Comparing the Cost of Caring for Medicare Beneficiaries in Federally Funded Health Centers to Other Care Settings

Objective

To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics.

Data Sources/Study Settings

Part A and B fee‐for‐service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC.

Study Design

We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects.

Data Collection

Data were obtained from the Centers for Medicare & Medicaid Services.

Principal Findings

Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs.

Conclusions

HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients.     

Using Medical Claims for Policy Effectiveness Surveillance: Reimbursement and Utilization of Abdomen/Pelvis Computed Tomography Scans

Objective

To quantify changes in private insurance payments for and utilization of abdominal/pelvic computed tomography scans (CTs) after 2011 changes in CPT coding and Medicare reimbursement rates, which were designed to reduce costs stemming from misvalued procedures.

Data Sources

TruvenHealth Analytics MarketScan Commercial Claims and Encounters database.

Study Design

We used difference‐in‐differences models to compare combined CTs of the abdomen/pelvis to CTs of the abdomen or pelvis only. Our main outcomes were inflation‐adjusted log payments per procedure, daily utilization rates, and total annual payments.

Data Extraction Methods

Claims data were extracted for all abdominal/pelvic CTs performed in 2009–2011 within noncapitated, employer‐sponsored private plans.

Principal Findings

Adjusted payments per combined CTs of the abdomen/pelvis dropped by 23.8 percent (p < .0001), and their adjusted daily utilization rate accelerated by 0.36 percent (p = .034) per month after January 2011. Utilization rate of abdominal‐only or pelvic‐only CTs dropped by 5.0 percent (p < .0001). Total annual payments for combined CTs of the abdomen/pelvis decreased in 2011 despite the increased utilization.

Conclusions

Private insurance payments for combined CTs of the abdomen/pelvis declined and utilization accelerated significantly after 2011 policy changes. While growth in total annual payments was contained in 2011, it may not be sustained if 2011 utilization trends persist.     

Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low‐Income Adults with Behavioral Health Conditions

Objective

To examine the effect of Medicaid expansions on health insurance coverage and access to care among low‐income adults with behavioral health conditions.

Data Sources/Study Setting

Nine years (2004–2012) of individual‐level cross‐sectional data from a restricted‐access version of National Survey on Drug Use and Health.

Study Design

A quasi‐experimental difference‐in‐differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low‐income adults under the Section §1115 waiver with those residing in the rest of the country.

Data Collection/Extraction Methods

The analytic sample includes low‐income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low‐income adults have past‐year serious psychological distress and 24,900 low‐income adults have a past‐year substance use disorder (SUD).

Principal Findings

Among low‐income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p < .05), a reduction in the probability of perceiving an unmet need for mental health (MH) treatment (p < .05) and for SUD treatment (p < .05), as well as an increase in the probability of receiving MH treatment (p < .01).

Conclusions

The ongoing implementation of Medicaid expansions has the potential to improve health insurance coverage and access to care for low‐income adults with behavioral health conditions.     

Community Discharge of Nursing Home Residents: The Role of Facility Characteristics

Objective

Using a socio‐ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long‐term services and supports systems.

Data Source

Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free‐standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008.

Study Design

Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community.

Principal Findings

Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay.

Conclusion

Short‐ and long‐stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states.     

The Effects of Medicaid Eligibility on Mental Health Services and Out‐of‐Pocket Spending for Mental Health Services

Objective

Millions of low‐income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out‐of‐pocket spending.

Data Sources

Secondary data from the 1998–2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.

Study Design

Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out‐of‐pocket spending for mental health services.

Data Extraction Methods

Person‐year files were constructed including adults ages 21–64 under 300 percent of the Federal Poverty Level.

Principal Findings

Medicaid expansions significantly increased health insurance coverage and reduced out‐of‐pocket spending on mental health services for low‐income adults. Effects of expanded Medicaid eligibility on out‐of‐pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.

Conclusions

Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out‐of‐pocket mental health care spending.     

