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      Early evidence from South Carolina’s Medicare-Medicaid dual-eligible financial alignment initiative: an observational study to understand who enrolled, and whether the program improved health?

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          Abstract

          Background

          Individuals dually eligible for Medicare and Medicaid coverage are among the sickest patients in the United States. Prior literature has identified a lack of care coordination or even conflicts of interest between the two programs as barriers to more efficient care and better health outcomes among dual-eligibles. The purpose of this study is to assess characteristics of dual eligibles who participated in South Carolina’s 2015 voluntary Medicare-Medicaid financial alignment demonstration project, and to evaluate whether their participation led to better observable health outcomes.

          Methods

          We obtained all inpatient and emergency department visits, and all Medicaid outpatient visits of individuals identified as Medicare-Medicaid dual eligibles from 2011 to 2016 from South Carolina’s Revenue and Fiscal Affairs Office. We employed logistic regressions to assess the characteristics of participants and quitters in the Medicare-Medicaid financial alignment demonstration project. To evaluate the impact of participation on health outcomes, we used an event study analysis that examines trends in outcomes over time, with participation in the demonstration project as the triggering event, and a difference-in-differences methodology that compares changes in health outcomes before and after participation in the demonstration project compared with a control group.

          Results

          Urban patients, female patients, and patients with heart problems, social and mental disorders, and importantly, patients with multiple comorbidities (as indicated by a higher Charlson comorbidity index) are less likely to join South Carolina’s demonstration project. Once having joined, female patients and patients with a higher Charlson index appear to be more likely to quit. Those who joined did not appear to enjoy better health outcomes in the short time frame.

          Conclusions

          Policy makers should explore and address reasons why dual eligibles with complex health problems hesitate to join the alignment project, and continue to monitor whether such a program improves health given that a prolonged period of exposure to the program may be required to achieve better health among the nation’s most vulnerable patients.

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          Most cited references18

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          A meta-analysis of interventions to improve care for chronic illnesses.

          To use empirical data from previously published literature to address 2 research questions: (1) Do interventions that incorporate at least 1 element of the Chronic Care Model (CCM) result in improved outcomes for specific chronic illnesses? (2) Are any elements essential for improved outcomes? Meta-analysis. Articles were identified from narrative literature reviews and quantitative meta-analyses, each of which covered multiple bibliographic databases from inception to March 2003. We supplemented this strategy by searching the MEDLINE database (1998-2003) and by consulting experts. We included randomized and nonrandomized controlled trials of interventions that contained 1 or more elements of the CCM for asthma, congestive heart failure (CHF), depression, and diabetes. We extracted data on clinical outcomes, quality of life, and processes of care. We then used random-effects modeling to compute pooled standardized effect sizes and risk ratios. Of 1345 abstracts screened, 112 studies contributed data to the meta-analysis: asthma, 27 studies; CHF, 21 studies; depression, 33 studies; and diabetes, 31 studies. Interventions with at least 1 CCM element had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied. The effects on quality of life were mixed, with only the CHF and depression studies showing benefit. Publication bias was noted for the CHF studies and a subset of the asthma studies. Interventions that contain at least 1 CCM element improve clinical outcomes and processes of care--and to a lesser extent, quality of life--for patients with chronic illnesses.
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            Behavioral Economics: Past, Present, and Future

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              Predictors of nursing home hospitalization: a review of the literature.

              Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.
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                Author and article information

                Contributors
                bchen@mailbox.sc.edu
                ytyang@gwu.edu
                Rachelle.Gajadhar@palmettohealth.org
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                29 November 2018
                29 November 2018
                2018
                : 18
                : 913
                Affiliations
                [1 ]ISNI 0000 0000 9075 106X, GRID grid.254567.7, University of South Carolina, ; 915 Greene Street Suite 354, Columbia, SC 29208 USA
                [2 ]ISNI 0000 0004 1936 9510, GRID grid.253615.6, George Washington University, ; 1919 Pennsylvania Ave. NW Suite 500, Washington, DC, 20006 USA
                [3 ]ISNI 0000 0000 9075 106X, GRID grid.254567.7, University of South Carolina, ; 3010 Farrow Rd. Suite 300, Columbia, SC 29203 USA
                Author information
                http://orcid.org/0000-0001-6384-1673
                Article
                3721
                10.1186/s12913-018-3721-6
                6267870
                30497468
                fc7a2da6-47e7-4f57-84d3-c66f72344f32
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 5 September 2018
                : 15 November 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100005509, Borchard Foundation Center on Law and Aging;
                Award ID: None
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Health & Social care
                medicare,medicaid,payment systems; aging/elderly/geriatrics
                Health & Social care
                medicare, medicaid, payment systems; aging/elderly/geriatrics

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