EVALUATION OF HEALTH POLICIES AND QUALITY MEASURES IN THE ERA OF VALUE-BASED CARE
Open Access
- Author:
- Ramian, Haleh
- Graduate Program:
- Health Policy and Administration
- Degree:
- Doctor of Philosophy
- Document Type:
- Dissertation
- Date of Defense:
- June 07, 2021
- Committee Members:
- Douglas Leslie, Outside Unit & Field Member
David Vanness, Major Field Member
Chris Hollenbeak, Major Field Member
Joel Segel, Chair & Dissertation Advisor
John Moran, Major Field Member
Chris Hollenbeak, Program Head/Chair - Keywords:
- Value-based care
Medicare
Hospital Readmission Reduction Program
Skilled Nursing Facility
Medicare Advantage
Readmission
Spillover Effect
Regression Discontinuity
Quality of Care
Medicare Penetration
Kidney Cancer - Abstract:
- High costs and poor patient outcomes are a challenge in the current healthcare system in the United States. In the last decade, health care has seen a major shift in emphasis from volume to value. Since the passage of the Affordable Care Act (ACA) in 2010, healthcare quality improvement efforts have brought together payers, providers, and policymakers implementing strategies that aim to provide the highest quality of care for the lowest cost. Moving towards this goal has led to an increasing use and evaluation of quality measures that reflect the value of care. This dissertation examines three topics related to patient outcomes commonly used as quality measures. In the first study, I examine the impact of receiving post-acute care at a skilled nursing facility (SNF) on 30-day readmission using a regression discontinuity approach. A comparison of SNF use among Medicare Advantage (MA) and Medicare fee-for-service (FFS) showed although most MA plans are not subject to the 3-Day rule for SNF coverage, MA enrollees had lower SNF discharge rates with similar (although statistically not significant) increase in readmission rates to FFS enrollees. This finding highlights three important policy improvement opportunities. First, the potential for reducing unnecessary SNF use. Second, the need for hospitals to carefully identify the appropriate post-acute care setting for their patients that is capable of meeting the patient's needs to avoid potentially avoidable readmissions. And third, the need to revisit Medicare’s SNF coverage policies to ensure all Medicare beneficiaries receive comparable SNF care, regardless of how they participate in Medicare. In the second study, I examine the spillover effects of MA growth on FFS readmission rates for three conditions targeted by the Hospital Readmission Reduction Program (HRRP). Using the Norms Hypothesis to support the conceptual model, a comparison of the change in FFS readmission rates before and after the implementation of the HRRP did not show a differential impact of the HRRP on FFS readmissions in areas with high MA enrollment rates. This finding can inform future research to explore the possibility of MA moderating FFS readmissions for individual conditions given the three studied conditions have different risk factors and practice patterns. Finally, in the third study, I evaluate the impact of a new kidney cancer treatment guideline on three quality indicators. This study showed a decrease in readmission and mortality rates and a shorter length of stay in the post-guidelines period among patients with stage I kidney tumors targeted by the new guidelines. The guidelines did not differentially impact the quality indicators across stage I and stage II. This finding has important policy and clinical implications. First, the possibility of positive spillover effect of the guidelines on patients with stage II kidney cancer is suggestive of an opportunity to explore effective treatments for patients with stage II kidney tumors. Second, the availability of minimally invasive surgery techniques (i.e., laparoscopy or robotic surgery) in recent years may have contributed to enhancing quality of care and improving patient outcomes for patients with stage II kidney cancer, thus minimizing the difference in outcomes between stage I and stage II. Postoperative complications are frequent and are strongly associated with the risk of subsequent death, readmission, or length of hospital stay, all of which contribute to considerable costs of care and excess health care resource use. As the healthcare system shifts to value-based reimbursement models, achieving better quality in surgical care seems to be an essential part of the broader hospital quality improvement efforts.