The strategic case for establishing public-private partnerships in cancer care.

BACKGROUND: In 2007, the National Cancer Institute (NCI) launched the NCI Community Cancer Centers Program (NCCCP) as a public-private partnership with community hospitals with a goal of advancing cancer care and research. In order to leverage federal dollars in a time of limited resources, matching funds from each participating hospital were required. The purpose of this paper is to examine hospitals' level of and rationale for co-investment in this partnership, and whether there is an association between hospitals' co-investment and achievement of strategic goals. METHODS: Analysis using a comparative case study and micro-cost data was conducted as part of a comprehensive evaluation of the NCCCP pilot to determine the level of co-investment made in support of NCI's goals. In-person or telephone interviews with key informants were conducted at 10 participating hospital and system sites during the first and final years of implementation. Micro-cost data were collected annually from each site from 2007 to 2010. Self-reported data from each awardee are presented on patient volume and physician counts, while secondary data are used to examine the local Medicare market share. RESULTS: The rationale expressed by interviewees for participation in a public-private partnership with NCI included expectations of increased market share, higher patient volumes, and enhanced opportunities for cancer physician recruitment as a result of affiliation with the NCI. On average, hospitals invested resources into the NCCCP at a level exceeding $3 for every $1 of federal funds. Six sites experienced a statistically significant change in their Medicare market share. Cancer patient volume increased by as much as one-third from Year 1 to Year 3 for eight of the sites. Nine sites reported an increase in key cancer physician recruitment. CONCLUSIONS: Demonstrated investments in cancer care and research were associated with increases in cancer patient volume and perhaps in recruitment of key cancer physicians, but not in increased Medicare market share. Although the results reflect a small sample of hospitals, findings suggest that hospital executives believe there to be a strategic case for a public-private partnership as demonstrated through the NCCCP, which leveraged federal funds to support mutual goals for advancing cancer care and research.

Nurse-Led Multidisciplinary Heart Failure Group Clinic Appointments: Methods, Materials, and Outcomes Used in the Clinical Trial.

BACKGROUND: The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure (HF) patients. OBJECTIVE: The purpose of this article is to (1) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies, (2) describe resources and materials used in the group clinic appointment, and (3) present results supporting this patient-centered group intervention. METHODS: This clinical trial included 198 HF patients (randomized to either group clinical appointments or to standard care). Data were collected from 72 group clinic appointments via patients' (1) group clinic session evaluations, (2) HF self-care behaviors skills, (3) HF-related discouragement and quality of life scores, and (4) HF-related reshopitalizations during the 12-month follow-up. Also, the costs of delivery of the group clinical appointments were tabulated. RESULTS: Overall, patients rated group appointments as 4.8 of 5 on the "helpfulness" in managing HF score. The statistical model showed a 33% decrease in the rate of rehospitalizations (incidence rate ratio, 0.67) associated with the intervention over the 12-month follow-up period when compared with control patients (χ(2)1=3.9, P=.04). The total cost for implementing 5 group appointments was $243.58 per patient. CONCLUSION: The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care. In turn, better self-care was associated with reductions in HF-related hospitalizations.

The impact of hospital-acquired conditions on Medicare program payments.

RESEARCH OBJECTIVE: Hospital-acquired conditions, or HACs, often result in additional Medicare payments, generated during the initial hospitalization and in subsequent health care encounters. The purpose of this article is to estimate the incremental cost to Medicare, as measured by Medicare program payments, of six HACs. STUDY DESIGN: The researchers used a matched case-control design to determine the incremental increase in Medicare payments attributable to each HAC. For each HAC patient, five comparison patients were matched on diagnosis group, sex, race, and age. Using the matched sample, we estimated a hospital fixed effects log-linear regression on total Medicare payments for the episode of care, further controlling for co-morbid conditions. Care episodes included the initial hospitalization and all inpatient, outpatient, physician, home health, and hospice care that occurred within 90 days of hospital discharge. POPULATION STUDIED: All Medicare fee-for-service patients discharged alive from a hospital between October 2008 and June 2010 with one of six HACs-severe pressure ulcer, fracture, catheter-associated urinary tract infection, vascular catheter-associated infection, surgical site infection following certain orthopedic procedures, or deep vein thrombosis/ pulmonary embolism following certain orthopedic procedures-were included in the sample and matched to five similar patients without the HACs. PRINCIPAL FINDINGS: The multivariate analysis suggests that Medicare paid an additional $146 million per year across these HAC care episodes compared with what would have been paid without the HACs. CONCLUSIONS: HACs create a significant financial burden for the Medicare program. We compare the incremental Medicare payments for these six HACs to the current and upcoming Medicare HAC payment penalties.

