Suchergebnisse

AbstractHealth insurance regulators often set minimum ratios of provider = per‐enrollee for health insurance plans to try to ensure that their provider networks offer enrollees adequate access to medical care. However, plan‐specific ratios only have an unambiguous interpretation when each provider participates in only one single network. Based on network data, we show that endocrinologists, obstetrician–gynecologists, cardiologists, and pediatricians in California participate on average in 64, 66, 72, and 63 networks, respectively. Such high participation rates in networks make provider‐per‐enrollee ratios measured at the plan level meaningless as metrics for access. We recommend that plan‐specific ratios be abandoned in favor of a more qualitative approach with strong dispute resolution protections as well as "police patrols" (e.g., regulator surveys to assess waiting times for appointments) and "fire alarms" (e.g., investing resources in consumer advocate organizations).

Throughout life, patients with multiple sclerosis (MS) require increasing levels of support, rehabilitative services, and eventual skilled nursing facility (SNF) care. There are concerns that access to SNF care for MS patients is limited because of perceived higher costs of their care. This study compares costs of caring for an MS patient versus those of a typical SNF patient. We merged SNF cost report data with the 2001-2006 Nursing Home Minimum Data Set (MDS) to calculate percentage of MS residents-days and facility case-mix indices (CMIs). We estimated the average facility daily cost using hybrid cost functions, adjusted for facility ownership, average facility wages, CMI-adjusted number of SNF days, and percentage of MS residents-days. We describe specific characteristics of SNF with high and low MS volumes and examine any sources of variation in cost. MS patients were no longer more costly than typical SNF patients. A greater proportion of MS patients had no significant effect on facility daily costs (P = 0.26). MS patients were more likely to receive care in government-owned facilities (OR = 1.904) located in the Western (OR = 2.133) and Midwestern (OR = 1.3) parts of the USA (P < 0.05). Cost of SNF care is not a likely explanation for the perceived access barriers that MS patients face.

Medicaid home‐ and community‐based services (HCBS) waiver programs serve a population at high risk for hospitalization. We examined whether enrollees in HCBS programs, in 21 states representing all regions of the United States, with higher intensity of services, measured by HCBS spending per enrollee, have lower rates of hospitalization and potentially avoidable hospitalization (PAH). We found no statistically significant association with hospitalization. This suggests that HCBS programs that provide higher intensity services are not focusing effort on reducing hospitalization. We also found that HCBS waiver enrollees in programs with greater generosity in eligibility, measured by a higher proportion of HCBS receipt among long‐term services and supports (LTSS) users, had statistically significantly lower rates of hospitalization and PAH. This suggests that more generous programs serve waiver enrollees who are at lower risk of hospitalization, which may be relevant to policymakers in establishing the eligibility criteria.

This study determined whether higher patient volume of skilled nursing facility (SNF) care was associated with a lower hospital transfer rate. Using the nursing home Minimum Data Set and the Online Survey, Certification, and Reporting file, we assembled a national cohort of Medicare SNF postacute care admissions between January and September of 2008. Multivariable analyses based on Cox proportional hazards models found that patients admitted to high-volume SNFs (annual number of admissions in the top tertile group) showed an approximately 15% reduced risk for 30-day rehospitalization and an approximately 25% reduced risk for 90-day rehospitalization, compared with patients admitted to low-volume SNFs (annual number of admissions in the bottom tertile group, or <45). Similar patterns of volume–outcome associations were found for hospital-based and freestanding facilities separately. The inverse volume–outcome association in postacute SNF care may reflect a "practice makes perfect" effect, a "selective referral" effect, or both.

The objective of this study was to examine the reasons for different hospitalization rates between Medicaid and private-pay nursing home residents—to disentangle within-facility differences from across-facility variations in hospitalizations between these two types of residents. Multiple data sources (2003) for New York State were linked. Hospitalization was the dependent variable. Individual payer status was the main independent variable. Facilities were stratified into four groups by ownership status and bed-hold payment eligibility. We found both within-facility (Medicaid residents were more likely to be hospitalized than private-pay residents within a facility) and across-facility differences (facilities with a higher concentration of Medicaid residents were more likely to hospitalize their residents) controlling for individual and facility characteristics. The magnitude of within-facility differences varied with facility ownership and bed-hold eligibility. To reduce hospitalizations of Medicaid residents and to improve both quality of care and costs, policymakers may need to align Medicaid's and Medicare's incentives.

