Medicaid Expansion Alone Not Associated With Improved Finances, Staffing, Or Quality At Critical Access Hospitals.

Critical access hospitals are important providers of care for rural and other underserved communities, but they face staffing and quality challenges while operating with low margins. Medicaid expansion has been found to improve hospital finances broadly and therefore may have permitted sustained investments in staffing and quality improvement at these vulnerable hospitals. In this difference-in-differences analysis, we found that critical access hospitals in Medicaid expansion states did not have statistically significant postexpansion increases in operating margins relative to hospitals in nonexpansion states.

Reducing False-Positive Results With Fourth-Generation HIV Testing at a Veterans Affairs Medical Center.

Background: In 2006, the Centers for Disease Control and Prevention issued guidelines advocating routine HIV screening for all patients. However, false-positive results are a potential patient care threat for low-risk populations even with accurate screening assays. A reduction in HIV false-positive screening results can potentially be seen by switching from the third-generation to a more sensitive and specific fourth-generation screening assay.

Nursing Home Staffing Levels Did Not Change Significantly During COVID-19.

Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services.

Liquid Biopsies in a Veteran Patient Population With Advanced Prostate and Lung Non-Small Cell Carcinomas: A New Paradigm and Unique Challenge in Personalized Medicine.

Introduction: Liquid biopsy in solid tumors is a major milestone in the field of precision oncology by analyzing circulating tumor cells in peripheral blood and genomic alterations. DNA damage repair gene (DDR) mutations have been reported in 25 to 40% of prostatic cancers and > 50% of non-small cell lung cancers (NSCLC). Tp53 mutation has been found to be associated with a poor prognosis and increased germline mutations.

Assessing The Effectiveness Of Peer Comparisons As A Way To Improve Health Care Quality.

Policy makers are increasingly using performance feedback that compares physicians to their peers as part of payment policy reforms. However, it is not known whether peer comparisons can improve broad outcomes, beyond changing specific individual behaviors such as reducing inappropriate prescribing of antibiotics. We conducted a cluster-randomized controlled trial with Blue Cross Blue Shield of Hawaii to examine the impact of providing peer comparisons feedback on the quality of care to primary care providers in the setting of a shift from fee-for-service to population-based payment.

Spending And Quality After Three Years Of Medicare's Voluntary Bundled Payment For Joint Replacement Surgery.

Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highest-volume episode in both BPCI and BPCI Advanced, there is a paucity of independent evidence about its long-term impact on outcomes and about whether improvements vary by timing of participation or arise from patient selection rather than changes in clinical practice. We found that over three years, compared to no participation, participation in BPCI was associated with a 1.

Changes In Physician Consolidation With The Spread Of Accountable Care Organizations.

While early evidence suggests that accountable care organizations (ACOs) are associated with higher quality and lower costs, there have been simultaneous concerns that ACOs may incentivize consolidation of physician groups. This is particularly concerning as previous research has shown that consolidation is associated with lower quality and higher prices. Using a difference-in-differences strategy and data from the Medicare Shared Savings Program, which began in 2012, we examined whether physician practices consolidated after ACOs entered health care markets.

In Hospitals With More Nurses Who Have Baccalaureate Degrees, Better Outcomes For Patients After Cardiac Arrest.

In 2010, prompted by compelling evidence that demonstrated better patient outcomes in hospitals with higher percentages of nurses with a bachelor of science in nursing (BSN), the Institute of Medicine recommended that 80 percent of the nurse workforce be qualified at that level or higher by 2020. Using data from the American Heart Association's Get With the Guidelines-Resuscitation registry (for 2013-18), RN4CAST-US hospital nurse surveys (2015-16), and the American Hospital Association (2015), we found that each 10-percentage-point increase in the hospital share of nurses with a BSN was associated with 24 percent greater odds of surviving to discharge with good cerebral performance among patients who experienced in-hospital cardiac arrest. Lower patient-to-nurse ratios on general medical and surgical units were also associated with significantly greater odds of surviving with good cerebral performance.

Accuracy Of The Relative Value Scale Update Committee's Time Estimates And Physician Fee Schedule For Joint Replacement.

Even though relative value units guide 70 percent of physician payment, little research has assessed their accuracy. We analyzed actual service time for total hip and knee replacements at two academic hospitals in the period January 1, 2013-October 1, 2016, using electronic health record time-stamp data, and we compared that time with the Medicare Physician Fee Schedule and most recent Relative Value Scale Update Committee recommendations. We found that the committee and fee schedule overestimated the operating time of original hip replacements by 18 percent and original knee replacements by 23 percent.

Perspectives and Practice in the Identification and Treatment of Opioid Use, Alcohol Use, and Depressive Disorders.

Objective: Little research has focused on the treatment of adults with substance use disorders in primary care despite the high occurrence, morbidity, and mortality associated with these disorders.

Methods: An electronic survey was administered to primary care providers in a large health system to assess screening and treatment practices and comfort managing opioid use, alcohol use, and depressive disorders. A total of 146 providers completed the survey (32%).

When Is The Price Of A Drug Unjust? The Average Lifetime Earnings Standard.

The majority of Americans believe that lowering drug prices should be the top health care priority for the federal government. Yet drug costs as a proportion of the country's medical expenditures have increased substantially in recent years. Because drugs are basic necessities, and because how much society should contribute toward providing basic necessities is a question of justice, policies regarding drug prices must fulfill principles of justice, not just economic efficiency.

