National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 14 of 14 Research Studies DisplayedLopez JM, Wing H, Ackerman SL
Community health center staff perspectives on financial payments for social care.
The purpose of this study was to examine how community health center (CHC) staff perceive the current and potential influence of fee-for-service payments on clinical teams' engagement in these activities. The researchers interviewed 42 clinicians, frontline staff, and administrative leaders employed by12 Oregon CHC clinical sites about their social care initiatives. The study grouped the findings into three categories: 1. participants' awareness of existing or anticipated financial incentives, 2. uses for incentive dollars, and 3. perceived impact of financial incentives on social care activities in clinical practices. Current or anticipated important uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest influence on clinic social care practices was the ability to provide responsive social services. Clinic leaders reported that for financial incentives to significantly change CHC practices would necessitate payments large enough to expand the social care workforce as well.
AHRQ-funded; HS026435.
Citation: Lopez JM, Wing H, Ackerman SL .
Community health center staff perspectives on financial payments for social care.
Milbank Q 2023 Dec; 101(4):1304-26. doi: 10.1111/1468-0009.12667..
Keywords: Community-Based Practice, Payment, Healthcare Delivery
Scott JW, Neiman PU, Scott KW
High deductibles are associated with severe disease, catastrophic out-of-pocket payments for emergency surgical conditions.
This retrospective analysis of claims data examined the association of a high-deductible health insurance plan (HDHP) with severe disease and catastrophic out-of-pocket payments for emergency surgical conditions (e.g., appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (e.g., perforation, abscess, diffuse peritonitis). The secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. Among 43,516 patients [mean age 48.4 years; 51% female], 41% were enrolled in HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%); even after adjusting for relevant demographics. HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%).
AHRQ-funded; HS027788; HS028672.
Citation: Scott JW, Neiman PU, Scott KW .
High deductibles are associated with severe disease, catastrophic out-of-pocket payments for emergency surgical conditions.
Ann Surg 2023 Oct 1; 278(4):e667-e74. doi: 10.1097/sla.0000000000005819..
Keywords: Health Insurance, Healthcare Costs, Payment, Surgery
Kwon Y, Perraillon MC, Drake C
Comparison of primary payer in cancer registry and discharge data.
The purpose of this cross-sectional study was to ascertain agreement between variables capturing the primary payer at cancer diagnosis across the Pennsylvania Cancer Registry (PCR) and statewide facility discharge records (Pennsylvania Health Care Cost Containment Council [PHC4]) for adults under 65 years, and to examine variables related with misclassification of Medicaid status in the registry given the role of managed care. The researchers evaluated agreement of payer at diagnosis across data sources. The study found that agreement of payers was high for private insurance, but there was misclassification and/or underreporting of Medicaid in the registry. Among cases with "other" and "unknown" insurance, 73.8% and 62.1%, respectively, had private insurance. Medicaid managed care was related with a statistically significant increase of 12.6 percentage points in the probability of misclassifying Medicaid enrollment as private insurance in the registry.
AHRQ-funded; HS027396.
Citation: Kwon Y, Perraillon MC, Drake C .
Comparison of primary payer in cancer registry and discharge data.
Am J Manag Care 2023 Sep; 29(9):455-62. doi: 10.37765/ajmc.2023.89425..
Keywords: Cancer, Payment
Waltman A, Konetzka RT, Chia S
Effectiveness of a bundled payments for care improvement program for chronic obstructive pulmonary disease.
This single-site retrospective observational study evaluated the impact of an evidence-based transitions of care program on episode costs and readmission rates, comparing patients hospitalized for COPD exacerbations who received versus those who did not receive the intervention. Between October 2015 and September 2018, 132 received and 161 did not receive the program. Below target mean episode costs were found for six out of eleven quarters for the intervention group, as opposed to only one out of twelve quarters for the control group. Overall, there were non-significant mean savings of $2551 in episode costs relative to target costs for the intervention group, though results varied by index admission diagnosis-related group (DRG). There were additional costs of $4184 per episode for the least-complicated cohort (DRG 192), but savings of $1897 and $1753 for the most complicated index admissions (DRGs 191 and 190, respectively). A significant mean decrease of 0.24 readmissions per episode for intervention was observed in 90-day readmission rates relative to control. Skilled nursing facility readmissions and hospital discharges were factors of higher costs (mean increases of $9098 and $17,095 per episode respectively).
AHRQ-funded; HS027804.
Citation: Waltman A, Konetzka RT, Chia S .
Effectiveness of a bundled payments for care improvement program for chronic obstructive pulmonary disease.
J Gen Intern Med 2023 Sep; 38(12):2662-70. doi: 10.1007/s11606-023-08249-6..
Keywords: Respiratory Conditions, Chronic Conditions, Payment, Quality Improvement, Quality of Care
Anderson KE, DiStefano MJ, Liu A
Incorporating added therapeutic benefit and domestic reference pricing into Medicare payment for expensive part B drugs.
