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.

Comparison Of Hospitals Participating In Medicare’s Voluntary And Mandatory Orthopedic Bundle Programs

Jun. 6, 2018

Abstract [from journal]

We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare’s voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals...

The Effect of Workforce Assignment on Performance: Evidence from Home Health Care

Research Brief
May. 22, 2018

In this study of more than 43,000 home health episodes following a hospitalization, handoffs between skilled nursing providers—a marker of discontinuity of care—substantially increased hospital readmissions, and were more detrimental for sicker patients. The estimates imply that a single handoff increases the likelihood of 30-day hospital readmission by 16% and that one in four hospitalizations during home health care could be avoided if handoffs were eliminated.

Trends in hospital-SNF relationships in the care of Medicare beneficiaries

May. 17, 2018

Joshua M. Liao, R. Tamara Konetzka, Rachel M. Werner

Abstract [from journal]

Improving the value of post-acute care at skilled nursing facilities (SNFs) has become a Medicare policy priority. Anecdotally, hospitals have responded by formally acquiring or pursuing tighter informal connections with SNFs. We evaluated the trend in connections between US acute care hospitals and Medicare-certified SNFs between 2000 and 2013 using vertical integration and two novel network-based measures (number of SNF partners, and...

Preventable Hospitalizations, Barriers to Care, and Disability

May. 17, 2018

Liliana E. Pezzin, Hillary R. Bogner, Jibby E. Kurichi, Pui L. Kwong, Joel E. Streim, Dawei Xie, Ling Na, Sean Hennessy

Abstract [from journal]

The AHRQ's Prevention Quality Indicators assume inpatient hospitalizations for certain conditions, referred as ambulatory-care sensitive (ACS) conditions, are potentially preventable and may indicate reduced access to and a lower quality of ambulatory care. Using a cohort drawn from the Medicare Current Beneficiary Survey (MCBS) linked to Medicare claims, we examined the extent to which barriers to healthcare are associated with ACS hospitalizations and related costs, and whether these associations differ by beneficiaries' disability status. Our results...

Outcomes of Care for Ischemic Heart Disease and Chronic Heart Failure in the Veterans Health Administration

May. 17, 2018

Peter W. Groeneveld, Elina L. Medvedeva, Lorrie Walker, Andrea G. Segal, Diane M. Richardson, Andrew J. Epstein

Abstract [from journal]

Importance: The Department of Veterans Affairs (VA) operates a nationwide system of hospitals and hospital-affiliated clinics, providing health care to more than 2 million veterans with cardiovascular disease. While data permitting hospital comparisons of the outcomes of acute cardiovascular care (eg, myocardial infarction) are publicly available, little is known about variation across VA medical centers (VAMCs) in outcomes of care for populations of patients with chronic, high-risk cardiovascular conditions.

Objective: ...

Organizational Processes and Patient Experiences in the Patient-Centered Medical Home

May. 10, 2018

Abstract [from journal]

Background: There is increasing emphasis on the use of patient-reported experience data to assess practice performance, particularly in the setting of patient-centered medical homes. Yet we lack understanding of what organizational processes relate to patient experiences.

Objective: Examine associations between organizational processes practices adopt to become PCMH and patient experiences with care.

Research Design: We analyzed visit data from patients (n=8356) at adult primary care practices...

Failure-to-Rescue After Acute Myocardial Infarction

May. 10, 2018

Jeffrey H. Silber, Alexander F. Arriaga, Bijan A. Niknam, Alexander S. Hill, Richard N. Ross, and Patrick S. Romano

Abstract [from journal]

Background: Failure-to-rescue (FTR), originally developed to study quality of care in surgery, measures an institution’s ability to prevent death after a patient becomes complicated.

Objectives: Develop an FTR metric modified to analyze acute myocardial infarction (AMI) outcomes.

Research Design: Split-sample design: a random 20% of hospitals to develop FTR definitions, a second 20% to validate test characteristics, and an out-of-sample 60% to validate results.


Best Practices for Reducing Unplanned Acute Care for Patients with Cancer

Research Brief
May. 3, 2018

Reducing preventable and unplanned emergency department visits and hospitalizations is a major challenge in cancer care. In this review of best practices and supporting evidence, the authors identified five strategies that health systems and cancer programs can use to reduce acute care: (1) identify patients at high risk of unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new sites for urgent cancer care, and; (5) use early palliative care. 

The Developmental Check-In: Development and Initial Testing of an Autism Screening Tool Targeting Young Children From Underserved Communities

May. 3, 2018

Yvette M. Janvier, Caroline N. Coffield, Jill F. Harris, David S. Mandell, Zuleyha Cidav

Abstract [from journal]

Children with autism spectrum disorder from low-income, minority families or those with limited English proficiency are diagnosed at a later age, or not at all, compared with their more advantaged peers. The Developmental Check-In is a new tool that could potentially be used to screen for autism that uses pictures to illustrate target behaviors. It was developed to enhance early identification of autism spectrum disorder in low literacy groups. The Developmental Check-In was tested in a sample of 376 children between the ages of 24 and 60 months, from...

Clinical Outcomes After Cardiac Stress Testing Among US Patients Younger Than 65 Years

May. 2, 2018

Vinay Kini, Elias J. Dayoub, Paul L. Hess, Lucas N. Marzec, Frederick A. Masoudi, P. Michael Ho, Peter W. Groeneveld

Abstract [from journal]

Background: Scientific statements have championed the measurement of clinical outcomes after cardiac stress testing to better define their value. Using contemporary national data, we sought to describe the characteristics of patients who experience outcomes after stress testing.

Methods and Results: Using administrative claims from a large national private insurer, we conducted an observational cohort study of


Rates of Hospital Readmission Among Medicare Beneficiaries With Gastrointestinal Bleeding Vary Based on Etiology and Comorbidities

May. 1, 2018

Abstract [from journal]

Background & Aims: Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed...