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.

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.


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...

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. 

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...

US National Trends in Mortality From Acute Myocardial Infarction and Heart Failure: Policy Success or Failure?

Apr. 26, 2018

Paula Chatterjee, Karen E. Joynt Maddox

Abstract [from journal]

Importance: Hospitals in the United States have been subject to mandatory public reporting of mortality rates for acute myocardial infarction (AMI) and heart failure (HF) since 2007 and to value-based payment programs for these conditions since 2011. However, whether hospitals with initially poor baseline performance have improved relative to other hospitals under these programs, and whether patterns of improvement differ by condition, is unknown. Understanding trends within...

Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce

Research Brief
Apr. 11, 2018

Surgical patients age 65 and over with Alzheimer’s disease and related dementias (ADRD) were more likely to die within 30 days of admission and to die after a complication than those without ADRD. Having better-educated nurses in the hospital improved the likelihood of good outcomes for all surgical patients, but had a much greater effect in individuals with ADRD. Specifically, a 10% increase in the proportion of nurses with a Bachelor of Science in Nursing (BSN) degree or higher was associated with 10% lower odds of death and 10% lower odds of dying after a complication for surgical patients with ADRD.

Prior Authorization Requirements for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Across US Private and Public Payers

Research Brief
Mar. 28, 2018

A comprehensive review of prior authorization (PA) requirements for a new class of expensive cholesterol-lowering drugs known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has found unusually complex and burdensome demands across public and private insurance plans in the United States. These findings raise concerns that current policies may create undue barriers to care even in medically appropriate patients, particularly since requirements were just as stringent for patients with a genetic condition that creates more clear-cut eligibility for PCSK9 inhibitor treatment.

Do Changes in Post-Acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

Mar. 22, 2018

Amol S. Navathe, Alexander M. Bain, Rachel M. Werner

Abtract [from journal]

While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.

The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare