Health Care Policy
Accountable care organizations that joined the Medicare Shared Savings Program (MSSP) when it launched in 2012 achieved modest savings while maintaining or improving performance on measures of quality of patient care in 2013, the first full year of the program, researchers at Harvard Medical School found in the first rigorous examination of this key health care payment reform program.
These early adopters lowered spending by 1.4 percent in 2013 relative to a control group of non-ACO providers in the same areas, which represents a $238 million reduction in spending.
These savings provide more evidence of early promising results from accountable care organization initiatives in Medicare, of which the MSSP is the largest, but the results also tell a more complex story about the pattern of savings across different types and cohorts of ACOs.
The findings were published in the New England Journal of Medicine.
ACOs are groups of health care providers who agree to provide care to a population of patients under a global budget known as a benchmark. ACOs that hold spending below the benchmark and perform well on measures of quality of care share in the savings.
In contrast with other ACO programs such as the Pioneer model, MSSP participants are not required to reimburse Medicare if spending exceeds the benchmark.
The first two cohorts of provider groups (220 in total) entered the MSSP in mid-2012 or at the beginning of 2013. Since then, the program has expanded and currently includes over 430 participants.
While the ACOs that joined in 2012 cut spending by $238 million, the next cohort of ACOs that joined in 2013 achieved no savings in their first full year in the program, suggesting that the early success of the first participants may not be replicated by the subsequent waves of ACOs that have joined the MSSP.
In addition, because Medicare paid out $244 million in shared-savings bonuses to ACOs in the 2012 cohorts, the lower spending in that cohort did not constitute net savings to Medicare.
“These results suggest that ACOs with no downside risk can achieve savings, but that savings to Medicare and society may be slow to develop,” said J. Michael McWilliams, the Warren Alpert Associate Professor of Health Care Policy at HMS and lead author of the study.
“But the incentives for ACOs to lower spending are currently very weak, so savings may accelerate if the incentives are strengthened.”
In particular, the current method for setting an ACO’s benchmark diminishes its incentives to save. Specifically, if an ACO lowers spending now, it is penalized with a lower benchmark later.
According to the authors, severing the link between an ACO’s benchmark and its previous savings could go a long way toward rewarding ACOs adequately for curbing wasteful practices and allowing the returns necessary for ACOs to invest in more efficient systems of care.
The investigators also found that independent primary care groups participating in the MSSP achieved significantly greater savings than hospital-integrated groups.
“Some have presumed that forming a large hospital system that owns a lot of outpatient practices is a prerequisite for ACO success,” McWilliams said. “We do not find this to be the case.”
One reason for this finding, the authors note, is that independent physician groups have stronger incentives to prevent hospitalizations than hospital-owned groups, since their shared-savings bonuses from doing so are not offset by foregone organizational profits from the reduction in hospital care.
Finally, the authors found that ACOs in the MSSP with high spending for their region achieved greater savings than ACOs with spending below the regional average. This suggests that ACOs with more opportunities to cut spending had an easier time doing so.
Recently, the Centers for Medicare and Medicaid Services proposed transitioning to a system in which an ACO’s benchmark would be primarily based on average spending in its region.
Because the participation of high-spending ACOs in the voluntary MSSP is particularly valuable for lowering overall spending in Medicare, the authors caution against moving to such regional benchmarks too quickly. Doing so could prompt ACOs with high spending for their region to leave the program, thereby diminishing program-wide savings.
“These early results are encouraging overall,” said McWilliams, who is also a practicing general internist and HMS associate professor of medicine at Brigham and Women’s Hospital. “But building on the initial success of ACO models in Medicare will require stronger incentives and rigorous evaluations to identify groups of systematically successful ACOs whose organizational models and strategies can be disseminated.”
This research was supported by grants from the National Institute on Aging of the National Institutes of Health (P01 AG032952 and F30 AG044106-01A1) and from the Laura and John Arnold Foundation.
Retail clinics, seen as a convenient and cost-saving alternative to physician offices and hospital emergency departments, may actually drive up medical spending by creating demand for new medical services, according to a new study.
