Christopher P. Tompkins

BALANCING DIVERSION CONTROL AND MEDICAL NECESSITY: THE CASE OF PRESCRIPTION DRUGS WITH ABUSE POTENTIAL

Narcotics and other prescription drugs play a significant and legitimate role in medical practice. The illicit use of prescribed medicines, however, remains a major problem. This paper examines the effectiveness of two drug diversion control programs, multiple copy prescriptions programs (MCPP) and electronic data transfer (EDT) systems, and their impact on medical practice. Current evidence demonstrates that these programs decrease prescription drug use, with much of the decrease due to declines in inappropriate use. MCPPs appear more effective than EDT in preventing diversion. More research is needed, however, to assess their effects on medical practice, particularly patient quality of care. [Translations are provided in the International Abstracts Section of this issue.]

Incidence and Cost of Pneumonia in Medicare Beneficiaries

BACKGROUND Pneumonia is a frequent and serious illness in elderly people, with a significant impact on mortality and health-care costs. Lingering effects may influence clinical outcomes and medical service use beyond the acute hospitalization. This study describes the incidence and mortality of pneumonia in elderly Medicare beneficiaries based on treatment setting (outpatient, inpatient) and location of origin (health-care associated, community acquired) and estimates short- and long-term direct medical costs and mortality associated with an inpatient episode of pneumonia. METHODS Administrative claims from a 5% sample of fee-for-service Medicare beneficiaries aged ≥ 65 years from 2005 through 2007 were used. Total direct medical costs for patients during and after hospitalization for pneumonia compared with similar patients without pneumonia (the excess cost of pneumonia) were estimated using propensity score matching. RESULTS The age-adjusted annual cumulative incidence of any pneumonia was 47.4 per 1,000 beneficiaries (13.3 per 1,000 inpatient primary pneumonia), increasing with age; one-half of pneumonia cases were treated in the hospital. Thirty-day mortality was twice as high among beneficiaries with health-care-associated pneumonia than among those hospitalized with community-acquired pneumonia (13.4% vs 6.4%). Total medical costs for beneficiaries during and 1 year following a pneumonia hospitalization were

Lessons Learned Preparing for Medicare Bundled Payments

15,682 higher than matched control patients without pneumonia. The total annual excess cost of hospital-treated pneumonia as a primary diagnosis in the elderly fee-for-service Medicare population in 2010 is estimated conservatively at >

Measuring Outcomes And Efficiency In Medicare Value-Based Purchasing

7 billion. CONCLUSIONS Pneumonia in elderly people is associated with high acute-care costs and an overall impact on total direct medical costs and mortality during and after an acute episode.

The impact of employment counseling on substance user treatment participation and outcomes.

Medicare typically spends as much or more in the 90 days after discharge as it does for the initial hospitalization, and post-acute care spending varies widely. This variation highlights opportunities for bundled payments to help improve quality and reduce spending.

The Relationship between Medicare's Process of Care Quality Measures and Mortality

The Medicare program may soon adopt value-based purchasing (VBP), in which hospitals could receive incentives that are conditional on meeting specified performance objectives. The authors advocate for a market-oriented framework and direct measures of system-level value that are focused on better outcomes and lower total cost of care. They present a multidimensional framework for measuring outcomes of care and a method to adjust incentive payments based on efficiency. Incremental reforms based on VBP could provoke transformational changes in total patient care by linking payments to value related to the whole patient experience, recognizing shared accountability among providers.

A randomized trial of telemonitoring heart failure patients.

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counselings impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.

Association of military deployment of a parent or spouse and changes in dependent use of health care services.

Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004–2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.

Applying Disease Management Strategies to Medicare

EXECUTIVESUMMARY The purpose of this study was to measure the ability of telemonitoring to reduce hospital days and total costs for Medicare managed care enrollees diagnosed with heart failure. Patients were recruited and randomly assigned for six months to either telemonitoring or standard care. Telemonitoring transmitted vital signs and clinical alerts daily to a central nursing station. Utilization of covered services was analyzed for the six‐month telemonitoring period to test for hypothesized reductions in hospital days and changes in utilization of the emergency department (ED), urgent care, and primary care. Negative binomial regressions adjusted for gender, age, co‐occurring diabetes, co‐occurring chronic obstructive pulmonary disease, and residence neighborhood were used to analyze units of service, and two‐part (hurdle) multivariable models were used for expenditures. The main finding was a tendency for lower total number of hospital days for patients assigned to telemonitoring. Results for other covered services were generally consistent with hypothesized direction and magnitude; however, statistical power was reduced because of lowerthan‐expected recruitment rates into the study. Within a managed‐care environment, telemonitoring appears to facilitate better ambulatory management of heart failure patients, including fewer ED visits, which were offset by more frequent primary care and urgent care visits.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

Background:U.S. Armed Forces members and spouses report increased stress associated with combat deployment. It is unknown, however, whether these deployment stressors lead to increased dependent medication use and health care utilization. Objective:To determine whether the deployment of Army active duty members (sponsors) is associated with changes in dependent health care utilization. Design:A quasi-experimental, pre-post study of health care patterns of more than 55,000 nonpregnant spouses and 137,000 children of deployed sponsors and a comparison group of dependents. Measures:Changes in dependent total utilization in the military health system, and separately in military-provided and purchased care services in the year following the sponsors’ deployment month for office visit services (generalist, specialist); emergency department visits; institutional stays; psychotropic medication (any, antidepressant, antianxiety, antistimulant classes). Results:Sponsor deployment was associated with net increased use of specialist office visits (relative percent change 4.2% spouses; 8.8% children), antidepressants (6.7% spouses; 17.2% children), and antianxiety medications (14.2% spouses; 10.0% children; P<0.01) adjusting for group differences. Deployment was consistently associated with increased use of purchased care services, partially, or fully offset by decreased use of military treatment facilities. Conclusions:These results suggest that emotional or behavioral issues are contributing to increased specialist visits and reliance on medications during sponsors’ deployments. A shift to receipt of services from civilian settings raises questions about coordination of care when families temporarily relocate, family preferences, and military provider capacity during deployment phases. Findings have important implications for the military health system and community providers who serve military families, especially those with children.