Impact of YMCA of the USA Diabetes Prevention Program on Medicare - - PowerPoint PPT Presentation

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Impact of YMCA of the USA Diabetes Prevention Program on Medicare Spending and Utilization

Maria L. Alva RTI International

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Goals and Background

Diabetes is preventable. Diabetes Prevention Program trial participants reduced their incidence of diabetes by 58% over 3 years.1

YMCA of the USA received a Health Care Innovation Award of $11.8 million from the Centers for Medicare & Medicaid Services to

• ffer a diabetes prevention program to Medicare

fee-for-service (FFS) beneficiaries with prediabetes.

1Diabetes Prevention Program Research Group, Knowler, et al.: 10-year follow-up of

diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet Nov 14;374(9702):1677-86, 2009.

Y-USA enrolled participants January 2013─June 2015.

Goals Participants will lose 5% or more of body weight and increase physical activity to 150 minutes/week while taking part in a 16- session program + maintenance meetings. Question Did the Y-USA Diabetes Prevention Program reduce health care spending and utilization?

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Study Sample and Design

We analyzed Medicare FFS claims data through December 2015 for 3,319 participants enrolled in FFS Medicare Parts A and B.

The Y-USA model test did not have random assignment. We used econometric methods to select a comparison group with similar characteristics to participants. People selected for the comparison group were good matches to participants based on observable factors.

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Conclusions

• The overall weighted average savings per member per quarter during the

innovation’s first 3 years was $278. There were also 9 fewer inpatient stays and 9 fewer ED visits per 1,000 participants per quarter.

• Evidence that the model led to lower spending for the innovation group

was strongest in the first three quarters after enrollment—i.e., when participants were actively engaged.

• Results of spending estimates from the first 2 years of this evaluation

informed CMS’ policy that Medicare will include diabetes prevention programs as a covered benefit in 2018.

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Do timely mental health services reduce recidivism among prison releasees with severe mental illness?

Marisa Elena Domino, Joe Morrissey, Alex Gertner, Brigid Grabert, Gary Cuddeback UNC-CH Funding: Research grant funding from the NIMH (MH086232) is gratefully

• acknowledged. (

Motivation

 Lack of insurance coverage upon release from prison for adults

with severe mental illness (SMI) is an important barrier to continuous psychiatric care and may affect subsequent incarceration.

 Prior research has shown that Medicaid coverage upon release

is linked to greater mental health services use but does not affect recidivism (Morrissey et al., 2016; Grabert et al., 2017)

 In this study, we examine whether the timely receipt of mental

health services after release from prison by adults with SMI leads to differences in criminal justice contacts.

Methods

 Data: linked administrative data on publicly funded mental

health services, criminal justice contacts, and other records

 Population: 3004 adults with SMI who were released from

prison in WA in 2006 or 2007.

 Methods: referral to expedited Medicaid (n=649) served as

an instrumental variable for mental health service receipt, using two measures of quality/timeliness. We model binary

• utcomes using 2SRI, 2SLS, and bivariate probit models.

 We examine four 12-month criminal justice outcomes.

Conclusions

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We find no evidence that timely receipt of services protects against prison re-incarceration generally.

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However,

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New Charges: We find substantial evidence that receiving timely mental health services reduces arrests and re- incarceration in prison for new charges within 12 months

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Treatment + Supervision: In sub-sample analyses, we find effects may be larger in a community custody sample, indicating treatment plus supervision may be more effective in deterring re-incarceration for new charges. 

We also find that mental health treatment reduces repeat episodes in prison among those with non-drug index crimes in contrast to no effect on prison use among those with drug crimes.

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Who is Referred for Inpatient Palliative Care Consultation?

Melissa M Garrido, PhD Department of Veterans Affairs Icahn School of Medicine at Mount Sinai

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Palliative Care for Cancer (PC4C) study (NCI/NINR R01, PI: Diane Meier)

• 3,096 patients with advanced cancer
• 5 hospitals
• 2007-2011

Palliative Care = Standard of Care for Patients with Advanced Cancer

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Palliative Care Consultation Referrals Sensitive to Physical Illness Burden

Lymphoma Needs transfer assistance On pain medication at admission Number of comorbidities Physical symptom severity Psychological symptom severity

1.0 0.5 1.5 2.5 2.0

Odds Ratios and 95% Confidence Intervals

More likely Less likely

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Need for Improved Access to Palliative Care

• All of the patients in our sample were appropriate candidates for

palliative care

• < 20% of our sample received a palliative care consultation referral

Penrod JD, Garrido MM, McKendrick K, May P, Aldridge MD, Meier DE, Ornstein KA, Morrison RS. Characteristics of hospitalized cancer patients referred for inpatient palliative care consultation. Forthcoming in Journal of Palliative Medicine.

