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California has long sought to achieve universal health insurance coverage for its residents. The state's uninsured population was dramatically reduced as a result of the Affordable Care Act (ACA). However, faced with federal threats to the ACA, California is exploring how it might take greater control over the financing of health care. In 2017 the state Senate passed the Healthy California Act, SB-562, calling for California to adopt a single-payer health care system. The state Assembly did not vote on the bill but held hearings on a range of options to expand coverage. These hearings highlighted the many benefits of unified public financing, whether a single- or multipayer system (which would retain health plans as intermediaries). The hearings also identified significant challenges to pooling financial resources, including the need for federal cooperation and for new state taxes to replace employer and employee payments. For now, California's single-payer legislation is stalled, but the state will establish a task force to pursue unified public financing to achieve universal health insurance. California's 2018 gubernatorial and legislative elections will provide a forum for further health policy debate and, depending on election outcomes, may establish momentum for more sweeping change.

Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services. We developed an evidence-based, all-payer collaborative care program called Behavioral Health Associates (BHA), operated as part of UCLA Health, an integrated academic medical center. Building BHA required several innovations, which included using our enterprise electronic medical record for behavioral health referrals and documentation; registering BHA providers with insurance plans' mental health carve-out products; and embedding BHA providers in primary care practices throughout the UCLA Health system. Since 2012 BHA has more than tripled the number of patients receiving behavioral health services through UCLA Health. After receiving BHA treatment, patients had a 13 percent reduction in emergency department use. Our efforts can serve as a model for other ACOs seeking to integrate behavioral health care into routine practice.

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion.

Alzheimers disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation, we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Postvisit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the Triple Aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the Triple Aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. It may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015.

Background: The purpose of this study is to determine whether episode Target Prices in the Bundled Payment for Care Improvement (BPCI) initiative sufficiently match the complexities and expenses expected for patients undergoing hip arthroplasty for femoral neck fracture (FNF) as compared to hip degenerative joint disease (DJD).Methods: Claims data under BPCI Model 2 were collected for patients undergoing hip arthroplasty at a single institution over a 2-year period. Payments from the index hospitalization to 90 days postoperatively were aggregated by Medicare Severity Diagnosis-Related Group (469 or 470), indication (DJD vs FNF), and categorized as index procedure, postacute services, and related hospital readmissions. Actual episode costs and Target Prices were compared in both the FNF and DJD cohorts undergoing hip arthroplasty to gauge the cost discrepancy in each group.Results: A total of 183 patients were analyzed (31 with FNFs, 152 with DJD). In total, the FNF cohort incurred a $415,950 loss under the current episode Target Prices, whereas the DJD cohort incurred a $172,448 gain. Episode Target Prices were significantly higher than actual episode prices for the DJD cohort ($32,573 vs $24,776, P < .001). However, Target Prices were significantly lower than actual episode prices for the FNF cohort ($32,672 vs $49,755, P = .021).Conclusion: Episode Target Prices in the current BPCI model fall dramatically short of the actual expenses incurred by FNF patients undergoing hip arthroplasty. Better risk-adjusting Target Prices for this fragile population should be considered to avoid disincentives and delays in care. [ABSTRACT FROM AUTHOR]

Objectives To describe differences in hospice services for patients living at home, in nursing homes or in assisted living facilities, including the overall number and duration of visits by different hospice care providers across varying lengths of stay. Design Retrospective cohort study using hospice patient electronic medical record data. Setting Large, national hospice provider. Participants Data from 32,605 hospice patients who received routine hospice care from 2009 to 2014 were analyzed. Measurements Descriptive statistics were calculated for utilization measures for each type of provider and by location of care. Frequency and duration of service contacts were standardized to a 1 week period and pairwise comparisons were used to detect differences in care provided between the three settings. Results Minimal differences were found in overall intensity of service contacts across settings, however, the mix of services were different for patients living at home versus nursing home versus assisted living facility. Overall, more nurse care was provided at the beginning and end of the hospice episode; intensity of aide care services was higher in the middle portion of the hospice episode. Nearly 43% of the sample had hospice stays less than 2 weeks and up to 20% had stays greater than 6 months. Conclusion There are significant differences between characteristics of hospice patients in different settings, as well as the mix of services they receive. Medicare hospice payment methodology was revised starting in 2016. While the new payment structure is in greater alignment with the U shape distribution of services, it will be important to evaluate the impact of the new payment methodology on length of stay and mix of services by different providers across settings of care. [ABSTRACT FROM AUTHOR]