Multidisciplinary group clinic appointments: the Self-Management and Care of Heart Failure (SMAC-HF) trial.

BACKGROUND: This trial tested the effects of multidisciplinary group clinic appointments on the primary outcome of time to first heart failure (HF) rehospitalization or death. METHODS AND RESULTS: HF patients (n=198) were randomly assigned to standard care or standard care plus multidisciplinary group clinics. The group intervention consisted of 4 weekly clinic appointments and 1 booster clinic at month 6, where multidisciplinary professionals engaged patients in HF self-management skills. Data were collected prospectively for 12 months beginning after completion of the first 4 group clinic appointments (2 months post randomization). The intervention was associated with greater adherence to recommended vasodilators (P=0.04). The primary outcome (first HF-related hospitalization or death) was experienced by 22 (24%) in the intervention group and 30 (28%) in standard care. The total HF-related hospitalizations, including repeat hospitalizations after the first time, were 28 in the intervention group and 45 among those receiving standard care. The effects of treatment on rehospitalization varied significantly over time. From 2 to 7 months post randomization, there was a significantly longer hospitalization-free time in the intervention group (Cox proportional hazard ratio=0.45 (95% confidence interval, 0.21-0.98; P=0.04). No significant difference between groups was found from month 8 to 12 (hazard ratio=1.7; 95% confidence interval, 0.7-4.1). CONCLUSIONS: Multidisciplinary group clinic appointments were associated with greater adherence to selected HF medications and longer hospitalization-free survival during the time that the intervention was underway. Larger studies will be needed to confirm the benefits seen in this trial and identify methods to sustain these benefits. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00439842.

Missing productivity gains in the Medicare physician Fee Schedule: where are they?

The Medicare Fee Schedule with payments for thousands of visits and procedures is updated periodically for the work component of changes in physician relative work. Three 5-year reviews of physician work by Medicare have been biased against finding productivity gains and reductions in physician work relative values. The authors present four studies showing shorter physician times with patients in their offices and in the operating room, increases in surgeons' self-reported total work in spite of declining operating room times, and growing numbers of costly handoffs to nonsurgeons, while surgeons receive full payment for postoperative follow-up with patients. Substantial savings exist in the fee schedule if productivity gains from greater delegation to ancillary staff and specialists, reengineering of services, and rapid learning by experience with new technologies were integrated into the periodic reviews.

Heart failure guidelines and implications for surgically treating heart failure.

In 2005, the American College of Cardiology and the American Heart Association released updated guidelines for the diagnosis and management of chronic heart failure in the adult, yielding new insights into the progression and treatment of this disease. Perioperative nurses need a working knowledge of these guidelines to provide optimal care when patients require surgical interventions for heart failure. This article provides an overview of the pathophysiology, classifications, and treatments for heart failure.

Distance to diagnosing provider as a measure of access for patients with melanoma.