Examining data about people who visited retail clinics for low-severity illnesses such as urinary tract infections and sinusitis, researchers found that in most cases people would have stayed home and not sought medical care if the retail clinic had not been available. The convenience of retail clinics, both in terms of location and expanded hours of operation, probably makes them an attractive alternative to staying home and suffering through a minor illness, researchers said.
Prior studies have shown that spending on retail clinic visits is lower than spending on office visits and especially emergency department visits, and the new study found that some people did trim spending by visiting retail clinics instead of costlier physician offices. However, such savings were overshadowed by the increased spending on new medical care.
The study, the first to examine whether retail clinics increase use of medical services, was published in the March edition of Health Affairs.
“These findings suggest retail clinics do not trim medical spending but instead may drive it up modestly because they encourage people to use more medical services,” said senior author Ateev Mehrotra, associate professor of health care policy at Harvard Medical School and an adjunct researcher at the RAND Corporation. “Retail clinics do offer benefits such as easier access to medical care, but the widely expected cost savings may not be realized.”
Retail clinics are walk-up medical providers typically located in drug stores and in retail chain stores such as Target and Wal-Mart. Care most often is provided by nurse practitioners rather than by physicians.
First appearing in 2000, there are now nearly 2,000 retail clinics across the United States, and they receive more than 6 million patient visits annually. Visits to retail clinics are less expensive than visits to physician offices or emergency departments, both because charges are lower for the visit and fewer tests are performed.
Researchers from HMS, RAND and other institutions assessed whether visits to retail clinics for low-intensity conditions represented substitution for higher-cost care or new use of medical services by examining information about a large group of people enrolled in health plans offered by a private health insurer in 22 U.S. cities in 2010 to 2012.
The analysis focused on visits for 11 low-acuity conditions that account for more than 60 percent of all visits to retail clinics. The health insurer covered retail clinic visits during the study period, with copayments for retail clinics that were similar to copays for visits to physician offices.
Researchers compared the experiences of 519,542 enrollees with at least one retail clinic visit with a random sample of 861,557 other enrollees who did not receive care at a retail clinic. Analyzing patterns of medical service use between the two groups allowed the study to determine whether retail clinic visits for low-acuity conditions represented substitutions or a new use of medical care.
Researchers estimated that 42 percent of the visits to retail clinics for low-acuity ailments represented substitution for a visit to a physician office or emergency department, with 58 percent representing new use of medical services.
Each use of retail clinics for new medical services increased per person spending by an average of $35 per year. That was partly offset by $21 in savings among those people whose visit to a retail clinic substituted for higher-priced medical care. So the overall spending increase prompted by retail clinics was $14 per enrollee annually, according to the study.
While the overall increase was modest, it did represent a 21 percent increase in spending for low-acuity conditions.
“While retail clinics do allow some users to lower their medical spending, the new use of medical services outweighed the savings from the substitution we observed among the large group of people we studied,” said Scott Ashwood, the study’s lead author and associate policy researcher at RAND, a nonprofit research organization.
Most health insurers now cover care at retail clinics and many have created financial incentives to encourage use of the clinics, such as waiving copays for such care.
“Our findings may impact the decisions of health plans as they decide whether and how to cover care at retail clinics,” said Mehrotra, who is also HMS associate professor of medicine and a hospitalist at Beth Israel Deaconess Medical Center. “If the goal is to lower costs, then encouraging use of retail clinics may not be a successful strategy.”
While the study challenges notions that retail clinics may help cut health costs, researchers said clinics do likely provide value by offering a source of health care for people who cannot obtain timely care from a primary care provider.
Future studies should further explore the influence of retail clinics on overall health spending, as well as how retail clinics affect the coordination of medical care and what quality of care retail clinics provide for chronic illnesses.
Support for the study was provided by the Robert Wood Johnson Foundation.
We see it happen all too often: The youthful visage of a candidate becomes, in a few short years, the grizzled countenance of a head of state. But is this oft-observed rapid aging evidence of a statistically significant health impact of simply being an elected head of state?
A team of researchers led by senior author Anupam Jena, associate professor of health care policy at Harvard Medical School, set out to test the theory that politicians elected to lead a country’s government may experience premature death.