Since 2005 Massachusetts has publicly reported results from biennial surveys of satisfaction with nursing homes, completed by responsible parties for residents, to promote consumer-centered care. Our analysis of the results from 2005, 2007, and 2009 revealed generally high satisfaction with care, which remained stable over time. On a scale of 1 to 5 (from very dissatisfied to very satisfied), average satisfaction with overall care was 4.22-4.31, and satisfaction that overall residents' needs were met was 4.09-4.16. Around 90percent of respondents would recommend the facility. Satisfaction ratings varied considerably across facilities, with higher scores associated with higher nursing staffing levels, fewer deficiency citations, and nonprofit or government ownership. Scores for six domains of care were, in general, closely associated with satisfaction scores. However, family members seemed less satisfied with the physical and social activities available to residents and with the food and meals served than with such attributes as the physical environment. Our findings suggest that including the consumer's perspective would improve the Centers for Medicare and Medicaid Services' current nursing home reporting efforts. However, refinements may be necessary to detect the impact of consumer reporting on the quality of patient-centered care.

Since 2005 Massachusetts has publicly reported results from biennial surveys of satisfaction with nursing homes, completed by responsible parties for residents, to promote consumer-centered care. Our analysis of the results from 2005, 2007, and 2009 revealed generally high satisfaction with care, which remained stable over time. On a scale of 1 to 5 (from very dissatisfied to very satisfied), average satisfaction with overall care was 4.22–4.31 and satisfaction that overall residents' needs were met was 4.09–4.16; 89.9–90.1 percent of respondents would recommend the facility. Satisfaction ratings varied considerably across facilities, with higher scores associated with higher nursing staffing levels, fewer deficiency citations, and nonprofit or government ownership. Scores for six domains of care were, in general, closely associated with satisfaction scores. However, family members seemed less satisfied with the physical and social activities available to residents and with the food and meals served than with such attributes as the physical environment. Our findings suggest that including the consumer's perspective would improve the Centers for Medicare and Medicaid Services' current nursing home reporting efforts, but that refinements may be necessary to detect the impact of consumer reporting on the quality of patient-centered care.

Home health performance gained visibility with the publication of Home Health Compare and the Home Health Value-Based Payment demonstration. Both provide incentives for home health agencies (HHA) to invest in quality improvements. The objective of this study is to identify the association between quality initiatives adopted by HHAs and improved performance. A 2018 national survey of 7459 HHAs, yielding a sample of 1192 eligible HHAs, provided information about 23 quality initiatives, which was linked to 5 composite Super Quality Measures (SQMs): ADL/pain, self-treatment, timely care, hospitalizations, and patient experience. Exclusions for missing data and outliers yielded a final analytical sample of 903 HHAs. Regression models estimated associations between quality initiatives and SQMs. The relationships between sixteen of the SQM/quality initiative pairs were positively associated with improvement and 7 were negatively associated. Web-based technologies for staff and care-givers improved performance but deteriorated patient experience. Web support-groups for staff and review of HHC rankings reduced hospitalization rates. While this study offers insights for quality improvement, a limitation may be a lack of sensitivity to the nuances of quality improvement implementation. Therefore, this study should be viewed as hypothesis-generating concerning initiatives likely to have the greatest potential meriting further investigation.

The Home Health Value-based Purchasing (HHVBP) demonstration, incorporating a payment formula designed to incentivize both high-quality care and quality improvement, is expected to become a national program after 2022, when the demonstration ends. This study investigated the relationship between costs and several quality dimensions, to inform HHVBP policy. Using Medicare cost reports, OASIS and Home Health Compare data for 7,673 home health agencies nationally, we estimated cost functions with instrumental variables for quality. The estimated net marginal costs varied by composite quality measure, baseline quality, and agency size. For four of the five composite quality measures, the net marginal cost was negative for low-quality agencies, suggesting that quality improvement was cost saving for this agency type. As the magnitude of the net marginal cost is commensurate with the payment incentive planned for HHVBP, it should be considered when designing the incentives for HHVBP, to maximize their effectiveness.