Financial Strain and Medication Adherence among Diabetes Patients in an Integrated Health Care Delivery System: The Diabetes Study of Northern California (DISTANCE)

Objective

To examine self‐reported financial strain in relation to pharmacy utilization adherence data.

Data Sources/Study Setting

Survey, administrative, and electronic medical data from Kaiser Permanente Northern California.

Study Design

Retrospective cohort design (2006, n = 7,773).

Data Collection/Extraction Methods

We compared survey self‐reports of general and medication‐specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models.

Principal Findings

Eight percent and 9 percent reported general and medication‐specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04–1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07–1.66); and medication‐specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09–1.84).

Conclusions

Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.     

Dual‐System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans

Objective

The concurrent use of multiple health care systems may duplicate or fragment care. We assessed the characteristics of veterans who were dually enrolled in both the Veterans Affairs (VA) health care system and a Medicare Advantage (MA) plan, and compared intermediate quality outcomes among those exclusively receiving care in the VA with those receiving care in both systems.

Data Sources/Study Setting

VA and MA quality and administrative data from 2008 to 2009.

Study Design

We used propensity score methods to test the association between dual use and five intermediate outcome quality measures. Outcomes included control of cholesterol, blood pressure, and glycosylated hemoglobin among persons with coronary heart disease (CHD), hypertension, and diabetes.

Data Collection/Extraction Methods

VA and MA data were merged to identify VA‐only users (n = 1,637) and dual‐system users (n = 5,006).

Principal Findings

We found no significant differences in intermediate outcomes between VA‐only and dual‐user populations. Differences ranged from a 3.2 percentage point (95 percent CI: −1.8 to 8.2) greater rate of controlled cholesterol among VA‐only users with CHD to a 2.2 percentage point (95 percent CI: −2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.

Conclusions

For the five measures studied, we did not find evidence that veterans with dual use of VA and MA care experienced improved or worsened outcomes as compared with veterans who exclusively used VA care.     

Do Racial/Ethnic Disparities in Quality and Patient Experience within Medicare Plans Generalize across Measures and Racial/Ethnic Groups?

Objective

To examine how similar racial/ethnic disparities in clinical quality (Healthcare Effectiveness Data and Information Set [HEDIS]) and patient experience (Consumer Assessment of Healthcare Providers and Systems [CAHPS]) measures are for different measures within Medicare Advantage (MA) plans.

Data Sources/Study Setting

5.7 million/492,495 MA beneficiaries with 2008–2009 HEDIS/CAHPS data.

Study Design

Binomial (HEDIS) and linear (CAHPS) hierarchical mixed models generated contract estimates for HEDIS/CAHPS measures for Hispanics, blacks, Asian‐Pacific Islanders, and whites. We examine the correlation of within‐plan disparities for HEDIS and CAHPS measures across measures.

Principal Findings

Plans with disparities for a given minority group (vs. whites) for a particular measure have a moderate tendency for similar disparities for other measures of the same type (mean r = 0.51/.21 and 53/34 percent positive and statistically significant for CAHPS/HEDIS). This pattern holds to a lesser extent for correlations of CAHPS disparities and HEDIS disparities (mean r = 0.05/0.14/0.23 and 4.4/5.6/4.4 percent) positive and statistically significant for blacks/Hispanics/API.

Conclusions

Similarities in CAHPS and HEDIS disparities across measures might reflect common structural factors, such as language services or provider incentives, affecting several measures simultaneously. Health plan structural changes might reduce disparities across multiple measures.     

EHR Adoption and Hospital Performance: Time‐Related Effects

Objective

To assess whether, 5 years into the HITECH programs, national data reflect a consistent relationship between EHR adoption and hospital outcomes across three important dimensions of hospital performance.

Data Sources/Study Setting

Secondary data from the American Hospital Association and CMS (Hospital Compare and EHR Incentive Programs) for nonfederal, acute‐care hospitals (2009–2012).

