Bundled payments for care improvement initiative – insights from the test pilots of payment reform

Background: The Medicare Bundled Payments for Care Improvement (BPCI) pilot program aims to reward high-value providers by setting a global payment target for particular episodes of care. The representativeness of BPCI participants will influence the ability of this pilot to inform policy decisions. Methods: We linked the Medicare lists of participants in the risk-bearing portion of BPCI Model 2, encompassing acute and post-acute care, to the American Hospital Association resource file and the 2013 Hospital Value-Based Purchasing quality performance data. We classified episode-initiating hospitals by the number of bundles in which they were participating into “narrow”, “medium” and “comprehensive”. The analysis described the characteristics of hospitals in each of these categories. Results: The 105 hospitals with linkable data were predominantly large, urban, non-profit, teaching hospitals. These hospitals were quite similar to the general population in terms of disproportionate share, Medicare, and Medicaid percentages. Most participants selected a narrow number of bundles, with the majority selecting a single bundle around joint replacement. There were only minor differences in quality between Model 2 participants and non-participants. Conclusions: Informing the decision about whether to scale the BPCI program nationally will require evaluation of the pilot’s performance by participants’ characteristics to understand in what conditions and for which providers the program is most effective

Meltwater Intrusions Reveal Mechanisms for Rapid Submarine Melt at a Tidewater Glacier

Submarine melting has been implicated as a driver of glacier retreat and sea level rise, but to date melting has been difficult to observe and quantify. As a result, melt rates have been estimated from parameterizations that are largely unconstrained by observations, particularly at the near-vertical termini of tidewater glaciers. With standard coefficients, these melt parameterizations predict that ambient melting (the melt away from subglacial discharge outlets) is negligible compared to discharge-driven melting for typical tidewater glaciers. Here, we present new data from LeConte Glacier, Alaska, that challenges this paradigm. Using autonomous kayaks, we observe ambient meltwater intrusions that are ubiquitous within 400 m of the terminus, and we provide the first characterization of their properties, structure, and distribution. Our results suggest that ambient melt rates are substantially higher (×100) than standard theory predicts and that ambient melting is a significant part of the total submarine melt flux. We explore modifications to the prevalent melt parameterization to provide a path forward for improved modeling of ocean-glacier interactions.This work was funded by NSF OPP Grants 1503910, 1504191, 1504288, and 1504521 and National Geographic Grant CP4-171R-17. Additionally, this research was supported by the NOAA Climate and Global Change Postdoctoral Fellowship Program, administered by UCAR’s Cooperative Programs for the Advancement of Earth System Science (CPAESS) under award #NA18NWS4620043B. These observations would not be possible without the skilled engineering team who developed the autonomous kayaks—including Jasmine Nahorniak, June Marion, Nick McComb, Anthony Grana, and Corwin Perren—and also the Captain and crew of the M/V Amber Anne. We thank Donald Slater and an anonymous reviewer for valuable feedback that improved this manuscript. Data availability: All of the oceanographic data collected by ship and kayak have been archived with the National Centers for Environmental Information (Accession 0189574, https://accession.nodc.noaa.gov/ 0189574). The glacier data have been archived at the Arctic Data Center (https://doi.org/10.18739/A22G44).Ye

Tracking icebergs with time-lapse photography and sparse optical flow, LeConte Bay, Alaska, 2016–2017

We present a workflow to track icebergs in proglacial fjords using oblique time-lapse photos and the Lucas-Kanade optical flow algorithm. We employ the workflow at LeConte Bay, Alaska, where we ran five time-lapse cameras between April 2016 and September 2017, capturing more than 400 000 photos at frame rates of 0.5–4.0 min−1. Hourly to daily average velocity fields in map coordinates illustrate dynamic currents in the bay, with dominant downfjord velocities (exceeding 0.5 m s−1 intermittently) and several eddies. Comparisons with simultaneous Acoustic Doppler Current Profiler (ADCP) measurements yield best agreement for the uppermost ADCP levels (∼ 12 m and above), in line with prevalent small icebergs that trace near-surface currents. Tracking results from multiple cameras compare favorably, although cameras with lower frame rates (0.5 min−1) tend to underestimate high flow speeds. Tests to determine requisite temporal and spatial image resolution confirm the importance of high image frame rates, while spatial resolution is of secondary importance. Application of our procedure to other fjords will be successful if iceberg concentrations are high enough and if the camera frame rates are sufficiently rapid (at least 1 min−1 for conditions similar to LeConte Bay).This work was funded by the U.S. National Science Foundation (OPP-1503910, OPP-1504288, OPP-1504521 and OPP-1504191).Ye

Medicare Payments for Common Inpatient Procedures: Implications for Episode-Based Payment Bundling

Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals.Using the national Medicare database, we identified patients undergoing one of four inpatient procedures in 2005 (coronary artery bypass [CABG], hip fracture repair, back surgery, and colectomy). For each procedure, price-standardized Medicare payments from the date of admission for the index procedure to 30 days postdischarge were assessed and categorized by payment type (hospital, physician, and postacute care) and subtype.Average total payments for inpatient surgery episodes varied from U.S.$26,515 for back surgery to U.S.$45,358 for CABG. Hospital payments accounted for the largest share of total payments (60–80 percent, depending on procedure), followed by physician payments (13–19 percent) and postacute care (7–27 percent). Overall episode payments for hospitals in the lowest and highest payment quartiles differed by U.S.$16,668 for CABG, U.S.$18,762 for back surgery, U.S.$10,615 for hip fracture repair, and U.S.$12,988 for colectomy. Payments to hospitals accounted for the largest share of variation in payments. Among specific types of payments, those associated with 30-day readmissions and postacute care varied most substantially across hospitals.Fully bundled payments for inpatient surgical episodes would need to be dispersed among many different types of providers. Hospital payments—both overall and for specific services—vary considerably and might be reduced by incentives for hospitals and physicians to improve quality and efficiency.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79298/1/j.1475-6773.2010.01150.x.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/79298/2/HESR_1150_sm_authormatrix.pd

Surgical treatment of breast cancer among the elderly in the United States

BACKGROUND: Breast-conserving therapy (BCT) has emerged as the preferred treatment for most women with early stage breast cancer. However, there is concern for underuse in the elderly, with previously documented low rates of BCT and large variations in practice patterns. The authors' purpose was to examine patterns and correlates of BCT for breast cancer in the elderly US population. METHODS: The primary outcome was receipt of BCT. The 2003 to 2004 Medicare inpatient, outpatient, and carrier files were used to identify incident breast cancer patients and the American Medical Association to ascertain surgeon information. The primary independent variables were US state where treatment was performed along with patient and surgeon sociodemographic information. Multivariate logistic regression was used for the analyses. RESULTS: BCT was performed in 81.8% of patients (N = 20,032). Variation in use of BCT across states was low, ranging from 74.2% in Utah to 84.0% in New Mexico. Several factors were significantly associated with low use of BCT: advanced patient age (>85 vs 3 vs ≤3: OR, 0.26; 95% CI, 0.24-0.28), and low socioeconomic status (SES) (lowest quintile vs highest quintile SES: OR, 0.60; 95% CI, 0.52-0.68). Variation in use of BCT by surgeon was low, although female surgeons aged 40 to 49 years and ≥60 years had significantly higher use compared with younger men. CONCLUSIONS: BCT has become the primary management among elderly breast cancer patients. Despite earlier studies to the contrary, there is now little variation in BCT use among Medicare patients. Cancer 2011. © 2010 American Cancer Society.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/83176/1/25617_ftp.pd

Disturbance‐mediated changes to boreal mammal spatial networks in industrializing landscapes

Funding: InnoTech Alberta. Grant Number: C2021000986; Alberta Innovates; Alberta Conservation Association; Petroleum Technology Alliance Canada. Grant Numbers: 17-ERPC-02, 18-ERPC-01, 19-ERPC-04; Algar Caribou Habitat Restoration Program. Grant Number: NXC-107980; Oil Sands Monitoring program; Natural Sciences and Engineering Research Council of Canada. Grant Numbers: RGPIN-2018–03958, Canada Research Chairs.Compound effects of anthropogenic disturbances on wildlife emerge through a complex network of direct responses and species interactions. Land‐use changes driven by energy and forestry industries are known to disrupt predator–prey dynamics in boreal ecosystems, yet how these disturbance effects propagate across mammal communities remains uncertain. Using structural equation modeling, we tested disturbance‐mediated pathways governing the spatial structure of multipredator multiprey boreal mammal networks across a landscape‐scale disturbance gradient within Canada's Athabasca oil sands region. Linear disturbances had pervasive direct effects, increasing site use for all focal species, except black bears and threatened caribou, in at least one landscape. Conversely, block (polygonal) disturbance effects were negative but less common. Indirect disturbance effects were widespread and mediated by caribou avoidance of wolves, tracking of primary prey by subordinate predators, and intraguild dependencies among predators and large prey. Context‐dependent responses to linear disturbances were most common among prey and within the landscape with intermediate disturbance. Our research suggests that industrial disturbances directly affect a suite of boreal mammals by altering forage availability and movement, leading to indirect effects across a range of interacting predators and prey, including the keystone snowshoe hare. The complexity of network‐level direct and indirect disturbance effects reinforces calls for increased investment in addressing habitat degradation as the root cause of threatened species declines and broader ecosystem change.Peer reviewe