After adjusting for life expectancy at time of last election, the team found that elected leaders lived 2.7 fewer years and experienced a 23 percent greater risk of death compared to runners-up.
“This suggests that the stress of governing may substantially accelerate mortality for our elected leaders,” said Anupam Jena, who is also a physician at Massachusetts General Hospital.
“By comparing the lifespans of elected leaders with runners-up, we were able to calculate the mortality cost of winning elections and serving as head of state,” said co-author Andrew Olenski, HMS research assistant in health care policy.
The researchers compared 279 nationally elected leaders from 17 countries to 261 unelected candidates who never served in office. The study group was made up of candidates in elections that took place from 1722 to 2015.
The researchers determined the number of years each competitor lived after the last election that they ran in, and compared the results to the average life span for an individual of the same age and sex as the candidate during the year of the election.
The researchers designed their study to overcome the limitations of similar studies of elected officials and other successful individuals.
The researchers said that earlier research by others found no significant effect on the life expectancies of U.S. presidents, perhaps because the sample size was too small. In addition, presidents would be expected to live longer than the general population due to higher socioeconomic status alone. The failure of prior studies to detect a difference suggests that mortality costs of being president may have been masked. Similar studies of life expectancies for winners of prestigious prizes such as the Academy Awards and the Nobel Prize have also been conducted.
This research was supported by the Office of the Director of the National Institutes of Health (NIH early independence award, grant 1DP5OD017897-01).
People diagnosed with mental health conditions did not see improvements in coordination and quality of their care, as some had hoped, but they also did not experience large cuts in access, as some had feared. Those were some of the findings of a team of researchers from Harvard Medical School and Johns Hopkins Bloomberg School of Public Health who studied an early alternative payment model designed to encourage coordinated health care.
The research team looked at claims data from 2006-2011 to examine whether the implementation of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract affected mental health service use, mental health care spending, total spending and quality of care.
They also interviewed providers and managers about the process of implementing the AQC and the potential for developing systems to improve coordination of care for people with mental health diagnoses.
The researchers said the interviews suggest that these organizations were not focused on mental health integration when the contract was first implemented but are now thinking creatively and innovatively about developing new programs. Some involve integrating social workers into treatment teams focused on non-mental health conditions, like diabetes, to better identify and support patients with mental health conditions who would benefit from more integration of mental health and medical care. They said it is too early to have seen results from these new programs.
“The initial effort didn't solve the problem of fragmented care for people with mental health conditions,” Huskamp said. “We still need to do more to integrate the care that they get.”
The study was led by Haiden Huskamp, professor of health care policy in the Department of Health Care Policy at Harvard Medical School, and Colleen Barry, professor and associate chair for research and practice in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. The findings are published in the December issue of Health Affairs.
“The initial effort didn't solve the problem of fragmented care for people with mental health conditions,” Huskamp said. “We still need to do more to integrate the care that they get.”
Payment reform experiments
While the traditional fee-for-service model provides a financial incentive for providers to perform more procedures, new payment models that provide a lump sum to cover all the costs of a person’s care can motivate physicians and hospital administrators to focus on providing the highest value care and improving care coordination, although the new models could also result in reduced access to care.
Various organizational approaches to this goal—accountable care organizations, bundled payments, global budgets—are part of many public and private health care reform efforts. One early example is the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract, which began in 2009.
An earlier study of the AQC found that for the general population, the growth of overall health care spending slowed and some measures of quality of care improved.
Huskamp, Barry and colleagues at HMS, Johns Hopkins and McLean Hospital wanted to know whether the model had the same effects on people who receive mental health care.
This is a crucial population for health care reform. Mental health disorders affect tens of millions of people in the United States each year, and the total direct and indirect costs of the most serious mental health illness are more than $300 billion per year, according to the National Institute of Mental Health.
Integrating fragmented care
Since care for mental health is even more fragmented than care in the rest of the health care system—with distinct insurance benefits for mental and behavioral health, and a separate mental health care system that is often not directly linked to primary or secondary medical care services—the researchers noted that it is an area that could benefit greatly from efforts to improve the quality and coordination of care.
