The Pennsylvania Health Care Cost Containment Council has released a report on complications from hip and knee replacement procedures performed at Pennsylvania hospitals.
The analysis looks at more than 56,000 procedures performed in 2013, quantifying complications, lengthy hospital stays, readmissions, and more.
Find the PHC4 report here.
Amid indications that assisting with permanent supportive housing can be a cost-effective, evidence-based way of helping to address the behavioral health needs of some Medicaid recipients, housing and behavioral health groups are beginning to take a closer look at how Medicaid resources might be used to help support such housing.
In a new report, the National Council for Behavioral Health examines the possibility of using Medicaid resources to finance the delivery of services in supportive housing for Medicaid beneficiaries facing behavioral health challenges.
The report examines the policy context for developing integrated permanent supportive housing options in state Medicaid programs; opportunities for Medicaid to finance and deliver housing-related services; and the implications for behavioral health authorities and providers.
For a closer look at the issue, its implications, and the means through which such resources might be brought to bear, go here to see the National Council for Behavioral Health report Using Medicaid to Finance and Deliver Services in Supportive Housing: Challenges and Opportunities for Community Behavioral Health Organizations and Behavioral Health Authorities.
It’s a new twist on an old concept: employ peers of low-income patients to go out into the community and work with those recently hospitalized to ensure that they are getting the care and assistance they need to recover from their illnesses and injuries.
Traditionally employed by local health departments and other government agencies, community health workers are increasingly being hired by hospitals to reach out to challenging patients and help prevent readmissions to the hospitals for which Medicare (through its hospital readmissions reduction program), and increasingly state Medicaid programs as well, penalize them.
And the early results are encouraging: some hospitals that employ community health workers have lowered their Medicare readmissions and avoided federal penalties.
Among the challenges hospitals face in employing such an approach is how to pay for community health workers. Some do so out of operating funds; others receive foundation grants; some have obtained funding from the federal government and some through enhanced Medicaid payments for this purpose; and even health insurers, lured by the prospect of reducing the cost of claims, have started helping.
For a closer look at how community health workers are helping hospitals keep their patients healthier and out of the hospital, see the Kaiser Health News report “Hospitals Eye Community Health Workers to Cultivate Patient Success.”
Medicare’s goal of reducing hospital readmissions 20 percent – a key aspect of its hospital readmissions reduction program – may be too ambitious, researchers have concluded after evaluating the results of a special Connecticut effort to reduce readmissions.
In that program, a new approach to reducing readmissions tested on 10,000 older patients considered at high risk of readmissions employed interventions, transition support, education, follow-up telephone calls, and assistance finding community resources and assistance. The result? It cut Medicare hospital readmissions nine percent – less than half the 20 percent goal Medicare has set.
The study’s creators concluded that
Our analysis revealed a fairly consistent and sustained but small, beneficial effect of the intervention on the target population as a whole.
Learn more about the study in this Fierce Healthcare report and find the study itself here, on the web site of JAMA Internal Medicine.
Despite Affordable Care Act policies that have enabled millions of Americans to obtain health insurance, the health care safety net is still needed.
Or so concludes a new report from the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms.
For the report A Tale of Three Cities: How the Affordable Care Act is Changing the Consumer Coverage Experience in 3 Diverse Communities, researchers visited and examined conditions in Tampa, Columbus, and Richmond (Virginia), and among their conclusions was:
We still need a safety net. Safety net programs in existence before the ACA were expected to become less necessary once the ACA coverage expansions took effect. And to some extent that has indeed been the case. But what was deemed affordable under the ACA for those with income too high for Medicaid eligibility is not necessarily perceived to be affordable to the individuals enrolling in the marketplace plans, particularly when health care spending must compete with other pressing household expenses. As a result, safety net providers report that many patients who start the year with coverage return to them later in the year uninsured.
The report also found that
Safety net providers are adapting to the new coverage and health system landscape ushered in by the ACA. However, there’s not yet enough data to know whether coverage has translated to better, more affordable access to health care services.
To learn more about the report and its findings, go here to read a Center on Health Insurance Reforms blog entry on the research and go here to see the report itself.
