Health affairs
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Ambulance diversion, which occurs when a hospital emergency department (ED) is temporarily closed to incoming ambulance traffic, is an important system-level interruption that causes delays in treatment and potentially lower quality of care. There is little empirical evidence investigating the mechanisms through which ambulance diversion might affect patient outcomes. ⋯ This led to a 4.6 percent decreased likelihood of revascularization and a 9.8 percent increase in one-year mortality compared to patients who did not experience diversion. Policy makers may wish to consider creating a policy to specifically manage certain time-sensitive conditions that require technological intervention during periods of ambulance diversion.
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Patients who accumulate multiple emergency department visits and hospital admissions, known as super-utilizers, have become the focus of policy initiatives aimed at preventing such costly use of the health care system through less expensive community- and primary care-based interventions. We conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers in an urban safety-net integrated delivery system for the period May 1, 2011-April 30, 2013. Our analysis found that consistently 3 percent of adult patients met super-utilizer criteria and accounted for 30 percent of adult charges. ⋯ This finding has important implications for program design and for policy makers because previous studies may have obscured this instability at the individual level. Our study also identified clinically relevant subgroups amenable to different interventions, along with their per capita utilization and costs before and after being identified as super-utilizers. Future solutions include improving predictive modeling to identify individuals likely to experience sustained levels of avoidable utilization, better classifying subgroups for whom interventions are needed, and implementing stronger program evaluation designs.
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The traditional Medicare program requires an enrollee to have a hospital stay of at least three consecutive calendar days to qualify for coverage of subsequent postacute care in a skilled nursing facility. This long-standing policy, implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner. ⋯ The elimination was not associated with more hospital or skilled nursing facility admissions or with longer lengths-of-stay in a skilled nursing facility. These findings suggest that eliminating the three-day stay requirement conferred savings on Medicare Advantage plans and that study of the requirement in traditional Medicare plans is warranted.
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Three separate pay-for-performance programs affect the amount of Medicare payment for inpatient services to about 3,400 US hospitals. These payments are based on hospital performance on specified measures of quality of care. ⋯ In 2015 four of five hospitals subject to these programs will be penalized under one or more of them, and more than one in three major teaching hospitals will be penalized under all three. Interactions among these programs should be considered going forward, including overlap among measures and differences in scoring performance.
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Medicaid was expanded to millions of individuals under the Affordable Care Act, but many states do not provide dental coverage for adults under their Medicaid programs. In the absence of dental coverage, patients may resort to costly emergency department (ED) visits for dental conditions. Medicaid coverage of dental benefits could help ease the burden on the ED, but ED use for dental conditions might remain a problem in areas with a scarcity of dentists. ⋯ Higher density of dental providers was associated with lower rates of dental ED visits by patients with Medicaid in rural counties but not in urban counties, where most dental ED visits occurred. County-level Medicaid-funded dental ED visit rates were lower in states where Medicaid covered nonemergency dental services than in other states, although this difference was not significant after other factors were adjusted for. Providing dental coverage alone might not reduce Medicaid-funded dental ED visits if patients do not have access to dental providers.