Instead, they found that some AQC patients with a mental health diagnosis were slightly less likely to receive mental health services than a comparable group covered by the same insurer. They also found that for people who did use mental health services, spending did not change.
In addition, people with mental health diagnoses were less likely to benefit from improvements in quality of care.
For example, to help prevent and treat chronic illnesses, the AQC offers incentives for clinicians to increase the use of diabetes management approaches. Providers working under the AQC were more likely to adopt certain diabetes management approaches for patients in the AQC than for a comparison group of Blue Cross Blue Shield enrollees not in the AQC, but these improvements were not found among the subgroup of AQC enrollees with both diabetes and a co-occurring mental health diagnosis.
According to the researchers, as accountable care evolves, policymakers, insurance companies and providers will need to understand how these reforms affect care for often high-cost individuals with mental health treatment needs.
“In order to take advantage of the transformative power of coordinated care,” Barry said, “we need to make sure that the incentives and quality measures we use address the needs of this crucial population.”
In addition to their quantitative analysis, the researchers also conducted interviews with providers and managers in a variety of organizations to understand the context for the complex transformations taking place.
Interview participants said that many organizations spent the first years of the contract building the basic infrastructure for collecting the data necessary to coordinate care and measure progress, and that their organizations have only recently begun to address some of the more challenging changes needed to manage mental health care delivery.
“They now have to think about the whole person, and that's changing how they do business,” Huskamp said.
The study was funded by Commonwealth Fund grant number 20130499.
Co-author Robert Mechanic is a trustee at Atrius Health, one of the provider organizations that signed the Alternative Quality Contract with Blue Cross Blue Shield of Massachusetts (BCBSMA).
Unless those who object to the Affordable Care Act are willing to put forth an alternative with comparable information about its effects on spending and access to care, then the huge amount of time that has been devoted to the ACA debate should be used for more constructive policymaking.
This was the theme at the 15th annual Seidman Lecture at Harvard Medical School on Nov. 2, delivered by the next dean of the Harvard John F. Kennedy School of Government, Douglas Elmendorf.
“We have a lot to do, and we should get going,” Elmendorf said.
Elmendorf drew upon his vast experience to share his analysis of the Affordable Care Act and his recommendations for next steps for federal health care policy. In addition to heading the Congressional Budget Office from January 2009 until March of this year, Elmendorf spent much of his prior professional career at the Federal Reserve Board, the Council of Economic Advisers and the Treasury Department
Elmendorf is currently serving as a visiting fellow at the Brookings Institution. He was named to head the Harvard Kennedy School in June and will assume that role in January 2016.
The audience for the Seidman Lecture included leading scholars in health policy from HMS, the Harvard T.H. Chan School of Public Health, the Harvard Kennedy School and the Harvard Faculty of Arts and Sciences, as well as physicians and leaders from Harvard-affiliated and other Boston area hospitals.
“The incoming dean was able to weave together judgments related to value and critical analysis in his review of the ACA,” said Barbara McNeil, Ridley Watts Professor of Health Care Policy and head of the HMS Department of Health Care Policy, in an interview after the event. “HMS was pleased to be the first school at Harvard to introduce him to this distinguished community.”
Assessing the state of federal policy
“In my view, the system of rules and subsidies established by the ACA is the right system in its fundamental elements, although we could discuss the pros and cons of specific changes within that system,” Elmendorf said.
His view was based on two judgments. “The first is a value judgment—I think we should bear the cost of achieving nearly universal health insurance in this country,” he said, “and the second is an analytic judgment—there are no alternatives to the ACA framework that would achieve that goal at significantly lower cost.”
Elmendorf made recommendations for changes to federal health care policy that he said could potentially further reduce spending and improve the value of care, including incentives to limit the use of unduly expansive health insurance, payment reforms for Medicare, and efforts to make markets for health care and health insurance more competitive.
“This was a remarkably clear, comprehensive assessment of where the American health care system is—the challenges it faces and how it might address those challenges,” said Michael Chernew, Leonard D. Schaeffer Professor of Health Care Policy at HMS, in an interview after the event.
