Examining different accountable care organization payment models

Two new studies published online by JAMA Internal Medicine take a look at different accountable care organization (ACO) payment models.

The first study by J. Michael McWilliams, M.D., Ph.D., of Harvard Medical School, Boston, and coauthors used a sample of fee-for-service Medicare claims to examine changes in postacute care spending and the use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program. The 20 percent sample of beneficiaries included more than 8.3 million hospital admissions and more than 1.5 million stays in skilled nursing facilities (SNFs).

Excessive use of postacute SNF care is thought to be a major source of wasteful spending and a target for health care professionals who participate in new payment models, such as Medicare ACO programs.

The authors report that entrance into the Medicare Shared Savings Program (MSSP) in 2012 for ACOs was associated with a 9 percent differential reduction in postacute spending by 2014 – driven by reductions in discharges to facilities, length of facility stays and acute inpatient care. Reductions were smaller for later program entrants and similar for ACOs with and without financial ties to hospitals, according to the article.

The study’s limitations include that the MSSP is a voluntary program and ACOs likely differ from providers who don’t participate.

“Participation in the MSSP has been associated with significant reductions in postacute care spending without ostensible changes in quality, suggesting gains in the value of health care. Postacute care spending reductions were more consistent with efforts by clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs. Understanding such early successes can support regulatory policy that enhances rather than inhibits the effectiveness of payment and delivery system reform,” the article concludes.

A second study by K. John McConnell, Ph.D., of the Oregon Health & Science University, Portland, examined early performance in Medicaid ACOs in Oregon and Colorado.

With a $1.9 billion investment from the federal government, Oregon started to transform Medicaid in 2012 by moving enrollees into 16 Coordinated Care Organizations so care was managed within a global budget. In 2011, Colorado began its Medicaid Accountable Care Collaborative by creating seven regional care collaborative organizations that were funded to coordinate care and connect Medicaid enrollees with community services, according to the article.

The authors report standardized expenditures, which have common codes across states, for selected services decreased in both states from 2010 to 2014 with no difference between the states. The Oregon model also was associated with improvements in some utilization, access and quality measures.

The study notes important limitations, including that the analysis did not include prescription drug expenditures, which is a growing portion of Medicaid spending.

“These results should be considered in the context of overall promising trends in both states. Continued evaluation of Medicaid reforms and payment models can inform the most effective approaches to improving and sustaining the value of this growing public program,” the article concludes.

Articles: Changes in Postacute Care in the Medicare Shared Savings Program, J. Michael McWilliams, MD, PhD; Lauren G. Gilstrap, MD; David G. Stevenson, PhD et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9115, published online 13 February 2017.

Early Performance in Medicaid Accountable Care Organizations A Comparison of Oregon and Colorado, K. John McConnell, PhD; Stephanie Renfro, MS; Benjamin K. S. Chan, MS et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9098, published online 13 February 2017.

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This entry was posted on February 14, 2017, in Main.

Study shows impact of dental benefits on meeting children's dental needs

A report in The Journal of the American Dental Association (JADA) shows that dental benefits play a significant role in meeting the dental needs of children, including checkups and treatments. The study is particularly timely as February is National Children’s Dental Health Month.

The report finds U.S. children enrolled in private or public dental care plans were more likely to receive dental care than children who did not have coverage from 1997 to 2014. The study also showed that unmet dental needs of children who were enrolled in a dental care plan, private or public, steadily decreased from 2009 to 2014.

“The number of uninsured children decreased by 58 percent from 1997 to 2014 with a significant shift from private to public insurance coverage,” stated authors Maryam Amin, D.M.D., M.S.c., Ph.D., Maryam Elyasi, D.D.S., and Zhou J. Yu, B.S.c. “The shift toward use of public insurance along with a significant association between unmet needs and dental visits support the effectiveness of publicly funded programs in facilitating the use of dental services in the United States.”

The authors examined data from more than 65,000 participants collected by the National Health Interview Survey (NHIS), which is conducted by the U.S. Census Bureau.

Dental needs are met by regular visits to the dentist and adequate access to dental care. According to the study, some barriers to receiving care include socioeconomic status, beliefs about dental care, and the accessibility of providers. Some enabling factors include level of education, household income, and dental insurance.