National Representativeness Of Hospitals And Markets In Medicare's Mandatory Bundled Payment Program.

In 2016 Medicare implemented its first mandatory alternative payment model, the Comprehensive Care for Joint Replacement (CJR) program, in which the agency pays clinicians and hospitals a fixed amount for services provided in hip and knee replacement surgery episodes. Medicare made CJR mandatory, rather than voluntary, to produce generalizable evidence on what results Medicare might expect if it scaled bundled payment up nationally. However, it is unknown how markets and hospitals in CJR compare to others nationwide, particularly with respect to baseline quality and spending performance and the structural hospital characteristics associated with early savings in CJR.

Nurses' And Patients' Appraisals Show Patient Safety In Hospitals Remains A Concern.

The Institute of Medicine concluded in To Err Is Human in 1999 that transformation of nurse work environments was needed to reduce patient harm. We studied 535 hospitals in four large states at two points in time between 2005 and 2016 to determine the extent to which their work environments improved, and whether positive changes were associated with greater progress in patient safety. Survey data from thousands of nurses and patients showed that patient safety remains a serious concern.

Assessing The Impact Of State Policies For Prescription Drug Monitoring Programs On High-Risk Opioid Prescriptions.

Policies and practices have proliferated to optimize prescribers' use of their states' prescription drug monitoring programs, which are statewide databases of controlled substances dispensed at retail pharmacies. Our study assessed the effectiveness of three such policies: comprehensive legislative mandates to use the program, laws that allow prescribers to delegate its use to office staff, and state participation in interstate data sharing. Our analysis of information from a large commercial insurance database indicated that comprehensive use mandates implemented during 2011-15 were associated with a 6-9 percent reduction in opioid prescriptions with high risk for misuse and overdose.

Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration.

A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes.

Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners.

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008-16.

Comparison Of Hospitals Participating In Medicare's Voluntary And Mandatory Orthopedic Bundle Programs.

We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost.

Most Primary Care Physicians Provide Appointments, But Affordability Remains A Barrier For The Uninsured.

The US uninsurance rate has nearly been cut in half under the Affordable Care Act, and access to care has improved for the newly insured, but less is known about how the remaining uninsured have fared. In 2012-13 and again in 2016 we conducted an experiment in which trained auditors called primary care offices, including federally qualified health centers, in ten states. The auditors portrayed uninsured patients seeking appointments and information on the cost of care and payment arrangements.

State Adoption of Incentives to Promote Evidence-Based Practices in Behavioral Health Systems.

Objective: Despite the critical role behavioral health care payers can play in creating an incentive to use evidence-based practices (EBPs), little research has examined which incentives are used in public mental health systems, the largest providers of mental health care in the United States.

Methods: The authors surveyed state mental health directors from 44 states about whether they used any of seven strategies to increase the use of EBPs. Participants also ranked attributes of each incentive on the basis of key characteristics of diffusion of innovation theory (perceived advantage, simplicity, compatibility, observability, and gradually implementable) and perceived effectiveness.

Innovative Environments In Health Care: Where And How New Approaches To Care Are Succeeding.

Organizations seeking to create innovative environments in health care need to pay attention to a number of factors. These include making available sufficient resources, notably money and physical space, but also coordination and consultation regarding intellectual property and licensing; enabling access to engineers, software developers, and behavioral scientists; making providers and patients available to innovators; having a sufficiently long-term view; and insulating the innovation group from operational demands. If there is a single essential key to success, it is making innovation a strategic priority.

Marketplace Plans With Narrow Physician Networks Feature Lower Monthly Premiums Than Plans With Larger Networks.

The introduction of health insurance Marketplaces under the Affordable Care Act has been associated with growth of restricted provider networks. The value of this plan design strategy, including its association with lower premiums, is uncertain. We used data from all silver plans offered in the 2014 health insurance exchanges in the fifty states and the District of Columbia to estimate the association between the breadth of a provider network and plan premiums.

A Synchronized Prescription Refill Program Improved Medication Adherence.

Synchronizing medication refills-renewing all medications at the same time from the same pharmacy-is an increasingly popular strategy to improve adherence to medication regimens, but there has been little research regarding its effectiveness. In light of increasing policy interest, we evaluated the impact of a pilot refill synchronization program implemented by a large national insurer. A random sample of Medicare Advantage patients receiving mail-order refills for common maintenance medications (antihypertensive, lipid-lowering, or antidiabetic agents) were invited to join the program and followed for twelve months.

Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care.

Little is known about how real-time online rating platforms such as Yelp may complement the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is the US standard for evaluating patients' experiences after hospitalization. We compared the content of Yelp narrative reviews of hospitals to the topics in the HCAHPS survey, called domains in HCAHPS terminology. While the domains included in Yelp reviews covered the majority of HCAHPS domains, Yelp reviews covered an additional twelve domains not found in HCAHPS.

For Third Enrollment Period, Marketplaces Expand Decision Support Tools To Assist Consumers.

The design of the Affordable Care Act's online health insurance Marketplaces can improve how consumers make complex health plan choices. We examined the choice environment on the state-based Marketplaces and HealthCare.gov in the third open enrollment period.