In 2000, on the occasion of his 50th reunion from Harvard Law School, Marshall J. Seidman provided endowment support to the Harvard Medical School Department of Health Care Policy to support research related to health care costs and quality and to host an annual meeting by a leading policy maker on issues related to costs and quality of health care with a particular emphasis on activities that are most likely to impact on federal and state approaches to these problems. The department has sponsored the lectures yearly since 2001.
Higher-spending physicians face fewer malpractice claims, a study led by researchers at Harvard Medical School has found.
Nearly three-quarters of physicians report practicing defensive medicine, which is broadly defined as the ordering of tests, procedures, physician consultations and other medical services solely to reduce risk of malpractice claims. Defensive medicine is estimated to cost the U.S. as much as $50 billion annually.
Despite its ubiquity among physicians, whether or not higher spending by physicians actually reduces malpractice claims is unknown. One view is that better communication and early apologies for errors can reduce a physician’s liability. However, greater spending by physicians could also either reduce errors or signal to patients, attorneys and courts that despite an error, a physician was exhaustive in his or her care.
The research was led by Anupam Jena, associate professor of health care policy at Harvard Medical School and an internist at Massachusetts General Hospital. The findings, published in the BMJ, combined data on 18,352,391 hospital admissions in Florida during 2000-2009 with data on the malpractice histories of the 24,637 physicians who treated patients during those hospitalizations. Overall, 4,342 malpractice claims were filed against physicians (2.8 percent per physician-year), with malpractice claims rates ranging from 1.6 percent per physician-year in pediatrics to 4.1 percent per physician-year in general surgery and obstetrics and gynecology.
Jena and colleagues at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California and at Stanford University found that in six out of seven specialties, higher-spending physicians faced fewer malpractice claims, accounting for differences in patient case-mix across physicians.
For example, among internal medicine physicians, those in the bottom 20 percent of hospital spending (approximately $19,000 per hospitalization) faced a 1.5 percent probability of being involved in an alleged malpractice incident the following year, compared to 0.3 percent in the top spending quintile (approximately $39,000 per hospital admission).
Similar findings were seen in C-section rates among obstetricians. High C-section rates are commonly considered a signal of defensive practice, and obstetricians who performed relatively more C-sections were less likely to face a malpractice claim.
“It has remarkably been unknown whether defensive medicine ‘works’ or whether the majority of U.S. physicians could be incorrect in believing that greater spending is associated with reducing malpractice liability,” said Jena.
Prior work by Jena and co-author Seth Seabury, a Fellow at the Schaeffer Center and associate professor of clinical emergency medicine at the Keck School of Medicine at USC, has found that the typical physician spends nearly 11 percent of their career with an open malpractice claim and that in high-risk specialties, the lifetime risk of being sued is nearly 100 percent.
“The threat of malpractice is a very salient risk for most practicing physicians, particularly in high-risk specialties,” Seabury said. “If physicians perceive that higher spending can protect them from malpractice claims, then they are likely to practice defensively even if they feel that the additional spending is unnecessary or offers no clinical benefits to patients.”
An important limitation of the study is that it could not conclude exactly why greater spending by physicians was associated with fewer malpractice claims. Moreover, whether higher levels of spending were defensively motivated by malpractice concerns is still unknown.
“Although not conclusive, our study provides initial evidence on why efforts to reduce health care spending among physicians may meet sluggish opposition. Physicians may perceive a potential tradeoff between lowering spending and increasing risk of malpractice,” Jena said. “Broader health care reform efforts should recognize the role that physician perceptions about malpractice play in resource utilization decisions.”
The study was funded by an Early Independence Award 1DP50D017897-01 from the National Institutes of Health.
In 2010, people in America spent 1.1 billion hours seeking health care for themselves or for loved ones. That time was worth $52 billion.
“That’s about the same as all of the time worked in a year by the entire working population of the city of Dallas,” said Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School.
Mehrotra is a lead author of two studies published this fall that measure the amount of time patients spend seeking care; calculate the total time costs to society; and analyze the difference in time burden by race, ethnicity and socioeconomic status.