“If an imbalance exists between barriers and enabling factors, a patient may have a higher chance of having unmet dental needs because of cost, which leads to delayed diagnosis of issues, more complex treatment, and ultimately increased burden on public health systems,” the authors stated.

Article: Associations among dental insurance, dental visits, and unmet needs of US children, Zhou J. Yu, BSc, Maryam Elyasi, DDS, Maryam Amin, DMD, MSc, PhD, The Journal of the American Dental Association, doi: 10.1016/j.adaj.2016.11.013, published February 2017.

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This entry was posted on February 8, 2017, in Main.

New survey finds many Americans want changes to ACA but few support immediate repeal

According to a new national survey on Americans’ opinions on the Affordable Care Act (ACA) conducted by The Associated Press-NORC Center for Public Affairs Research, 12 percent of Americans want the ACA kept in its current form, 40 percent say it should be preserved with improvements, 16 percent say the law should be repealed immediately, and 31 percent want a repeal to wait until a replacement is ready. While most Americans express a desire for change, few report being negatively impacted by the law, and nearly half say they haven’t been affected at all. Forty-six percent of Americans say they have not been personally affected by the law, while 27 percent say the law has improved their lives, and 26 percent say it has had a detrimental effect.

“It is clear that very few Americans want to keep the law as it currently is,” said Trevor Tompson, director of The AP-NORC Center. “However, there are many elements of the law that appear to be popular, and there is support for retaining those provisions in any replacement legislation that might be passed.”

Key findings from the poll include:

  • Fifty-three percent disagree with the new administration and say the health care law should remain. But only 12 percent of Americans support keeping the law as it is now; 40 percent would like to see changes to make it better. Nearly half of Americans, 46 percent, agree that the law should be repealed. However, 31 percent want to wait until a replacement law is ready, while only 16 percent want to see the law repealed immediately.

  • Even a majority of those who oppose the ACA support eliminating out-of-pocket costs for some preventive health care (70 percent), allowing adult children to remain on their parents’ insurance until age 26 (65 percent), and protecting people with pre-existing medical conditions (60 percent).

  • The individual mandate that requires most Americans to be insured or pay a fine is the least popular element of the ACA, even among those who support it. Less than half (49 percent) of those who want the law to remain support the mandate, along with only 12 percent of those who want it repealed.

  • Despite provisions in the health care law that impact Americans regardless of their source of health insurance, 46 percent say they have not been personally affected by the law, and 26 percent say it has had a detrimental effect. Only 27 percent say the law has improved their lives.

  • Overall, 40 percent say the ACA has helped average Americans, 33 percent say it has hurt them, and 25 percent do not perceive any difference. Fifty-three percent say the health care law has helped low-income families, and 44 percent say it has been beneficial for women. But 41 percent say the law has hurt small businesses.

  • Fifty-six percent of Americans are extremely or very concerned that many people will lose their coverage if the health care law is repealed. And 49 percent expect the elimination of the ACA to be detrimental for most Americans; only 26 percent think it will be advantageous.

  • The idea of a government-financed single payer insurance program gets mixed support. Thirty-eight percent favor the concept, while 39 percent oppose it. Support drops to 24 percent when asked if a single payer system meant large increases in government spending.

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This entry was posted on January 31, 2017, in Main.

Most primary care doctors 'strongly endorse' key elements of the Affordable Care Act

Proponents of repealing the Affordable Care Act, including President Donald Trump’s nominee for Secretary of Health and Human Services, Tom Price, have argued that the law places an undue burden on physicians. However, according to new research, while nearly 74 percent of physicians surveyed favor making some changes to the law, only 15 percent favor repealing the legislation in its entirety. Additional results of the survey, published in the New England Journal of Medicine, show that participants almost universally support prohibiting insurance companies from denying coverage or charging higher prices on the basis of pre-existing conditions, and allowing young adults to remain on their parents’ insurance plan until 26 years of age.

“Tens of millions of people could be at risk of losing health insurance if critical elements of the Affordable Care Act are repealed. Given the central role physicians play in the health care system, their views of the legislation are important for informing the public debate,” said co-author David Grande, MD, MPA, an assistant professor of Medicine at the Perelman School of Medicine and director of Policy at Penn’s Leonard Davis Institute of Health Economics. “We don’t yet know what provisions may be repealed or modified, but we have started to see signs of what could be coming, and what has been absent in the conversation so far is how physicians feel the law has impacted their patients’ and the care they are able to deliver.”

