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Frontloading of home health visits has been described as a strategy for reducing unnecessary hospital readmissions, yet there is no consistent practical definition. This study examines visit characteristics of post-acute home health episodes for heart failure patients in the Medicare fee-for-service population and explores whether alternative definitions can empirically distinguish frontloaded episodes. Using 100% Medicare claims and enrollment data for 2016 and 2017, we descriptively examine the first post-acute home health episodes occurring after discharge for patients with heart failure as a primary diagnosis. We use the number and timing of visits during 60-day episodes highlight two definitions of frontloading related to the existing empirical literature. Among heart failure home health episodes, almost 24% meet one definition of frontloading (60% of visits within 14 days) and 40% meet the second definition (3 or more nurse visits in 7 days). Little overlap exists between the populations identified by the two definitions. Each definition relates to patient need and represents a threshold chosen within a distribution of care, rather than distinguishing a type of care. Without an agreed upon empirical definition, observational studies measuring the effects of frontloading on outcomes may differ in patients identified as receiving frontloaded care. Furthermore, statistical methods to control for patient need may result in measuring the effects of marginal changes in care, estimating small or indistinguishable effects of frontloading on patient outcomes.

The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas.We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending.Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending.With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers. (Funded by the Centers for Medicare and Medicaid Services.).

Objectives To examine the effects of MD-Value in Prevention (MDVIP) enrollment on Medicare expenditures and utilization among fee-for-service (FFS) beneficiaries with diabetes over a 5-year period. Study design We obtained participating physician and beneficiary enrollment lists from MDVIP and Medicare FFS claims data through the Virtual Research Data Center to compare changes in outcomes, before and after enrollment dates, with those of nonenrolled beneficiaries receiving primary care in the same local market. Methods We employed propensity score matching to identify comparison beneficiaries similar in observed characteristics and preenrollment trends. Individual fixed effects were used to control for time-consistent differences between treatment and comparison populations. Results We found that enrollment is statistically associated with reductions in outpatient expenditures, Medicare expenditures in year 5, emergency department (ED) utilization, and unplanned inpatient admissions, accompanied by significant increases in evaluation and management visits and expenditures. Total Medicare expenditures over the 5-year period, as well as all inpatient admissions, were not statistically different between the MDVIP and comparison groups. Conclusions Our finding of reduced unplanned inpatient admissions and ED utilization supports the previous findings regarding MDVIP enrollees. We did not find significant changes in overall third-party expenditures, although savings were estimated in year 5, the last year of observation, and may occur later. Our approach, however, strengthens controls for baseline characteristics of the population and uses a comparison population drawn from the same markets who do not experience the loss of their primary care physician at the time of enrollment.

RESEARCH OBJECTIVE: The ACO Investment Model (AIM) was designed to encourage providers in rural or underserved areas to participate in the Medicare Shared Savings Program (SSP) by providing up‐front financial support for care transformation. In the second performance year, there were 41 ACOs that continued participation in AIM, with 423,434 beneficiaries assigned them. Our research objective was to determine whether the significant reductions in total Medicare spending we found in the first performance year were sustained in the second year, and whether specific ACO or market characteristics were associated with spending in both performance years. STUDY DESIGN: We utilized a difference‐in‐differences evaluation design to estimate differences in total spending between Medicare fee‐for‐service (FFS) beneficiaries attributed to AIM ACOs and comparison beneficiaries, before versus after the start of AIM. The comparison group included beneficiaries residing in each AIM ACO’s market who were eligible but not attributed to an ACO. Regression and weighting were used to adjust for demographic characteristics and health status. We stratified first and second performance year results based on ACO and market characteristics, including whether an ACO used a management company; partnered with a hospital; had fewer than 6,500 enrolled beneficiaries; was in the top quartile of rurality among AIM markets; had a discontinuous market; or had total Medicare spending at baseline that was above the median among all AIM markets. POPULATION STUDIED: Medicare FFS beneficiaries attributed to ACOs in AIM, which targeted ACO formation in rural/underserved areas in 2016 and 2017. PRINCIPAL FINDINGS: Across all 41 AIM ACOs, we estimated a significant reduction in total spending of $36.94 per beneficiary per month (PBPM) in the second performance year—a reduction of 3.5% and similar to findings from the first performance year. There were no significant differences in AIM impacts based on any of our six stratifications, but results across the two performance years suggest that greater reductions were achieved by ACOs working with a management company. CONCLUSIONS: ACOs participating in AIM sustained reductions in total Medicare spending across the first two performance years and across diverse ACO and market characteristics. IMPLICATIONS FOR POLICY OR PRACTICE: Results from the second performance year strengthen the evidence that ACOs can help reduce Medicare spending in rural or underserved areas. Among AIM markets, variations in market‐level baseline spending, market dispersion, and high rurality were not barriers to achieving spending reductions. ACOs locating in rural or underserved areas may benefit through partnership with a management company. PRIMARY FUNDING SOURCE: Centers for Medicare and Medicaid Services.

