ABSTRACT
PURPOSE: The Centers for Medicare & Medicaid Services (CMS) has facilitated the development of Medicare accountable care organizations (ACOs), mostly through the Medicare Shared Savings Program (MSSP). To inform the operation of the Center for Medicare & Medicaid Innovation's (CMMI) ACO programs, we assess the financial performance of rural ACOs based on different levels of rural presence. METHODS: We used the 2014 performance data for Medicare ACOs to examine the financial performance of rural ACOs with different levels of rural presence: exclusively rural, mostly rural, and mixed rural/metropolitan. RESULTS: Of the ACOs reporting performance data, we identified 97 ACOs with a measurable rural presence. We found that successful rural ACO financial performance is associated with the ACO's organizational type (eg, physician-based) and that 8 of the 11 rural ACOs participating in the Advanced Payment Program (APP) garnered savings for Medicare. Unlike previous work, we did not find an association between ACO size or experience and rural ACO financial performance. CONCLUSIONS: Our findings suggest that rural ACO financial success is likely associated with factors unique to rural environments. Given the emphasis CMS has placed on rural ACO development, further research to identify these factors is warranted.
Subject(s)
Accountable Care Organizations/economics , Financial Management/methods , Rural Health Services/economics , Accountable Care Organizations/organization & administration , Accountable Care Organizations/standards , Cross-Sectional Studies , Financial Management/standards , Humans , Medicare/organization & administration , Medicare/statistics & numerical data , Retrospective Studies , Rural Health Services/standards , United StatesABSTRACT
Continued growth in the number of individuals with dementia residing in assisted living (AL) facilities raises concerns about their safety and protection. However, unlike federally regulated nursing facilities, AL facilities are state-regulated and there is a high degree of variation among policies designed to protect persons with dementia. Despite the important role these protection policies have in shaping the quality of life of persons with dementia residing in AL facilities, little is known about their formation. In this research, we examined the adoption of AL protection policies pertaining to staffing, the physical environment, and the use of chemical restraints. For each protection policy type, we modeled policy rigor using an innovative point-in-time approach, incorporating variables associated with state contextual, institutional, political, and external factors. We found that the rate of state AL protection policy adoptions remained steady over the study period, with staffing policies becoming less rigorous over time. Variables reflecting institutional policy making, including legislative professionalism and bureaucratic oversight, were associated with the rigor of state AL dementia protection policies. As we continue to evaluate the mechanisms contributing to the rigor of AL protection policies, it seems that organized advocacy efforts might expand their role in educating state policy makers about the importance of protecting persons with dementia residing in AL facilities and moving to advance appropriate policies.
Subject(s)
Assisted Living Facilities/standards , Dementia , Patient Safety/standards , State Government , Administrative Personnel/education , Humans , Patient Safety/legislation & jurisprudence , Politics , Public Policy , Quality of LifeABSTRACT
BACKGROUND: In response to increasing fiscal pressures, the Affordable Care Act (ACA) sought to reduce Medicare Advantage plan expenses by restructuring the bidding and payment processes. The purpose of this study is to assess the effects of the ACA's payment freeze and restructuring of the bidding and payment processes on favorable risk selection in Medicare Advantage plan enrollment (objective 1) and changes in the health status of beneficiaries enrolled in Medicare Advantage plans over time (objective 2). METHODS: We used the Medicare Health Outcome Survey baseline data (2007â2013) for analyses of the first objective (7 cohorts, 1.7 million beneficiaries) and the linked baseline and follow-up data (2007-2009â2011-2013) for analyses of the second objective (5 cohorts, 0.5 million beneficiaries). To examine favorable risk selection we used the following outcomes: self-rated health, falls, balance problems, falls management, frailty, and morbidity. To examine changes in beneficiary health status over time, we examined changes (over time) in these same outcomes. The focal independent variable is the policy implementation measure, which is time dependent and measures the accumulation of changes to Medicare Advantage payment policies resulting from the ACA. Multiple regression models were developed to examine the relationship between ACA implementation and outcomes of interest. RESULTS: In terms of favorable selection, individuals enrolled in Medicare Advantage plans post-ACA have, on average, better self-rated health (b = 0.003, p < 0.01), lower odds of falls (AOR = 0.981, p < 0.001), higher odds of falls management (AOR = 1.040, p < 0.001), lower frailty risks (IRR = 0.983, p < 0.001), and lower risks of comorbidities (IRR = 0.989, p < 0.001). In terms of health status changes over time, the results indicate that in the post-ACA period, beneficiaries reported better self-rated health (b = 0.028, p < 0.001), lower odds of falls (AOR = 0.965, p < 0.001), lower odds of balance problems (AOR = 0.958, p < 0.001), lower odds of falls management (AOR = 0.981, p < 0.05), lower frailty risks (IRR = 0.944, p < 0.001), and lower risks of comorbidity (IRR = 0.986, p < 0.001) at follow up compared to the same risks at baseline. CONCLUSIONS: These findings suggest that as the Medicare Advantage payment policies in the ACA were being implemented, plans may have engaged in favorable selection activities, yet beneficiaries exhibited more favorable health outcomes.