Given the rapidly and dramatically changing political landscape, the authors conducted a survey of more than 400 physicians randomly selected from the American Medical Association’s Masterfile from December 2016 through January 2017 to gauge perspectives of the ACA and specific policy options put forth in recent public debate. Though responses varied according to the physicians’ self-reported political party affiliation (no Democrats wanted to see the ACA repealed, while 32 percent of Republicans did), among all participants, only 37.9 percent of those who reported voting for Trump wanted to repeal the ACA in its entirety.

In general, participants responded most favorably to policy changes that might increase choice for consumers, such as creating a public option resembling Medicare to compete with private plans, providing tax credits to allow people who are eligible for Medicaid to purchase private health insurance, and increasing the use of health savings accounts. Physicians responded most negatively to policies that would shift more costs to consumer through high-deductible health plans, and less than half were in favor of proposals to decrease insurance-market regulations, require states to expand Medicaid, or expand Medicare to adults 55 to 64 years of age.

“With his new executive order, President Trump has sent a message that he may try to unravel key elements of the ACA,” said lead author Craig Pollack, MD, MHS, an associate professor of General Internal Medicine at the Johns Hopkins University School of Medicine. “By and large, primary care physicians are open to modifications of the law, but believe several aspects of the ACA with its focus on increasing insurance coverage are important to patient’s health. They worry about changes that rely on high deductible health plans that require patients to shoulder more health care costs.”

Article: A View from the Front Line – Physicians’ Perspectives on ACA Repeal, Craig Evan Pollack, M.D., M.H.S., Katrina Armstrong, M.D., and David Grande, M.D., M.P.A., New England Journal of Medicine, doi: 10.1056/NEJMp1700144, published 25 January 2017.

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This entry was posted on January 28, 2017, in Main.

Inability to work: Medical experts often disagree

Independent medical evaluations are often used to adjudicate disability claims. But different doctors assessing the same patient often disagree on whether the patient is disabled or not. This problem can be mitigated by applying standardized procedures, says an international study led by researchers at the University of Basel and the University Hospital Basel in Switzerland. The results have just been published in the scientific journal BMJ.

The findings from a team of researchers from Switzerland, the Netherlands and Canada are based on a systematic review of 23 studies by scientists and insurance companies across 12 countries. The earlier studies had analyzed the extent to which healthcare providers agreed when assessing patients’ capacity to work in situations where this could validate disability claims.

Half of the claims were rejected

“Globally, around half of all disability claims were denied based on independent medical evaluations. However, our review of the studies found that experts are frequently in disagreement on whether an individual is incapable of working,” says Regina Kunz, Professor of Insurance Medicine at the University of Basel and Head of Evidence-based Insurance Medicine at the University Hospital Basel.

Medical evaluations are often used to assess a person’s capacity to work and have far-reaching consequences for employees, whose ability to work can be restricted by illness or accident.

Lack of standards

The reason medical professionals tend to offer varying assessments can likely be traced back to the lack of standards. “We found evidence that structured evaluation processes could improve the reliability of assessments,” said Regina Kunz.

“Any assessment cannot be valid unless it is reliable – that is, if it is incapable of measuring what it is supposed to measure,” adds co-author Jason W. Busse of McMaster University in Hamilton, Canada. “Our findings are troubling because disability claimants need valid assessments – on the one hand, to avoid delays in wage replacement benefits, and on the other to prevent prolonged disability by ensuring they receive the appropriate care.”

As a result, researchers determined that tools and structured approaches needed to be developed and tested in order to improve the assessment of incapacity to work. Professor Kunz’s research team succeeded in developing and evaluating a new method – function-oriented assessment – for people with mental disorders as part of a study funded by the Swiss National Science Foundation (SNSF), the Swiss Federal Social Insurance Office (BSV) and the Swiss National Accident Insurance Fund (Suva). The results will be presented in the near future.

Article: Inter-rater agreement in evaluation of disability: systematic review of reproducibility studies, J├╝rgen Barth, Wout E L de Boer, Jason W Busse, Jan L Hoving, Sarah Kedzia, Rachel Couban, Katrin Fischer, David Y von Allmen, Jerry Spanjer, Regina Kunz, BMJ, doi: 10.1136/bmj.j14, published 25 January 2017.

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This entry was posted on January 28, 2017, in Main.