Payer Mix Research Articles

The Association of Chronic Opioid Use with Resource Utilization and Outcomes after Emergency General Surgery

Introduction Chronic opioid use is prevalent among patients undergoing emergent surgery. We sought to understand it on the outcomes of the most common emergency surgery procedures, Appendectomy and Cholecystectomy. Methods We used the National Inpatient Sample to identify chronic opioid use in emergency appendectomies (n = 953) and cholecystectomies (n = 2826) from 2005 to 2014. Primary outcome was length of stay (LOS), and secondary outcomes included total charges and mortality. LOS was analyzed with multivariate Poisson regression, total charges with multivariate linear regression. Results For Appendectomy, the opioid abuse group was younger, had similar gender and racial demographics, had more Medicaid and private insurance and less self-pay, and had no clinically significant differences in comorbidities. Those with chronic opioid use had a 24% increased LOS (20–29%, p < .001) and $5532(±$881, p < .001) higher hospital charges. Mortality was very rare and not different (0.2% vs 0.6%, aOR 0.54 [0.11–2.58], p = .44). For Cholecystectomy, the opioid abuse group was similar in age and gender, had slightly more white individuals, had a slightly different payor mix including higher rate of private insurance, and had no clinically significant differences in comorbidities. Patients with preoperative chronic opioid abuse showed a 14% increased LOS (12–16%, p < .001) and $5352 (± $1065, p < .001) higher hospital charges, but no significant increase in mortality (0.7% vs 0.6%, aOR 1.58 [0.77–3.25], p = .22). Conclusion Patients with chronic opioid abuse did not have increased mortality following EGS but had increased resource utilization and LOS. These findings may help explore the impact of opioid abuse on hospital and societal cost.

Examination of nursing home financial distress via Porter's five competitive forces framework.

Nursing homes face increased risk of closure because of poor financial performance. Using resource dependency theory, Porter's Five Forces of Competition framework, and Altman's Z -score model, this study examines the relationship between market factors and nursing home financial distress. This study utilizes Medicare Cost Reports, LTCFocus, Certification and Survey Provider Enhanced Reporting, Online Survey Certification and Reporting, and the Area Health Resource File to examine an average of 10,454 nursing homes per year from 2000 to 2015. Using Porter's framework, market factors were conceptualized as the bargaining power of buyers and suppliers, threat of substitutes and new entrants, and industry rivalry. Organizational control variables include occupancy, payer mix, size, and chain affiliation. Data were analyzed using multinomial logistic regression with robust clustering, year, and state fixed effects. Distressed nursing homes (Relative Risk Ratios [RRR] = 0.991) were less likely to be in counties with higher Medicaid concentration. Distressed (RRR = 0.717) and at-risk-of-distress nursing homes (RRR = 0.807) were less likely to be in markets with home health agencies, and nursing homes at risk of distress (RRR = 1.005) were more likely to be in markets with a higher number of hospital-based skilled nursing facility beds compared to healthy organizations. The organizational-level variables, occupancy, payer mix, size, and chain affiliation had a significant impact on nursing home financial distress. The effects of external market forces on nursing home financial distress were limited; however, organizational-level variables had a significant impact on nursing home financial distress. Study findings can inform policy makers on specific factors associated with nursing home financial distress and provide greater insight as it relates to designing new policies and interventions.

Impact of Pharmaceutical Prescription Assistance Programs on the Care of Patients with Chronic Myeloid Leukemia in a Safety Net Hospital