OBJECTIVE: To examine the effect of travel distance and other sociodemographic factors on access to a diagnosing provider for patients with melanoma. DESIGN: Analysis was performed of all incident cases of melanoma in 2000 from 42 North Carolina counties. SETTING: Academic research. PARTICIPANTS: Patients and providers from 42 North Carolina counties were geocoded to street address. MAIN OUTCOME MEASURES: Associations between Breslow thickness and clinical and sociodemographic factors (age, sex, poverty rate, rurality, provider supply, and distance to diagnosing provider) were examined. RESULTS: Of 643 eligible cases, 4.4% were excluded because of missing data. The median Breslow thickness was 0.6 mm (range, 0.1-20.0 mm). The median distance to diagnosing provider was 8 miles (range, 0-386 miles). For each 1-mile increase in distance, Breslow thickness increased by 0.6% (P =.003). For each 1% increase in poverty rate, Breslow thickness increased by 1% (P =.04). Breslow thickness was 19% greater for patients aged 51 to 80 years than for those aged 0 to 50 years (P =.02) and was 109% greater for patients older than 80 years than for those aged 0 to 50 years (P < .001). Sex, rurality, and supply of dermatologists were not associated with Breslow thickness. CONCLUSIONS: For patients with melanoma, distance to the diagnosing provider is a meaningful measure of access that captures different information than community-level measures of rurality, provider supply, and socioeconomic status. Future work should be targeted at identifying factors that may affect distance to diagnosing provider and serve as barriers to melanoma care.

Using propensity stratification to compare patient outcomes in hospital-based versus freestanding skilled-nursing facilities.

Medicare skilled-nursing facility (SNF) patients exhibit differences in resource use and outcomes by whether the SNF is hospital-based or freestanding. Some of the differences may be attributable to patient selection rather than underlying institutional differences. This study adjusts for patient selection by stratifying Medicare SNF patients by their likelihood of hospital-based SNF referral. Three outcomes are analyzed to illustrate this approach: Medicare SNF length of stay, discharge to home within 30 days, and preventable hospital readmissions. The estimations use claims and patient-assessment data merged with facility and market characteristics. The results provide strong evidence that good candidates for faster recovery and discharge to the community are preferentially selected into hospital-based units. While the unstratified regression approach controls for much of the selection, stratified regressions provide further reductions in setting-specific differences. Remaining differences may be because of patterns of care or reflect residual bias from unobserved factors.

Medicaid enrollment and mental health service use following release of jail detainees with severe mental illness.

OBJECTIVE: This study assessed the extent to which Medicaid enrollment increased access to and use of services by persons with severe mental illness after their release from jail. METHODS: A prospective cohort design was used that linked administrative data from several agencies in two large urban areas: King County (Seattle) from 1996 to 1998 and Pinellas County (Clearwater and St. Petersburg), Florida, from 1998 to 2000. Access to and use of community mental health services within 90 days after release from jail was examined, depending on whether persons were enrolled in Medicaid at the time of their release. All analyses were based on detentions, rather than unique persons. The effects of Medicaid status (enrolled or not enrolled) on four dependent variables (probability of use, days to first service, number of services used, and rate of service use) were estimated separately for each county. RESULTS: A total of 1,210 persons who had 2,878 detentions were identified in Pinellas County: 2,215 of these detentions represented persons with Medicaid and 663 represented those without Medicaid. For King County, the corresponding numbers were 1,816 persons and 4,482 detentions: 2,752 of these detentions represented persons with Medicaid and 1,730 represented those without Medicaid. In both counties, those who had Medicaid at the time of their release were more likely to use services (p < .001), accessed community services more quickly (p < .001), and received more days of services (p < .001) than those without Medicaid. CONCLUSIONS: Medicaid enrollment enhanced receipt of community services after jail release in these two large urban counties. These are the best currently available data, and the data suggest that efforts to enroll persons with severe mental illness in Medicaid and ensure enrollment upon jail release will improve their access to and receipt of community-based services after release.

Assessing gaps between policy and practice in Medicaid disenrollment of jail detainees with severe mental illness.

