Social determinants of health can adversely affect health and therefore lead to poor health care outcomes. When it launched in 2017, the Accountable Health Communities (AHC) Model was at the forefront of US health policy initiatives seeking to address social determinants of health. The AHC Model, sponsored by the Centers for Medicare and Medicaid Services, screened Medicare and Medicaid beneficiaries for health-related social needs and offered eligible beneficiaries assistance in connecting with community services. This study used data from the period 2015-21 to test whether the model had impacts on health care spending and use. Findings show statistically significant reductions in emergency department visits for both Medicaid and fee-for-service Medicare beneficiaries. Impacts on other outcomes were not statistically significant, but low statistical power may have limited our ability to detect model effects. Interviews with AHC Model participants who were offered navigation services to help them find community-based resources suggested that navigation services could have directly affected the way in which beneficiaries engage with the health care system, leading them to be more proactive in seeking appropriate care. Collectively, findings provide mixed evidence that engaging with beneficiaries who have health-related social needs can affect health care outcomes.

The Center for Medicare and Medicaid Innovation launched the Accountable Health Communities (AHC) Model in 2017 to assess whether identifying and addressing Medicare and Medicaid beneficiaries' health-related social needs reduced health care use and spending. We surveyed a subset of AHC Model beneficiaries with one or more health-related social needs and two or more emergency department visits in the prior twelve months to assess their use of community services and whether their needs were resolved. Survey findings indicated that navigation-connecting eligible patients with community services-did not significantly increase the rate of community service provider connections or the rate of needs resolution, relative to a randomized control group. Findings from interviews with AHC Model staff, community service providers, and beneficiaries identified challenges connecting beneficiaries to community services. When connections were made, resources often were insufficient to resolve beneficiaries' needs. For navigation to be successful, investments in additional resources to assist beneficiaries in their communities may be required.

There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White.

In 2014, Maryland incorporated global budgets into its long-running all-payer rate-setting model for hospitals in order to improve health, increase health care quality, and reduce spending. We used difference-in-differences models to estimate changes in Medicare and commercial insurance utilization and spending in Maryland relative to a hospital-based comparison group. We found slower growth in Medicare hospital spending in Maryland than in the comparison group 4.5 years after model implementation and for commercial plan members after 4 years. We identified reductions in Maryland Medicare admissions but no changes for commercial plan members, although their inpatient spending declined. Relative declines in emergency department and other hospital outpatient spending in Maryland drove slower Medicare hospital spending growth, saving $796 million. Our findings suggest global budgets reduce hospital spending and utilization but aligning incentives between hospital and nonhospital providers may be necessary to further reduce utilization and total spending.

PURPOSE To identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries. METHODS Regression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services’ 8-state Multi-Payer Advanced Primary Care Practice demonstration. RESULTS Six activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM) (P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P =0.00). CONCLUSIONS Practices seeking to deliver more efficient care may benefit from implementing these 6 activities.

OBJECTIVES: We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries. STUDY DESIGN: For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began. METHODS: We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes. RESULTS: Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations. CONCLUSIONS: Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.

Background: Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014. Objectives: To evaluate the effect of hospital global budgets on health care utilization and expenditures. Research Design: Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group. Subjects: Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas. Measures: Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses. Results: Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group. Conclusions: This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.