Introduction: The ever-rising cost of the oncology prescription drugs not only impacts the global cost of cancer care, but also affects the individual patient's financial toxicity, compliance, and outcomes. In safety-net setting, where the quality and quantity of care can be limited by the institution's budget, Prescription Assistance Programs (PAPs) are critical to patient care. Navigating the application process for these programs can be challenging for patients, especially for minorities and those with low health literacy. We looked at a pharmacy-run service for PAP enrollment at our safety-net hospital for patients diagnosed with chronic myeloid leukemia (CML). Methods: A total of 113 patients with CML who were receiving care at Parkland Health and Hospital System in Dallas, Texas, between January 2018 and December of 2019 were identified. Our pharmacy-run PAP service utilizes medication access technicians to complete PAP application packets for oncology patients. Patient records were reviewed to identify the payor mix, the choice of tyrosine kinase inhibitor (TKI), and number of prescriptions filled during the study period. Cost estimates are based on best advertised price for the individual drugs. For imatinib, cost estimate was based on the generic form. Results: Of the 113 CML patients, 78 did not have insurance. The majority of patients were Hispanic (61%); 19% were Black. In 62 patients (55%), English was not the primary language. TKIs used in first-line (insured vs uninsured) were: imatinib (49% vs 46%), dasatinib (31% vs 49%) and nilotinib (11% vs 5%). All uninsured patients were enrolled in Prescription Assistance Programs (PAP). The average time from diagnosis to application approval by the pharmaceutical companies was 23 days. Patients on average received the drug shipment 7 days after application approval. Uninsured patients received a total of 623 months' supply of their TKIs during the study period. Of these, only 7 were covered by the institution, most commonly to allow timely initiation of treatment while the PAP application was being processed. The estimated medication cost for the uninsured patients over the study period was $5.4m, of which $93k (2%) was covered by the institution. Conclusion: Our pharmacy-run PAP service allowed for rapid enrollment of all uninsured patients in pharmaceutical free drug programs and significantly reduced the cost of CML care for the institution. An expansion of this service to allow better utilization of copay assistance programs for insured patients can impact the financial toxicity associated with TKIs and is currently being planned. Disclosures No relevant conflicts of interest to declare.

Changes in Opioid Overdose Emergency Encounters Associated with Expansion of Wisconsin Medicaid to Childless Adults in Poverty

The purpose of this study was to measure changes in the payer mix and incidence of emergency department (ED) opioid-related overdose encounters after an April 2014 expansion of Medicaid to childless adults led to a 43% increase in Medicaid coverage for men and 8% for women statewide. We explored two competing hypotheses using data visualization and comparative interrupted time-series analysis (CITS): (a) expanded eligibility for Medicaid is associated with a change in payer mix only and (b) sociodemographic groups that gained Medicaid eligibility were more likely to use ED services for opioid overdose. Data included encounters at all Wisconsin nonfederal hospitals over 23 quarters from 2010 to 2015 and American Community Survey estimates of pre- and post-policy Medicaid eligibility by sex and age. We found an increase in the share of opioid-related ED visits covered by Medicaid for men and women ages 19-29 and for men ages 30-49 following the expansion. The number of visits increased substantially in April 2014 for men ages 30-49, with Medicaid-covered visits driving this result. We found little evidence of an increase in overall visits for other age groups for either men or women. The relationship between Medicaid expansion and opioid ED use is complex. Changes in case mix and increased access to care likely both play a role in the overall increase in these ED visits. Being uninsured may be an important barrier to seeking emergency care for opioid-related overdoses.

Access to Minimally Invasive Gynecologic Surgery for Adnexal Surgery: Impact of Race and Payer Mix

Study Objective To determine racial and social disparities regarding adnexal surgery. Design Retrospective cohort. Setting Data was obtained from the Statewide Planning and Research Cooperative System (SPARCS) for New York State. The database was reviewed from 2011 - 2015 for ovarian cystectomy with or without salpingectomy for benign indications. Patients or Participants There were 68,029 patients included in this analysis. Average age was 43 years, with 81.3% between 18-55 and 17.7% older than 55. Racial composition comprised of 68.7% Caucasian, 4.8% Asian, 11.2% Black, and 15.3% as other. Payor mix included 79.6% insured, 7.4% Medicaid, 8.3% Medicare, and 4.7% other or self-payment. Majority resided in metropolitan areas (90.6%) and did not travel greater than 15 miles for care. Interventions Adnexal surgery performed via laparotomy or laparoscopy. Measurements and Main Results Of the 68,029 patients included, 54,829 were performed via laparoscopy (80.6%) while 13,200 were via laparotomy (19.4%). Compared to Caucasian, odds ratio of having a laparoscopy was 0.68 for Black, 0.81 for Hispanic, and 0.80 for other. Compared to commercial insurance, odds ratio of having a laparoscopy was 0.69 for Medicaid, 0.72 for Medicare, 0.92 self. At high-volume surgical facilities, the odds ratio for utilizing laparoscopy was 1.83 compared to low volume facilities and 1.49 compared to medium volume facilities. At institutions with major teaching affiliation, the odds ratio was 0.91 compared to non-teaching and 1.0 for minor affiliation. Conclusion Race is not the only factor associated with a lower likelihood of laparoscopy for adnexal surgery. Other factors such as institution type and payer mix also impact likelihood.

