Can bundled payment improve quality and efficiency of care for patients with hip fractures?

The current Medicare reimbursement for hip fractures lacks accountability and promotes cost cutting. A bundled payment system-analogous to the Medicare Acute Care Episodes Demonstration for Orthopedic and Cardiovascular Surgery-may help curtail costs, foster communication among health care providers, and improve their accountability for patient outcomes. In hip fracture care, bundled payment may spur development of multidisciplinary best practice guidelines, quality assessment, and reporting, and result in benchmarking and best practices sharing. However, its implementation may face challenges: the need for quality assessment criteria and risk adjustment methods and possible risks of pushing costs outside of Medicare boundaries.

Dietetics supply and demand: 2010-2020.

The Academy of Nutrition and Dietetics, in conjunction with the Commission on Dietetic Registration (CDR), invited The Lewin Group to undertake an analysis of the dietetics workforce. The purpose of the workforce study was to develop a model that can project the supply and demand for both registered dietitians (RDs) and dietetic technicians, registered (DTRs) (collectively referred to as CDR-credentialed dietetics practitioners) as the result of various key drivers of change. The research team was asked to quantify key market factors where possible and to project likely paths for the evolution of workforce supply and demand, as well as to assess the implications of the findings. This article drew on the survey research conducted by Readex Research and futurist organizations such as Signature i and Trend Spot Consulting. Furthermore, members of the Dietetics Workforce Demand Task Force were a source of institutional and clinical information relevant to the credentialed dietetics workforce--including their opinions and judgment of the current state of the health care market for dietetic services, its future state, and factors affecting it, which were useful and were integrated with the objective sources of data. The model is flexible and accommodates the variation in how RDs and DTRs function in diverse practice areas. For purposes of this study and model, the dietetics workforce is composed of RDs and DTRs. This report presents the results of this workforce study and the methodology used to calculate the projected dietetics workforce supply and demand. The projections are based on historical trends and estimated future changes. Key findings of the study included the following: • The average age of all CDR-credentialed dietetics practitioners in baseline supply (2010) is 44 years; approximately 96% are women. • Approximately 55% of CDR-credentialed dietetics practitioners work in clinical dietetics. • The annual growth rate of supply of CDR-credentialed dietetics practitioners declined from 3% in the early 1990s to 1.5% by 2010. • The net supply of CDR-credentialed dietetics practitioners is projected to grow by 1.1% annually. • Approximately 75% of the demand for the dietetics workforce will be met by the 2020 supply of CDR-credentialed dietetics practitioners. • The aging population, health care reform, increased prevalence of certain conditions (including obesity), and growth in the food industry are key factors affecting the demand.

A retrospective comparison of clinical outcomes and Medicare expenditures in skilled nursing facility residents with chronic wounds.

Medicare skilled nursing facility (SNF) residents with chronic wounds require more resources and have relatively high healthcare expenditures compared to Medicare patients without wounds. A retrospective cohort study was conducted using 2006 Medicare Chronic Condition Warehouse claims data for SNF, inpatient, outpatient hospital, and physician supplier settings along with 2006 Long-Term Care Minimum Data Set (MDS) information to compare Medicare expenditures between two groups of SNF residents with a diagnosis of pressure, venous, ischemic, or diabetic ulcers whose wounds healed during the 10-month study period. The study group (n = 372) was managed using a structured, comprehensive wound management protocol provided by an external wound management team. The matched comparison group consisted of 311 SNF residents who did not receive care from the wound management team. Regression analyses indicate that after controlling for resident comorbidities and wound severity, study group residents experienced lower rates of wound-related hospitalization per day (0.08% versus 0.21%, P < 0.01) and shorter wound episodes (94 days versus 115 days, P < 0.01) than comparison group patients. Total Medicare costs were $21,449.64 for the study group and $40,678.83 for the comparison group (P < 0.01) or $229.07 versus $354.26 (P < 0.01) per resident episode day. Additional studies including wounds that do not heal are warranted. Increasing the number of SNF residents receiving the care described in this study could lead to significant Medicare cost savings. Incorporating wound clinical outcomes into a pay-for-performance measures for SNFs could increase broader SNF adoption of comprehensive wound care programs to treat chronic wounds.

The cost-shift payment 'hydraulic': foundation, history, and implications.

The cost-shift payment "hydraulic" is an integral component of the fragmented U.S. health care financing system. If private payers' acceptance of the cost-shifting burden were to erode, our system of health care financing could become unstable. This is especially true for the hospital industry. In this paper we provide a series of examples of cost shifting and a historical profile of the cost shift in the hospital industry since 1980, noting that cost-shifting pressures seem to fluctuate over time and across health care markets. Cost shifting need not be dollar per dollar, as hospitals can absorb some degree of cost-shifting pressure through increased efficiency and decreases in service provision.

Specialty heart hospital care: a comparative study.

The objective of this study was to compare measures of MedCath heart hospital patient severity, quality, and Medicare-related expenditures for comparable services to a group of comparison heart hospitals. This analysis is relevant to stakeholders' concerns over the emergence of the specialty care hospital industry. The study incorporates Medicare data for seven MedCath hospitals as compared with 1192 hospitals that performed open-heart surgery in federal fiscal year 2001. The authors developed cardiac-specific patient severity measures based on All Patient Refined-Diagnostic Related Groups and all subsequent analyses were standardized for differences in case mix between MedCath and comparison group hospitals. Study results indicate that MedCath hospitals have higher cardiac case mix severity, fare better in indicators for quality of care, and provide care at less expense to Medicare than comparison group heart hospitals. These results imply that "cherry picking" arguments and quality-of-care concerns of the specialty care hospital industry critics do not seem applicable for MedCath hospitals.