Medicaid Expansion Reduced Uncompensated Care Costs At Louisiana Hospitals; May Be A Model For Other States.

We examined changes in hospital uncompensated care costs in the context of Louisiana's Medicaid expansion. Louisiana remains the only state in the Deep South to have expanded Medicaid under the Affordable Care Act and can serve as a model for states that have not adopted expansion, many of which are located in the South census region. We found that Medicaid expansion was associated with a 33 percent reduction in the share of total operating expenses attributable to uncompensated care costs for general medical and surgical hospitals in Louisiana in the first three years after expansion. Reductions varied by hospital type, with larger effects found for rural and public hospitals versus urban and for-profit or private nonprofit hospitals. As hospital operating expenses consistently increased during the sample period, our results imply that hospitals in Louisiana are treating fewer patients for whom no reimbursement was provided since the state expanded Medicaid.

The impact of accountable care organization participation on hospital patient experience.

BACKGROUND: Accountable care organizations (ACOs) are being implemented rapidly across the Unites States. Previous studies indicated an increasing number of hospitals have participated in ACOs. However, little is known about how ACO participation could influence hospitals' performance. PURPOSE: This study aims to examine the impact of Medicare ACO participation on hospitals' patient experience. METHODOLOGY/APPROACH: Difference-in-difference analyses were conducted to compare 10 patient experience measures between hospitals participating in Medicare ACOs and those not participating. RESULTS: In general, hospitals participating in Pioneer ACOs had significantly improved scores on nursing communication and doctor communication. Shared Savings Program (SSP) ACO participation did not show significant improvement of patient experience. Subgroup analyses indicate that, for hospitals in the middle and top tertile groups in terms of baseline experience, Pioneer ACO and SSP ACO participation was associated with better patient experience. For hospitals in the bottom tertile, Pioneer ACO and SSP ACO participation had no association with patient experience. CONCLUSION: ACO participation improved some aspects of patient experience among hospitals with prior good performance. However, hospitals with historically poor performance did not benefit from ACO participation. PRACTICE IMPLICATIONS: Prior care coordination and quality improvement experience position Medicare ACOs for greater success in terms of patient experience. Hospital leaders need to consider the potential negative consequences of ACO participation and the hospital's preparedness for care coordination.

The Association Between Hospital ACO Participation and Readmission Rates.

EXECUTIVE SUMMARY: Accountable care organizations (ACOs) were established as part of the Affordable Care Act to reduce costs, improve the patient experience, and increase the quality of care. While previous studies have examined the quality, costs, and patient experience among ACOs, the relationship between hospitals' ACO participation and its effects on hospitals' performance have been incompletely characterized. The main purpose of this study is to measure the association between hospitals' participation in Medicare Pioneer and Shared Savings Program (SSP) ACOs and readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. We employed a cross-sectional design using hospital readmission data from Hospital Compare, hospital characteristics data from the American Hospital Association Annual Survey, and market environmental data from Area Health Resource Files. We employed a descriptive analysis and linear regressions to examine how ACO participation is associated with readmission rates in these three conditions.Overall, we found that SSP ACO participation is significantly associated with a decrease in the HF readmission rate (ß = 0.320, p < .05), while Pioneer ACO participation is not associated with a decrease in the HF readmission rate. In addition, we found no evidence that Pioneer ACO or SSP ACO participation is associated with reduced readmission rates for AMI or pneumonia. This study concluded that Medicare ACO programs have limited effects on readmission rates. Policy makers should consider adjusting the accountable care model to improve the quality of care.

Assessing Trends in Hospital System Structures From 2008 to 2015.