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study.

BackgroundDespite available evidence‐based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness.ObjectiveThis study assessed barriers and facilitators to HKTP implementation preparation.MethodsInterviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis.ResultsForty‐four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health‐care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders’ focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients’ transplant education needs. Implementation barriers included: stakeholders’ perceptions that Hispanics’ health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion.Discussion and ConclusionsOur study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations’ implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators.

To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.

Small sleepers, big data: leveraging big data to explore sleep-disordered breathing in infants and young children.

Infants represent an understudied minority in sleep-disordered breathing (SDB) research and yet the disease can have a significant impact on health over the formative years of neurocognitive development that follow. Herein we report data on SDB in this population using a big data approach. Data were abstracted using the Cerner Health Facts database. Demographics, sleep diagnoses, comorbid medication conditions, healthcare utilization, and economic outcomes are reported. In a cohort of 68.7 million unique patients, over a 9-year period, there were 9,773 infants and young children with a diagnosis of SDB (obstructive sleep apnea [OSA], nonobstructive sleep apnea, and "other" sleep apnea) who met inclusion criteria, encompassing 17,574 encounters, and a total of 27,290 diagnoses across 62 U.S. health systems, 172 facilities, and 3 patient encounter types (inpatient, clinic, and outpatient). Thirty-nine percent were female. Thirty-nine percent were ≤1 year of age (6,429 infants), 50% were 1-2 years of age, and 11% were 2 years of age. The most common comorbid diagnoses were micrognathia, congenital airway abnormalities, gastroesophageal reflux, chronic tonsillitis/adenoiditis, and anomalies of the respiratory system. Payor mix was dominated by government-funded entities. We have used a novel resource, large-scale aggregate, de-identified EHR data, to examine SDB. In this population, SDB is multifactorial, closely linked to comorbid medical conditions and may contribute to a significant burden of healthcare costs. Further research focusing on infants at highest risk for SDB can help target resources and facilitate personalized management.

Adapting Diabetes Shared Medical Appointments to Fit Context for Practice-Based Research (PBR).

Complex behavioral interventions such as diabetes shared medical appointments (SMAs) should be tested in pragmatic trials. Partnerships between dissemination and implementation scientists and practice-based research networks can support adaptation and implementation to ensure such interventions fit the context. This article describes adaptations to and implementation of the Targeted Training in Illness Management (TTIM) intervention to fit the primary care diabetes context. The Invested in Diabetes pragmatic trial engaged 22 practice-based research network practices to compare 2 models of diabetes SMAs, based on TTIM. We used surveys, interviews, and observation to assess practice contextual factors, such as practice size, location, payer mix, change and work culture, motivation to participate, and clinical and administrative capacity. The enhanced Replicating Effective Programs framework was used to guide adaptations to TTIM and implementation in participating practices. Practices varied in size and patient demographics. All practices had integrated behavioral health, but limited health educators or prescribing providers. Adaptations to SMA delivery accommodated the need for flexibility in personnel and reduced scheduling burden. Adaptations to TTIM content were designed to fit general primary care diabetes and Spanish-speaking patients. Enhanced Replicating Effective Programs is a useful process framework for adaptation, implementation, and testing of diabetes SMAs in primary care. Adapting intervention content, delivery, and training to fit context can help ensure pragmatic trials have both internal and external validity. Attention to intervention fit to context can support continued practice engagement in research and sustainability of evidence-based interventions.

COVID-19’s Impact on Genetics at One Medical Center in New York

COVID-19’s Impact on Genetics at One Medical Center in New York

Cost-Effectiveness of Intraoperative CT Scanning in Cochlear Implantation in Fee-for-Service and Bundled Payment Models.