Xinxin Han, MS, Qian Luo, MPSA, Leighton Ku, PhD, MPH AcademyHealth Annual Research Meeting New Orleans, LA June 27, 2017

DOI: 10.1377/hlthaff.2016.0929. HEALTH AFFAIRS 36, NO. 1 (2017): 49–56

• The expansion of Medicaid under the Affordable Care Act (ACA)

has increased the number of Medicaid beneficiaries in expansion states, which could potentially affect community health center capacity

• The ACA also sought to enhance the capacity of community health

centers to serve more low-income population in medically underserved areas through increases in core federal funds

• Using data from 2012-2015 Uniform Data System (UDS), we

employed a difference-in-difference (DID) approach to examine the effects of Medicaid expansion and changes in federal grant level

• n patient and visit volumes, by type of insurance and services

category, in 805 federally funded health centers nationally

Objective

Xinxin Han et al. Health Aff 2017;36:49-56 (C) 2017 by Project HOPE/Health Affairs Presentation reuse permitted

• The American Health Care Act (AHCA) would end the ACA’s

enhanced funding for adult expansion population and cap federal spending per Medicaid enrollee

• The additional mandatory federal funding to health centers expires

at the end of fiscal year 2017, creating a “funding cliff”

• Changes to Medicaid’s eligibility requirements or to other aspects
• f the program and drops in funding to health centers would likely

affect health centers’ capacity to serve more low-income population, which in return could result in harder access to care

Implication

Experiences of PCPs and Staff After Lean Redesign of Care Team Workflows

Dorothy Y. Hung,*1 Michael I. Harrison,2 Quan A. Truong,1 Xue Du1

1Palo Alto Medication Foundation Research Institute 2Agency for Healthcare Research and Quality

AcademyHealth Annual Research Meeting New Orleans, June 27, 2017 * hungd@PAMFRI.org

Background

• Pre-post study of staff in Primary Care (PC) clinics within large

ambulatory delivery system that underwent Lean-based redesigns.

• Lean: seeks to enhance quality, efficiency, and improvement

capacity through staff empowerment, workflow standardization, & measurement.

• Limited findings to date on staff responses to Lean redesigns,

especially in PC.

Lean Redesigns; Data Sources

• Implementation: 46 departments housed within

17 clinics (1 pilot; 3 beta sites;13 role-out sites)

• Redesigns:

► Equipment & supply standardization ► Co-location of physician or other PC provider (PCP) &

medical assistant (MA) teams in shared workspace

► Workflows: daily team huddles, MA visit agenda

setting; joint MA-MD management of electronic inboxes

• Data: Baseline surveys of PCPs & staff

(n=1333); follow-up in same departments 18-36 months post implementation (n=1,164)

Findings and Conclusions

• After redesign PCPs & other staff report higher levels of

engagement (e.g., motivation, ownership), participation in decision making, teamwork, favorable perceptions of Lean.

• They also reported higher burnout & finding work overly

busy & stressful.

• Survey responses may reflect redesign’s unique work

demands, but results may also reflect growing work burden across primary care.

• Redesigns for quality and efficiency must produce direct

benefits to PCPs and staff without overtaxing an already

• verstretched workforce.

How Have 30-Day Readmission Penalties Affected Racial/Ethnic Disparities in Readmissions?

Cameron M. Kaplan, Michael M. Thompson & Teresa M. Waters

University of Tennessee Health Science Center, Department of Preventive Medicine

• Medicare’s Hospital Readmission Reduction Program

(HRRP)

– Financial penalties on hospitals with higher than expected readmissions

• after adjusting for case mix
• but not socioeconomic factors
• More likely to penalize safety net, urban, and minority-

serving hospitals

• What effect does HRRP have on disparities in

readmissions?

– higher penalties may incentivize hospitals that treat minority patients to improve more than other hospitals – penalties may place a burden on already financially constrained hospitals

• Data: 2009-2013 HCUP state inpatient data from 5 states

(AR, FL, IA, NY, WA)

– N= 1,120,475

• Readmissions for: acute myocardial infarction (AMI),

congestive heart failure (CHF), and pneumonia (PN).

• Logistic regression to predict readmissions as a function
• f race by year interactions, controlling for age, sex, and

comorbidies (Elixhauser).

Results

Overall Population Patients Treated in Safety Net Hospitals Adjusted Readmission Rate Odds Ratio Adjusted Readmission Rate Odds Ratio 2009, White

21.9% 1.23*** 23.4% 1.19***

2009, Black

25.7% 26.7%

2013, White

18.2% 1.15*** 18.7% 1.10***

2013, Black

20.4% 20.1%

Odds Ratio Difference

1.07*** 1.09**

*** Significant at P<0.01 ** Significant at P<0.05

Conclusions

• Black patients had greater reductions in

readmissions during the first several years of the HRRP program compared to White patients

• Significant disparities remain
• Safety net hospitals and those that received larger

penalties reduced disparities to a greater extent

• Risk adjustment that includes socioeconomic

factors may alter this relationship, so it will be important to monitor disparities moving forward

Cameron Kaplan ckaplan@uthsc.edu

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Improving Interdisciplinary Teamwork in Surgical Care In the Context of a Bundled Payment Pilot

Caroline Logan, Abt Associates Jody Hoffer Gittell, Brandeis University

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Study Design & Methods

• Bundled payments and other alternative payment models are shifting

industry towards shared accountability and reward structures

• Evaluation of relational coordination theory change effort support

improving teamwork in context of bundled payment for joint replacement surgery

• RC survey distributed to 223 clinical staff involved in care for total

joint replacement patients over two points in time. (T1: 72% response rate; T2: 76% response rate)

• Inpatient nurses, CNAs, care managers, rehab therapists, hospitalists,
• rthopedic surgeons and PAs.

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Changes in RC Scores Over Time

RC Score as rated by others Time 1 Time 2 T-test P-Value Inpatient RNs 4.27 4.02 2.13 0.09 Inpatient CNAs 4.09 3.81 2.47 0.06 Rehab Therapists 4.14 4.21

• 0.89

0.41 Care Managers 4.13 4.25

• 0.96

0.38 Orthopedic MDs/PAs 3.79 3.89

• 0.65

0.54 Hospitalists 3.59 3.97

• 2.34

0.06

RC score includes the mean score of each workgroup as rated by their own by workgroup and other workgroups

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Improvements & Findings

• Clarified hand-offs between the surgical service and the hospital

service

• Particularly for patients with complex medical needs
• Standardized communication across staff around planning
• Prior to surgery and during inpatient stay
• Greatest gains were around coordination with physicians
• Nurses and other staff still reported challenges

Mortality and Hospitalizations in Intensive Dialysis:

A Systematic Review and Meta-analysis

Anna Mathew MD, MPH Associate Professor of Medicine Hofstra Northwell School of Medicine Division of Kidney Diseases and Hypertension Northwell Health, NY

BACKGROUND & METHODS

BACKGROUND

• Conventional vs. Intensive hemodialysis (HD)
• Current evidence on mortality and hospitalization are

conflicting

METHODS

• Systematic Review and Meta-analysis (PRISMA)
• Cochrane Central Register, MEDLINE, EMBASE, Pubmed, ISI

Web of Science, conference abstracts (March 2016)

• Inclusion Criteria: intensive HD (> 4/wk or >5.5 hrs/session)
• vs. conventional dialysis, observational and RCT

RESULTS: Study Selection and Quality

• Low or Very Low quality of evidence using GRADE approach
• due to imprecision, residual confounding, selection bias

RESULTS: Mortality and Hospitalization

FIG 1: Comparative risk of Mortality in Nocturnal Home HD vs Conventional HD

CONCLUSIONS

Need focus on patients’ values/preferences Future trials on patient subgroups that may have clear benefit

FIG 2: Comparative Mean Difference in Hospitalization days/patient-year for Nocturnal Home HD vs Conventional HD

