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.

Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial

Research Brief
Jan. 15, 2016

To whom should financial incentives be targeted to achieve a desired clinical or health outcome—physicians or patients? Using insight from behavioral economics, a research team led by LDI Senior Fellows David Asch and Kevin Volpp sought to determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective in promoting medication adherence and reducing cholesterol levels of patients at high risk for cardiovascular disease. Though physician and patient incentives are becoming more common, they are rarely combined, and effectiveness of these approaches is not well-established. This study offers insight into what incentive structure leads to the greatest impact on health promotion. 

Hospice Care in Assisted Living Facilities Versus at Home: Results of a Multisite Cohort Study

Jan. 11, 2016

Meredith Dougherty, Pamela Harris, Joan Teno, Amy Corcoran, Cindy Douglas, Jackie Nelson, Deborah Way, Joan Harrold, David Casarett

In the Journal of the American Geriatrics Society, Meredith Dougherty and colleagues, including David Casarett, compare residents of assisted living facilities receiving hospice with people receiving hospice care at home. The researchers conducted an electronic health record-based retrospective cohort study to compare the difference in the two groups’ length of stay in hospice, use of opioids for pain, and site of death. The authors find the assisted living population was more likely than the home hospice population to have a diagnosis of dementia (23.5% vs 4.7%) and enroll in...

The Role of Dementia in Nursing Home Report Cards

Dec. 18, 2015

R. Tamara Konetzka, Daniel Brauner, Marcelo Coca Perraillon, Rachel Werner

In Medical Care Research and Review, R. Tamara Konetzka and colleagues, including Rachel Werner, explore the intended and unintended effects of quality reporting for nursing home residents with severe dementia relative to other residents. Selected quality measures are examined using a difference-in-difference design. The authors find that before public reporting, nursing home residents with severe dementia scored worse on most reported quality measures, such as physical restraint use and worsening of activities of daily living. After public reporting was launched (Nursing Home...

Post–Acute Care Use and Hospital Readmission after Sepsis

Dec. 18, 2015

Tiffanie Jones, Barry Fuchs, Dylan Small, Scott Halpern, Asaf Hanish, Craig Umscheid, Charles Baillie, Meeta Prasad Kerlin, David Gieski, Mark Mikkelsen

In the Annals of the American Thoracic Society, Tiffanie Jones and colleagues, including Dylan Small, Scott Halpern, Craig Umscheid, and Meeta Prasad Kerlin, examine the rate of post-acute care and hospital readmission after sepsis, and the risk factors for these readmissions. In an observational cohort study conducted in an academic health care system, the researchers compared post-acute care use at discharge and hospital readmission after sepsis hospitalizations with non-sepsis hospitalizations. Post–acute care use at discharge was more likely after sepsis, driven by skilled...

Variation in cost of total thyroidectomy across the United States, 2007 to 2008

Dec. 18, 2015

Caroline Reinke, Elizabeth Sonnenberg, Giorgos Karakousis, Douglas Fraker, Rachel Kelz

In the American Journal of Surgery, Caroline Reinke and colleagues, including Rachel Kelz, share their findings on state-level variation in wage-adjusted total cost (WATC) of a common surgical procedure. Using data from the Nationwide Inpatient Sample, the researchers performed a retrospective cohort study of patients undergoing a total thyroidectomy.  WATC was calculated from charges and adjusted for the area wage index. The authors find that 37% of WATC variance is due to differences across hospitals, 28% is explained by patient-level factors and 8% is due to differences across...

Evidence Synthesis Activities of a Hospital Evidence-Based Practice Center and Impact on Hospital Decision Making

Dec. 7, 2015

Kishore Jayakumar, Julia Lavenberg, Matthew Mitchell, Jalpa Doshi, Brian Leas, David Goldmann, Kendal Williams, Patrick Brennan, Craig Umscheid

In the Journal of Hospital Medicine, Kishore Jayakumar and colleagues, including Jalpa Doshi and Craig Umscheid, assess whether the evidence synthesized and locally disseminated by a hospital evidence-based practice center (EPC) impacts institutional decision-making. Looking at a large academic health care system, the authors examined the EPC’s database of systemic reviews and a survey on the EPC’s reports, which assessed them for their usability, impact and satisfaction. Of the 249 reviews completed by the EPC since its inception, the most common requests came from clinical...

A Tale of Two States: Do Consumers See Mental Health Insurance Parity When Shopping on State Exchanges?

Nov. 19, 2015

Kelsey Berry, Haiden Huskamp, Howard Goldman, Colleen Barry

In Psychiatric Services, Kelsey Berry and colleagues, including Colleen Barry, present an analysis of parity compliance in how behavioral health benefits are presented to consumers shopping on health insurance exchanges established by the Affordable Care Act.  All insurance plans sold on the exchanges are required to offer mental health and substance use disorder benefits in compliance with requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The researchers reviewed summaries of benefits documents available to...

Cost Differences After Initial CT Colonography Versus Optical Colonoscopy in the Elderly

Nov. 19, 2015

Hanna Zafar, Jianing Yang, Katrina Armstrong, Peter Groeneveld

In Academic Radiology, Hanna Zafar and colleagues, including Peter Groeneveld, compare differences in total Medicare costs among asymptomatic elderly patients in the year after initial computed tomographic colonography (CTC) or initial optical colonoscopy (OC). In 2009, the Centers for Medicare and Medicaid Services stopped covering CTC screening among asymptomatic individuals based on the scarcity of data regarding differences in outcomes and costs between patients who received CTC and OC. Zafar and colleagues performed a retrospective cohort study of asymptomatic Medicare...

Diagnostic errors related to acute abdominal pain in the emergency department

Nov. 17, 2015

Laura Medford-Davis, Elizabeth Park, Gil Shlamovitz, James Suliburk, Ashley Meyer, Hardeep Singh

In Emergency Medicine Journal, Laura Medford-Davis and colleagues evaluate possible diagnostic errors and associated process breakdowns for patients who presented to the emergency department (ED) with abdominal pain. The authors conducted a retrospective chart review of adult ED patients at an urban academic hospital, using a computerized algorithm to identify high-risk patients. They considered patients to be high-risk if they presented to the ED with abdominal pain and were discharged, but returned to the ED within 10 days and were then hospitalized.  Diagnostic errors were...

An Assessment of State-Led Reform of Long-Term Services and Supports

Nov. 16, 2015

Mary Naylor, Ellen Kutzman, Edward Miller, Pamela Nadash, Peter Fitzgerald

In the Journal of Health Politics, Policy and Law, Mary Naylor and colleagues evaluate the strategies used by state governments to improve long-term services and supports (LTSS) for adults with disabilities and functionally impaired older adults. Three strategies have been most commonly pursued by state governments to improve LTSS: expanding noninstitutioal care, integrating payment and care delivery, and realigning incentives through market-based reforms. Naylor and colleagues evaluate these strategies based on nine dimensions, including: ease of access, quality of care/life,...