Electrode array tip fold-over is a complication of cochlear implant surgery that results in poor hearing outcomes and often leads to revision surgery. However, tip fold-over can be corrected immediately if identified through intraoperative computed tomography, which also potentially provides information about final intracochlear positioning. Our objective was to provide the first economic analysis of intraoperative computed tomography by generating models in fee-for-service and bundled payment reimbursement structures of payer and institutional cost-effectiveness of this technology used in cochlear implantation over 1, 5, and 10-year time periods. Cost data specific to a commerically available intraoperative computed tomography machine was obtained from the manufacturer, Xoran Technologies. Institutional tip fold-over rate was obtained from already published data. Medicare reimbursement rate for cochlear implantation was obtained from institutional accountants. Private payer reimbursement for and cost of revision cochlear implantation were estimated based on available data. At large volume centers, cost-effectiveness of this technology is possible in both fee-for-service and bundled payment reimbursement structures at various time points dependent on payer mix. Even low volume cochlear implantation centers (<150 per year) can financially benefit from intraoperative computed tomography in bundled payment models at 5- and 10-year periods regardless of payer mix. This model demonstrates key factors at play in determining cost-effectiveness of this technology including institutional factors and payer type and suggests this technology can align incentives both to improve patient care and outcomes with institutional and payer financial well-being.

The Three-Year Effect of Medicaid Expansion on Emergency Department Visits and Admissions

We examine the effect of the Medicaid expansion in 2014 under in the Patient Protection and Affordable Care Act on emergency department (ED) utilization and ED admission rates (fraction of ED visits that lead to hospital admission) during the first 3 postexpansion years (2014 to 2016). We compared ED utilization and ED admission rates in 151 EDs in 14 expansion states with those in 376 EDs in 14 nonexpansion states, using difference-in-differences methods with data from 3 national emergency medicine groups from 2013 to2016. In expansion states, the volume of Medicaid-paid ED visits increased 49% (95% confidence interval 34% to 65%), and the volume of uninsured visits decreased 44% (95% confidence interval -52% to -34%) relative to that of nonexpansion states. Both effects on payer mix leveled off during 2015. There was no significant relative change in overall ED utilization or overall ED admission rates in expansion versus nonexpansion states during the study. However, relative ED admission rates for uninsured patients declined 8% (95% confidence interval -18% to -2%) in expansion states. Large changes in payer mix in expansion versus nonexpansion states were observed but leveled off during 2015, with more Medicaid-paid visits and fewer uninsured visits in expansion states. Despite these large changes, during this 3-year period, there was no evidence that expansion affected either overall ED visit volume or ED admission rates. The relative decline in ED admission rates in expansion states among the uninsured may reflect a selection effect in which, among newly Medicaid-eligible persons, sicker persons were more likely to enroll than healthier ones.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Intersection of Bias, Structural Racism, and Social Determinants With Health Care Inequities.

* Abbreviation: SDoH — : social determinant of health Race, and more specifically, racism, is recognized as an important social determinant of health (SDoH) and a key driver of health inequities.1–3 The study “Race, Postoperative Complications, and Death in Apparently Healthy Children” in this issue of Pediatrics provides new evidence of race as a critical social determinant of surgical outcomes.4 The investigators demonstrate that apparently healthy Black children had a higher risk of postoperative mortality, complications, and serious adverse events than their white counterparts. Identifying these disparities using the National Surgical Quality Improvement Program pediatric database highlights the importance of health care practices to more deliberately consider equity in their quality improvement portfolios. The analyses were done among children with American Society of Anesthesiologists physical status 1 (normal healthy patients) or 2 (patients with mild systemic disease, such as mild asthma). By excluding children with significant comorbidities, this study helps advance knowledge beyond most previous pediatric disparities research focused on identifying disparities by exploring potential root causes. The findings suggest that, although preoperative comorbidities have previously been proposed as a factor contributing to postoperative disparities, they do not explain the results in the current study. Implicit racial bias has been proposed as another potential source of health care … Address correspondence to Tiffani J. Johnson, MD, MSc, Department of Emergency Medicine, University of California, Davis, 4150 V St, Suite 2100, Sacramento, CA 95817. E-mail: tjo{at}ucdavis.edu