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Substance use disorders affect 12% of Medicaid beneficiaries. The prescription drug epidemic and growing need for treatment of alcohol and opioid dependence have refocused states' attention on their provision of substance use disorder treatment services, including medications. This study characterized how Medicaid programs cover these treatment medications. Data were from 2013 Medicaid pharmacy documents, 2011 and 2012 Medicaid state drug utilization records, and a 2013 American Society of Addiction Medicine survey. Results showed that only 13 state Medicaid programs included all medications approved for alcohol and opioid dependence on their preferred drug lists. The most commonly excluded were extended-release naltrexone (19 programs), acamprosate (19 programs), and methadone (20 programs). For combined buprenorphine–naloxone, 48 Medicaid programs required prior authorization, and 11 programs used 1- to 3-year lifetime treatment limits. Given the chronic nature of substance use disorders and the overwhelming evidence supporting ongoing coverage for many of these medications, states may want to reexamine substance use disorder benefits. [ABSTRACT FROM AUTHOR]

In 1997 Congress created the Sustainable Growth Rate (SGR) formula for the payment of physicians under Part B of Medicare. SGR established a target rate of growth for aggregate costs of physician services under Part B, linked to growth in overall GDP. If growth in aggregate Part B costs exceeds the target, the rate at which physicians are paid in the following year is to be reduced by a corresponding amount. In SGR, Congress and the U.S. medical profession jointly confront a policy dilemma with no clear solution. For several years running, Congress has elected to postpone cuts in payment to physicians required under SGR. Absent further Congressional action, in 2013 physicians' fees under Part B of Medicare will be reduced by more than 30 %. The historical roots of SGR suggest that a potential solution lies in shifting to regional expenditure targets-an approach applied successfully in Canada in the 1970s when Canadian Medicare confronted rising physician fees. The commission that created what was to become SGR was aware of the lessons learned in Canada, and recommended that they also be applied to U.S. Medicare. [ABSTRACT FROM AUTHOR]

The complexity of the problem the national health care program confronts with and which must be solved through the measures of the respective reform lead to a SWOT analysis, particularly for this reform. The capacity to generate the necessary income it is a very important criteria in establishing a certain method of financing in order to be the most desired one represents the cornerstone of its capacity to line up additional funds for HEALTHCARE. It is very well known that in poor countries, the abilities of governments to collect taxes is somewhat limited, thus it becomes somehow difficult to allocate additional resources towards the healthcare system. There are special taxes (alcohol and tobacco), but there is always the probability of fiscal evasion. The healthcare social responsibility, financed through income tax allocation has a wider capacity of generating revenue. [ABSTRACT FROM AUTHOR]

The key obstacle in contemporary medicine consists in rapidly growing financial demands of diagnostic techni-ques and frequently expensive modern drugs. Their undoubted effectiveness presents itself through an increa-se in life expectancy, especially of men in the pasttwo decades in the Czech Republic. Due to the rapid growth in financial demands of the therapy, primary prevention, thus preventing disease, found itself in the role of a Cin-derella. Why? Without a doubt will useful investments pay off, yet unfortunately in such a long time in which seve-ral political leaderships may rotate. This is one of the main reasons, why attempts for a primary prevention are often left aside. When realized, they are frequently just in a form of a limited campaign. The paradox of today's era is, and one can't exclude that in the near future, a situation may appear, in which the costs of patient therapy will set such high demands on society, that politicians will finally critically understand the importance of investing into primary prevention. This concerns cardiovascular diseases including hypertension and diabetes type II, which go hand in hand with today's plague -- obesity, just like as the primary prevention of malignant neoplasms and other growing problems of general public's health. This also includes e.g. osteoporosis and neuro-degenerative diseases linked to the increasing age of our population. Last but not leastthere is the field of highly desired preventive activities in stomatology branch. The neglected dental caries and paradontosis related problems directly and quite negatively affectthe quality of our life. The challenge of 21st century medicine is the anticipation of diseases and their primary prevention as an sub-stantial, elementary contribution towards increasing the quality of life of not only our, but for coming generati-ons as well [ABSTRACT FROM AUTHOR]