Background:Patient-centered medical homes are expected to reduce expenditures by increasing the use of primary care services, shifting care from inpatient to outpatient settings, and reducing avoidable utilization. Under the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare joined Medicaid and commercial payers in 8 states to support ongoing patient-centered medical home initiatives.Objective:To evaluate the effects of the MAPCP Demonstration on health care utilization and expenditures for Medicare beneficiaries.Research Design:We used difference-in-differences regression modeling to estimate changes in utilization and expenditures before and after the start of the MAPCP Demonstration, comparing beneficiaries engaged with MAPCP Demonstration practices to beneficiaries engaged with primary care practices that were not medical homes. Qualitative data collected during annual site visits provided contextual information on participating practices to inform interpretations of the demonstration outcomes.Subjects:Fee-for-service Medicare beneficiaries attributed to MAPCP Demonstration practices or to comparison group practices.Measures:Medicare claims were used to measure total Medicare expenditures and utilization and expenditures for inpatient, emergency room, primary care, and specialist services.Results:Despite the transformation of practices over the demonstration period, there was minimal evidence of a shift to more efficient utilization of health care services, and only 1 state saw a statistically significant reduction in total per-beneficiary expenditures.Conclusions:Although the MAPCP Demonstration did not have strong, consistent impacts on utilization and expenditures, this evaluation provides insights that may be useful for the design of future health care transformation models.

Congress is considering fundamental changes to Medicaid’s financing structure that seek to make federal funding for Medicaid more predictable and achieve substantial federal budgetary savings. The American Health Care Act (AHCA) as passed by the House of Representatives converts federal Medicaid matching funds, which currently are guaranteed as state spending increases, to a per capita cap that would limit the amount of federal Medicaid funding that states could receive per enrollee. Under the AHCA, states also would have the option to receive a block grant, a set amount of federal Medicaid funding that would not vary based on enrollment, for certain populations.

The patient-centered medical home (PCMH) is a health system innovation aimed to improve cost, quality, and health outcomes. Research shows that Medicare beneficiaries at practices with PCMH recognition have lower Medicare costs than those at practices without such recognition. Our study explores whether greater care continuity—an ongoing relationship between the patient and clinicians at a practice that monitors the patient’s health status and care—drives these lower costs in PCMH-recognized practices. We used Medicare Parts A and B claims data to calculate Medicare payments for services. We conducted weighted least squares regression analyses at the practice level to examine the association of Medicare payments with PCMH recognition and care continuity. We measured care continuity using an index that reflects the concentration of visits in the practice that serves as the beneficiary’s usual source of care. Medicare beneficiaries at PCMH-recognized practices had lower total annual Medicare payments (-$1,099; p < 0.01) than patients at nonrecognized practices. After controlling for care continuity, the association with PCMH recognition decreased substantially and beneficiaries in practices with high (compared to low) care continuity had significantly lower total payments (-$1,872, p = 0.02). Evidence from this study indicates that care continuity is a key driver of cost reductions associated with PCMH recognition.

STUDY OBJECTIVES:Medicaid programs are not required to pay the full Medicare coinsurance and deductibles for Medicare-Medicaid dually eligible beneficiaries. We examined the association between the percentage of Medicare cost sharing paid by Medicaid and the likelihood that a dually eligible beneficiary used evaluation and management (E&M) services and safety net provider services.DATA SOURCES:Medicare and Medicaid Analytic eXtract enrollment and claims data for 2009.STUDY DESIGN:Multivariate analyses used fee-for-service dually eligible and Medicare-only beneficiaries in 20 states. A comparison group of Medicare-only beneficiaries controlled for state factors that might influence utilization.PRINCIPAL FINDINGS:Paying 100 percent of the Medicare cost sharing compared to 20 percent increased the likelihood (relative to Medicare-only) that a dually eligible beneficiary had any E&M visit by 6.4 percent. This difference in the percentage of cost sharing paid decreased the likelihood of using safety net providers, by 37.7 percent for federally qualified health centers and rural health centers, and by 19.8 percent for hospital outpatient departments.CONCLUSIONS:Reimbursing the full Medicare cost-sharing amount would improve access for dually eligible beneficiaries, although the magnitude of the effect will vary by state and type of service.