SNF‐VBP Penalizes Skilled Nursing Facilities with Negative Profit Margins

Research ObjectiveSkilled Nursing Facility‐Value‐based Purchasing Program (SNF‐VBP) from the Centers of Medicare and Medicaid Services (CMS) incentivizes facilities to improve quality through lower hospital readmissions. However, SNF‐VBP may penalize nursing homes that are unable to invest resources to reduce readmissions. Although existing research has examined facility characteristics and SNF‐VBP performance, the relationship between financial performance and SNF‐VBP performance is unknown. In this study, we examine the SNF‐VBP performance by the financial performance of SNFs.Study DesignWe use data from three sources: 2019 SNF‐VBP performance data from CMS, and latest available CMS cost reports for SNFs (2017), and SNF characteristic data from LTCfocus.org (2017). We use descriptive methods to examine total profit margins and SNF‐VBP performance. We examine the characteristics of facilities with positive and negative profit margins, and within these, we further examine characteristics of facilities that are rewarded or penalized under SNF‐VBP. In the adjusted analysis, we evaluate the relationship between having a negative profit margin and experiencing penalty under the SNF‐VBP controlling for several SNF characteristics including resident acuity index, occupancy percentage, payer mix, size, profit status, chain membership, and market competition.Population StudiedAll freestanding SNFs with valid SNF‐VBP and cost report data (n = 12 420).Principal FindingsOf the 12 420 SNFs, about 46.4% have a negative profit margin. Furthermore, there is a 14‐percentage point difference in average profit margins for SNFs with positive profit margins vs. SNFs with negative profit margins (6.1% vs −8.15%). About 74.5% of SNFs with negative profit margins and 71.7% of the SNFs with positive profit margins are penalized under SNF‐VBP (P &lt; .05). Among the 9063 SNFs that are penalized, about 47.4% of the SNFs have negative profit margins with an average profit margin of −8.23%. These penalized SNFs with negative profit margins (n = 4295) have an average loss of $24 400 from SNF‐VBP (range: −$4 to −$170 000). In the adjusted analysis, the odds of being penalized under the SNF VBP program for SNFs with negative profit margins are 13% higher vs. SNFs with positive profit margins (OR: 1.13; 95% CI: 1.04‐1.23).ConclusionsSNFs with negative profit margins are more likely to be penalized under the SNF‐VBP.Implications for Policy or PracticeAlthough we want to incentivize quality improvement through programs like SNF‐VBP, we need to ensure that SNFs with negative profit margins have the resources to improve. Facilities with negative profit margins that are penalized under SNF‐VBP have an average loss of $24 400—an amount that roughly approximates average annual salary of a certified nursing assistant, one of the key nursing home direct care staffs. These losses may further exacerbate quality problems in facilities that are already struggling. Alternative approaches to assist financially struggling SNFs may help them improve quality and perform better under SNF‐VBP.

Factors Associated with U.S. Hospital Bankruptcies: 2007-2019

From 2007 through 2019 the hospital industry underwent significant changes including the Great Recession and the passage of the Affordable Care Act. Healthcare organizations faced significant challenges that contributed to a number of alarming trends, including provider burnout and hospital closures. Throughout this period, 48 hospitals and health systems filed for bankruptcy protection. Half of these hospitals eventually ceased operations. This article examines factors associated with hospitals that file bankruptcy. Non-financial factors associated with bankruptcy filings were identified from a literature review of hospital trade publications and other available sources. Organizational characteristics of filing hospitals were identified using the American Hospital Association Annual Survey. Poor financial management, challenges related to payer mix and reimbursement, and poor management are the most common factors that filing hospitals faced. A comparison between these results and similar research examining the period from 2000-2006 reveals that most of the non-financial factors contributing to bankruptcy are relatively stable over time. These findings emphasize that hospital managers and boards must evaluate the financial health of their organizations using a broad framework that includes political and economic factors as well as financial characteristics.

Preventive Care and Chronic Disease Management Comparison of Appalachian and Non-Appalachian Community Health Centers in the United States.

IntroductionThe Appalachian region is often characterized by poor health outcomes and economic depression. Health centers (HCs) are community-based and patient-directed organizations that deliver comprehensive, culturally competent, high-quality primary healthcare services in high need areas, including Appalachia, where economic, geographic, or cultural factors can hinder access to healthcare services.PurposeThe study compares the clinical quality performance in preventive care and chronic disease management between Appalachian HCs and their non-Appalachian counterparts.MethodsUsing 2015 Uniform Data System (UDS) health center data, bivariate and multivariate linear regression analyses examine the association of Appalachian HC with performance on preventive and chronic care clinical quality measures (CQMs).ResultsIn the multivariate analysis, patients served at Appalachian HCs are more likely to receive colorectal cancer screening and pediatric weight assessment and counseling than at non-Appalachian HCs. No statistically significant differences in performance observed among other CQMs. The percentage of Medicaid patients and total physician FTEs have positive associations with preventive care in colorectal and cervical cancer screening, pediatric weight assessment and counseling, and tobacco screening and cessation intervention as well as chronic disease management of aspirin therapy for ischemic vascular disease and hypertension control in the multivariate model.ImplicationsOverall Appalachian HCs perform as well as or better than non-Appalachian HCs in delivering preventive and chronic care services. Further examination of clinical quality improvement programs, insurance payer mix, and practice size among Appalachian HCs could advance the replication of clinical quality success for clinics in similar underserved communities.

