Medical Care Research and Review最新文献

This article studies the determinants and consequences of low-cost provider use for lab tests. Using all-payer claims data, I measure price variation across lab providers and link individual tests to referring providers, primary care providers, and clinician-hospital ownership information. I find that independent labs are 70% to 80% less expensive than hospital-based facilities, highlighting a path for considerable potential savings. Referring providers are overwhelmingly the strongest determinant of per-lab spending and hospital-based use, explaining 73% of the explained variance in site of care. Switching from a bottom-quintile independent-lab referrer to one in the top quintile is associated with a 39% drop in spending per test. Vertically integrated providers are less likely to be associated with independent lab use and are instead associated with higher spending per test. These findings suggest that clinician relationships, referral dynamics, and vertical integration are critical determinants of spending and site of care.

Medicare and Medicaid dual-eligible beneficiaries (i.e., dual eligibles) have complex care needs and often experience poor outcomes in skilled nursing facilities (SNFs). The newly implemented patient-driven payment model (PDPM) changed SNFs' postacute care delivery model and may differentially impact dual eligibles. This study describes the trend breaks due to the PDPM on therapy use, patient outcomes, SNF expenditures, and postacute care use, by dual eligibility status. We utilized health care administrative data and regression discontinuity analysis to examine the change in outcomes among 2 million SNF beneficiaries. We found that dual eligibles experienced greater increases in SNF expenditures than Medicare-only beneficiaries ($771.4 vs. $418.5). No meaningful differences were observed in the change in quality or postacute care use patterns. The increase in SNF expenditure could be due to upcoding or comorbidities not accounted for previously. Our results illustrate the heterogeneous effects of the PDPM.

Health care providers participating in five accountable care organization (ACO) models designed, implemented, and evaluated by the Innovation Center at the Centers for Medicare & Medicaid Services have cared for almost six million fee-for-service Medicare patients over the past decade. This systematic review summarizes the features and performance of these ACO models, capturing five major themes arising from their evaluation reports: spending performance by ACO organization type; the role of management companies in ACO structure and performance; financial risk and ACO participation; clinician incentives, waivers, and payment mechanisms; and patient engagement with ACOs. In difference-in-differences analyses, these 214 ACOs lowered spending by an estimated $2.8 billion, or $316.9 million after accounting for shared savings payouts derived from benchmarks, with no evident decrements in quality of care. ACOs' challenge in ongoing and future ACO models is to apply their accrued experience to reduce spending and improve quality within a fee-for-service payment system.

In February 2017, the Department of Veterans Affairs (VA) restructured outpatient medication copayments, creating three medication tiers comparable with private-sector value-based insurance designs (with copayments: US$5, US$8, US$11 per 30-day supply for Tiers 1-3, respectively); however, Veteran medication management experiences have not been assessed following this change. We invited a random sample of Veterans with chronic conditions (e.g., diabetes, hypertension) who utilized VA services to complete a mailed survey about VA and non-VA pharmacy use and medication management experiences following this restructuring. There were 2,884 respondents (29% response rate). Veterans with the lowest proportion of medications from Tier 1 after the restructuring had the highest predicted probability of non-VA pharmacy use from regression analyses. Among respondents subject to VA copayments, 27% reported being better able to afford medications after the restructuring. However, 29% reported worrying about paying for medications, and 18% reported making tradeoffs (e.g., spending less on utilities, food) to pay for prescriptions.

Research shows care coordination contributes to integrated care experiences. Yet evidence from system-level initiatives is lacking. Using a survey of Veterans Health Administration (VHA) patients linked with clinical records, this nonrandomized, cross-sectional study compares perceived care integration among patients at high risk of hospitalization or mortality who did and did not receive care coordination services at 31 VHA sites during early implementation of a national initiative. Six validated dimensions included: knowledge about patient's medical history among staff, providers, and specialists; provider support for self-directed care and for medication adherence and home care; and test results communication. Among 714 respondents, 48% had received care coordination services, 78% were 65 or older, and 95% were male. Regression models suggest little association between receipt of care coordination and perceived care integration. Implementation monitoring followed by responsive adaptations may be needed to boost patient perceptions of care integration.

Hospital-physician vertical integration has become a defining feature of the health care landscape. While some evidence exists regarding integration's effect on clinical outcomes, little has examined patient-reported experience. We used the 2021 Medicare Current Beneficiary Survey, constructing psychometric scales of care coordination and quality, communication, and accessibility from survey responses. We analyzed how patient experience with each scale differed by the proportion of care received from integrated physicians, adjusting for patients' characteristics. Integrated care was significantly and positively associated with patients' perceptions of coordination and quality. This relationship was driven by patients with high clinical complexity, with effects twice as large as for patients with low clinical complexity. However, integrated care was not significantly associated with communication or accessibility. These findings suggest a nuanced relationship between integration and patient experience. Policymakers, who often discuss integration in terms of outcomes and affordability, should also consider ways in which it shapes patients' experiences.

Coverage gaps and periods of uninsurance are associated with decreased health care utilization, treatment nonadherence, and health-related work limitations. Yet little is known about long-term trajectories of insurance coverage. We used sequence analysis and a nationally representative cohort study to identify and describe three trajectories of health insurance coverage from ages 25 to 37: stable private coverage (40%); stabilizing public coverage (16%); and recurrent uninsurance (44%). Estimated time exposed to uninsurance for each group was 0.2, 1.7, and 5.2 years, respectively. Those with recurrent uninsurance were more likely to be male, Black or Hispanic, working part-time, in poorer health, or living in the U.S. South or West. Prolonged and cyclical uninsurance is common in the years following the transition to adulthood, with disadvantaged adults more likely to experience recurrent uninsurance. Furthermore, examining insurance status cross-sectionally underestimates long-term exposure to coverage instability and may impede effective interventions aimed at securing long-term access to coverage.

Patients increasingly use online rating and review websites to share their clinical experiences, yet few studies have taxonomized how patients perceive their physicians. We developed a theoretical framework identifying the factors comprising patients' perceptions of their physicians' interpersonal manner and technical competence. We conducted a qualitative content analysis of 2,000 online reviews sampled from distinct physicians across the United States, balanced to represent primary care physicians and surgeons, males and females, and low- and high-star rated reviews. Reviews were received between 2015 and 2020 on a large commercial rating and review website. Our theoretical framework identifies 16 interpersonal manner factors and 10 technical competence factors. Interpersonal manner factors were grouped by physicians' attitude and character, behavior, and communication; technical competence factors were grouped by physicians' expertise, treatment approach, and outcomes. This framework may help physicians and health systems seeking to improve care quality, delivery, and patient satisfaction.

To compare the performance of the Chronic Conditions Warehouse (CCW) and the 38-condition Elixhauser Comorbidity Index in predicting all-cause mortality among Medicare beneficiaries with dementia, we used a national sample of 1,566,359 community-dwelling Medicare beneficiaries (age ≥65) with dementia, identified in 2018 claims data. Using elastic net logistic regression, we applied 30 CCW conditions and 38 Elixhauser comorbidities from 2018 to predict mortality at 30, 60, 180 days, and 1 year through December 31, 2019. Mortality rates were 2.42% (30 days), 4.27% (60 days), 10.77% (180 days), and 19.0% (1 year). All models demonstrated good discrimination (C-statistics: 0.696-0.731) and calibration, with no meaningful performance differences between the two measures. Elastic net models produced parsimonious predictors with performance comparable to traditional logistic regression. Both CCW and Elixhauser measures predicted all-cause mortality in dementia with similar accuracy. Elastic net offers a robust approach to claims-based mortality prediction.