Medicare Advantage Health Risk Assessments Contribute Up To $12 Billion Per Year To Risk-Adjusted Payments.

With Medicare Advantage (MA) enrollment surpassing 50 percent of Medicare beneficiaries, accurate risk-adjusted plan payment rates are essential. However, artificially exaggerated coding intensity, where plans seek to enhance measured health risk through the addition or inflation of diagnoses, may threaten payment rate integrity. One factor that may play a role in escalating coding intensity is health risk assessments (HRAs)-typically in-home reviews of enrollees' health status-that enable plans to capture information about their enrollees. In this study, we evaluated the impact of HRAs on Hierarchical Condition Categories (HCC) risk scores, variation in this impact across contracts, and the aggregate payment impact of HRAs, using 2019 MA encounter data. We found that 44.4 percent of MA beneficiaries had at least one HRA. Among those with at least one HRA, HCC scores increased by 12.8 percent, on average, as a result of HRAs. More than one in five enrollees had at least one additional HRA-captured diagnosis, which raised their HCC score. Potential scenarios restricting the risk-score impact of HRAs correspond with $4.5-$12.3 billion in reduced Medicare spending in 2020. Addressing increased coding intensity due to HRAs will improve the value of Medicare spending and ensure appropriate payment in the MA program.

Trends in the Concurrent Prescription of Opioids and Gabapentin in the US, 2006 to 2018.

This cohort study examines trends in concurrent gabapentin and opioid prescribing in the US, overall and by prescriber, patient, and county characteristics, between 2006 and 2018.

Empirically identified networks of healthcare providers for adults with mental illness.

BACKGROUND: Policies target networks of providers who treat people with mental illnesses, but little is known about the empirical structures of these networks and related variation in patient care. The goal of this paper is to describe networks of providers who treat adults with mental illness in a multi-payer database based medical claims data in a U.S. state. METHODS: Provider networks were identified and characterized using paid inpatient, outpatient and pharmacy claims related to care for people with a mental health diagnosis from an all-payer claims dataset that covers both public and private payers. RESULTS: Three nested levels of network structures were identified: an overall network, which included 21% of providers (N = 8256) and 97% of patients (N = 476,802), five communities and 24 sub-communities. Sub-communities were characterized by size, provider composition, continuity-of-care (CoC), and network structure measures including mean number of connections per provider (degree) and average number of connections who were connected to each other (transitivity). Sub-community size was positively associated with number of connections (r = .37) and the proportion of psychiatrists (r = .41) and uncorrelated with network transitivity (r = -.02) and continuity of care (r = .00). Network transitivity was not associated with CoC after adjustment for provider type, number of patients, and average connection CoC (p = .85). CONCLUSIONS: These exploratory analyses suggest that network analysis can provide information about the networks of providers that treat people with mental illness that is not captured in traditional measures and may be useful in designing, implementing, and studying interventions to improve systems of care. Though initial results are promising, additional empirical work is needed to develop network-based measures and tools for policymakers.

Effectiveness of value-based purchasing for substance use treatment engagement and retention.

INTRODUCTION: Many people drop out of substance use disorder (SUD) treatment within the first few sessions, which suggests the need for innovative strategies to address this. We examined the effectiveness of incentive-based contracting for Maine's publicly funded outpatient (OP) and intensive outpatient (IOP) SUD treatment, to determine its potential for improving treatment engagement and retention. METHODS: Maine's incentive-based contract with federally block grant-funded OP and IOP treatment agencies created a natural experiment, in which we could compare treatment engagement and retention with a group of state-licensed treatment agencies that were not part of the incentive-based contract. We used administrative data for OP (N = 18,375) and IOP (N = 5986) SUD treatment admissions from FY2005-FY2011 to capture trends prior to and after the FY2008 contract implementation date. We performed multivariable difference-in-difference logistic regression models following propensity score matching of clients. RESULTS: Two-thirds (66%) of OP admissions engaged in treatment, defined as 4+ treatment sessions, and 85% of IOP admissions satisfied the similar criteria of 4+ treatment days. About 40-45% of OP admissions reached the threshold for retention, defined as 90 days in treatment. IOP treatment completion was attained by 50-58% of admissions. For OP, the incentive and nonincentive groups had no significant differences in percentages with treatment engagement (AOR = 1.28, DID = 5.9%, p = .19), and 90-day retention was significant in the opposite direction of what we hypothesized (AOR = 0.80, DID = -4.6%, p = .0003). For IOP, the incentive group had a significant, but still small, increase in percentage with treatment engagement (AOR = 1.52, DID = 5.5%, p = .003), but the corresponding increase in treatment completion was not similarly significant (AOR = 1.12, DID = 2.7%, p = .53). In all models, individual-level variables were strong predictors of outcomes. CONCLUSION: We found little to no impact of the incentive-based contract on the treatment engagement, retention, and completion measures, adding to the body of evidence that shows few or null results for value-based purchasing in SUD treatment programs. The limited success of such efforts is likely to reflect the bandwidth that providers and programs have to focus on new endeavors, the importance of the incentive funding to their bottom line, and forces beyond their immediate control.