Objective: To examine the association among nursing home residents between strength of relationship with a primary care provider (PCP) and inpatient hospital and emergency room (ER) utilization. Method: Medicare administrative data for beneficiaries residing in a nursing home between July 2007 and June 2009 were used in multivariate analyses controlling for beneficiary, nursing home, and market characteristics to assess the association between two measurespercentage of months with a PCP visit and whether the patient maintained the same usual source of care after nursing home admissionand hospital admissions and ER visits for all causes and for ambulatory care sensitive conditions (ACSCs). Results: Both measures of strength of patient-provider relationships were associated with fewer inpatient admissions and ER visits, except regularity of PCP visits and ACSC ER visits. Discussion: Policy makers should consider increasing the strength of nursing home resident and PCP relationships as one strategy for reducing inpatient and ER utilization.

ObjectivesTo quantify end-of-life (EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer.Data SourcesWe linked Medicaid administrative data with 2000-2003 cancer registry data to identify 3,512 adult Medicaid beneficiaries who died after a cancer diagnosis and matched them to a cohort of beneficiaries without cancer who died during the same period.Study DesignWe used multivariable regression analysis to estimate incremental per-person EOL cost after controlling for beneficiaries' age, race/ethnicity, sex, cancer site, and state of residence.Principal FindingsEnd-of-life costs during the final 4months of life were about $10,000 higher for Medicaid cancer patients than for those without cancer. Medicaid cancer patients are more intensive users of inpatient and ambulatory services than are Medicaid patients without cancer. Medicaid cancer patients who die soon after diagnosis have higher costs of care and use inpatient services more intensely than do Medicaid patients without cancer.ConclusionsMedicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL.

This study estimates the cost burden of 6 prevalent invasive cancers—breast, cervical, colorectal, lung, melanoma, and prostate—on Medicaid programs in 4 states. The analyses use Medicaid claims and enrollment data for all Medicaid-only beneficiaries over age 18 in Georgia, Illinois, Louisiana, and Maine with at least 1 month of enrollment in fee-for-service Medicaid from 2000 to 2003. We applied ordinary least squares regression analysis to a data set created from Medicaid claims and enrollment data to estimate annual expenditures attributable to each cancer after controlling for age, race, gender, and comorbid conditions. Cancers and comorbid conditions were identified on the basis of claims with an appropriate diagnosis code. Cancers include both incident and prevalent cases. In 2003 dollars, annualized Medicaid expenditures attributable to the 6 cancers combined in the Medicaid-only population were $84.0 million in Georgia, $79.7 million in Illinois, $51.4 million in Louisiana, and $29.4 million in Maine. Attributable annualized per-capita Medicaid expenditures were highest for lung cancer, then colorectal cancer. After adjusting for sociodemographics and comorbidities, only 10% to 50% of medical expenditures among Medicaid-only beneficiaries with cancer were attributable to cancer. Estimates of the costs of care for Medicaid-eligible cancer patients are critical to understanding the implications of cancer for state and federal budgets. The Patient Protection and Affordable Care Act (ACA) of 2010 is expected to substantially expand the adult Medicaid population. These estimates provide important baseline information for assessing the potential effects of increased Medicaid enrollment on Medicaid expenditures for cancer.

6500 Background: Reports have demonstrated barriers in access to and quality of care for Medicaid enrollees, including enrollees with cancer. State-specific Medicaid eligibility policies and low reimbursements for medical care services provided to enrollees with cancer may hinder receipt of high-quality cancer treatment. This study examined how eligibility and reimbursement policies affect timely receipt of breast cancer surgery among Medicaid enrollees diagnosed with breast cancer. Methods: The study utilized 2006-2008 Medicaid data for all women 21-64 years of age diagnosed with breast cancer and enrolled in fee-for-service Medicaid for at least 4 months. We examined the association of state-specific Medicaid breast surgery reimbursements, Medicaid income eligibility requirements, and frequency of Medicaid eligibility renewal on time from diagnosis to receipt of breast cancer surgery. Analyses used multivariate logistic regressions controlling for correlation between beneficiaries within a state. Results: We identified 10,968 Medicaid enrollees with breast cancer. Lower reimbursements for breast cancer surgery were associated with greater delays for breast conserving surgery, mastectomy, and all breast cancer surgery combined. Shorter time periods for Medicaid eligibility renewal were also associated with greater surgery delays. Income eligibility thresholds did not affect delays. Black, Hispanic, and blind/disabled patients had greater delays, while older patients were less likely to experience delays. Conclusions: Low reimbursements were associated with less timely surgery for Medicaid enrollees with breast cancer. In addition, within the Medicaid population, disparities in timeliness of surgery based on patient race, age, and eligibility category were observed. With substantial expansion of Medicaid expected as part of the Affordable Care Act, state legislators and health policy makers need to consider how reimbursements affect receipt of high quality care and develop programs to address disparities within this vulnerable population.