BACKGROUND: The Affordable Care Act introduced a major systematic change aimed to promote coordination across the care continuum. Yet, it remains unknown the extent to which hospital system structures have changed following the Affordable Care Act. The structure of hospital systems has important implications for the cost, quality, and accessibility of health services. OBJECTIVES: To assess trends in the structures of hospital systems. RESEARCH DESIGN: We aggregated data from the American Hospital Association (AHA) Annual Survey to the system level. Using a panel of hospital systems from 2008 to 2015, we assessed trends in the number of hospital systems, their size, ownership characteristics, geospatial arrangements, and integration with outpatient services. RESULTS: In the period 2008-2015, there was an increasing percentage of hospitals that were system affiliated as well as growth in the number of hospital systems. A greater percentage of hospital systems that were organized as moderately centralized systems transitioned to centralized systems than to decentralized systems (19.8% vs. 4.7%; P<0.001). In terms of geospatial arrangement, a greater percentage of hub-and-spoke systems moved to a regional design than to national systems (20.0% vs. 8.2%; P<0.05). An increasing trend over time toward greater integration with outpatient services was found in a measure of total system level integration with outpatient services. CONCLUSIONS: Our findings suggest that hospital systems may be moving toward more regional designs. In addition, the trend of increasing integration offered across hospital systems overall, and as portion of total integration, suggests that systems may be increasing their services along the continuum of care.

Comparison of objective measures and patients' perceptions of quality of services in government health facilities in the Democratic Republic of Congo.

OBJECTIVE: Examine the relationship between patients' perceptions of quality and the objective level of quality at government health facilities, and determine whether the pre-existing attitudes and beliefs of patients regarding health services interfere with their ability to accurately assess quality of care. DESIGN: Cross-sectional, visit-level analysis. SETTING: Three regions (Nord-Ubangi, Kasai/Kasai-Central and Maniema/Tshopo) of the Democratic Republic of Congo. PARTICIPANTS: Data related to the inpatient and outpatient visits to government health facilities made by all household members who were included in the survey was used for the analysis. Data were collected from patients and the facilities they visited. MAIN OUTCOME MEASURES: Patients' perceptions of the level of quality related to availability of drugs and equipment; patient-centeredness and safety serve compared with objective measures of quality. RESULTS: Objective measures and patient perceptions of the drug supply were positively associated (ß = 0.16, 95% CI = 0.03, 0.28) and of safety were negatively associated (ß = -0.12, 95% CI = -0.23, -0.01). Several environmental factors including facility type, region and rural/peri-urban setting were found to be significantly associated with respondents' perceptions of quality across multiple outcomes. CONCLUSIONS: Overall, patients are not particularly accurate in their assessments of quality because their perceptions are impacted by their expectations and prior experience. Future research should examine whether improving patients' knowledge of what they should expect from health services, and the transparency of the facility's quality data can be a strategy for improving the accuracy of patients' assessments of the quality of the health services, particularly in low-resourced settings.

Effects of Early Dual-Eligible Special Needs Plans on Health Expenditure.

OBJECTIVE: To examine the effects of the penetration of dual-eligible special needs plans (D-SNPs) on health care spending. DATA SOURCES/STUDY SETTING: Secondary state-level panel data from Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. STUDY DESIGN: A difference-in-difference strategy that adjusts for dual-eligibles' demographic and socioeconomic characteristics, state health resources, beneficiaries' health risk factors, Medicare/Medicaid enrollment, and state- and year-fixed effects. DATA COLLECTION/EXTRACTION METHODS: Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee-for-service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. PRINCIPAL FINDINGS: Results indicate that D-SNPs penetration was associated with reduced Medicare spending per dual-eligible beneficiary. Specifically, a 1 percent increase in D-SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D-SNPs penetration and Medicaid or total spending. CONCLUSION: Involving Medicaid services in D-SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual-eligible beneficiaries. Starting from 2013, D-SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D-SNPs on health care spending. More research is needed to examine the impact of D-SNPs on dual-eligible spending.

County Smoke-Free Laws and Asthma Discharges: Evidence from 17 US States.

BACKGROUND: Although approximately 82 percent of the US population was covered by some form of law that restricted smoking in public establishments as of 2014, most research examining the relationship between smoke-free laws and health has been focused at the state level. PURPOSE: To examine the effect of county workplace smoke-free laws over and above the effect of other (restaurant or bar) smoke-free laws on adult asthma. METHODS: The study estimated the effect of rates of adult asthma discharges before and after the implementation of county nonhospitality workplace smoke-free laws and county restaurant and bar smoke-free laws. Data were from 2002 to 2009, and all analyses were performed in 2011 through 2013. RESULTS: A statistically significant relationship (-5.43, p < .05) was found between county restaurant or bar smoke-free laws and reductions in working age adult asthma discharges. There was no statistically significant effect of nonhospitality workplace smoke-free laws over and above the effect of county restaurant or bar laws. CONCLUSIONS: This study suggests that further gains in preventable asthma-related hospitalizations in the US are more likely to be made by focusing on smoke-free laws in bars or restaurants rather than in nonhospitality workplaces.