The National Academies of Science, Engineering, and Medicine has published a new report that acknowledges the challenges faced by hospitals that care for socio-economically challenged patients and offers suggestions for how to serve those patients more effectively.
The report, Systems Practices for the Care of Socially At-Risk Populations, is the second in a projected series of five reports on the subject.
The study notes that
Emerging evidence suggests that providers disproportionately serving patients with social risk factors for poor health outcomes may be more likely to fare poorly on quality rankings and to receive financial penalties, and less likely to receive financial rewards.
Because the study did not include any original empirical research and is based instead on literature reviews and case studies, the Academy declined to suggest best practices for serving this challenging population but did offer six recommendations for improving care to socio-economically disadvantaged communities:
The study also acknowledged the importance of adequate provider (primarily Medicare) payments in serving such a challenging population:
Both the availability of resources and alignment of financial incentives are prerequisites for the adoption and sustainability of these practices…Resources can provide the incentives to reduce disparities by targeting interventions at socially at-risk populations and incorporating equitable care and outcomes into accountability processes. Interventions that improve health and quality of care or reduce utilization and cost are only sustainable if the provider’s profits are higher with the intervention than without. Most of the efforts presented by the committee involve fixed costs and potentially shared benefits across multiple payers, so their economic feasibility depends on Medicare’s payment system and that of other payers. Environments in which a greater share of a provider’s revenue derives from payments related to health outcomes will make it more sustainable for them to invest in programs that improve quality and reduce cost.
The communities described in the report are the very types of communities Pennsylvania’s safety-net hospitals serve.
To learn more about what the Academy learned and what it has recommended, go here to see its news release accompanying publication of the report and go here to see the report itself.
While Medicare’s readmissions reduction program has produced a decline in the number of Medicare readmissions within 30 days of discharge, critics – among them many safety-net hospitals – argue that the program is unfair to hospitals that serve especially large numbers of low-income patients whose distinct needs pose a greater risk of requiring readmission to address.
In a new report, the journal Health Affairs notes that such arguments have given rise to a number of proposals for possible changes in the readmissions reduction program. Among them, the Medicare Payment Advisory Commission
…has proposed a revision to the method for calculating readmissions. Rather than including patient SES [note: socio-economic status] in the risk-adjustment step, which MedPAC argues would take years to develop empirically and could mask true quality disparities, MedPAC suggests grouping hospitals into peer groups based on their share of low-income Medicare patients and then set readmissions targets for each peer group. Put another way, hospitals with similar shares of low-income patients would be compared with each other instead of all hospitals.
Other suggestions for modifying the readmissions reduction program include shortening the window on readmissions, which might better reflect the quality of care a hospital provides rather than the nature of the patients it serves; changing the quality measures on which hospitals are judged, choosing new measures that might be less sensitive to socio-economic factors; and providing additional financial or other support to hospitals that serve especially large numbers of low-income patients.
To learn more about the kinds of challenges Medicare’s hospital readmissions reduction program pose and what might be done to address them without discarding the program entirely, go here for the Health Affairs article “The Challenges Of Rewarding Value Over Volume Without Penalizing Safety-Net Hospitals.”
The March edition of the journal Health Affairs offers a compelling snapshot of a type of patient many safety-net hospitals serve on an almost daily basis: the “superutilizer” who lacks the ability and resources to address his own medical needs.
The article “Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital” tells the story of a patient who
…had been using drugs and alcohol since his teenage years, and he was addicted to crack cocaine and alcohol…He had been released from prison six months before we first met him, without any basic resources to help him transition back into society – not even a state ID. Lacking this fundamental necessity, he could not apply for state health insurance or a Supplemental Nutrition Assistance Program card to receive food stamps. As an ex-felon with no income, he couldn’t find a place to live. He told us he was living on the streets, where he spent his days panhandling and using the money he got to buy tacos from street vendors and hash browns from McDonald’s.
