Rachel M. Werner

Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care

IMPORTANCE Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear. OBJECTIVE To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care. DESIGN, SETTING, AND PARTICIPANTS Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilots beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design. EXPOSURES Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). MAIN OUTCOMES AND MEASURES Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care. RESULTS Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of

Comparison of change in quality of care between safety-net and non-safety-net hospitals.

92,000 per primary care physician during the 3-year intervention. CONCLUSIONS AND RELEVANCE A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.

Racial profiling: the unintended consequences of coronary artery bypass graft report cards.

CONTEXT Safety-net hospitals (ie, those that predominantly treat poor and underserved patients) often have lower quality of care than non-safety-net hospitals. While public reporting and pay for performance have the potential to improve quality of care at poorly performing hospitals, safety-net hospitals may be unable to invest in quality improvement. As such, some have expressed concern that these incentives have the potential to worsen existing disparities among hospitals. OBJECTIVE To examine trends in disparities of quality of care between hospitals with high and low percentages of Medicaid patients. DESIGN AND SETTING Longitudinal study of the relationship between hospital performance and percentage Medicaid coverage from 2004 to 2006, using publicly available data on hospital performance. A simulation model was used to estimate payments at hospitals with high and low percentages of Medicaid patients. MAIN OUTCOME MEASURES Changes in hospital performance between 2004 and 2006, estimating whether disparities in hospital quality between hospitals with high and low percentages of Medicaid patients have changed. RESULTS Of the 4464 participating hospitals, 3665 (82%) were included in the final analysis. Hospitals with high percentages of Medicaid patients had worse performance in 2004 and had significantly smaller improvement over time than those with low percentages of Medicaid patients. Hospitals with low percentages of Medicaid patients improved composite acute myocardial infarction performance by 3.8 percentage points vs 2.3 percentage points for those with high percentages, an absolute difference of 1.5 (P = .03). This resulted in a relative difference in performance gains of 39%. Larger performance gains at hospitals with low percentages of Medicaid patients were also seen for heart failure (difference of 1.4 percentage points, P = 0.04) and pneumonia (difference of 1.3 percentage points, P <.001). Over time, hospitals with high percentages of Medicaid patients had a lower probability of achieving high-performance status. In a simulation model, these hospitals were more likely to incur financial penalties due to low performance and were less likely to receive bonuses. CONCLUSIONS Safety-net hospitals tended to have smaller gains in quality performance measures over 3 years and were less likely to be high-performing over time than non-safety-net hospitals. An incentive system based on these measures has the potential to increase disparities among hospitals.

Survival and Functional Outcomes After Hip Fracture Among Nursing Home Residents

Background—Although public release of quality information through report cards is intended to improve health care, there may be unintended consequences of report cards, such as physicians avoiding high-risk patients to improve their ratings. If physicians believe that racial and ethnic minorities are at higher risk for poor outcomes, report cards could worsen existing racial and ethnic disparities in health care. Methods and Results—To investigate the impact of New Yorks CABG report card on racial and ethnic disparities in cardiac care, we estimated differences in the use of CABG, PTCA, and cardiac catheterization between white versus black and Hispanic patients hospitalized for acute myocardial infarction in New York before and after New Yorks first CABG report card was released, adjusting for patient and hospital characteristics and national changes in racial and ethnic disparities in cardiac care. The racial and ethnic disparity in CABG use significantly increased in New York immediately after New Yorks CABG report card was released, whereas disparities did not change significantly in the comparison states. There was no differential change in racial and ethnic disparities between New York and the comparison states in the use of cardiac catheterization or PTCA after the CABG report card was released. Over time, this increase in racial and ethnic disparities decreased to levels similar to those before the release of report cards. Conclusions—The release of CABG report cards in New York was associated with a widening of the disparity in CABG use between white versus black and Hispanic patients.

Impact of Public Reporting on Quality of Postacute Care

IMPORTANCE Little is known regarding outcomes after hip fracture among long-term nursing home residents. OBJECTIVE To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009. MAIN OUTCOMES AND MEASURES Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture. RESULTS Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P < .001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P < .001]), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P < .001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P < .001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P < .001]), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 [P < .001]). CONCLUSIONS AND RELEVANCE Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.