Challenges to Conducting Health Information Exchange Research and Evaluation: Reflections and Recommendations for Examining the Value of HIE.

INTRODUCTION: Health information exchange (HIE) promises cost and utilization reductions. To date, only a small number of HIE studies have demonstrated benefits to patients, providers, public health, or payers. This may be because evaluations of HIE are methodologically challenging. Indeed, the quality of HIE evaluations is often limited and authors frequently note unmet evaluation objectives. We provide a systematic identification of HIE research challenges that can be used to inform strategies for higher quality scientific evidence. METHODS: We conducted qualitative interviews with 23 HIE researchers and leaders of HIE efforts representing experiences with more than 20 HIE efforts. We also conducted a six-person focus group to expand on and confirm individual interview findings. Qualitative analysis followed a grounded theory approach using multiple coders. RESULTS: Participants experienced similar challenges across seven themes (i.e., HIE maturity, data quality, data availability, goal alignment, cooperation, methodology, and policy). CONCLUSION: Several options may exist to improve HIE research, including developing better conceptual models and methodological approaches to HIE research; formal partnerships between researchers and HIE entities; and establishing a nationwide database of HIE information. Our proposed approaches of promoting data availability, resource sharing, and new partnerships can help to overcome existing barriers and facilitate HIE research.

Estimating the costs of supporting safety-net transformation into patient-centered medical homes in post-Katrina New Orleans.

There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007-March 21, 2008), transformation (March 22, 2008-March 21, 2009), and maintenance (March 22, 2009-September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.

Assessing the relationship between patient safety culture and EHR strategy.

Purpose - The purpose of this paper is to explore the relationship between hospitals' electronic health record (EHR) adoption characteristics and their patient safety cultures. The "Meaningful Use" (MU) program is designed to increase hospitals' adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated. Design/methodology/approach - Providers' perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality's surveys on patient safety culture (level 1) and the American Hospital Association's survey and healthcare information technology supplement (level 2). Findings - The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers' perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research. Originality/value - Relating EHR MU and providers' care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.

Meaningful Use Of EHRs Among Hospitals Ineligible For Incentives Lags Behind That Of Other Hospitals, 2009-13.

The Centers for Medicare and Medicaid Services' meaningful-use incentive program aims to promote the adoption and use of electronic health records (EHRs) throughout health care settings in the United States. However, psychiatric, long-term care, and rehabilitation hospitals are ineligible for these incentive payments. Using national data from the period 2009-13, we compared eligible and ineligible hospitals' rates of EHR adoption. All three types of ineligible hospitals had significantly lower rates of adoption than eligible hospitals did, yet both groups experienced similar growth rates. This growth has widened the gap in adoption of health information technology between eligible and ineligible hospitals, which could stymie efforts to lower costs and improve quality across the health care continuum. Future policies might target ineligible hospitals specifically, as the lag in EHR adoption among this group of providers might undermine the achievement of more coordinated and collaborative health care.

Exploring the barriers to rigorous monitoring and evaluation of health systems strengthening activities: qualitative evidence from international development partners.

The number of health systems strengthening (HSS) programs has increased in the last decade. However, a limited number of studies providing robust evidence for the value and impact of these programs are available. This study aims to identify knowledge gaps and challenges that impede rigorous monitoring and evaluation (M&E) of HSS, and to ascertain the extent to which these efforts are informed by existing technical guidance. Interviews were conducted with HSS advisors at United States Agency for International Development-funded missions as well as senior M&E advisors at implementing partner and multilateral organizations. Findings showed that mission staff do not use existing technical resources, either because they do not know about them or do not find them useful. Barriers to rigorous M&E included a lack suitable of indicators, data limitations, difficulty in demonstrating an impact on health, and insufficient funding and resources. Consensus and collaboration between international health partners and local governments may mitigate these challenges. Copyright © 2016 John Wiley & Sons, Ltd.

Hospital Adoption of Health Information Technology to Support Public Health Infrastructure.

