Payment & Delivery

How insurers and providers are organized and paid to deliver care. Research by LDI Senior Fellows examines the shift from fee-for-service payments to newer models of paying for and delivering value, such as Accountable Care Organizations and Patient-Centered Medical Homes.

The Effect of Predictive Analytics-Driven Interventions on Healthcare Utilization

Research Brief
Apr. 3, 2019

Among high-risk Medicare Advantage members with congestive heart failure, a proactive outreach program driven by a claims-based predictive algorithm reduced the likelihood of an emergency department (ED) or specialist visit in one year by 20% and 21%, respectively. The average number of visits dropped as well, with a 40% reduction in the volume of ED visits and a 27% reduction in the volume of cardiology visits after the first year.

Assessing First Visits By Physicians To Medicare Patients Discharged To Skilled Nursing Facilities

Research Brief
Kira Rysinka, MD
Apr. 1, 2019

In this study of postacute care, more than 10% of Medicare skilled nursing facility (SNF) stays included no visit from
a physician or advanced practitioner. Of stays with visits, about half of initial assessments occurred within a day of
admission, and nearly 80% occurred within four days. Patients who did not receive a visit from a physician or advanced
practitioner were nearly twice as likely to be readmitted to a hospital (28%) or to die (14%) within 30 days of SNF
admission than patients who had an initial visit.

Do Longer Shifts Affect Residents’ Sleep or Patient Safety?

Mar. 25, 2019

Do residents need more sleep? Two new studies in the New England Journal of Medicine compare the effects of standard versus flexible duty-hours on residents’ sleep and patient safety.

The iCOMPARE trial randomized 63 internal medicine residency programs, consisting of over 5,000 trainees, to standard duty-hour policies or flexible policies. All programs were held to an 80-hour work week, but flexible policies had no limits on shift lengths and did not mandate time off between shifts.

Patient Outcomes After Hospital Discharge to Home with Home Health Care vs to a Skilled Nursing Facility

Research Brief
Mar. 11, 2019

In this study of more than 17 million Medicare hospitalizations between 2010 and 2016, patients discharged to home
health care had a 5.6 percent higher 30-day readmission rate than similar patients discharged to a skilled nursing facility
(SNF). There was no difference in mortality or functional outcomes between the two groups, but home health care was
associated with an average savings of $4,514 in total Medicare payments in the 60 days after the first hospital admission.

The Tension Between Care Coordination and Conflicts of Interest

Feb. 6, 2019

Should providers participating in accountable care organizations (ACOs) be exempt from existing regulations that prevent financial conflicts of interest in physician referrals? On the one hand, these regulations, collectively known as the Stark Law, can impede efforts to coordinate care across providers and facilities. On the other hand, ACOs and other alternative payment and delivery models do not necessarily obviate the need for regulations that prohibit physician kickbacks or self-referrals.

Improving End of Life Care – Ask the Nurses

Dec. 7, 2018

Everyone wants a dignified death – yet few actually experience one. Despite preferring to remain at home, most older adults spend their final days in hospitals, where they often undergo medical care that neither improves survival, quality of life, nor satisfaction and is often incongruent with their wishes and goals. A new study in the Journal of the American Geriatrics Society describes these problems in end of life care in nearly 500 U.S.

Changes to Racial Disparities in Readmission Rates After Medicare’s Hospital Readmissions Reduction Program Within Safety-Net and Non-Safety-Net Hospitals

Research Brief
Dec. 6, 2018

After the Medicare Hospital Readmissions Reduction Program began enforcing financial penalties, disparities in readmissions between white and black patients widened at safety-net hospitals for conditions not targeted by the program. Disparities were stable for conditions targeted by the program. At non-safety-net hospitals, disparities were unchanged for both targeted and non-targeted conditions.

Cost Impact of The Transitional Care Model for Hospitalized Cognitively Impaired Older Adults

Research Brief
Nov. 19, 2018

Using advanced practice nurses to support high risk patients and their families to transition from hospital to home can reduce postacute care use and costs. A study comparing three evidence-based care management interventions for a population of hospitalized older adults with cognitive impairment found that the Transitional Care Model, which relies on advanced practice nurses to deliver services from hospital to home, was associated with lower postacute care costs when compared to two “hospital only” interventions.

Nurses' and Patients' Appraisals Show Patient Safety in Hospitals Remains a Concern

Research Brief
Nov. 5, 2018

In the report To Err is Human (1999), the National Academy of Medicine called for national action to improve patient safety in hospitals. The report concluded that improving nurse work environments—assuring adequate nurse staffing and supporting nurses’ ability to care for patients—was critical to these efforts. Two decades later, have nurse work environments improved, and has that had a noticeable impact on patient safety? To find out, a research team led by LDI Senior Fellow Linda Aiken, PhD, RN surveyed more than 800,000 patients and 53,000 nurses in 535 hospitals in 2005, and again in 2016.

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