RESUMO
OBJECTIVES: To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration. DESIGN: Cross-sectional observational study comparing ACO-attributed beneficiaries with propensity score-matched beneficiaries not attributed to an ACO. SETTING: A total of 21 hospital referral regions (HRRs) in the United States. PARTICIPANTS: Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013-2014. MEASUREMENTS: Outcome measures were claims-based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics. RESULTS: Compared with beneficiaries not in an ACO, ACO-attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0-4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = -1.7 percentage points; CI = -3.1 to -.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO-penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non-ACO patients in both medium and high ACO-penetration HRRs. CONCLUSION: Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961-968, 2019.
Assuntos
Organizações de Assistência Responsáveis/métodos, Planos de Pagamento por Serviço Prestado/estatística & dados numéricos, Gastos em Saúde, Medicare, Neoplasias/epidemiologia, Assistência Terminal/métodos, Idoso, Idoso de 80 Anos ou mais, Estudos Transversais, Feminino, Seguimentos, Humanos, Masculino, Neoplasias/economia, Estudos Retrospectivos, Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues. METHODS: Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010-April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session. RESULTS: The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs. CONCLUSIONS: Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care.
Assuntos
Continuidade da Assistência ao Paciente, Atenção à Saúde/organização & administração, Medicaid/economia, Pacotes de Assistência ao Paciente/economia, Transtornos Relacionados ao Uso de Substâncias/terapia, Adolescente, Adulto, Feminino, Humanos, Masculino, Massachusetts, Pessoa de Meia-Idade, Mecanismo de Reembolso, Transtornos Relacionados ao Uso de Substâncias/economia, Estados UnidosRESUMO
OBJECTIVE: To evaluate whether Medicare-style bundled payments are lower or higher for beneficiaries discharged from hospitals with postacute care (PAC) referrals concentrated among fewer PAC providers. DATA SOURCE: Medicare Part A and Part B claim (2008-2012) for all beneficiaries residing in any of 17 market areas: the Provider of Service file, the Healthcare Cost Report Information System, and the Dartmouth Atlas. STUDY DESIGN: An observational study in which hospitals were distinguished according to PAC referral concentration, which is the tendency to utilize fewer rather than more PAC providers. We tested the hypothesis that higher referral concentration would be associated with total Medicare bundled payments. DATA COLLECTION/EXTRACTION METHODS: The data represent a convenience sample of market areas that were defined by the locations of grantees from the ONC Beacon Community Program. PRINCIPAL FINDINGS: The four most-used PAC providers accounted for an average of 60 percent of patients discharged from hospitals in the sample. Regression analysis suggested that higher referral concentration was associated with lower Medicare costs per bundle. CONCLUSIONS: Hospitals that tend to use fewer PAC providers may lead to lower costs for payers such as Medicare. The study results reinforce the importance of limited networks for PAC services under bundling arrangements for hospital and PAC payments.
Assuntos
Medicare/economia, Pacotes de Assistência ao Paciente/economia, Encaminhamento e Consulta/economia, Encaminhamento e Consulta/estatística & dados numéricos, Cuidados Semi-Intensivos/economia, Fatores Etários, Idoso, Idoso de 80 Anos ou mais, Feminino, Humanos, Modelos Lineares, Masculino, Medicare/estatística & dados numéricos, Alta do Paciente/economia, Fatores Sexuais, Fatores Socioeconômicos, Cuidados Semi-Intensivos/organização & administração, Estados UnidosRESUMO
OBJECTIVE: We propose a method of processing and displaying imaging utilization data for large populations. CONCLUSION: The comprehensive and finely grained picture of imaging utilization yielded by our methods is a first step toward population-based imaging utilization management. We believe that our methods for the categorization and display of imaging utilization will prove to be widely useful.