CONTEXT: Health information technology (IT) has the potential to improve the nation's public health infrastructure. In support of this belief, meaningful use incentives include criteria for hospitals to electronically report to immunization registries, as well as to public health agencies for reportable laboratory results and syndromic surveillance. Electronic reporting can facilitate faster and more appropriate public health response. However, it remains unclear the extent that hospitals have adopted IT for public health efforts. OBJECTIVE: To examine hospital adoption of IT for public health and to compare hospitals capable of using and not using public health IT. DESIGN: Cross-sectional design with data from the 2012 American Hospital Association annual survey matched with data from the 2013 American Hospital Association Information Technology Supplement. Multivariate logistic regression was used to compare hospital characteristics. Inverse probability weights were applied to adjust for selection bias because of survey nonresponse. PARTICIPANTS: All acute care general hospitals in the United States that matched across the surveys and had complete data available were included in the analytic sample. MAIN OUTCOME MEASURES: Three separate outcome measures were used: whether the hospital could electronically report to immunization registries, whether the hospital could send electronic laboratory results, and whether the hospital can participate in syndromic surveillance. RESULTS: A total of 2841 hospitals met the inclusion criteria. Weighted results show that of these hospitals, 62.7% can electronically submit to immunization registries, 56.6% can electronically report laboratory results, and 54.4% can electronically report syndromic surveillance. Adjusted and weighted results from the multivariate analyses show that small, rural hospitals and hospitals without electronic health record systems lag in the adoption of public health IT capabilities. CONCLUSION: While a majority of hospitals are using public health IT, the infrastructure still has significant room for growth. Differences in hospitals' adoption of public health IT may exacerbate existing health disparities.

Measuring Patient Satisfaction's Relationship to Hospital Cost Efficiency: Can Administrators Make a Difference?

OBJECTIVE: The aim of this study was to assess the ability and means by which hospital administrators can influence patient satisfaction and its impact on costs. DATA SOURCES: Data are drawn from the American Hospital Association's Annual Survey of Hospitals, federally collected Hospital Cost Reports, and Medicare's Hospital Compare. STUDY DESIGN: Stochastic frontier analyses (SFA) are used to test the hypothesis that the patient satisfaction-hospital cost relationship is primarily a latent "management effect." The null hypothesis is that patient satisfaction measures are main effects under the control of care providers rather than administrators. PRINCIPLE FINDINGS: Both SFA models were superior to the standard regression analysis when measuring patient satisfaction's relationship to hospitals' cost efficiency. The SFA model with patient satisfaction measures treated as main effects, rather than "latent, management effects," was significantly better comparing the log-likelihood statistics. Higher patient satisfaction scores on the environmental quality and provider communication dimensions were related to lower facility costs. Higher facility costs were positively associated with patients' overall impressions (willingness to recommend and overall satisfaction), assessments of medication and discharge instructions, and ratings of caregiver responsiveness (pain control and help when called). CONCLUSIONS: In the short term, managers have a limited ability to influence patient satisfaction scores, and it appears that working through frontline providers (doctors and nurses) is critical to success. In addition, results indicate that not all patient satisfaction gains are cost neutral and there may be added costs to some forms of quality. Therefore, quality is not costless as is often argued.

Health Information Exchange Readiness for Demonstrating Return on Investment and Quality of Care.

OBJECTIVE: To study the extent to which community health information exchanges (HIEs) deliver and measure return on investment (ROI) and improvements in the quality of care. MATERIALS AND METHODS: We surveyed operational HIEs for their characteristics, information domains, impact on quality of care, and ROI. RESULTS: A 60 percent response rate was achieved. Two-thirds of respondents agreed that community HIEs demonstrated a positive ROI, while one-third had no opinion or disagreed. One-fourth or fewer respondents reported using various metrics to calculate ROI. Most respondents agreed that HIEs improve the quality of care, though several were not sure and were awaiting further evidence. Most respondents indicated that they did not deliver reports on quality measures (76 percent) and that data were not being used to measure quality performance of participating providers (73 percent). DISCUSSION: Respondents from most HIEs believe that the HIEs are demonstrating a positive ROI; however, a minority of them indicated they had used or will use specific metrics to calculate ROI. HIE representatives overwhelmingly reported that they believe the HIE activities improve the quality of healthcare delivered, but only a few are using data to evaluate provider performance or generate reports on quality measures. CONCLUSION: This study demonstrates the challenge faced by policy makers and healthcare organizations that are investing millions of dollars in HIEs that are believed to improve health outcomes and increase efficiency, but still need more time to develop the evidence to confirm that belief. Our study shows that calculating ROI for HIEs or their impact on quality of care remains a secondary priority for most HIEs. This finding raises serious questions for the sustained support of HIEs, both financially and as a policy lever, given the end of Health Information Technology for Economic and Clinical Health (HITECH) Act funding.