Public Reporting On Hospital Process Improvements Is Linked To Better Patient Outcomes

OBJECTIVE Evidence supporting the use of public reporting of quality information to improve health care quality is mixed. While public reporting may improve reported quality, its effect on quality of care more broadly is uncertain. This study tests whether public reporting in the setting of nursing homes resulted in improvement of reported and broader but unreported quality of postacute care. DATA SOURCES/STUDY SETTING 1999-2005 nursing home Minimum Data Set and inpatient Medicare claims. STUDY DESIGN We examined changes in postacute care quality in U.S. nursing homes in response to the initiation of public reporting on the Centers for Medicare and Medicaid Services website, Nursing Home Compare. We used small nursing homes that were not subject to public reporting as a contemporaneous control and also controlled for patient selection into nursing homes. Postacute care quality was measured using three publicly reported clinical quality measures and 30-day potentially preventable rehospitalization rates, an unreported measure of quality. PRINCIPAL FINDINGS Reported quality of postacute care improved after the initiation of public reporting for two of the three reported quality measures used in Nursing Home Compare. However, rates of potentially preventable rehospitalization did not significantly improve and, in some cases, worsened. CONCLUSIONS Public reporting of nursing home quality was associated with an improvement in most postacute care performance measures but not in the broader measure of rehospitalization.

Do consumers respond to publicly reported quality information? Evidence from nursing homes

The Centers for Medicare and Medicaid Services publicly reports so-called process performance at all U.S. hospitals, such as whether certain recommended treatments are given to specific types of patients. We examined whether hospital performance on key process indicators improved during the three years since this reporting began. We also studied whether or not these changes improved patient outcomes or yielded other quality improvements, such as reduced hospital readmission rates. We found that, from 2004 to 2006, hospital process performance improved and was associated with better patient and quality outcomes. Most notably, for acute myocardial infarction, performance improvements were associated with declines in mortality rates, lengths-of-stay, and readmission rates. Although we cannot conclude that public reporting caused the improvement in processes or outcomes, these results are encouraging, since improving process performance may improve quality more broadly.

Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine

Public reporting of quality information is designed to address information asymmetry in health care markets. Without public reporting, consumers may have little information to help them differentiate quality among providers, giving providers little incentive to compete on quality. Public reporting enables consumers to choose highly ranked providers. Using a four-year (2000-2003) panel dataset, we examine the relationship between report card scores and patient choice of nursing home after the Centers for Medicare and Medicaid Services began publicly reporting nursing home quality information on post-acute care in 2002. We find that the relationship between reported quality and nursing home choice is positive and statistically significant suggesting that patients were more likely to choose facilities with higher reported post-acute care quality after public reporting was initiated. However, the magnitude of the effect was small. We conclude that there has been minimal consumer response to information in the post-acute care market.

Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care

Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients.

Use of Social Media Across US Hospitals: Descriptive Analysis of Adoption and Utilization

IMPORTANCE Published evaluations of medical home interventions have found limited effects on quality and utilization of care. OBJECTIVE To measure associations between participation in the Northeastern Pennsylvania Chronic Care Initiative and changes in quality and utilization of care. DESIGN, SETTING, AND PARTICIPANTS The northeast region of the Pennsylvania Chronic Care Initiative began in October 2009, included 2 commercial health plans and 27 volunteering small primary care practice sites, and was designed to run for 36 months. Both participating health plans provided medical claims and enrollment data spanning October 1, 2007, to September 30, 2012 (2 years prior to and 3 years after the pilot inception date). We analyzed medical claims for 17,363 patients attributed to 27 pilot and 29 comparison practices, using difference-in-difference methods to estimate changes in quality and utilization of care associated with pilot participation. EXPOSURES The intervention included learning collaboratives, disease registries, practice coaching, payments to support care manager salaries and practice transformation, and shared savings incentives (bonuses of up to 50% of any savings generated, contingent on meeting quality targets). As a condition of participation, pilot practices were required to attain recognition by the National Committee for Quality Assurance as medical homes. MAIN OUTCOMES AND MEASURES Performance on 6 quality measures for diabetes and preventive care; utilization of hospital, emergency department, and ambulatory care. RESULTS All pilot practices received recognition as medical homes during the intervention. By intervention year 3, relative to comparison practices, pilot practices had statistically significantly better performance on 4 process measures of diabetes care and breast cancer screening; lower rates of all-cause hospitalization (8.5 vs 10.2 per 1000 patients per month; difference, -1.7 [95% CI, -3.2 to -0.03]), lower rates of all-cause emergency department visits (29.5 vs 34.2 per 1000 patients per month; difference, -4.7 [95% CI, -8.7 to -0.9]), lower rates of ambulatory care-sensitive emergency department visits (16.2 vs 19.4 per 1000 patients per month; difference, -3.2 [95% CI, -5.7 to -0.9]), lower rates of ambulatory visits to specialists (104.9 vs 122.2 per 1000 patients per month; difference, -17.3 [95% CI, -26.6 to -8.0]); and higher rates of ambulatory primary care visits (349.0 vs 271.5 per 1000 patients per month; difference, 77.5 [95% CI, 37.3 to 120.5]). CONCLUSIONS AND RELEVANCE During a 3-year period, this medical home intervention, which included shared savings for participating practices, was associated with relative improvements in quality, increased primary care utilization, and lower use of emergency department, hospital, and specialty care. With further experimentation and evaluation, such interventions may continue to become more effective.