. 2012 30(8):705–13.
Higher Rates of Surgical Procedures Suggests Mass. Law Has Increased Access to Outpatient Care
To assess whether Massachusetts' health reform law increased outpatient access to care among poor and minority populations, researchers examined the change in rates of inpatient surgical procedures that are commonly initiated by outpatient physician referral. They found that overall increases in procedure rates post reform were 13 percent higher among low-income patients, 15 percent higher among middle-income patients, and 2 percent higher among high-income patients. The increases in procedures were 22 percent higher among Hispanics, 5 percent higher among blacks, and 7 percent higher among whites. The results suggest that the law has improved access to outpatient care for these vulnerable populations. The authors note the increase may reflect a combination of pent-up demand from previously uninsured patients and need from new diagnoses. A. Hanchate, K. E. Lasser, A. Kapoor et al., "Massachusetts Reform and Disparities in Inpatient Care Utilization," Medical Care, Aug. 2012 30(8):569–77.
Local Scorecard Finds Wide Variation in Quality and Access Across Regions
The Commonwealth Fund's report "Rising to the Challenge: Results from a Scorecard on Local Health System" performance found wide regional variation in measures of quality and access. Among the report's key findings: the proportion of uninsured adults (ages 18 to 64) ranged from 5 percent in Massachusetts' three local areas to more than half in two local areas in Texas. Wide variation was also seen in the proportion of adults who went without care because of cost (5% to 33%) and among adults age 50 or older or with a chronic disease who visited a doctor in the previous two years (67% to 95%). Although the uninsured were at greatest risk, among the insured there was wide variation in having a regular source of care and receipt of recommend preventive care across the country. For example, the percentage of adults age 50 or older who received recommended screenings for cancer and other preventive care ranged from 31 percent to 58 percent among insured adults across local areas, and the percentage of insured adult diabetics who received recommended care for their condition ranged from 28 percent to 71 percent. The authors note that findings indicate that health insurance alone is not sufficient—comprehensiveness and affordability of coverage, as well as access to primary care, are also important. D. C. Radley and C. Schoen, "Geographic Variation in Access to Care — The Relationship with Quality," New England Journal of Medicine, July 2012 367(1):3–6.