The objective of this retrospective analysis was to identify expensive Part B drugs and to consider the evidence for each drug's added benefit in order to model a reimbursement policy for Medicare that integrates added benefit assessment and domestic reference pricing. Data were taken from a nationally representative sample of traditional Medicare Part B claims. The analysis showed that more than one-third of the expensive Part B drugs prescribed in 2019 offered low added benefit. The authors concluded that reference pricing based on added benefit assessment could be used to address the launch prices for expensive Part B drugs with low added benefit.
AHRQ-funded; HS000029.
Citation: Anderson KE, DiStefano MJ, Liu A .
Incorporating added therapeutic benefit and domestic reference pricing into Medicare payment for expensive part B drugs.
Value Health 2023 Sep; 26(9):1381-88. doi: 10.1016/j.jval.2023.05.018..
Keywords: Medicare, Payment, Medication, Healthcare Costs
Lewis A, Howland RE, Horwitz LI
Medicaid value-based payments and health care use for patients with mental illness.
This retrospective cohort study’s objective was to investigate if New York State's Medicaid value-based payment reform was associated with improved utilization patterns for patients with mental illness (major depression disorder, bipolar disorder, and/or schizophrenia). The cohort included Medicaid 306,290 individuals with depression (67.4% female; mean age, 38.6 years), 85,105 patients with bipolar disorder (59.6% female; mean age, 38.0 years), and 71,299 patients with schizophrenia (45.1% female mean age, 40.3 years). After adjustment, the analysis estimated a statistically significant, positive association between value-based payments and behavioral health visits for patients with depression (0.91 visits) and bipolar disorder (1.01 visits). There were no statistically significant changes to primary care visits for patients with depression and bipolar disorder, but value-based payments were associated with reductions in primary care visits for patients with schizophrenia (-1.31 visits). In every diagnostic population, value-based payment was associated with significant reductions in mental health emergency department visits (population with depression: -0.01 visits; population with bipolar disorder: -0.02 visits; population with schizophrenia: -0.04 visits).
AHRQ-funded; HS026980; HS026120.
Citation: Lewis A, Howland RE, Horwitz LI .
Medicaid value-based payments and health care use for patients with mental illness.
JAMA Health Forum 2023 Sep; 4(9):e233197. doi: 10.1001/jamahealthforum.2023.3197..
Keywords: Medicaid, Behavioral Health, Payment, Depression
Landon BE, Lam MB, Landrum MB
Opportunities for savings in risk arrangements for oncologic care.
High spending for cancer care is a target for savings as the United States hastens adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA). The purpose of this study was to quantify the level at which Accountable Care Organizations ACOs and other risk-bearing organizations operating in a specific geographic area could realize savings by directing patients to efficient medical oncology practices. The incident cohort included 1,309,825 patients Options for directing differed across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57,314 in 2009 to 2010 to $66,028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% greater than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods followed by Part B (infused) chemotherapy. Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high.
Citation: Landon BE, Lam MB, Landrum MB .
Opportunities for savings in risk arrangements for oncologic care.
JAMA Health Forum 2023 Sep; 4(9):e233124. doi: 10.1001/jamahealthforum.2023.3124..
Keywords: Cancer, Medicare, Healthcare Costs, Payment
Tummalapalli SL, Struthers SA, White D
Optimal care for kidney health: development of a Merit-based Incentive Payment System (MIPS) value pathway.
This article detailed the iterative consensus-building process used by the American Society of Nephrology Quality Committee to develop the Optimal Care for Kidney Health Merit-based Incentive Payment System (MIPS) Value Pathway (MVP). The Optimal Care for Kidney Health MVP, published in the 2023 Medicare Physician Fee Schedule Final Rule, included measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The MVP nephrology’s goal was to streamline measure selection in MIPS and served as a case study of collaborative policymaking between one professional organization and national regulatory agencies.
AHRQ-funded; HS028684.
Citation: Tummalapalli SL, Struthers SA, White D .
Optimal care for kidney health: development of a Merit-based Incentive Payment System (MIPS) value pathway.
J Am Soc Nephrol 2023 Aug; 34(8):1315-28. doi: 10.1681/asn.0000000000000163..
Keywords: Kidney Disease and Health, Payment, Healthcare Costs, Medicare
Loomer L, Rahman M, Mroz TM
Impact of higher payments for rural home health episodes on rehospitalizations.
This article evaluated the impact of higher Medicare payments for rural home health care on rehospitalizations. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries. The authors used Medicare data on postacute HH episodes from 2007 to 2014 to estimate the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. Their sample included 5.6 million post acute HH episodes (18% rural). After 2010 30- and 60-day rehospitalization rates declined by 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points and 0.57 percentage points for 30- and 60-day rehospitalization, respectively.
AHRQ-funded; HS027054.
Citation: Loomer L, Rahman M, Mroz TM .
Impact of higher payments for rural home health episodes on rehospitalizations.
J Rural Health 2023 Jun; 39(3):604-10. doi: 10.1111/jrh.12725..