The Role of Blue Carbon in Climate Change Mitigation and Carbon Stock Conservation

The potential for Blue Carbon ecosystems to combat climate change and provide co-benefits was discussed in the recent and influential Intergovernmental Panel on Climate Change Special Report on the Ocean and Cryosphere in a Changing Climate. In terms of Blue Carbon, the report mainly focused on coastal wetlands and did not address the socio-economic considerations of using natural ocean systems to reduce the risks of climate disruption. In this paper, we discuss Blue Carbon resources in coastal, open-ocean and deep-sea ecosystems and highlight the benefits of measures such as restoration and creation as well as conservation and protection in helping to unleash their potential for mitigating climate change risks. We also highlight the challenges—such as valuation and governance—to marshaling their mitigation role and discuss the need for policy action for natural capital market development, and for global coordination. Efforts to identify and resolve these challenges could both maintain and harness the potential for these natural ocean systems to store carbon and help fight climate change. Conserving, protecting, and restoring Blue Carbon ecosystems should become an integral part of mitigation and carbon stock conservation plans at the local, national and global levels.</jats:p

Morainal Bank Evolution and Impact on Terminus Dynamics During a Tidewater Glacier Stillstand

Sedimentary processes are known to help facilitate tidewater glacier advance, but their role in modulating retreat is uncertain and poorly quantified. In this study we use repeated seafloor bathymetric surveys and satellite‐derived terminus positions from LeConte Glacier, Alaska, to evaluate the evolution of a morainal bank and related changes in terminus dynamics over a 17‐year period. The glacier experienced a rapid retreat between 1994 and 1999, before stabilizing at a constriction in the fjord. Since then, the glacier terminus has remained stabilized while constructing a morainal bank up to 140 m high in water depths of 240–260 m, with rates of sediment delivery of 3.3 Å~ 105 to 3.8 Å~ 105 m3 a−1. Based on repeated interannual surveys between 2016 and 2018, the moraine is a dynamic feature characterized by push ridges, evidence of active gravity flows, and bulldozing by the glacier at rates of up to meters per day. Beginning in 2016, the summertime terminus has become increasingly retracted, revealing a newly emerging basin potentially signaling the onset of renewed retreat. Between 2000 and 2016, the growing moraine reduced the exposed submarine area of the terminus by up to 22%, altered the geometry of the terminus during seasonal advances, and altered the terminus stress balance. These feedbacks for calving, melting, and ice flow likely represent mechanisms whereby moraine growth may delay glacier retreat, in a system where readvance is unlikely.This work was supported by NSF Arctic Natural Sciences Grants OPP—1503910, 1504191, 1504288, and 1504521. National Geographic CP4‐171R‐17 to E. Pettit and J. Nash helped support 2018 cruise logistics.Ye

Developing cardiac and skeletal muscle share fast-skeletal myosin heavy chain and cardiac troponin-I expression

Skeletal muscle derived stem cells (MDSCs) transplanted into injured myocardium can differentiate into fast skeletal muscle specific myosin heavy chain (sk-fMHC) and cardiac specific troponin-I (cTn-I) positive cells sustaining recipient myocardial function. We have recently found that MDSCs differentiate into a cardiomyocyte phenotype within a three-dimensional gel bioreactor. It is generally accepted that terminally differentiated myocardium or skeletal muscle only express cTn-I or sk-fMHC, respectively. Studies have shown the presence of non-cardiac muscle proteins in the developing myocardium or cardiac proteins in pathological skeletal muscle. In the current study, we tested the hypothesis that normal developing myocardium and skeletal muscle transiently share both sk-fMHC and cTn-I proteins. Immunohistochemistry, western blot, and RT-PCR analyses were carried out in embryonic day 13 (ED13) and 20 (ED20), neonatal day 0 (ND0) and 4 (ND4), postnatal day 10 (PND10), and 8 week-old adult female Lewis rat ventricular myocardium and gastrocnemius muscle. Confocal laser microscopy revealed that sk-fMHC was expressed as a typical striated muscle pattern within ED13 ventricular myocardium, and the striated sk-fMHC expression was lost by ND4 and became negative in adult myocardium. cTn-I was not expressed as a typical striated muscle pattern throughout the myocardium until PND10. Western blot and RT-PCR analyses revealed that gene and protein expression patterns of cardiac and skeletal muscle transcription factors and sk-fMHC within ventricular myocardium and skeletal muscle were similar at ED20, and the expression patterns became cardiac or skeletal muscle specific during postnatal development. These findings provide new insight into cardiac muscle development and highlight previously unknown common developmental features of cardiac and skeletal muscle. © 2012 Clause et al