Translating research evidence into daily practice is a challenging process at the organizational level. Conceptual models about this process point to the importance of resources for change and environmental influences as two key factors that need to be addressed in translation efforts. Two organizational case studies focused on improving care for adults with depression are described that illustrate lessons about translating evidence to practice that may be helpful to others. [ABSTRACT FROM AUTHOR]

In the United States, Medicare's flagship Accountable Care Organization (ACO) program, the Medicare Shared Savings Program (MSSP), is under close scrutiny to improve health care quality and decrease costs. First year measures, released in November 2014, reveal a wide range of financial and quality performance across MSSP participants. In this observational study we used 2013 results for 220 participating ACOs to assess key characteristics associated with generating savings. ACOs with higher baseline expenditures were significantly more likely to generate savings than lower cost ACOs. Average quality scores for ACOs that successfully reported on quality were not different between organizations that did and did not generate savings. These findings suggest ACOs that had lower utilization prior to program enrollment are less likely to be rewarded in the current program. This has important policy implications for the MSSP's ability to attract and retain efficient ACOs and incent efforts to reduce waste and improve quality.

California became very successful in controlling rising health care costs by promoting price competition through market-based, managed care policies. However, recent data reveal that the state has not been able sustain its initial success in controlling growth in hospital prices. Two powerful trends emerged in California that eroded the conditions needed to sustain price competition. To ensure timely access to emergency hospital services, government regulators enacted regulations that had the unintended effect of giving hospitals tremendous leverage when contracting with health plans. Also, antitrust authorities allowed hospitals to consolidate into multihospital systems by adding members that were not direct competitors in local markets. The combined effect of these policies and consolidation trends was a substantial reduction in the competitiveness of provider markets in California, which reduced health plans' ability to leverage competitive provider markets and negotiate lower prices and other benefits for their members. Policy makers can and should act to restore competitive conditions.

Good research evidence exists to suggest that social determinants of health, including access to housing, nutrition, and transportation, can influence health outcomes and health care use for vulnerable populations. Yet adequate, sustainable financing for interventions that improve social determinants of health has eluded most if not all US communities. This article argues that underinvestment in social determinants of health stems from the fact that such investments are in effect public goods, and thus benefits cannot be efficiently limited to those who pay for them-which makes it more difficult to capture return on investment. Drawing on lesser-known economic models and available data, we show how a properly governed, collaborative approach to financing could enable self-interested health stakeholders to earn a financial return on and sustain their social determinants investments.

Cost containment for dual-eligible beneficiaries (those enrolled in Medicare and Medicaid) is a key policy goal, but few studies have examined spending trends for this population. We contrasted growth in Medicare fee-for-service per beneficiary spending for those with and without Medicaid in the period 2007-15. Relative to Medicare-only enrollees, dual-eligible beneficiaries consistently had higher overall Medicare spending levels; however, they experienced steeper declines in spending growth over the study period. These trends varied across populations of interest. For instance, dual-eligible beneficiaries ages sixty-five and older went from having annual spending growth rates that were 1.8 percentage points higher than Medicare-only beneficiaries in 2008 to rates that were 1.1 percentage points lower in 2015. Across population groups, long-term users of nursing home care had some of the highest spending growth rates, averaging 1.7-4.1 percent annually depending on age group and Medicaid participation. These findings have implications for value-based payment and other Medicare policies aimed at controlling spending for dual-eligible beneficiaries.

Between 1996 and 2015, mean annual increases in per visit emergency department (ED) expenditures were significantly greater for private insurance than Medicare, Medicaid, and no insurance, with no corresponding difference in ED charges. Expenditures as a proportion of charges decreased for all insurers over time. Private insurance had the highest expenditure-to-charge ratio in each year.

The Affordable Care Act (ACA) attempted to minimize disruptions to employer-sponsored insurance in part by implementing an employer mandate. Research has shown that employer coverage rates have been stable nationally under the ACA. Massachusetts enacted its own employer mandate in 2006 before eliminating it in 2014, in anticipation of the federal mandate. But the ACA's employer mandate was delayed until 2015 and exempted smaller firms that had been covered by the Massachusetts' mandate. In this unique policy environment, we found that the employer-sponsored insurance rate in Massachusetts fell by 2.3 percentage points after the ACA's coverage expansion took effect (2014-16), compared to the rest of the US. Coverage dropped more for middle-income workers than for lower-income workers, which suggests that crowd-out by Medicaid was not the primary factor. Employer surveys show that employer coverage offer rates declined significantly at small firms in Massachusetts beginning in 2014, but not at large firms. Our findings suggest that eliminating Massachusetts's employer mandate may have contributed to falling employer coverage rates in the state, although other policy and economic factors cannot be ruled out. These results may have implications for understanding the effects of the ACA's employer mandate and its potential repeal.