Background: Little is known as to whether medical home principles, such as continuity of care (COC), would have the same effect on health service use for individuals whose primary (or predominant) provider is a specialist instead of a primary care provider (PCP).Objective: To test associations between health service use and expenditures and (1) beneficiaries' predominant provider type (PCP or specialist) and (2) COC among beneficiaries who primarily see a PCP and those who primarily see a specialist.Research Design: This is a cross-sectional analysis of Medicare fee-for-service claims data from July 2007 to June 2009. Negative binomial and generalized linear models were used in multivariate regression modeling.Subjects: The study cohort comprised 613,471 community-residing Medicare fee-for-service beneficiaries.Measures: Beneficiaries' predominant provider type and COC index during a baseline period (July 2007-June 2008) were studied. All-cause and ambulatory care sensitive condition (ACSC) hospitalizations and emergency department (ED) visits and related expenditures and total expenditures in a 1-year follow-up period (July 2008-June 2009) were also reported.Results: Twenty-five percent of beneficiaries primarily saw a specialist. Having a specialist predominant provider was associated with 9% fewer ED visits, 14% fewer ACSC ED visits, and 8% fewer ACSC hospitalizations (all P < 0.001). Regardless of whether the beneficiary's predominant provider was a specialist or a PCP, higher continuity was associated with fewer all-cause hospitalizations and ED visits and lower expenditures for these services. Higher continuity was also associated with lower total expenditures.Conclusions: Regardless of the predominant provider's specialty, greater continuity was associated with less use of high-cost services and lower expenditures for these services.

BACKGROUND:Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries. METHODS:Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal. RESULTS:Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined. CONCLUSIONS:Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population.

This study quantifies treatment costs for melanoma and breast, cervical, colorectal, lung, and prostate cancer among patients with dual Medicare and Medicaid eligibility. The analyses use merged Medicare and Medicaid Analytic eXtract enrollment and claims data for dually eligible beneficiaries age>18 in Georgia, Illinois, Louisiana, and Maine in 2003 (n=892,001). We applied ordinary least squares regression analysis to estimate annual expenditures attributable to each cancer after controlling for beneficiaries' age, race/ethnicity, sex, and comorbid conditions, and state fixed effects. Cancers and comorbid conditions were identified on the basis of diagnosis codes on insurance claims. The most prevalent cancers were prostate (38.4 per 1,000 men) and breast (30.7 per 1,000 women). Dual eligibles with the study cancers had higher rates of other chronic conditions such as hypertension and arthritis than other beneficiaries. Total Medicare and Medicaid expenditures for dual eligibles with the study cancers ranged from $30,328 for those with lung cancer to $17,011 for those with breast cancer, compared with $10,664 for beneficiaries without the cancers. However, only 9% to 30% of medical expenditures for dual eligibles with the study cancers were attributable to the cancer itself. In 2003, combined Medicare/Medicaid spending for dual eligibles attributable to the six cancers in the four study states exceeded $256 million ($314 million in 2012 dollars). Dual eligibles with these cancers also had high rates of other medical conditions. These comorbidities should be recognized, both in documenting cancer treatment costs and in developing programs and policies that promote timely cancer diagnosis and treatment.