OBJECTIVE: This prospective cohort study in two large metropolitan jail systems examined whether Medicaid disenrollment policies for persons detained in jail were enforced. The extent to which persons with severe mental illness lost their Medicaid benefits while detained was determined. METHODS: Mailed questionnaires to state Medicaid directors in 2000 yielded a 95 percent response rate. Directors responded to questions about procedures that are followed when enrollees become inmates in public institutions. In addition, community mental health service records, jail detention records, and Medicaid enrollment records were linked in King County (Seattle) and in Pinellas County (Clearwater and St. Petersburg), Florida, to identify persons with severe mental illness who were incarcerated at any time during a two-year period (1996-1998 in King County and 1998-2000 in Pinellas County). The samples consisted of 1,816 persons representing 4,482 detentions in King County and 1,210 persons representing 2,878 detentions in Pinellas County. Detentions were used as the unit of analysis to determine how often Medicaid disenrollment occurred during jail incarceration. RESULTS: The stated policy in many states, including Florida and Washington, is to terminate Medicaid benefits upon incarceration, but termination occurred for only 3 percent of the detainees enrolled in Medicaid in each county. In both counties, in 97 percent of the detentions, persons who had Medicaid at entry also had it upon release. In both counties, the 3 percent who lost Medicaid while jailed had longer jail stays (three to five months compared with 16 to 30 days). CONCLUSIONS: Stated policies do not align with actual Medicaid disenrollment of persons with severe mental illness who become incarcerated. In most instances, short jail stays allowed detainees with severe mental illness to retain their Medicaid benefits.

Choosing to convert to critical access hospital status.

The authors profile facilities converting to critical access hospitals (CAHs) from 1998-2000, comparing characteristics of their communities, operations, and finances to those of other small rural providers. Counties where CAHs are located are more sparsely populated, but do not have substantially different sociodemographic profiles than other rural counties. Converting hospitals' acute daily census averaged well below the statutory limit of 15, but over one-half reduced unused bed capacity to meet CAH size limitations. The average case-mix adjusted Medicare cost per case was 16-percent higher for CAH converters than for other small hospitals and their financial ratios were substantially worse, although many other operating characteristics were similar.

Developing capacity for integrated trauma-related behavioral health services for women: start-up costs from five community sites.

Violence against women is a growing public health concern. Many community agencies are interested in expanding their service delivery capacity to better meet these needs, but little information is currently available about the costs of implementing comprehensive services for women who have experienced various types of trauma. This article responds to this need by presenting findings from a study of start-up costs incurred by five regionally-diverse sites in the Women, Co-Occurring Disorders, and Violence Study (Women's Study) during the initial two years of a 5-year federal demonstration grant. Using a cost-finding approach that included project-related expenditures without regard to the source of funding, information was obtained with a structured data collection instrument that was completed during in-person interviews with local project staff. Phase 1 start-up project costs ranged from 0.6 million dollars to almost 1.2 million dollars per site. Of the five sites, start-up costs were lowest in the two mixed urban/suburban settings, and highest in the two rural settings, where few of the project-related services had been in place prior to grant funding. Implications for public health interventions are highlighted.

Market entry and exit in long-term care: 1985-2000.

Market entry and exit of skilled nursing providers is analyzed to observe initial industry responses to Medicare prospective payment. Supply adjustments were immediate, and were stronger in urban than in rural areas. After 12 years of steady growth, widespread market expansion ceased in 1998, but net reductions in the number of facilities occurred primarily in the hospital-based sector. In county-level modeling with controls for State policy effects, post-prospective payment system (PPS) reductions in the number of skilled nursing facilities (SNFs) were associated with supply considerations; reductions were more likely to occur in areas with higher bed-to-population ratios prior to PPS implementation, and in areas that had recently seen expansion in capacity. County-level reduction in the number of SNFs was not associated with low income or other sociodemographic risk factors.

Rural hospital wages and the area wage index.

We examined data on hospital hourly wages and the prospective payment system (PPS) wage index from 1990 to 1997, to determine if incremental changes to the index have improved its precision and equity as a regional cost adjuster. The differential between average rural and urban PPS hourly wages has declined by almost one-fourth over the 8-year study period. Nearly one-half of the decrease is attributable to regulatory and reporting changes in the annual hospital wage survey. Patterns of within-market wage variation across rural-urban continuum codes identify three separate sub-markets within the State-level aggregates defining rural labor markets. Geographic reclassification decisions appear to eliminate one of the three. Remaining systematic within-market rural wage differences work to the reimbursement advantage of hospitals in the smaller and more isolated communities.