Maureen T. Stewart

Evaluating the Role of Patient Sample Definitions for Quality Indicators Sensitive to Nurse Staffing Patterns

BackgroundAdministrative data are an attractive data source for the construction of quality indicators to assess and monitor quality of nursing care in hospitals. Current approaches to constructing measures from discharge abstracts apply substantial restrictions to exclude patients at high risk or with preexisting conditions. This study evaluates whether broader sample definitions combined with risk adjustment would allow for larger samples and increase analytic power. MethodsEight indicators were constructed from discharge abstracts of major surgical and medical patients from 799 hospitals in 11 states using existing definitions: pneumonia, urinary tract infection, decubitus ulcers, central nervous system complications, shock, sepsis, pulmonary failure, and upper gastrointestinal bleeding. We tested the effect of broadening the samples in 4 ways: comparing indicator rates in the broader and restrictive samples; assessing correlations of hospital ranks in the broader and restrictive samples; performing clinical reviews of cases in the added samples; and using different samples in regressions of indicators on nurse staffing variables, adjusting for patient risk. ResultsIndicator rates in the broader samples tended to be higher but did not change hospital rankings significantly. Clinical review suggested that many sample restrictions could be dropped. Using indicators based on broader definitions, coefficients on staffing variables increased in magnitude ConclusionLess restrictive sample definitions were shown to be feasible and increased the sensitivity of the indicators and thus the power of the analysis. Particularly in surgical patients, the samples could be broadened, although more conservative definitions appeared appropriate for medical patients.

Nurse Staffing and Quality of Care in Hospitals in the United States

The size and mix of nurse staffing in U.S. hospitals has a direct impact on the outcome of patient health according to a study based on discharge data for more than 6 million patients and financial reports and hospital staffing surveys from 799 hospitals in 11 states. The data were analyzed to determine staffing levels of RNs, licensed practicing/vocational nurses, and aides and to measure the frequency of a wide range of complications that patients developed during their hospital stays. Of the hospital inpatient nursing personnel studied, the study found that registered nurse staffing makes the biggest impact on adverse patient outcomes. The researchers found that lower levels of nurse staffing were associated with higher rates of urinary tract infections, pneumonia, shock and cardiac arrest, upper gastrointestinal bleeding, “failure to rescue,” and length of hospital stay in both medical and major surgery patients treated in hospitals.

Performance-Based Contracting Within a State Substance Abuse Treatment System: A Preliminary Exploration of Differences in Client Access and Client Outcomes

To explore whether the implementation of performance-based contracting (PBC) within the State of Maine’s substance abuse treatment system resulted in improved performance, one descriptive and two empirical analyses were conducted. The first analysis examined utilization and payment structure. The second study was designed to examine whether timeliness of access to outpatient (OP) and intensive outpatient (IOP) substance abuse assessments and treatment, measures that only became available after the implementation of PBC, differed between PBC and non-PBC agencies in the year following implementation of PBC. Using treatment admission records from the state treatment data system (N = 9,128), logistic regression models run using generalized equation estimation techniques found no significant difference between PBC agencies and other agencies on timeliness of access to assessments or treatment, for both OP and IOP services. The third analysis, conducted using discharge data from the years prior to and after the implementation of performance-based contracting (N = 6,740) for those agencies that became a part of the performance-based contracting system, was designed to assess differences in level of participation, retention, and completion of treatment. Regression models suggest that performance on OP client engagement and retention measures was significantly poorer the year after the implementation of PBC, but that temporal rather than a PBC effects were more significant. No differences were found between years for IOP level of participation or completion of treatment measures.

Performance contracting and quality improvement in outpatient treatment: Effects on waiting time and length of stay

We evaluate the effects of a performance contract (PC) implemented in Delaware in 2001 and participation in quality improvement (QI) programs on waiting time for treatment and length of stay (LOS) using client treatment episode level data from Delaware (n = 12,368) and Maryland (n = 147,151) for 1998-2006. Results of difference-in-difference analyses indicate that waiting time declined 13 days following the PC, after controlling for client characteristics and historical trends. Participation in the PC and a formal QI program was associated with a decrease of 20 days. LOS increased 22 days under the PC and 24 days under the PC and QI programs, after controlling for client characteristics. The PC and QI programs were associated with improvements in LOS and waiting time, although we cannot determine which aspects of the programs (incentives, training, and monitoring) resulted in these changes.