Writing in the American Journal of Managed Care, the researchers reported that the average total visit time for a person seeking care for themselves, a child or another adult was 121 minutes. That total includes 37 minutes of travel time and 84 minutes in the clinic. Of those 84 minutes, people spent only 20 minutes with physicians; they spent the rest of the time waiting, interacting with nonphysician staff, or completing paperwork or billing.
Economists calculate the value of time spent doing an activity—known as opportunity cost—based on the income that an individual would earn working the same amount of time. The researchers calculated that the average opportunity cost per visit was $43, compared to an average out-of-pocket cost per visit of $32.
“We also found that this time burden fell disproportionately on the disadvantaged,” said Kristin Ray, assistant professor of pediatrics at University of Pittsburgh School of Medicine.
Writing in JAMA Internal Medicine, the researchers reported that, while all groups spent the same 20 minutes face-to-face with physicians, blacks and Hispanics spent approximately 25 percent longer when seeking health care than whites, due to increased travel, wait and administrative times. Lower-income groups and the unemployed also spent more time seeking care than their better-off counterparts.
“Typically, when we talk about how much we spend on health care, we focus on what is paid to doctors and hospitals through co-pays and insurance payments,” said Mehrotra, who is also a physician and HMS professor medicine at Beth Israel Deaconess Medical Center. “This work helps us put a dollar amount on the significant time it costs people to seek health care.”
The researchers said that it is important to consider time costs when evaluating innovative treatment and care delivery models designed to create higher value, more patient-centered care and to reduce health care disparities. They noted that many initiatives currently underway might offer considerable benefits in reducing the time-cost burden of health care. These initiatives include streamlining office visits; incorporating clinics into schools, community centers, and places of work; and using new models of care delivery, such as telemedicine visits, e-visits and other Internet-powered medicine.
The researchers combined data from several sources to calculate time spent in transit, at the clinic and with clinicians face-to-face. One key resource was the American Time Use Survey, which ties detailed reporting about how respondents spend their day in a given 24-hour period with demographic and income information.
These studies were supported in part by grants from the California HealthCare Foundation, the Health Resources and Services Administration National Research Service Award for Primary Medical Care, the Agency for Healthcare Research and Quality, and the National Institutes of Health.
Women physicians are substantially less likely to be full professors than men of similar age, experience, specialty and research productivity.
With recent increases in the number of women attending medical school, women now comprise nearly half of all new physicians. But the proportion of women at the rank of full professor at U.S. medical schools has not changed since 1980, despite efforts to increase equity, according to a new research study led by Anupam Jena, associate professor of health care policy at Harvard Medical School. The results are published today in JAMA.
“Many people have opinions about why women in medicine are less likely to be promoted than men,” said Jena, who is also a physician at Massachusetts General Hospital. “We're trying to separate fact from conjecture by using detailed data.”
Taking advantage of a database from Doximity, a commercial social networking service for physicians containing professional data from more than a million doctors and more than 90,000 U.S. medical school faculty members, the researchers were able to analyze data from state licensing boards, Pub Med and other sources, which was compiled by the company and verified by registered users.
Many theories exist to explain the persistent gap between male and female promotions, Jena said, including suggestions that women are promoted less often because they take time off from their careers during childbearing, that they choose specialties that offer fewer opportunities for promotion, or that they are less productive because, on average, they make different work-life choices than men.
It is also thought that the pre-existing shortage of senior women faculty members may make it hard for young women trainees to find mentors. These and other factors, the thinking goes, might make women less productive than men, and therefore, less likely to be promoted in a system that rewards research productivity.
Jena and colleagues wanted to see what the numbers said.
First, they found that there were some significant differences in productivity. Women averaged fewer total publications than men (on average, 11.6 publications for women vs. 24.8 publications for men) and fewer papers on which they were the first or last author (5.9 first or last authorships for women vs. 13.7 for men). They were also less likely to have NIH grants (6.8 vs. 10.3) or to have led large clinical trials (6.4 percent vs. 8.8 percent). But most of these differences stemmed from the fact that female faculty were younger, on average, than male faculty.