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Apresentação de Dados/tendências, Diagnóstico por Imagem/estatística & dados numéricos, Aplicações da Informática Médica, Current Procedural Terminology, Diagnóstico por Imagem/economia, Pesquisa sobre Serviços de Saúde, Humanos, Medicare Part B/economia, Software, Estados UnidosAssuntos
Atitude do Pessoal de Saúde, Educação Técnica em Enfermagem, Bacharelado em Enfermagem, Enfermeiros Administradores/psicologia, Seleção de Pessoal/métodos, Competência Clínica, Educação Técnica em Enfermagem/normas, Bacharelado em Enfermagem/normas, Educação de Pós-Graduação em Enfermagem, Escolaridade, Humanos, Enfermeiros Administradores/educação, Seleção de Pessoal/normas, Salários e Benefícios/economiaRESUMO
BACKGROUND: Contradictory findings about the effectiveness of health care teams may relate to the actual structure of teams-loose rather than formal-and the nature of decision making-hierarchical rather than egalitarian. We introduce the concept of collaborative capacity-the likelihood that providers, no matter how brief their exchange, will collaborate as if they were members of an egalitarian team even in the absence of a formal team structure. OBJECTIVE: To examine aspects and determinants of collaborative capacity, namely task interdependence, norms of working together, and egalitarian collaboration among interdisciplinary providers on health care units. RESEARCH DESIGN: We collected survey data from unit-based staff in 45 units across 9 hospitals and 7 health systems in upstate New York. One thousand five hundred twenty-seven surveys were returned for an overall response rate of 68.5%. RESULTS: Measures for team structure and collaboration do not vary significantly between hospitals, only by unit and occupational group, with higher status providers reporting greater interdependence, higher quality of interactions, and more collaborative influence in decision making. Clear task direction, namely an emphasis on patient-centered care, and organizational contexts supportive of work are both significantly associated with higher levels of task interdependence, quality of staff interactions, and collaborative influence. CONCLUSIONS: Collaborative capacity is somewhat constrained by a rigid hierarchy of health care occupations and division of labor that make teamwork more similar than different across hospitals. At the unit level, collaborative capacity may be improved, however, by an emphasis on patient-centered care and a context that supports providers' work.
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Fortalecimento Institucional, Comportamento Cooperativo, Unidades Hospitalares/organização & administração, Equipe de Assistência ao Paciente/organização & administração, Análise de Variância, Atenção à Saúde/estatística & dados numéricos, Eficiência Organizacional, Feminino, Hospitais/estatística & dados numéricos, Humanos, Comunicação Interdisciplinar, Relações Interprofissionais, Liderança, Modelos Lineares, Masculino, New York, Inquéritos e QuestionáriosRESUMO
This study compares the demographic, clinical, and health care characteristics of 2,156 persons over and under age 65 who are participants in the Sonya Slifka Longitudinal Multiple Sclerosis Study and examines the effects of current age, age at diagnosis, course, and duration of illness on disability-related outcomes. Compared to younger MS patients, significantly higher percentages of older patients lived alone, had lower incomes, and were severely disabled; 85% needed help with activities of daily living and 40% received home care services. Almost all older patients had health insurance, 75% had prescription drug coverage, and few reported difficulty accessing general medical and specialized MS care; perceptions of health status and quality of life were relatively positive. Duration and course of illness were the major predictors of disability, although older current age and younger age at diagnosis were also associated. The relationship among age- and disease-related variables is complex and they likely exert independent effects on disability-related outcomes. Planning is needed by caregivers and policy makers to ensure that the specialized needs of elderly persons with MS are adequately met.
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Pessoas com Deficiência, Esclerose Múltipla/fisiopatologia, Atividades Cotidianas, Adulto, Idoso, Idoso de 80 Anos ou mais, Atenção à Saúde, Demografia, Nível de Saúde, Serviços de Assistência Domiciliar, Humanos, Seguro Saúde, Estudos Longitudinais, Pessoa de Meia-Idade, Esclerose Múltipla/psicologia, Prognóstico, Qualidade de Vida, AutoimagemRESUMO
Data from the Worcester Family Research Project were analyzed to determine whether social support processes are altered by poverty and whether kin and nonkin support are differentially related to mental health in low-income mothers. The authors found that conflict with family and friends predicted adverse mental health and more strongly predicted these outcomes than emotional and instrumental support. Moreover, sibling conflict was a stronger predictor of mental health than parent conflict. Finally, only instrumental support from professionals predicted mental health.