Collaborative capacity and patient-centered care in the Veterans' Health Administration Community Living Centers.

INTRODUCTION: Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. METHODS: We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. RESULTS: A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration-measured as task interdependence, quality of interactions and collaborative influence-did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. DISCUSSION: Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.

Incentives in a public addiction treatment system: Effects on waiting time and selection.

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005-2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008-2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.

The importance of a high-performance work environment in hospitals.

OBJECTIVE: To examine the benefits of a high-performance work environment (HPWE) for employees, patients, and hospitals. STUDY SETTING: Forty-five adult, medical-surgical units in nine hospitals in upstate New York. STUDY DESIGN: Cross-sectional study. DATA COLLECTION: Surveys were collected from 1,527 unit-based hospital providers (68.5 percent response rate). Hospitals provided unit turnover and patient data (16,459 discharge records and 2,920 patient surveys). PRINCIPAL FINDINGS: HPWE, as perceived by multiple occupational groups on a unit, is significantly associated with desirable work processes, retention indicators, and care quality. CONCLUSION: Our findings underscore the potential benefits for providers, patients, and health care organizations of designing work environments that value and support a broad range of employees as having essential contributions to make to the care process and their organizations.

Building collaborative capacity: promoting interdisciplinary teamwork in the absence of formal teams.

BACKGROUND: Contradictory findings about the effectiveness of health care teams may relate to the actual structure of teams-loose rather than formal-and the nature of decision making-hierarchical rather than egalitarian. We introduce the concept of collaborative capacity-the likelihood that providers, no matter how brief their exchange, will collaborate as if they were members of an egalitarian team even in the absence of a formal team structure. OBJECTIVE: To examine aspects and determinants of collaborative capacity, namely task interdependence, norms of working together, and egalitarian collaboration among interdisciplinary providers on health care units. RESEARCH DESIGN: We collected survey data from unit-based staff in 45 units across 9 hospitals and 7 health systems in upstate New York. One thousand five hundred twenty-seven surveys were returned for an overall response rate of 68.5%. RESULTS: Measures for team structure and collaboration do not vary significantly between hospitals, only by unit and occupational group, with higher status providers reporting greater interdependence, higher quality of interactions, and more collaborative influence in decision making. Clear task direction, namely an emphasis on patient-centered care, and organizational contexts supportive of work are both significantly associated with higher levels of task interdependence, quality of staff interactions, and collaborative influence. CONCLUSIONS: Collaborative capacity is somewhat constrained by a rigid hierarchy of health care occupations and division of labor that make teamwork more similar than different across hospitals. At the unit level, collaborative capacity may be improved, however, by an emphasis on patient-centered care and a context that supports providers' work.

Nursing assistants' job commitment: effect of nursing home organizational factors and impact on resident well-being.

PURPOSE: The purpose of this study was to investigate (a) whether certified nursing assistants (CNAs) are more committed to nursing home jobs when they perceive their jobs as enhanced (greater autonomy, use of knowledge, teamwork), and (b) whether CNA job commitment affects resident satisfaction. DESIGN AND METHODS: A qualitative exploration of management philosophy and practice and of CNAs' views of their jobs in 18 Massachusetts nursing homes formed the basis for a survey administered to 255 CNAs in 15 homes. A quality-of-life questionnaire was administered to 105 residents. Logistic regression accounting for clustering estimated the effect of personal characteristics, satisfaction with tangible job rewards, and aspects of job design on CNAs' intent to stay in current jobs. A general linear model estimated the effect of job commitment on residents' satisfaction with their relationship to nursing staff. RESULTS: After we accounted for satisfaction with wages, benefits, and advancement opportunities, good basic supervision was most important in affecting CNAs' intent to stay in their jobs. Job enhancements were not significantly related to intent to stay. Residents were more satisfied with their relationships to nursing staff and their quality of life on units where a higher proportion of CNAs were committed to their jobs. IMPLICATIONS: The finding that greater job commitment of CNAs is associated with better quality of relationships and life for residents implies that better jobs lead to better care. Culture change transformation that increases CNA autonomy, knowledge input, and teamwork may not increase workers' commitment to jobs without improvements in basic supervision.

Certified nurse assistants making meaning of direct care.

Using qualitative data from 87 focus groups with certified nurse assistants (CNAs) in 16 nursing homes in Massachusetts, we explore ways that CNAs make meaning of their work despite devaluations, such as lack of respect from management and residents, and the physical and emotional demands of such low-status work. CNAs' meaning making represents an effort to assert a positive identity rather than accept the stigmatization associated with their work. Assertions of the value help CNAs reconstitute their identities. Assertions of meaning, which depend upon providing good care to residents regardless of financial reward or management respect and support, make CNAs vulnerable to exploitation.

Patient benefits from participating in an integrated delivery system: impact on coordination of care.