Study Design

We examined the relationship between EHR adoption and three hospital outcomes (process adherence, patient satisfaction, efficiency) using ordinary least squares models with hospital fixed effects. Time‐related effects were assessed through comparing the impact of EHR adoption pre (2008/2009) versus post (2010/2011) meaningful use and by meaningful use attestation cohort (2011, 2012, 2013, Never). We used a continuous measure of hospital EHR adoption based on the proportion of electronic functions implemented.

Data Collection/Extraction Methods

We created a panel dataset with hospital‐year observations.

Principal Findings

Higher levels of EHR adoption were associated with better performance on process adherence (0.147; p < .001) and patient satisfaction (0.118; p < .001), but not efficiency (0.01; p = .78). For all three outcomes, there was a stronger, positive relationship between EHR adoption and performance in 2010/2011 compared to 2008/2009. We found mixed results based on meaningful use attestation cohort.

Conclusions

Performance gains associated with EHR adoption are apparent in more recent years. The large national investment in EHRs appears to be delivering more consistent benefits than indicated by earlier national studies.     

Availability of New Medicaid Patient Appointments and the Role of Rural Health Clinics

Objective

To examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers.

Data Sources

Experimental (audit) data from a 10‐state study of primary care practices, county‐level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services.

Study Design

We generate appointment rates for rural and nonrural areas by patient‐payer type (private, Medicaid, self‐pay) to then motivate our focus on within‐rural variation by clinic type (RHC vs. non‐RHC). Multivariate linear models test for statistical differences and assess the estimates’ sensitivity to the inclusion of control variables.

Data Collection

The primary data are from a large field study.

Principal Findings

Approximately 80 percent of Medicaid callers receive an appointment in rural areas—a rate more than 20 percentage points greater than nonrural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non‐RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment.

Conclusions

Our study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees.     

Higher Incentive Payments in Medicare Advantage's Pay‐for‐Performance Program Did Not Improve Quality But Did Increase Plan Offerings

Objective

To evaluate the effects of the size of financial bonuses on quality of care and the number of plan offerings in the Medicare Advantage Quality Bonus Payment Demonstration.

Data Sources

Publicly available data from CMS from 2009 to 2014 on Medicare Advantage plan quality ratings, the counties in the service area of each plan, and the benchmarks used to construct plan payments.

Study Design

The Medicare Advantage Quality Bonus Payment Demonstration began in 2012. Under the Demonstration, all Medicare Advantage plans were eligible to receive bonus payments based on plan‐level quality scores (star ratings). In some counties, plans were eligible to receive bonus payments that were twice as large as in other counties. We used this variation in incentives to evaluate the effects of bonus size on star ratings and the number of plan offerings in the Demonstration using a differences‐in‐differences identification strategy. We used matching to create a comparison group of counties that did not receive double bonuses but had similar levels of the preintervention outcomes.

Principal Findings

Results from the difference‐in‐differences analysis suggest that the receipt of double bonuses was not associated with an increase in star ratings. In the matched sample, the receipt of double bonuses was associated with a statistically insignificant increase of +0.034 (approximately 1 percent) in the average star rating (p > .10, 95 percent CI: −0.015, 0.083). In contrast, the receipt of double bonuses was associated with an increase in the number of plans offered. In the matched sample, the receipt of double bonuses was associated with an overall increase of +0.814 plans (approximately 5.8 percent) (p < .05, 95 percent CI: 0.078, 1.549). We estimate that the double bonuses increased payments by $3.43 billion over the first 3 years of the Demonstration.

Conclusions

At great expense to Medicare, double bonuses in the Medicare Advantage Quality Bonus Payment Demonstration were not associated with improved quality but were associated with more plan offerings.     

Trends in Nurse Practitioner and Physician Assistant Practice in Nursing Homes, 2000–2010

Objective

To examine nurse practitioner (NP) and physician assistant (PA) practice in nursing homes (NHs) during 2000–2010.

Data Sources

Data were derived from the Online Survey Certification and Reporting system and Medicare Part B claims (20 percent sample).

Methods

NP/PA state average employment, visit per bed year (VPBY), and providers per NH were examined. State fixed‐effect models examined the association between state regulations and NP/PA use.