Subject(s)
Health Status , Patient Protection and Affordable Care Act , Aged , Health Expenditures , Humans , Managed Care Programs/economics , Medicare/economics , Medicare Part C/economics , Reimbursement Mechanisms/economics , Risk Assessment , United StatesABSTRACT
BACKGROUND: An aging population, with its associated rise in cancer incidence and strain on the oncology workforce, will continue to motivate patients, healthcare providers and policy makers to better understand the existing and growing challenges of access to chemotherapy. Administrative data, and SEER-Medicare data in particular, have been used to assess patterns of healthcare utilization because of its rich information regarding patients, their treatments, and their providers. To create measures of geographic access to chemotherapy, patients and oncologists must first be identified. Others have noted that identifying chemotherapy providers from Medicare claims is not always straightforward, as providers may report multiple or incorrect specialties and/or practice in multiple locations. Although previous studies have found that specialty codes alone fail to identify all oncologists, none have assessed whether various methods of identifying chemotherapy providers and their locations affect estimates of geographic access to care. METHODS: SEER-Medicare data was used to identify patients, physicians, and chemotherapy use in this population-based observational study. We compared two measures of geographic access to chemotherapy, local area density and distance to nearest provider, across two definitions of chemotherapy provider (identified by specialty codes or billing codes) and two definitions of chemotherapy service location (where chemotherapy services were proven to be or possibly available) using descriptive statistics. Access measures were mapped for three representative registries. RESULTS: In our sample, 57.2 % of physicians who submitted chemotherapy claims reported a specialty of hematology/oncology or medical oncology. These physicians were associated with 91.0 % of the chemotherapy claims. When providers were identified through billing codes instead of specialty codes, an additional 50.0 % of beneficiaries (from 23.8 % to 35.7 %) resided in the same ZIP code as a chemotherapy provider. Beneficiaries were also 1.3 times closer to a provider, in terms of driving time. Our access measures did not differ significantly across definitions of service location. CONCLUSIONS: Measures of geographic access to care were sensitive to definitions of chemotherapy providers; far more providers were identified through billing codes than specialty codes. They were not sensitive to definitions of service locations, as providers, regardless of how they are identified, generally provided chemotherapy at each of their practice locations.
Subject(s)
Health Services Accessibility , Neoplasms/drug therapy , Professional Practice Location , Databases, Factual , Humans , Medical Oncology , SEER Program , United StatesABSTRACT
Iowa is one of six states to expand Medicaid through section 1115 waivers. Iowa's alternative approach to Medicaid expansion, known as the Iowa Health and Wellness Plan, was the result of a bipartisan compromise, motivated by the pending expiration of a preexisting section 1115 waiver that served sixty-five thousand Iowans. The Iowa Health and Wellness Plan emphasizes personal responsibility and private involvement. Key features include beneficiary premiums, incentives for healthy behaviors, and premium assistance for some beneficiaries to purchase insurance in the health insurance marketplace. However, Iowa has struggled to implement its expansion as initially envisioned, due largely to the lack of private insurers willing and able to insure new Medicaid enrollees in the marketplace. In 2016 Iowa will dramatically increase the role of managed care in Medicaid, with the vast majority of beneficiaries receiving almost all Medicaid services through a capitated managed care organization. This article highlights the local factors driving expansion, the interplay of the state and federal political landscape, the challenges of providing consumer choice within Iowa's marketplace, and the future of Iowa's Medicaid program under managed care.
Subject(s)
Managed Care Programs/organization & administration , Medicaid/organization & administration , Health Insurance Exchanges , Humans , Insurance Coverage/statistics & numerical data , Iowa , Medicaid/legislation & jurisprudence , Patient Protection and Affordable Care Act , Politics , United StatesABSTRACT
Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.
Subject(s)
Assisted Living Facilities , Dementia/therapy , Health Policy , Homes for the Aged/legislation & jurisprudence , Nursing Homes/legislation & jurisprudence , Aged , Aged, 80 and over , Deja Vu , Dementia/psychology , Health Care Reform , Homes for the Aged/standards , Humans , Quality of Health Care , Quality of LifeABSTRACT
Prior RUPRI Center policy briefs have described the role of rural pharmacies in providing many essential clinical services (in addition to prescription and nonprescription medications), such as blood pressure monitoring, immunizations, and diabetes counseling, and the adverse effects of Medicare Part D negotiated networks on the financial viability of rural pharmacies.1 Because rural pharmacies play such a broad role in health care delivery, pharmacy closures can sharply reduce access to essential health care services in rural and underserved communities. These closures are of particular concern in rural areas served by a sole, independently owned pharmacy (i.e., a pharmacy unaffiliated with a chain or franchise). This policy brief characterizes the population of rural areas served by a sole, independently owned pharmacy. Dependent on a sole pharmacy, these areas are at highest risk to lose access to many essential clinical services. Key Findings. (1) In 2014 over 2.7 million people lived in 663 rural communities served by a sole, independently owned pharmacy. (2) More than one-quarter of these residents (27.9 percent) were living below 150 percent of the federal poverty level. (3) Based on estimates from 2012, a substantial portion of the residents of these areas were dependent on public insurance (i.e., Medicare and/or Medicaid, 20.5 percent) or were uninsured (15.0 percent). (4) If the sole, independent retail pharmacy in these communities were to close, the next closest retail pharmacy would be over 10 miles away for a majority of rural communities (69.7 percent).
Subject(s)
Community Pharmacy Services/statistics & numerical data , Pharmacies/supply & distribution , Rural Population , Health Services Accessibility , Humans , Poverty , Private Sector , Rural Health , Socioeconomic Factors , United StatesABSTRACT
This Policy Brief presents characteristics contributing to the formation of four accountable care organizations (ACOs) that serve rural Medicare beneficiaries. Doing so provides considerations for provider organizations contemplating creating rural-based ACOs. Key Findings. (1) Previous organizational integration and risk-sharing experience facilitated ACO formation. (2) Use of an electronic health record system fostered core ACO capabilities, including care coordination and population health management. (3) Partnerships across the care continuum supported utilization of local health care resources.