Dataset Information

Low-Value Medical Services in the Safety-Net Population.

ABSTRACT:

Importance

National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.

Objective

To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians.

Design, setting, and participants

This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics.

Exposures

Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%).

Main outcomes and measures

Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit.

Results

Overall, 193?062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n?=?94?707) was 44.7 (44.5-44.9) years; patients on Medicaid (n?=?45?123), 39.8 (39.3-40.3) years; and uninsured patients (n?=?19?530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services.

Conclusions and relevance

Overuse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.

SUBMITTER: Barnett ML

PROVIDER: S-EPMC5540058 | biostudies-literature | 2017 Jun

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Low-Value Medical Services in the Safety-Net Population.

Barnett Michael L ML Linder Jeffrey A JA Clark Cheryl R CR Sommers Benjamin D BD

JAMA internal medicine 20170601 6

<h4>Importance</h4>National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.<h4>Objective</h4>To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians.<h4>Design, setting, and participants</h4>This multiyear cross-sectio ...[more]

PMID: 28395014

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Project description:ImportanceSafety net hospitals (SNH) provide many community services. The cost of providing these services is unknown.ObjectiveTo determine what safety net criteria are associated with differences in hospital operating margin.Design, setting, and participantsThis cross-sectional study of US acute care hospitals from 2017 to 2019 included eligible hospitals identified from US Centers for Medicare & Medicaid Services Cost Reports.ExposuresFive domains of SNH: undercompensated care measured using the Disproportionate Share Hospital index, uncompensated care, essential community services, neighborhood disadvantage, and sole community hospital and critical access hospital status. Each was categorized as a quintile or binary response. Covariates included hospital ownership, size, teaching status, census region, urbanicity, and wage index.Main outcomes and measuresOperating margin and its association with each safety net criterion was determined using linear regression adjusting for all safety net criteria and covariates.ResultsA total of 4219 hospitals were analyzed, of which 3329 hospitals (78.9%) satisfied at least 1 safety net criterion; 23 hospitals (0.5%) met 4 or all 5 criteria. Among safety net criteria, the highest quintile of undercompensated care (-6.2 percentage point difference compared with lowest quintile; 95% CI, -8.2 to -4.2 percentage points), uncompensated care (-3.4 percentage points; 95% CI, -5.1 to -1.6 percentage points), and neighborhood disadvantage (-3.9 percentage points; 95% CI, -5.7 to -2.1 percentage points) were each associated with a lower operating margin. No association with operating margin was found between critical access or sole community hospital status (0.9 percentage points; 95% CI, -0.8 to 2.7 percentage points) or the highest vs lowest quintile of essential services (0.8 percentage points; 95% CI, -1.2 to 2.7 percentage points). Among essential services, burn, inpatient psychiatry, and primary care services were associated with lower operating margin, while others were either not associated or showed positive association. Fall-off in operating margin by level of uncompensated care was most severe in the highest percentiles of uncompensated care, with the most marked declines among those with the lowest operating margin.Conclusions and relevanceIn this cross-sectional study of SNH, hospitals in the highest quintiles of undercompensated care, uncompensated care, and neighborhood disadvantage were more financially vulnerable than those not in the top quintile, especially when they met numerous of these criteria. Ensuring targeting of financial support to these hospitals could improve their financial stability.

Project description:BackgroundExisting tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.ObjectiveDevelop a scale to measure PCMH adoption in safety-net clinics.Research designCross-sectional survey.SubjectsSixty-five clinics in five states.Main measuresFifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales (0-100): Access and Communication, Patient Tracking and Registry, Care Management, Test and Referral Tracking, Quality Improvement, and External Coordination. The scale was tested for internal consistency reliability and tested for convergent validity using The Assessment of Chronic Illness Care (ACIC) and the Patient-Centered Medical Home Assessment (PCMH-A). The scale was applied to centers in the sample. In addition, linear regression models were used to measure the association between clinic characteristics and medical home adoption.ResultsThe SNMHS had high internal consistency reliability (Cronbach's alpha = 0.84). The SNMHS score correlated moderately with the ACIC score (r = 0.64, p < 0.0001) and the PCMH-A (r = 0.56, p < 0.001). The mean SNMHS score was 61 ± SD 13. Among the subscales, External Coordination (66 ± 16) and Access and Communication (65 ± 14) had the highest mean scores, while Quality Improvement (55 ± 17) and Care Management (55 ± 16) had lower mean scores. Clinic characteristics positively associated with total SNMHS score were having more providers (β 15.8 95% CI 8.1-23.4 >8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (β 8.4 95% 1.6-15.3).ConclusionThe SNMHS demonstrated reliability and convergent validity for measuring PCMH adoption in safety-net clinics. Some clinics have significant PCMH adoption. However, room for improvement exists in most domains, especially for clinics with fewer providers.