Principal Findings

NHs using any NPs/PAs increased from 20.4 to 35.0 percent during 2000–2010. Average NP/PA VPBY increased from 1.0/0.3 to 3.0/0.6 during 2000–2010. Average number of NPs/PAs per NH increased from 0.2/0.09 to 0.5/0.14 during 2000–2010. The impact of state scope‐of‐practice regulations was mixed.

Conclusions

NP and PA scope‐of‐practice regulations impact their practice in NHs, not always as intended.     

Benchmarking Outpatient Rehabilitation Clinics Using Functional Status Outcomes

Objective

To utilize functional status (FS) outcomes to benchmark outpatient therapy clinics.

Data Sources

Outpatient therapy data from clinics using Focus on Therapeutic Outcomes (FOTO) assessments.

Study Design

Retrospective analysis of 538 clinics, involving 2,040 therapists and 90,392 patients admitted July 2006–June 2008. FS at discharge was modeled using hierarchical regression methods with patients nested within therapists within clinics. Separate models were estimated for all patients, for those with lumbar, and for those with shoulder impairments. All models risk‐adjusted for intake FS, age, gender, onset, surgery count, functional comorbidity index, fear‐avoidance level, and payer type. Inverse probability weighting adjusted for censoring.

Data Collection Methods

Functional status was captured using computer adaptive testing at intake and at discharge.

Principal Findings

Clinic and therapist effects explained 11.6 percent of variation in FS. Clinics ranked in the lowest quartile had significantly different outcomes than those in the highest quartile (p < .01). Clinics ranked similarly in lumbar and shoulder impairments (correlation = 0.54), but some clinics ranked in the highest quintile for one condition and in the lowest for the other.

Conclusions

Benchmarking models based on validated FS measures clearly separated high‐quality from low‐quality clinics, and they could be used to inform value‐based‐payment policies.     

Measuring Prices in Health Care Markets Using Commercial Claims Data

Objective

To compare methods of price measurement in health care markets.

Data Sources

Truven Health Analytics MarketScan commercial claims.

Study Design

We constructed medical prices indices using three approaches: (1) a “sentinel” service approach based on a single common service in a specific clinical domain, (2) a market basket approach, and (3) a spending decomposition approach. We constructed indices at the Metropolitan Statistical Area level and estimated correlations between and within them.

Principal Findings

Price indices using a spending decomposition approach were strongly and positively correlated with indices constructed from broad market baskets of common services (r > 0.95). Prices of single common services exhibited weak to moderate correlations with each other and other measures.

Conclusions

Market‐level price measures that reflect broad sets of services are likely to rank markets similarly. Price indices relying on individual sentinel services may be more appropriate for examining specialty‐ or service‐specific drivers of prices.     

Accelerating Improvement and Narrowing Gaps: Trends in Patients' Experiences with Hospital Care Reflected in HCAHPS Public Reporting

Objective

Measure HCAHPS improvement in hospitals participating in the second and fifth years of HCAHPS public reporting; determine whether change is greater for some hospital types.

Data

Surveys from 4,822,960 adult inpatients discharged July 2007–June 2008 or July 2010–June 2011 from 3,541 U.S. hospitals.

Study Design

Linear mixed‐effect regression models with fixed effects for time, patient mix, and hospital characteristics (bedsize, ownership, Census division, teaching status, Critical Access status); random effects for hospitals and hospital‐time interactions; fixed‐effect interactions of hospital characteristics and patient characteristics (gender, health, education) with time predicted HCAHPS measures correcting for regression‐to‐the‐mean biases.

Data Collection Methods

National probability sample of adult inpatients in any of four approved survey modes.

Principal Findings

HCAHPS scores increased by 2.8 percentage points from 2008 to 2011 in the most positive response category. Among the middle 95 percent of hospitals, changes ranged from a 5.1 percent decrease to a 10.2 percent gain overall. The greatest improvement was in for‐profit and larger (200 or more beds) hospitals.