When the researchers looked at women and men with identical age, experience and research productivity, they found that women were nearly 13 percent less likely to be full professors than their male peers.
Answering the question of equal pay for equal work is challenging across professions, Jena noted, because it can be difficult to find big data sources with good measures of productivity. Since research productivity is the major currency of success in academic medicine, the number of papers, grants and clinical trials serve as an objective measure to compare the output of individuals of different sexes.
“What we see here is that women and men doing equal work are not being equally rewarded,” Jena said. “If the goal is to achieve equity, or to give incentives for the best researchers to stay in academic medicine, we need to work on closing that gap.”
This research was funded by the Office of the Director, National Institutes of Health (NIH Early Independence Award, 1DP5OD017897-01).
To encourage hospitals to improve quality of care, Medicare penalizes those with higher than expected rates of readmission within 30 days of discharge.
The logic behind the penalties is that if patients receive high quality care, including proper discharge planning, they should be less likely to end up back in the hospital.
This seems straightforward, but it turns out that the social and clinical characteristics of a hospital's patient population that are not included in Medicare’s calculation explain nearly half of the difference in readmission rates between the best — and the worst — performing hospitals, according to the results of a study published in JAMA Internal Medicine.
Using the standard Medicare formula—which adjusts only for patient age, sex and certain diagnoses—the best-performing hospitals had 4.4 percent fewer readmissions than the worst-performing hospitals.
Researchers from Harvard Medical School’s Department of Health Care Policy found that including a more comprehensive set of patient characteristics—including clinical variables such as self-reported health, cognition and functional status, as well as sociodemographic variables such as race and ethnicity, income and educational attainment — cut the difference nearly in half, to 2.3 percent.
In 2014, Medicare levied penalties totaling $428 million on 2,600 hospitals with higher than expected readmission rates. The fines were concentrated among hospitals that serve disadvantaged communities.
The researchers wanted to find out if that was because these hospitals do a worse job of treating their patients or because the people who use the hospital have a higher risk of readmission due to their socioeconomic and clinical status.
“The readmissions reduction program is designed to penalize hospitals for poor quality of care, but our findings suggest that hospitals are penalized to a large extent based on the patients that they serve,” said J. Michael McWilliams, HMS associate professor of health care policy and medicine, a practicing internist at Brigham and Women’s Hospital and senior author of the study.
Using nationally representative survey data and linked Medicare claims, the researchers assessed 29 characteristics not included in standard adjustments as potential predictors of 30-day readmission.
They found that the distribution of many of those characteristics differed substantially between hospitals with higher vs. lower readmission rates reported by Medicare.
They then compared the difference in readmission rates between these hospitals before and after adjusting for the more comprehensive patient profile.
“By extension, our findings suggest that the hospitals treating the sickest, most vulnerable patients are being deprived of resources that they could use to take better care of their communities,” said Michael Barnett, research fellow in medicine at HMS and Brigham and Women’s and lead author of the study.
Barnett, McWilliams and co-author John Hsu, HMS associate professor of health care policy and medicine at Massachusetts General Hospital noted that there are a number of potential solutions that would serve the goal of reducing readmissions and improving quality of care without exacerbating disparities by penalizing hospitals that treat sicker patients.
“Efforts to improve quality do not have to be at cross purposes with the goal of eliminating disparities,” McWilliams noted.
Risk adjustment, for example, could be more comprehensive. The authors cite recent legislation that calls for investigation of the effects of adjustment for more clinical and social characteristics on how providers perform on quality measures.
Because detailed information on patients is difficult to collect, however, programs like the Hospital Readmissions Reduction Program may need to be redesigned to achieve their goals while minimizing unintended consequences.
For example, inadequately adjusted comparisons against national averages could be replaced with incentives for hospitals to improve over their baseline performance.
Alternatively, payment models that place the full spectrum of care under a global budget could allow providers greater discretion in identifying and reducing avoidable events such as readmissions.