This study examines the importance of parental health in the development of child behavior during early childhood. Our analysis is based on child psychometric measures from a longitudinal German dataset, which tracks mothers and their newborns up to age six. We identify major changes in parental health (shocks) and control for a variety of initial characteristics of the child including prenatal conditions. The results are robust to placebo regressions of health shocks that occur after the outcomes are measured. Our findings point to negative effects of maternal health shocks on children’s emotional symptoms, conduct problems and hyperactivity. We estimate that maternal health shocks worsen outcomes by as much as 0.9 standard deviations. In contrast, paternal health seems to be less relevant to children’s behavioral skills.

We examine how parental health shocks affect children’s non-cognitive skills. Based on a German mother-and-child data base, we draw on significant changes in self-reported parental health as an exogenous source of health variation to identify effects on outcomes for children at ages of three and six years. At the age of six, we observe that maternal health shocks in the previous three years have significant negative effects on children’s behavioral outcomes. The most serious of these maternal health shocks decrease the observed non-cognitive skills up to half a standard deviation. Paternal health does not robustly affect non-cognitive outcomes.

We examine how parental health shocks affect children’s non-cognitive skills. Based on a German mother-and-child data base, we draw on significant changes in selfreported parental health as an exogenous source of health variation to identify effects on outcomes for children at ages of three and six years. At the age of six, we observe that maternal health shocks in the previous three years have significant negative effects on children’s behavioral outcomes. The most serious of these maternal health shocks decrease the observed non-cognitive skills up to half a standard deviation. Paternal health does not robustly affect non-cognitive outcomes.

We use longitudinal data from the 1984-2007 waves of the Panel Study of Income Dynamics to examine how occupational status is related to the health transitions of 30-59 year-old U.S. males. A recent history of blue-collar employment predicts a substantial increase in the probability of transitioning from very good into bad self-assessed health, relative to white-collar employment, but with no evidence of a difference in movements from bad to very good health. Service work is also associated with a higher probability of transitioning into bad health and possibly with a lower probability of recovery. These findings suggest that blue-collar and service workers “wear out” faster with age because they are more likely than their white-collar counterparts to experience negative health shocks. There is also evidence that this partly reflects differences in the physical demands of jobs.

We use longitudinal data from the 1984-2007 waves of the Panel Study of Income Dynamics to examine how occupational status is related to the health transitions of 30-59 year-old U.S. males. A recent history of blue-collar employment predicts a substantial increase in the probability of transitioning from very good into bad self-assessed health, relative to white-collar employment, but with no evidence of a difference in movements from bad to very good health. Service work is also associated with a higher probability of transitioning into bad health and possibly with a lower probability of recovery. These findings suggest that blue-collar and service workers “wear out” faster with age because they are more likely than their white-collar counterparts to experience negative health shocks. There is also evidence that this partly reflects differences in the physical demands of jobs.