BACKGROUND: Although the presumption in health services literature has been that integrated delivery systems (IDSs) should improve the coordination of care, the benefits have not yet been well established through empirical research. PURPOSES: This study assesses whether receiving care from providers who belong to the same IDS improves patient-perceived coordination of care; concurrently, we develop a new approach for assessing the performance of IDS. METHODOLOGY/APPROACH: A study was conducted of 222 patients who received primary unilateral total knee arthroplasty at a large IDS' acute care hospital. To isolate the effects of provider membership, we enrolled patients who received surgery from the same surgical department in the same acute care hospital in the IDS. We used baseline and 6-week postoperation patient surveys to assess the impact of the participation of the patients' providers in the IDS on patient-perceived coordination of care. FINDINGS: We found no consistent effects of IDS membership on patient-perceived coordination of care. Patients with in-network rehabilitation care experienced fewer problems than patients with out-of-network rehabilitation care did, while patients with in-network home care experienced more problems than patients with out-of-network home care did. Membership of a patient's primary care physician had no observed effects. PRACTICE IMPLICATIONS: Health care managers and administrators need to undertake a realistic examination of the care-coordinating mechanisms that exist in their IDS. This study has shown that the integration of financial, contractual, and administrative processes is not enough to improve care from the patient's perspective; to improve care, it is advised that an IDS take a patient-centered approach in its design and implementation. We discuss potential reasons for uneven integration of IDS, particularly with respect to the lack of coordinating mechanisms, and argue for the usefulness of the approach developed here for assessing IDS performance over time.

Coordination between formal providers and informal caregivers.

BACKGROUND: The increased "outsourcing" of care-related tasks to patients and their informal caregivers is part of a broader trend in service industries toward engaging customers as "coproducers" of service outcomes. As both quasi-patients and quasi-providers, caregivers may play a critical role in successful coproduction, but they require coordination with care providers to play this role effectively. When tasks are highly interdependent, uncertain, and time constrained, as they often are in health care, relational forms of coordination are expected to be most effective. PURPOSES: This study explores the effects of coordination between formal providers and informal caregivers on caregiver preparation to provide care at home and the effect of caregiver preparation on patient outcomes. Gittell's theory of relational coordination posits that effective coordination occurs through frequent, high-quality communication that is supported by relationships of shared goals, shared knowledge, and mutual respect. We extend the relational coordination model, previously used to examine coordination between formal providers, to encompass coordination of care between formal providers and informal caregivers. METHODOLOGY: We surveyed patients before and 12 weeks after knee replacement surgery to assess outcomes. At 6 weeks postsurgery, we surveyed their caregivers regarding coordination with providers and preparation to provide care. FINDINGS: We found that relational coordination between formal providers and caregivers improves caregiver preparation to provide care, which, in turn, is positively associated with patients' freedom from pain, functional status, and mental health. IMPLICATIONS: Providers should be encouraged to attend to the interpersonal aspects of their interactions with caregivers to promote relational coordination, which may ultimately benefit the patient's health. It is not enough, however, to urge providers to build shared goals, shared knowledge, and mutual respect with patients and caregivers. Dedicated resources and support are needed, given the context of constrained resources and brief encounters in which providers deliver care.

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.

OBJECTIVES: To investigate patients' experience with coordination of their postsurgical care across multiple settings and the effects on key outcomes. DATA SOURCES: Primary data collected over 18 months from 222 unilateral knee-replacement patients at Brigham and Women's Hospital in Boston, MA. STUDY DESIGN: Patients were surveyed about the coordination of their postdischarge care during the 6-week period postdischarge when they received care from rehabilitation facilities and/or home care agencies and follow-up care from the surgeon. DATA COLLECTION: Patients were surveyed before surgery and at 6 and 12 weeks postsurgery. PRINCIPAL FINDINGS: Patient reports highlight problems with coordination across settings and between providers and themselves. These problems, measured at 6 weeks, were associated with greater joint pain, lower functioning, and lower patient satisfaction at 6 weeks after surgery. At 12 weeks after surgery, coordination problems were associated with greater joint pain, but were not associated with functional status. CONCLUSION: Coordination across settings affects patients' clinical outcomes and satisfaction with their care. Although accountable for transfer to the next care setting, providers are neither accountable for nor supported to coordinate across the continuum. Addressing this system problem requires both introducing coordinating mechanisms and also supporting their use through changes in providers' incentives, resources, and time.

Health plans' strategies to control prescription drug spending.

A number of recent studies have documented the sizable impact of consumer cost sharing without accounting for the other drug management strategies being adopted simultaneously. This qualitative case study of five of California's largest health plans examines the strategies and methods used to control prescription drug use and spending. Higher cost sharing is being used increasingly. Concurrently, major administrative efforts directed at physicians-including rules, incentives, and education-are being undertaken. These efforts have focused on lowering the cost per prescription by emphasizing generic substitution and therapeutic interchange of less costly drugs.