“Hospital readmissions are complex and can result from any number of factors, like poor health literacy or lack of access to transportation,” Barnett said. “Therefore, it’s crucial to have a comprehensive picture of patients’ social and clinical context when assessing hospital quality.”
This study was supported by grants from the National Institute on Aging (P01AG032952) and Health Resources and Services Administration (HRSA) (T32-HP10251).
Hundreds of millions of times every year many of us turn to a new kind of online software called symptom checkers to try to self-diagnose our symptoms and to get advice on whether we should seek further medical care or just rest at home until we feel better.
But how good is the information we receive?
The first wide-scale study of the accuracy of general-purpose symptom checkers found that while the online programs are often wrong, they are roughly equivalent to telephone triage lines commonly used at primary care practices—and they are better than general Internet-search self-diagnosis and triage. The study, led by researchers at Harvard Medical School, is published in the BMJ.
“These tools may be useful in patients who are trying to decide whether they should get to a doctor quickly, but in may cases, users should be cautious and not take the information they receive from online symptom checkers as gospel,” said senior author Ateev Mehrotra, associate professor of health care policy and medicine at HMS and Beth Israel Deaconess Medical Center.
Symptom checkers are hosted by medical schools (including Harvard Medical School), hospital systems, insurance companies and government agencies (including the United Kingdom’s National Health Service). This type of software asks users to list their symptoms, using methods such as multiple choice checklists and free text entry. Once a program has collected the information, the computer returns a list of potential illnesses that might cause the listed symptoms and suggests whether the patient should seek care immediately, visit a doctor in the next few days or use self-care methods, such as resting at home.
To test the symptom checkers, the researchers created standardized lists of symptoms from 45 clinical vignettes that are used to teach and test medical students and then inputted those symptoms into 23 different symptom checkers. Overall, the software algorithms that the researchers studied listed the correct diagnosis first in 34 percent of cases. The correct diagnosis was included in the top 3 diagnoses in the list in 51 percent of cases and in the top 20 in 58 percent.
In many cases, getting the exact diagnosis may not be as important as getting the correct advice about whether—or how quickly—to go to the doctor.
“It’s not nearly as important for a patient with fever, headache, stiff neck and confusion to know whether they have meningitis or encephalitis as it is for them to know that they should get to an ER quickly,” Mehrotra said.
Overall the 23 symptom checkers provided correct triage advice in 58 percent of cases with the checkers performing much better in more critical cases, correctly recommending emergency care in 80 percent of urgent cases. In comparison, other studies have found that Internet search engines for urgent symptoms only led to content that suggested emergency medical treatment 64 percent of the time.
The symptom checkers that were evaluated tended to be overly cautious, encouraging users to seek care for situations where staying at home might be reasonable. The researchers noted that this tendency toward overly cautious advice encouraged people to seek unnecessary care—an outcome that health care reform seeks to minimize in order to reduce costs.
The researchers found that there was a great deal of variation between checkers, but none were without limitations; for example, checkers with the most accurate diagnoses (Isabel, iTriage, Mayo Clinic, and Symcat) were not on the list of the programs that did the best job of recommending the appropriate level of care for a given case (Healthychildren.org, Steps2Care and Symptify).
Symptom checkers are part of a larger trend of both patients and practitioners using online platforms for a range of health care tasks, such as patient-doctor chat sessions and algorithmic tools used to aid the diagnosis and triage of patients, the researchers said.
“The tools are not likely to go away,” said first author Hannah Semigran, HMS research assistant in health care policy. “With symptom trackers, we’re looking at the first generation of a new technology. It’s important to continue to track their performance to see if they can reach their full potential in helping patients get the right care.”
Other authors on the study were Courtney Gidengil, HMS instructor in pediatrics at Boston Children’s Hospital and a physician scientist at the RAND Corporation, and Jeffrey Linder, HMS associate professor of medicine and a physician and researcher at Brigham and Women’s Hospital.
Harvard Medical School’s Family Health Guide is used as the basis for one of the symptom checkers evaluated. None of the study authors is involved with the HMS-related symptom checker.
This study was funded by the U.S. National Institutes of Health (National Institute of Allergy and Infectious Diseases grant #R21 AI097759-01).