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Objective: To evaluate whether Medicare's Hospital Readmissions Reduction Pro-gram (HRRP) is associated with increased observation stay use. Data Sources and Study Setting: A nationally representative sample of fee-for-service Medicare claims, January 2009-September 2016. Study Design: Using a difference-in-difference (DID) design, we modeled changes in observation stays as a proportion of total hospitalizations, separately comparing the initial (acute myocardial infarction, pneumonia, heart failure) and subsequent (chronic obstructive pulmonary disease) target conditions with a control group of nontarget conditions. Each model used 3 time periods: baseline (15 months before program announcement), an intervening period between announcement and implementation, and a 2-year post-implementation period, with specific dates defined by HRRP policies. Data Collection/Extraction Methods: We derived a 20% random sample of all hospitalizations for beneficiaries continuously enrolled for 12 months before hospitalization (N = 7,162,189). Principal Findings: Observation stays increased similarly for the initial HRRP target and nontarget conditions in the intervening period (0.01% points per month [95% CI -0.01, 0.3]). Post-implementation, observation stays increased significantly more for target versus nontarget conditions, but the difference is quite small (0.02% points per month [95% CI 0.002,0.04]). Results for the COPD analysis were statistically insignificant in both policy periods. Conclusions: The increase in observation stays is likely due to other factors, including audit activity and clinical advances. KEYWORDS difference-in-differences, hospital readmissions reduction program, inpatient, Medicare, observation stays, recovery audit contractors What is known on this topic * Observation stays have increased significantly over the last 15 years. * Observation stays are excluded from the numerator and denominator of readmissions measures. * Medicare's Hospital Readmissions Reduction Program (HRRP) may incentivize hospitals to substitute observation stays for inpatient readmissions, although evidence of this is mixed. What this study adds * Ours is the first study to examine how hospitals may have responded to the HRRP by using observation stays in lieu of both index admissions and readmissions. * Using quasi-experimental methods, we find that the HRRP was not meaningfully associated with differential increases in the use of observation stays for target versus nontarget conditions. * The increase in observation stays is more likely the result of advances in clinical care and hospitals taking steps to avoid payment audits., 1 | INTRODUCTION Medicare's Hospital Readmissions Reduction Program (HRRP) has been controversial since its announcement. One ongoing concern is whether the HRRP incentivizes hospitals to use observation stays to avoid [...]

Objective: To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid. Data Sources: Data were obtained from 2012 to 2018 Medicare claims. Study Design: We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and non-emergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality. Data Extraction Methods: Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease. Principal Findings: After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period). Conclusions: FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population. KEYWORDS aged, community health centers, disabled persons, hospitalization, Medicaid, Medicare, primary health care What is known on this topic * Individuals dually enrolled in Medicare and Medicaid are a high-cost, high-need population. * Improving access to primary care may reduce the use of costly and potentially avoidable hospital-based care, but prior studies have excluded dual enrollees, used aggregated data, focused on just a few states, and failed to consider the full spectrum of hospital-based care. * Health centers provide improved access to primary care for certain populations, but there are little data on the use of health centers by dual enrollees. What this study adds * Dually-enrolled individuals who use health centers for their primary care had significantly less hospital-based care after implementation of the Medicare prospective payment system. * Greater reliance on health centers is associated with larger reductions in the use of hospital-based care. * Many dual enrollees are likely to benefit from receiving care at a health center., 1 | INTRODUCTION In 2018, over 12 million Medicare beneficiaries were also enrolled in Medicaid. (1) These dual enrollees have disproportionately high medical spending and substantial health needs. (2) Dual [...]

In 2020 and 2021, health centers received federal funding to support their COVID-19 pandemic response, yet little is known about how the funds were distributed. This study identified ten sources of funding distributed to 1,352 centers, ranging from $19 to $1.22 billion per center. When we examined patient and organizational characteristics by quartiles of funding per patient, health centers in the highest-funded quartile (quartile 4) were more likely rural and in the South; employed lower percentages of physicians; and had the highest percentages of sicker, uninsured, and unhoused patients. Centers in the lowest-funded quartile (quartile 1) were more likely urban, employed lower percentages of nurse practitioners, and had the highest percentages of Medicaid enrollees. With the end of pandemic-related funding in 2023, combined with Medicaid unwinding concerns, targeted investment is needed to mitigate a financial cliff and help maintain health centers’ capacity to provide high-quality services to those most in need.

Objective. To examine the effects of Medicare's Medical Review (MR) program on short-stay inpatient hospitalization.Data Sources/Study Setting. One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007-2010).Study Design. Retrospective observational study using a difference-indifferences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed size, system membership, and inpatient admission rate to test for differential effects. The comparison group was hospital visits occurring in those MACs that had yet to implement, as well as those that did not implement during the period of interest.Data Collection. None.Principal Findings. Medical Review significantly reduced the likelihood of inpatient admission for patients with an intake diagnosis of 'Non-Specific Chest Pain' by 1.29 percentage points (p < .001). This effect was stronger in larger hospitals (-2.03, p < .001), nonsystem hospitals (-2.54, p < .001), and those with a lower inpatient rate (-1.86, p< .001).Conclusions. Short inpatient hospitalizations were emphasized by MR, and our results show that MR modestly reduced their prevalence among certain patients and certain hospitals. Future work should examine whether this resulted in adverse patient outcomes.Key Words. Medical review, observation, hospital, Medicare, inpatient, BackgroundShort inpatient hospital stays (i.e., two days or fewer) have long been an area of emphasis for the Centers for Medicare & Medicaid Services in their efforts to reduce costs [...]