As of January 1, 2014, the Affordable Care Act designated mental health and substance use services as an essential health benefit in Marketplace plans and extended parity protections to the individual and small-group markets. We analyzed documents for seventy-eight individual and small-group plans in 2014 (after parity provisions took effect) and sixty comparison plans in 2013 (the year before parity provisions took effect) to understand the degree to which coverage for mental health and substance use care improved relative to medical/surgical benefits. The results suggest that plan issuers did what the provisions required them to do. Although in 2013 a lower proportion of plans covered mental health or substance use care, compared to medical/surgical care, in 2014 the proportions were the same. If essential health benefit requirements were to be removed and mental health and substance use coverage becomes similar to that in 2013, as many as 20 percent of the plans in our sample would not cover these conditions. To determine whether increases in behavioral health coverage will result in improved access to behavioral health services requires complementary data on the size of provider networks and use of services.

We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost. These findings suggest that while both voluntary and mandatory approaches can play a role in engaging hospitals in bundled payment, mandatory programs can produce more robust, generalizable evidence. Either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payment programs.

A successful strategy for improving population health requires acting in several sectors by implementing a portfolio of interventions. The mix of interventions should be both tailored to meet the community's needs and balanced in several dimensions-for example, time frame, level of risk, and target population. One obstacle is finding sustainable financing for both the interventions and the community infrastructure needed. This article first summarizes Vermont's experience as a laboratory for health reform. It then presents a conceptual model for a community-based population health strategy, using a balanced portfolio and diversified funding approaches. The article then reviews Vermont's population health initiative, including an example of a balanced portfolio and lessons learned from the state's experience.

Delivering food to nutritionally vulnerable patients is important for addressing these patients' social determinants of health. However, it is not known whether food delivery programs can reduce the use of costly health services and decrease medical spending among these patients. We sought to determine whether home delivery of either medically tailored meals or nontailored food reduces the use of selected health care services and medical spending in a sample of adults dually eligible for Medicare and Medicaid. Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program. Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending. These findings suggest the potential for meal delivery programs to reduce the use of costly health care and decrease spending for vulnerable patients.

Under current law, national health spending is projected to grow 5.5 percent annually on average in 2017-26 and to represent 19.7 percent of the economy in 2026. Projected national health spending and enrollment growth over the next decade is largely driven by fundamental economic and demographic factors: changes in projected income growth, increases in prices for medical goods and services, and enrollment shifts from private health insurance to Medicare that are related to the aging of the population. The recent enactment of tax legislation that eliminated the individual mandate is expected to result in only a small reduction to insurance coverage trends.

Congress established the Center for Medicare and Medicaid Innovation (CMMI) to design, test, and spread innovative payment and service delivery models that either reduce spending without reducing the quality of care or improve the quality of care without increasing spending. CMMI sought to leverage these models to foster market innovation and accelerate the transformation of payment and care delivery to achieve the Triple Aim of better health, better care, and lower cost. This article provides a perspective on the design and execution of CMMI's five initial models, the resulting outcomes and lessons, and how their core concepts evolved within and spread beyond CMMI. This experience yields three key insights that could inform future efforts by CMMI and public and private payers, including model designs and policy decisions. These insights center on the need for iterative testing and learning guided by market feedback, more realistic time frames to demonstrate impact on cost and quality, and greater integration of models.