Presenter: Semret Seyoum, MPH PI: Holly Mead, PhD AcademyHealth ARM June 27, 2017

CER Study: To compare quality, effectiveness of survivorship models of care

• Recruited 35 programs in 32 CoC-Accredited Cancer centers
• Identified three models of care: 1) specialized consultative, 2) specialized longitudinal, 3) oncology embedded
• Classified into models: Models 1=16 programs; Model 2=6 programs; Model 3=13 programs

CER Design: Cancer Center Sampling and Model Classification

• Recruited 991 breast, prostate colorectal cancer survivors who had completed all active cancer treatment
• Collected data at 4 time points: baseline, week 1, month 3, months 6 through patient surveys
• 20% attrition rate for final study sample N=774

CER Design: Patient Sampling and data collection

• Newly developed and tested Survivorship Care Quality Index: measures 9 components of quality prioritized by

patients

• Cancer-related quality of life with 3 domains: physical concerns, emotional concerns, practical concerns
• Self-efficacy index reflecting how well patients can manage their health and health care

CER Design: Patient-Centered Outcomes

Quality of Care Key Findings

• Oncology-embedded models underperform compared

to specialized models

• Quality scores significantly lower on 8 of 9 quality

components at week 1 (p<.05)

– Mental health/social support; information/resources – Empowering patients; meaningful communication – Care coordination; access to full spectrum of care

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QOL, Self Efficacy Key Findings

• Patients in Oncology Embedded model report lowest physical & emotional

QOL concerns, highest self-efficacy scores at baseline

• Patients in consultative specialized model report lower concerns over time

for top QOL indicators

• Patients in longitudinal specialized model report higher concerns over

time

• Patients in embedded model report significantly higher self-efficacy scores
• ver time, but start higher at baseline (p<.01)
• Patients in longitudinal specialized model show biggest increase in self-

efficacy scores over time (p<.05)

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Medical Expenditures Associated with Hypertension in the United States, 2000-2013

Donglan Zhang, PhD,1 Guijing Wang, PhD,2 Ping Zhang, PhD,3 Jing Fang, MD,2 Carma Ayala, RN, MPH, PHD 2

1 Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia; 2 Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; 3 Division for Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia

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INTRODUCTION

• During 2000–2013, the prevalence of hypertension among U.S. adults

aged 18 years or older was largely unchanged (28.4% during 1999– 2000 and 29.3% during 2013–2014). Over this period, treatment of hypertension with antihypertensive medications significantly improved. This study analyzes the trend of medical expenditures associated with hypertension from 2000 to 2013 among U.S. adults.

• METHODS
• This study used data from the Household Component of Medical

Expenditure Panel Survey (MEPS).

• Study population: men and non-pregnant women aged ≥18 years.
• Two-part regression models were applied to analyze the expenditures.

Trend analyses for medical expenditure estimates were conducted using Joinpoint software.

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RESULTS

300 400 500 600 700 800 00-01 02-03 04-05 06-07 08-09 10-11 12-13 Year Outpatient Medication Others Per-Person Medical Expenditures Associated with Hypertension by Types of Services

US Adults 2000-2013 1000 1500 2000 2500 3000 00-01 02-03 04-05 06-07 08-09 10-11 12-13 Year Age 18-44 Age 45-64 Age >=65

US Adults 2000-2013 Per-Person Medical Expenditures Associated with Hypertension by Age Group

1000 1500 2000 00-01 02-03 04-05 06-07 08-09 10-11 12-13 Year Male Female

US Adults 2000-2013 Per-Person Medical Expenditures Associated with Hypertension by Gender

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RESULTS

500 1,000 1,500 2,000 00-01 02-03 04-05 06-07 08-09 10-11 12-13

Year

Source: Medical Expenditure Panel Survey 2000-2013

Per-Person Medical Expenditures Associated with Hypertension 20 40 60 80 100 00-01 02-03 04-05 06-07 08-09 10-11 12-13

Year

Source: Medical Expenditure Panel Survey 2000-2013

Annual National Medical Expenditures Associated with Hypertension

Variables Average annual percent change P-value for trend Per-Person Medical Expenditures –0.6 0.794

• No. with hypertension (million)

9.8 <0.001 Annual National Spending (billion) 8.3 0.015