Keywords: Payment, Rural Health, Rural/Inner-City Residents, Hospital Readmissions, Hospitalization
Maclean JC, McClellan C, Pesko MF
AHRQ Author: McClellan C
Medicaid reimbursement rates for primary care services and behavioral health outcomes.
This AHRQ-authored research studied the effects of changing Medicaid reimbursement rates for primary care services on behavioral health outcomes-defined here as mental illness and substance use disorders. The authors applied two-way fixed-effects regressions to survey data specifically designed to measure behavioral health outcomes over the period 2010-2016. They found that higher primary care reimbursement rates reduce mental illness and substance use disorders among non-elderly adult Medicaid enrollees, although they interpreted findings for substance use disorders with some caution as they may be vulnerable to differential pre-trends. Overall, their findings suggest positive spillovers from a policy designed to target primary care services to behavioral health outcomes.
AHRQ-authored.
Citation: Maclean JC, McClellan C, Pesko MF .
Medicaid reimbursement rates for primary care services and behavioral health outcomes.
Health Econ 2023 Jan 6;32(4):873-909. doi: 10.1002/hec.4646.
Keywords: Medicaid, Payment, Primary Care, Behavioral Health, Outcomes, Access to Care, Substance Abuse, Health Insurance
Ko H, Martin BI, Nelson RE
How does the effect of the comprehensive Care for Joint Replacement model vary based on surgical volume and costs of care?
This article described differences in costs, quality, and patient selection between hospitals that continued to participate in the comprehensive Care for Joint Replacement (CJR) program after the CMS policy revision and those that withdrew from CJR before and after the implementation of CJR. Study subjects were Medicare beneficiaries who had undergone elective lower extremity joint replacement from 2013 to 2017. The results indicated that hospitals that continued to participate in CJR achieved a greater cost reduction. The authors noted that these the cost reductions were partly attributable to the avoidance of potential higher-cost patients.
AHRQ-funded; HS024714.
Citation: Ko H, Martin BI, Nelson RE .
How does the effect of the comprehensive Care for Joint Replacement model vary based on surgical volume and costs of care?
Med Care 2023 Jan;61(1):20-26. doi: 10.1097/mlr.0000000000001785..
Keywords: Orthopedics, Surgery, Healthcare Costs, Medicare, Payment
Auty SG, Daw JR, Wallace J
State-level variation in supplemental maternity kick payments in Medicaid managed care.
The purpose of the cross-sectional study described in this research letter was to assesses the prevalence and magnitude of state-level delivery event–triggered kick payments to Medicaid managed care (MMC) plans for covering pregnant patients and the association of such payments with delivery costs. MMC kick payment rates were compared with average state Medicaid fee-for-service (FFS) payments for delivery hospitalizations and state kick payment rates compared with the Medicaid-Medicare fee index. The authors found “substantial and potentially unwarranted” state variation in delivery kick payment rates within MMC. They noted that if kick payment rates are set too low, plans may attempt to avoid pregnant enrollees by limiting coverage of certain services or restricting maternity care clinicians in their networks, with consequences for Black and Indigenous maternity patients.
AHRQ-funded; HS028754.
Citation: Auty SG, Daw JR, Wallace J .
State-level variation in supplemental maternity kick payments in Medicaid managed care.
JAMA Intern Med 2023 Jan; 183(1):80-82. doi: 10.1001/jamainternmed.2022.5146..
Keywords: Care Management, Health Insurance, Access to Care, Payment, Maternal Care
Zhang M, Shubina M, Morrison F
Following the money: copy-paste of lifestyle counseling documentation and provider billing.
To find out whether copied documentation of lifestyle counseling was used to justify higher evaluation and management (E&M) charges, researchers investigated 12,527 patient encounters in which lifestyle counseling was documented. When time spent on counseling was recorded, copied lifestyle counseling was associated with a decrease of 70.5% in the odds of higher E&M charges.
AHRQ-funded; HS017030
Citation: Zhang M, Shubina M, Morrison F .
Following the money: copy-paste of lifestyle counseling documentation and provider billing.
BMC Health Serv Res. 2013 Oct 2;13:377. doi: 10.1186/1472-6963-13-377..
Keywords: Diabetes, Electronic Health Records (EHRs), Health Information Technology (HIT), Health Insurance, Lifestyle Changes, Payment
DeVoe JE, Stenger R
Aligning provider incentives to improve primary healthcare delivery in the United States.
This critical review uses a theoretical framework from game-theory models to discuss some of the dominant primary care provider payment models and how they create 'prisoner's dilemmas' that have stalled past reform efforts, then illustrates an escape from the dilemma. It concludes that a blend of guaranteed payment and selective incentives designed to encourage primary care providers to deliver high quality care, efficient and equitable care and to eliminate incentives towards over-servicing could reach outcomes leading to shared benefits for everyone involved.
AHRQ-funded; HS014645; HS016181.
Citation: DeVoe JE, Stenger R .
Aligning provider incentives to improve primary healthcare delivery in the United States.
OA Fam Med 2013 Jun 1;1(1):7.
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Keywords: Healthcare Delivery, Payment, Primary Care, Quality Improvement