Decisions by states about whether to expand Medicaid under the Affordable Care Act (ACA) have implications for hospitals' financial health. We hypothesized that Medicaid expansion of eligibility for childless adults prevents hospital closures because increased Medicaid coverage for previously uninsured people reduces uncompensated care expenditures and strengthens hospitals' financial position. We tested this hypothesis using data for the period 2008-16 on hospital closures and financial performance. We found that the ACA's Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion. Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

Demographic and epidemiological changes are shifting the disease burden from communicable to noncommunicable diseases in lower-income countries. Within a generation, the share of disease burden attributed to noncommunicable diseases in some poor countries will exceed 80 percent, rivaling that of rich countries, but this burden is likely to affect much younger people in poorer countries. The health systems of lower-income countries are unprepared for this change. We examined the shift to noncommunicable diseases and estimated preparedness for the shift by ranking 172 nations using a health system capacity index for noncommunicable disease. We project that the countries with the greatest increases in the share of disease burden attributable to noncommunicable disease over the next twenty-five years will also be the least prepared for the change, as they ranked low on our capacity index and are expected to have the smallest increases in national health spending. National governments and donors must invest more in preparing the health systems of lower-income countries for the dramatic shift to noncommunicable diseases and in reducing modifiable noncommunicable disease risks.

Policy makers and providers are under increasing pressure to find innovative approaches to achieving better health outcomes as efficiently as possible. Accountable care, which holds providers accountable for results rather than specific services, is emerging in many countries to support such care innovations. However, these reforms are challenging and complex to implement, requiring significant policy and delivery changes. Despite global interest, the evidence on how to implement accountable care successfully remains limited. To improve the evidence base and increase the likelihood of success, we applied a comprehensive framework for assessing accountable care implementation to three promising reforms outside the United States. The framework relates accountable care policy reforms to the competencies of health care organizations and their health policy environments to facilitate qualitative comparisons of innovations and factors that influence success. We present emerging lessons to guide future implementation and evaluation of accountable care reforms to improve access to and the quality and affordability of care.

Globally, two-thirds of child deaths could be prevented by increased provision of health interventions such as vaccines, micronutrient supplements, and water purification tablets. We report the results from a randomized controlled trial in Haiti during 2012 that tested whether microfinance institutions-which reach 200 million households worldwide-can effectively deliver health products. These institutions provide loans to underserved entrepreneurs, primarily poor women in rural areas. In the intervention group, micronutrient powders to improve the nutrition of young children were distributed at regularly occurring microfinance meetings by a trained borrower. In both the control and the intervention groups, nurses led seminars on nutrition and extended breastfeeding during microfinance meetings. At three-month follow-up, the mean difference in hemoglobin concentration between children in the intervention group and those in the control group was 0.28 grams per deciliter (g/dL)-with a subsample of younger children (under two years of age) showing greater relative improvement (0.46 g/dL)-and the odds ratio for children in the intervention group meeting the diagnostic criteria for anemia was 0.64. The results are similar to those of previous studies that evaluated micronutrient powder distribution through dedicated health institutions. Our findings suggest that microfinance institutions are a promising platform for the large-scale delivery of health products in low-income countries.

Background: Rural healthcare facilities in low-income countries play a major role in providing primary care to rural populations. We examined the link of foreign aid with government investments and medical service provision in rural health centres in Rwanda., Methods: Using the District Health System Strengthening Tool, a web-based database built by the Ministry of Health in Rwanda, we constructed two composite indices representing provision of (1) child and maternal care and (2) HIV, tuberculosis (TB) and malaria services in 330 rural health centres between 2009 and 2011. Financing variables in a healthcare centre included received funds from various sources, including foreign donors and government. We used multilevel random-effects model in regression analyses and examined the robustness of results to a range of alternative specification, including scale of dependent variables, estimation methods and timing of aid effects., Findings: Both government and foreign donors increased their direct investments in the 330 rural healthcare centres during the period. Foreign aid was positively associated with government investments (0.13, 95% CI 0.06 to 0.19) in rural health centres. Aid in the previous year was positively associated with service provision for child and maternal health (0.008, 95% CI 0.002 to 0.014) and service provision for HIV, TB and malaria (0.014, 95% CI 0.004 to 0.022) in the current year. The results are robust when using fixed-effects models., Conclusions: These findings suggest that foreign aid did not crowd out government investments in the rural healthcare centres. Foreign aid programmes, conducted in addition to government investments, could benefit rural residents in low-income countries through increased service provision in rural healthcare facilities., Competing Interests: Competing interests: None declared.

Medicaid expansion in Arizona has helped the Indian Health Service and tribally run health systems improve access., (Project HOPE—The People-to-People Health Foundation, Inc.)

For one family, Medicare's bundled payment program felt more like a health care assembly line than coordinated care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program., (Project HOPE—The People-to-People Health Foundation, Inc.)