Conclusions

Five years after HCAHPS public reporting began, meaningful improvement of patients'' hospital care experiences continues, especially among initially low‐scoring hospitals, reducing some gaps among hospitals.     

Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges

Objective

Compare health care utilization and charges for low‐back‐pain (LBP) patients receiving advanced imaging or physical therapy as a first management strategy following a new primary care consultation.

Data Source

Electronic medical record (EMR) and insurance claims data.

Study Design

Retrospective analysis of propensity‐matched groups.

Data Collection/Extraction

Claims and EMR data were used. Utilization and LBP‐related charges over a 1‐year period were extracted from claims data.

Principal Findings

In the propensity‐matched sample (n = 406), advanced imaging recipients had higher odds of all utilization outcomes. Charges were higher with advanced imaging by an average $4,793 (95 percent CI: $3,676, $5,910).

Conclusions

For patients with LBP whom newly consulted primary care referred for additional management, advanced imaging as a first management was associated with higher health care utilization and charges than physical therapy.     

Cost‐Effectiveness Analysis of a Capitated Patient Navigation Program for Medicare Beneficiaries with Lung Cancer

Objective

To assess the cost‐effectiveness of implementing a patient navigation (PN) program with capitated payment for Medicare beneficiaries diagnosed with lung cancer.

Data Sources/Study Setting

Cost‐effectiveness analysis.

Study Design

A Markov model to capture the disease progression of lung cancer and characterize clinical benefits of PN services as timeliness of treatment and care coordination. Taking a payer''s perspective, we estimated the lifetime costs, life years (LYs), and quality‐adjusted life years (QALYs) and addressed uncertainties in one‐way and probabilistic sensitivity analyses.

Data Collection/Extraction Methods

Model inputs were extracted from the literature, supplemented with data from a Centers for Medicare and Medicaid Services demonstration project.

Principal Findings

Compared to usual care, PN services incurred higher costs but also yielded better outcomes. The incremental cost and effectiveness was $9,145 and 0.47 QALYs, respectively, resulting in an incremental cost‐effectiveness ratio of $19,312/QALY. One‐way sensitivity analysis indicated that findings were most sensitive to a parameter capturing PN survival benefit for local‐stage patients. CE‐acceptability curve showed the probability that the PN program was cost‐effective was 0.80 and 0.91 at a societal willingness‐to‐pay of $50,000 and $100,000/QALY, respectively.

Conclusion

Instituting a capitated PN program is cost‐effective for lung cancer patients in Medicare. Future research should evaluate whether the same conclusion holds in other cancers.     

Percutaneous Coronary Intervention in the United States: Risk Factors for Untimely Access

Objective

To determine how access to percutaneous coronary intervention (PCI) is distributed across demographics.

Data Sources

Secondary data from the 2011 American Hospital Association (AHA) survey data combined with 2010 Census.

Study Design

We calculated prehospital times from 32,370 ZIP codes to the nearest PCI center. We used a multivariate logit model to determine the odds of untimely access by the ZIP code''s concentration of vulnerable populations.

Data Collection

We used ZIP code–level data on community characteristics from the 2010 Census and supplemented it with 2011 AHA survey data on service‐line availability of PCI for responding hospitals.

Principal Findings

For approximately 306 million Americans, the median prehospital time to the nearest PCI center is 33 minutes. While 84 percent of Americans live within one hour of a PCI center, the odds of untimely access are higher in low‐income (OR: 3.00; 95 percent CI: 2.39, 3.77), rural (8.10; 95 percent CI: 6.84, 9.59), and highly Hispanic communities (2.55; 95 percent CI: 1.86, 3.49).

Conclusions

While the majority of Americans live within 60 minutes of a PCI center, rural, low‐income, and highly Hispanic communities have worse PCI access. This may translate into worse outcomes for patients with acute myocardial infarction.     

The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

Objective

To assess the impact of the Patient Protection and Affordable Care Act''s (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.

Data Sources

Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010–2011.

Study Design

We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.

Principal Findings

Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.

Conclusions

The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.