Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences

Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients—those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs—those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks—to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient–provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured highneed adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study's findings highlight the importance of tailoring interventions to address their need

Integrated Care for Older Adults in Rural Communities

Recognizing that traditional models of health care delivery and payment often produce fragmented and costly care and poor outcomes for those with the highest needs, many reforms under the Affordable Care Act (ACA) focus on realigning payment incentives and integrating care. These reforms presuppose the existence of supporting infrastructure and capacity, including dedicated care management staffing and health information technology and exchange. With a focus on community-dwelling older adults in need of integrated physical, behavioral health services, and long term services and supports (LTSS), this brief reviews the opportunities and challenges these reform initiatives present for rural communities: How easily can current models for integrating care be adapted to a rural context and culture? How well do they account for gaps and variations in local delivery systems, capacity, and infrastructure? Which strategies offer the greatest promise for addressing the needs of rural residents? Because Medicaid is a primary source of funding for LTSS, we focus this inquiry on models serving Medicaid-eligible individuals; in some cases these programs may also serve individuals who are also eligible for Medicare

Dually-Eligible Working-Age Adults with Disabilities: Issues and Challenges as Health Reform is Implemented

This special section on working-age adults with disabilities dually eligible for Medicare and Medicaid is based on two panel presentations at the June 2012 meeting of the AcademyHealth Disability Research Interest Group. The papers included here consider the issues of health care access and outcomes as well as employment for this group of approximately four million individuals, many with complex health care needs and high costs.iThe Commonwealth Fund, AcademyHealth Disability Research Interest Group (DRIG

Socioeconomic Status and Medical Care Expenditures in Medicare Managed Care

This study examined the effects of education, income, and wealth on medical care expenditures in two Medicare managed care plans. The study also sought to elucidate the pathways through which socioeconomic status (SES) affects expenditures, including preferences for health and medical care and ability to navigate the managed care system. We modeled the effect of SES on medical care expenditures using Generalized Linear Models, estimating separate models for each component of medical expenditures: inpatient, outpatient, physician, and other expenditures. We found that education, income, and wealth all affected medical care expenditures, although the effects of these variables differed across expenditure categories. Moreover, the effects of these SES variables were much smaller than the effects found in earlier studies of fee-for-service Medicare. The pathway variables also were associated with expenditures. Accounting for the pathways through which SES affects expenditures narrowed the effect of SES on expenditures; however, the change in the estimates was very small. Thus, although our measures of preferences and ability to navigate the system were associated with expenditures, they did not account for an appreciable share of the impact of SES on expenditures.

End-of-life care in the United States: policy issues and model programs of integrated care

BACKGROUND: End-of-life care financing and delivery in the United States is fragmented and uncoordinated, with little integration of acute and long-term care services. OBJECTIVE: To assess policy issues involving end-of-life care, especially involving the hospice benefit, and to analyse model programs of integrated care for people who are dying. METHODS: The study conducted structured interviews with stakeholders and experts in end-of-life care and with administrators of model programs in the United States, which were nominated by the experts. RESULTS: The two major public insurance programs—Medicare and Medicaid—finance the vast majority of end-of-life care. Both programs offer a hospice benefit, which has several shortcomings, including requiring physicians to make a prognosis of a six month life expectancy and insisting that patients give up curative treatment—two steps which are difficult for doctors and patients to make—and payment levels that may be too low. In addition, quality of care initiatives for nursing homes and hospice sometimes conflict. Four innovative health systems have overcome these barriers to provide palliative services to beneficiaries in their last year of life. Three of these health systems are managed care plans which receive capitated payments. These providers integrate health, long-term and palliative care using an interdisciplinary team approach to management of services. The fourth provider is a hospice that provides palliative services to beneficiaries of all ages, including those who have not elected hospice care. CONCLUSIONS: End-of-life care is deficient in the United States. Public payers could use their market power to improve care through a number of strategies

Prevalence of Chronic Atrial Fibrillation in Dialysis Patients

Background: Atrial fibrillation (AF) is reported to be common in patients on maintenance dialysis, but estimates of prevalence vary substantially. To date, no Medicare claims-based approach has been employed to rigorously assess prevalence of chronic AF. Methods: A novel database was created to identify patients undergoing maintenance dialysis who were dually-eligible for Medicare and Medicaid for at least 3 months in 2004-05. A Medicare claims-based algorithm was used to generate a plausible range of chronic AF prevalences using four approaches. Poisson analysis was employed to determine the demographic, functional status, comorbidity, and other factors, as assessed by the Medical Evidence Form, associated with chronic AF. Results: Of 102,748 dually-eligible individuals for whom data was complete, 21,540 (21.0%) had at least one claim for non-perioperative AF. Raw percentages (irrespective of length of follow-up time) of individuals with chronic AF ranged from 9.8% (using the most inclusive strategy) to 4.6% (the most exclusive); intermediate approaches led to closely-clustered estimates of 8.1% and 6.4%. The intermediate approaches demonstrated chronic AF prevalence to range from 64.2 (95% confidence intervals, 62.9 - 65.5) to 50.4 (49.2 - 51.7) per 1000 patient-years. Age 60 years, male sex, Caucasian race, body mass index 30 kg/m2, and inability to ambulate were associated with chronic AF; hypertension as a comorbidity was inversely associated with AF. Occurrence of AF was roughly 10 times greater in the youngest patients when compared to similar individuals not on dialysis. Conclusions: A linked Medicare-Medicaid database, together with a claims-based diagnostic algorithm, was used to generate prevalence estimates for chronic AF in dually-eligible dialysis patients. As expected, AF is far more common than in the non-dialysis population