Mr. G’s first several admissions to our hospital were similar. He would walk into the emergency department, unable to breathe, and would be admitted to the hospital for treatment related to heart failure. He had a complex medical history including diabetes and extremely poor heart function – which was complicated by a clot in his heart that required the chronic use of blood thinners. Furthermore, he suffered from schizophrenia.
The hospital faced a problem in addition to caring for Mr. G.
The problem with Mr. G’s admissions, aside from their drain on hospital resources, is that to motivate hospitals to improve care, Medicare penalizes hospitals for certain patients who are readmitted within thirty days. This policy assumes that all patients have the means and internal resources to care for themselves effectively and that hospitals, by simply adhering to best practices of medical management, can avoid redundant care. Medicare fails to consider the complications imposed by poverty and the significant burden safety-net hospitals face in trying to address overwhelming social issues.
A typical admission was set in motion by Mr. G’s nonadherence to his medications, poor diet, substance abuse, or a combination of the three. With each admission, additional problems and complications cropped up that extended his stay.
The problems continue, and the article explains that
Patients like Mr. G frustrate health care providers. These patients are often dismissed as being nonadherent, and their psychosocial needs go unrecognized. Their daily challenges are compounded by poverty, mental illness, substance abuse, lack of social support, lack of transportation, and unstable housing. These factors – and other social determinants of health – set the stage for poor health outcomes in patients with low socioeconomic status.
The article concludes by noting that
Current health care policy emphasizes the reduction of readmissions but does not support the time and resources needed to achieve this goal. As the basis for payment shifts from volume to value, it will become exceedingly expensive to continue ignoring the social determinants of health.
To learn more about Mr. G, the hospital that served him, and the challenges Pennsylvania’s safety-net hospitals face when serving patients CMS has labeled “superutilizers,” go here, to the web site of the journal Health Affairs, to see the complete article “Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital.”
Under pressure from federal regulators and MedPAC, the advocacy group 340B Health is attempting to rally hospital groups behind the 340B prescription drug discount program that requires pharmaceutical companies to provide discounts to qualified hospitals for drugs dispensed on an outpatient basis to Medicaid patients.
Last year the Health Resources and Services Administration, which runs the program, issued proposed regulations that would change how the program operates and is governed. Recently, MedPAC proposed reducing the size of the discount hospitals receive for the drugs, with the savings to be redirected to fund additional Medicare disproportionate share (Medicare DSH) payments for selected hospitals.
More than 2100 organizations participate in the 340B program, including most Pennsylvania safety-net hospitals.
For a closer look at the 340B program, the changes that have been proposed, and what hospitals are attempting to do about it, see this report from CQ Roll Call presented by the Commonwealth Fund.
When the federal government turns housing, health, and social services programs into block grants, funding for such programs erodes over time, according to a new analysis by the Center on Budget and Policy Priorities.
The study found that
Policymakers advancing these proposals often accompany them… with assurances that the new block grant would get the same overall amount of funding as currently goes to the individual programs that it would replace. This new analysis of several decades of budget data strongly suggests, however, that even if a new block grant’s funding in its initial year matched the prior funding for the programs merged into the block grant, the initial level likely wouldn’t be sustained. History shows that when social programs are merged into (or created as) broad block grants, funding typically contracts — often sharply — in subsequent years and decades, with the reductions growing over time.
Of 13 such transitions from appropriation to block grant status in recent years, 11 of the programs shrunk in inflation-adjusted terms, some of them significantly so, with a median decline for the 13 of 26 percent to date.
The analysis also found that
The marked deterioration in block-grant funding over time controverts the common claim by block grant proponents that if funding levels prove inadequate, Congress will step in to provide appropriate additional funding. The general lack of responsiveness of block-grant funding to changes in need contrasts sharply with the high degree of responsiveness of entitlement programs such as SNAP (formerly known as the Food Stamp Program).
The study comes at a time when some policy-makers are talking about converting Medicaid into a block grant program. This proposal has been around for years and periodically resurfaces, as it has in the past year.
For a closer look at what happens when the federal government turns a program into a block grant, go here to see the Center on Budget and Policy Priorities’ report “Funding for Housing, Health, and Social Services Block Grants Has Fallen Markedly Over Time.”