Project description:ImportanceIn the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown.ObjectiveTo assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals.Design, setting, and participantsThis interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019.ExposuresHACRP and HVBP implementation in fiscal year 2015 or 2016.Main outcomes and measuresThe primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates.ResultsOf the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20).Conclusions and relevanceThis study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.

Project description:IntroductionSafety-net sexually transmitted disease services can prevent transmission of sexually transmitted disease. This study assesses the availability of safety-net sexually transmitted disease clinical services across the U.S.MethodsA 2018 survey of U.S. local health departments examined the availability of safety-net providers and the availability of specific sexually transmitted disease clinical services, including point-of-care testing and treatment. In 2019, Rao-Scott chi-square tests were used to compare service availability by clinic type (sexually transmitted disease clinic versus other clinics).ResultsA total of 326 local health departments completed the survey (49% response rate). Of respondents, 64.4% reported that a clinic in their jurisdiction provided safety-net sexually transmitted disease services. Having a safety-net clinic that provided sexually transmitted disease services was more common in medium and large jurisdictions. Sexually transmitted disease clinics were the primary provider in 40.5% of jurisdictions. A wide range of specific sexually transmitted disease services was offered at the primary safety-net clinic for sexually transmitted diseases. Most clinics offered human papillomavirus vaccination and appropriate point-of-care treatment for gonorrhea and syphilis. Fewer than one-quarter of clinics offered point-of-care rapid plasma reagin or darkfield microscopy syphilis testing. Compared with other clinics, services more commonly offered at sexually transmitted disease clinics included same-day services, hepatitis B vaccination, rapid plasma reagin testing (syphilis), any point-of-care testing for gonorrhea, point-of-care trichomonas testing, and extragenital chlamydia or gonorrhea testing.ConclusionsOne-third of local health departments reported no safety-net sexually transmitted disease services or were not aware of the services, and availability of specific services varied. Without an expansion of resources, local health departments might explore collaborations with healthcare systems and innovations in testing to expand sexually transmitted disease services.

Project description:Importance:Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective:To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants:This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n?=?469) and Harbor-UCLA (University of California, Los Angeles) (control, n?=?585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n?=?1002; control, n?=?511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions:Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures:Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results:Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P?<?.001 for all time-group interactions in both periods). At LAC-USC, losses of $42?241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67?241 in savings. In a simulation of a FFS health system at 3 years, $88?151 in losses were estimated, and for societal 3-year perspectives, $217?322 in savings were estimated. Conclusions and Relevance:This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.

Project description:ImportanceThe patient-centered medical home (PCMH) model holds promise for improving primary care delivery, but it has not been adequately tested in teaching settings.Design, setting, and participantsWe implemented an intervention guided by PCMH principles at a safety-net teaching clinic with resident physician providers. Two similar clinics served as controls.Main outcomes and measuresUsing a cross-sectional design, we measured the effect on patient and resident satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, respectively. Both surveys were conducted at baseline and 1 year after the intervention. We also measured the effect on emergency department and hospital utilization.ResultsFollowing implementation of our intervention, the clinic’s score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points, although our clinic did not achieve all must-pass elements to qualify as a PCMH. During the 1-year study period, 4676 patients were exposed to the intervention; 39.9% of these used at least 1 program component. Compared with baseline, patient-reported access and overall satisfaction improved to a greater extent in the intervention clinic, and the composite satisfaction rating increased from 48% to 65% in the intervention clinic vs from 50% to 59% in the control sites (P = .04). The improvements were particularly notable for questions relating to access. For example, satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic vs from 14% to 18% in the control clinics (P < .001). Resident satisfaction also improved in the intervention clinic: the composite satisfaction score increased from 39% to 51% in the intervention clinic vs a decrease from 46% to 42% in the control clinics (P = .01). Emergency department utilization did not differ significantly between the intervention and control clinics, and hospitalizations increased from 26 to 27 visits per 1000 patients per month in the intervention clinic vs a decrease from 28 to 25 in the control clinics (P = .02).Conclusions and relevanceOur PCMH-guided intervention, which represented a modest but substantive step toward the PCMH vision, had favorable effects on patient and resident satisfaction at a safety-net teaching clinic but did not reduce emergency department or hospital utilization in the first year. Our experience may provide lessons for other teaching clinics in safety-net settings hoping to implement PCMH-guided reforms.

Dataset Information

Low-Value Medical Services in the Safety-Net Population.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

Low-Value Medical Services in the Safety-Net Population.

Similar Datasets

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