Analyzing Determinants of Hospitals' Accountable Care Organizations Participation: A Resource Dependency Theory Perspective.

Accountable care organizations (ACOs) are rapidly being implemented across the United States, but little is known about what environmental and organizational factors are associated with hospital participation in ACOs. Using resource dependency theory, this study examines external environmental characteristics and organizational characteristics that relate to hospital participation in Medicare ACOs. Results indicate hospitals operating in more munificent environments (as measured by income per capita: ß = 0.00002, p < .05) and more competitive environments (as measured by Health Maintenance Organization penetration: ß = 1.86, p < .01) are more likely to participate in ACOs. Organizational characteristics including hospital ownership, health care system membership, electronic health records implementation, hospital type, percentage of Medicaid inpatient discharge, and number of nursing home beds per 1,000 population over 65 are also related to ACO participation. Should the anticipated benefits of ACOs be realized, findings from this study can guide strategies to encourage hospitals that have not gotten involved in ACOs.

Patient-centered medical homes in Louisiana had minimal impact on Medicaid population's use of acute care and costs.

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.

Identifying hospitals that may be at most financial risk from Medicaid disproportionate-share hospital payment cuts.

Medicaid disproportionate-share hospital (DSH) payments are expected to decline by $35.1 billion between fiscal years 2017 and 2024, a reduction brought about by the Affordable Care Act (ACA) and recent congressional action. DSH payments have long been a feature of the Medicaid program, intended to partially offset uncompensated care costs incurred by hospitals that treat uninsured and Medicaid populations. The DSH payment cuts were predicated on the expectation that the ACA's expansion of health insurance to millions of Americans would bring about a decline in many hospitals' uncompensated care costs. However, the decision of twenty-five states not to expand their Medicaid programs, combined with residual coverage gaps, may leave as many as thirty million people uninsured, and hospitals will bear the burden of their uncompensated care costs. We sought to identify the hospitals that may be the most financially vulnerable to reductions in Medicaid DSH payments. We found that of the 529 acute care hospitals that will be particularly affected by the cuts, 225 (42.5 percent) are in weak financial condition. Policy makers should recognize that decreases in revenue may affect these hospitals' ability to give vulnerable populations access to care.

Hospital characteristics associated with achievement of meaningful use.

The objective of this study was to identify factors associated with hospitals that achieved the Medicare meaningful use incentive thresholds for payment under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. We employed a cross-sectional design using data from the 2011 American Hospital Association Annual Survey, including the Information Technology Supplement; the Centers for Medicare & Medicaid Services report of hospitals receiving meaningful use payments; and the Health Resources and Services Administration's Area Resource File. We used a lagged value from 2010 to determine electronic health record (EHR) adoption. Our methods were a descriptive analysis and logistic regression to examine how various hospital characteristics are associated with the achievement of Medicare meaningful use incentives. Overall, 1,769 (38%) of 4,683 potentially eligible hospitals achieved meaningful use incentive thresholds by the end of 2012. Characteristics associated with organizations that received incentive payments were having an EHR in place in 2010, having a larger bed size, having a single health information technology vendor, obtaining Joint Commission accreditation, operating under for-profit status, having Medicare share of inpatient days in the middle two quartiles, being eligible for Medicaid incentives, and being located in the Middle Atlantic or South Atlantic census region. Characteristics associated with not receiving incentive payments were being a member of a hospital system and being located in the Mountain or Pacific census region. Thus far, little evidence suggests that the HITECH incentive program has enticed hospitals without an EHR system to adopt meaningful use criteria. Policy makers should consider modifying the incentive program to accelerate the adoption of and meaningful use in hospitals without EHRs.