Improving Medication Management of Depression in Health Plans

OBJECTIVE Improving depression treatment is critical given low rates of appropriate care. Health plan performance measures that address quality of antidepressant medication management, specifically, have been stagnating at relatively low levels. Identifying health plan characteristics associated with better performance could contribute to quality improvement for this aspect of depression treatment. METHODS Data for 2003 were linked from two sources: a nationally representative survey of 368 health plans about their behavioral health services and the National Committee for Quality Assurances Health Plan Employer Data and Information Set (HEDIS) antidepressant medication management (AMM) scores, which reflect the percentage of eligible members whose care met specified criteria. The analytic sample present in both data sets totaled 361 products offered by 183 plans. Plan characteristics were grouped into organizational, provider, and consumer domains. Bivariate tests and regression analyses were conducted to estimate the relationship between these characteristics and health plan performance on three AMM measures: effective acute-phase treatment, effective continuation-phase treatment, and optimal practitioner contact. RESULTS Mean HEDIS AMM scores were 60% for effective acute-phase treatment, 43% for continuation-phase treatment, and 22% for optimal practitioner contact. Individual feedback to clinicians about their performance, lower cost sharing for outpatient mental health, and greater access to selective serotonin reuptake inhibitors were significantly associated with better plan performance in terms of antidepressant medication management. CONCLUSIONS Health plan characteristics were significantly associated with the quality of one important aspect of depression care, antidepressant medication management. Many of the factors that were identified suggest actionable ways for plans to improve quality of depression care.

Accessing Specialty Behavioral Health Treatment in Private Health Plans

Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 (N = 368 plans with 767 managed care products; 83% response rate). Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment.

The Role of Health Plans in Supporting Behavioral Health Integration

Health plan policies can influence delivery of integrated behavioral health and general medical care. This study provides national estimates for the prevalence of practices used by health plans that may support behavioral health integration. Results indicate that health plans employ financing and other policies likely to support integration. They also directly provide services that facilitate integration. Behavioral health contracting arrangements are associated with use of these policies. Delivery of integrated care requires systemic changes by both providers and payers thus health plans are key players in achieving this goal.

Massachusetts Substance Use Disorder Treatment Organizations’ Perspectives on the Affordable Care Act: Changes in Payment, Services, and System Design

ABSTRACT The Affordable Care Act (ACA) expanded insurance benefits and coverage for substance use disorder (SUD) treatment and encouraged delivery and payment reforms. Massachusetts passed a similar reform in 2006. This study aims to assess Massachusetts SUD treatment organizations’ responses to the ACA. Organizational interviews addressing challenges of and responses to the ACA were conducted in person June–December 2014 with 31 leaders at 12 treatment organizations across Massachusetts. Many organizations were affiliated with medical or social services and offered a range of SUD services. Sampling was based on services offered (detoxification only, detoxification and outpatient, outpatient only). Framework analysis was used. Challenges identified were considered similar to ongoing challenges, not unique to the ACA. Organizations experienced insurance expansions in 2006 and faced new challenges, including insurance coverage, payment arrangements, expansion of services, and system design. System design efforts included care coordination/integration, workforce development, and health information technology. Differences in responses related to connections with medical and social service organizations. Many organizations engaged in efforts to respond to changing policies by expanding capacity and services. Offering a range of SUD treatment (e.g., detoxification and outpatient) and affiliating with a medical organization could enable organizations to respond to new insurance, delivery, and payment reforms.

Private Health Plans’ Contracts with Managed Behavioral Healthcare Organizations

Contracts between health plans and managed behavioral health care organizations (MBHOs) influence access and quality of behavioral health care. This report presents information on performance requirements, information sharing, and financial risk from a nationally representative survey of private health plans. Most contracts include geographic access to providers (93.3%) and NCQA’s performance standards (84.2%). Health plans and MBHOs share data (99.0%), generally by the MBHO sending information to the health plan (96.3%). About a quarter of contracts impose financial penalties (23.0%), but few include incentives related to performance standards (<1.0%). Contract terms can shape the provision of behavioral health services in response to changes such as parity legislation or health reform. If current trends continue towards increases in value-based purchasing in the privately financed behavioral health sector, the focus on quality in contracts between health plans and MBHOs will be critical to understand.

Provider payment approaches and incentives to implement screening

Screening in primary care is widely recommended (e.g. U.S. Preventive Services Task Force and UK National Institute for Health and Care Excellence), and is increasingly targeted for improvement. As health care payers try to influence the implementation and delivery of alcohol screening and brief intervention (SBI), some are using provider payment approaches. These include specific reimbursement for conducting screening, other financial incentives and linking payment with performance measures. We present 2010 data from a nationally representative survey of private US health plans and US health plan claims data (private health plans and Medicare), supplemented by literature review. Results indicate, among private health plan products in the US, 72.6% report allowing primary care physicians to bill for alcohol SBI, yet claims data analysis found only 0.01% of individuals in private plans or Medicare had an SBI procedure code on a medical claim in 2010. As of April 2013 the UK National Health Service requires that primary care practices conduct screening of individuals 16 and over and reimburses for SBI. In the US, although financial incentives for providers are becoming more common in private health plans (used by 31.6% for any condition), only 6% of health plans provided financial incentives for primary care screening for alcohol and drug use problems. Provider payment policies may be tied to performance measures to improve the quality of care. Alcohol screening is one of more than 300 performance measures selected for inclusion in the US Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System. Despite this recognition, CMS analyses indicate the alcohol screening measure was not among the top five measures chosen by primary care providers. Although alcohol SBI is beneficial, it is not as widely implemented as it could be. Favorable payment policies are necessary, but not sufficient to encourage implementation of SBI.