Arnold Milstein

A Systemic Approach to Containing Health Care Spending

Two Sounding Board articles, by Emanuel et al. and Antos et al., discuss different approaches to controlling rising health care costs in the United States. The editors hope that the range of options presented will stimulate discussion and debate on the best ways to bend the health care cost curve.

California Safety-Net Hospitals Likely To Be Penalized By ACA Value, Readmission, And Meaningful-Use Programs

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.

How the Pioneer ACO Model needs to change: lessons from its best-performing ACO.

On July 16, 2013, the Center for Medicare & Medicaid Innovation released results from the first performance year of its Pioneer Accountable Care Organization (ACO) Model. The Pioneer program is the first ACO pilot administered by the government and the first to report results. This important experiment may offer lessons for how to avoid Medicare�s predicted fiscal crisis. Even short of that, however, the findings demonstrate that, for the experiment to ultimately succeed, value-based payment and patient incentives to reward clinicians and health care organizations that offer more real value to patients must spread rapidly to other payers. Otherwise, the very delivery systems that are improving cost and quality may drop out of these important experiments.

Consumers’ And Providers’ Responses To Public Cost Reports, And How To Raise The Likelihood Of Achieving Desired Results

There is tremendous interest in different approaches to slowing the rise in US per capita health spending. One approach is to publicly report on a providers costs--also called efficiency, resource use, or value measures--with the hope that consumers will select lower-cost providers and providers will be encouraged to decrease spending. In this paper we explain why we believe that many current cost-profiling efforts are unlikely to have this intended effect. One of the reasons is that many consumers believe that more care is better and that higher-cost providers are higher-quality providers, so giving them information that some providers are lower cost may have the perverse effect of deterring them from accessing these providers. We suggest changes that can be made to content and design of public cost reports to increase the intended consumer and provider response.

Reductions in Mortality Associated With Intensive Public Reporting of Hospital Outcomes

It is unclear whether public reporting of hospital and physician performance has improved outcomes for the conditions being reported. We studied the effect of intensive public reporting on hospital mortality for 6 high-frequency, high-mortality medical conditions. Patients in Pennsylvania were matched to patients in other states with varying public reporting environments using propensity score methods. The effect of public reporting was estimated using a difference in differences approach. Patients treated at hospitals subjected to intensive public reporting had significantly lower odds of in-hospital mortality when compared with similar patients treated at hospitals in environments with no public reporting or only limited reporting. Overall, the 2000-2003 in-hospital mortality odds ratio for Pennsylvania patients versus non-Pennsylvania patients ranged from 0.59 to 0.79 across 6 clinical conditions (all P < .0001). For the same comparison using the 1997-1999 period, odds ratios ranged from 0.72 to 0.90, suggesting improvement when intensive public reporting occurred. (Am J Med Qual 2008;23:279-286)

Safety in numbers: the development of Leapfrog's composite patient safety score for U.S. hospitals.

Objective To develop a composite patient safety score that provides patients, health-care providers, and health-care purchasers with a standardized method to evaluate patient safety in general acute care hospitals in the United States. Methods The Leapfrog Group sought guidance from a panel of national patient safety experts to develop the composite score. Candidate patient safety performance measures for inclusion in the score were identified from publicly reported national sources. Hospital performance on each measure was converted into a “z-score” and then aggregated using measure-specific weights. A reference mean score was set at 3, with scores interpreted in terms of standard deviations above or below the mean, with above reflecting better than average performance. Results Twenty-six measures were included in the score. The mean composite score for 2652 general acute care hospitals in the United States was 2.97 (range by hospital, 0.46–3.94). Safety scores were slightly lower for hospitals that were publicly owned, rural in location, or had a larger percentage of patients with Medicaid as their primary insurance. Conclusions The Leapfrog patient safety composite provides a standardized method to evaluate patient safety in general acute care hospitals in the United States. While constrained by available data and publicly reported scores on patient safety measures, the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety. Additional analyses are needed, but the score did not seem to have a strong bias against hospitals with specific characteristics. The composite score will continue to be refined over time as measures of patient safety evolve.

Hospital adoption of automated surveillance technology and the implementation of infection prevention and control programs

BACKGROUND This research analyzes the relationship between hospital use of automated surveillance technology (AST) for identification and control of hospital-acquired infections (HAI) and implementation of evidence-based infection control practices. Our hypothesis is that hospitals that use AST have made more progress implementing infection control practices than hospitals that rely on manual surveillance. METHODS A survey of all acute general care hospitals in California was conducted from October 2008 through January 2009. A structured computer-assisted telephone interview was conducted with the quality director of each hospital. The final sample includes 241 general acute care hospitals (response rate, 83%). RESULTS Approximately one third (32.4%) of Californias hospitals use AST for monitoring HAI. Adoption of AST is statistically significant and positively associated with the depth of implementation of evidence-based practices for methicillin-resistant Staphylococcus aureus and ventilator-associated pneumonia and adoption of contact precautions and surgical care infection practices. Use of AST is also statistically significantly associated with the breadth of hospital implementation of evidence-based practices across all 5 targeted HAI. CONCLUSION Our findings suggest that hospitals using AST can achieve greater depth and breadth in implementing evidenced-based infection control practices.

Code Red and Blue — Safely Limiting Health Care's GDP Footprint

U.S. health care value is low, and the gap between health spending growth and growth of the GDP saps economic vitality. Our health care system needs to adopt new work methods, outlined in the Institute of Medicines vision of a learning health system.

Impact of Financial Incentives for Prenatal Care on Birth Outcomes and Spending

OBJECTIVE To evaluate the impact of offering US

Financial and Clinical Impact of Team-Based Treatment for Medicaid Enrollees With Diabetes in a Federally Qualified Health Center

100 each to patients and their obstetricians or midwives for timely and comprehensive prenatal care on low birth weight, neonatal intensive care admissions, and total pediatric health care spending in the first year of life. DATA SOURCES/STUDY SETTING Claims and enrollment profiles of the predominantly low-income and Hispanic participants of a union-sponsored, health insurance plan from 1998 to 2001. STUDY DESIGN Panel data analysis of outcomes and spending for participants and nonparticipants using instrumental variables to account for selection bias. DATA COLLECTION/ABSTRACTION METHODS: Data provided were analyzed using t-tests and chi-squared tests to compare maternal characteristics and birth outcomes for incentive program participants and nonparticipants, with and without instrumental variables to address selection bias. Adjusted variables were analyzed using logistic regression models. PRINCIPLE FINDINGS Participation in the incentive program was significantly associated with lower odds of neonatal intensive care unit admission (0.45; 95 percent CI, 0.23-0.88) and spending in the first year of life (estimated elasticity of -0.07; 95 percent CI, -0.12 to -0.01), but not low birth weight (0.53; 95 percent CI, 0.23-1.18). CONCLUSION The use of patient and physician incentives may be an effective mechanism for improving use of recommended prenatal care and associated outcomes, particularly among low-income women.