Interview With Cathleen Wheatley, DNP, RN, CENP

There are interviews with colleagues that are intriguing. Then there are interviews that raise the level of nursing’s collective consciousness. Cathleen Wheatley, DNP, RN, CENP, does both. As president of Wake Forest Baptist Medical Center and system chief nurse executive of Wake Forest Baptist Health System, her impact and influence not only benefit those in her care, but those nursing professionals aspiring to effect lasting change. She humbly shares her thoughts and ideas about the changing health care milieu, never realizing how relevant they truly are.

The Affordable Care Act Is Associated With Increased Coverage and Decreased Charges, but Limited Improvement in Access to Vascular Surgery for Medicaid Patients

The Centers for Medicare and Medicaid Services estimate that 10 million people gained Medicaid coverage following implementation of the Patient Protection and Affordable Care Act (ACA); yet, it remains unclear how the expansion of Medicaid coverage has affected vascular surgical practice. We examined patients (18-65 years) in the National Inpatient Sample undergoing vascular procedures and total charges pre-ACA implementation (2006-2013) and post-ACA implementation (2014-October 2015). Western and Southern US census regions were surrogate exposure markers for Medicaid expansion status. International Classification of Diseases, 9th edition, procedure codes identified carotid endarterectomy, carotid artery stenting, abdominal aortic aneurysm repair (AAA) repair, endovascular AAA repair (EVAR), thoracic EVAR (TEVAR), major amputation (AMP), minor amputation (mAMP), and arteriovenous fistula/graft creation. Generalized linear models with modified Poisson distributions were calculated to compare pre- versus post-ACA outcomes, adjusted for gender and race/ethnicity. A difference-in-differences (DiD) analysis was conducted to compare post-ACA changes in vascular surgery access for Western versus Southern regions. A total of 196,684 procedures (South) and 76,031 procedures (West) were included. The proportion of uninsured patients undergoing surgery in the West decreased from 6.8% pre-ACA to 3.4% post-ACA but increased from 7.3% pre-ACA to 10.2% post-ACA in the South (P < .001). A significantly greater proportion of vascular procedures were covered by Medicaid in the West (pre-ACA 19.8% vs post-ACA 37.1%) compared to the South (pre-ACA 12.9% vs post-ACA 24.8%; P < .001; Figure). Total charges were reduced in the West (median pre-ACA $65,601 [interquartile range (IQR), $84,893], post-ACA ($55,718 [IQR, $83,950]) compared to the South (pre-ACA $44,124 [IQR, $55,079], post-ACA $39.199 [IQR, 60,142]; P < .001). In regression analyses, the post-ACA relative risk (RR) of undergoing surgery in the West versus South for Medicaid patients demonstrated a higher proportion undergoing surgery on DiD for carotid endarterectomy (adjusted RR [aRR] 2.37 [standard error, 0.05]; P < .001), mAMP (aRR, 1.17 [standard error, 0.03]; P < .001) and TEVAR (aRR, 1.35 [standard error, 0.17]; P = .008), but the RR decreased on DiD for arteriovenous fistula/graft creation (aRR, 0.49 [standard error, 0.04]; P < .001) and peripheral vascular intervention (aRR, 0.85 [standard error, 0.03]; P < .001). There were no significant differences post-ACA implementation for AAA (P = .36), carotid artery stenting (P = .49), EVAR (P = .18), lower extremity revascularization (P = .23), and AMP (P = .59) (Table). Implementation of the ACA’s Medicaid expansion was associated with significant transformation in payer mix for vascular surgery and reduction in the median charges per patient; however, improving access to limb revascularization and reducing amputations continues to lag for Medicaid patients. Future research is needed to understand the impact of Medicaid expansion on individual patient level outcomes and population health measures.TableGeneralized linear model with modified Poisson regression comparing the likelihood of a Medicaid patient undergoing a given vascular procedure in the Western versus Southern Region (referent) stratified by pre-Affordable Care Act (ACA) implementation vs post-ACA implementation and adjusted for gender and race/ethnicityWestern regionSouthern regionPre versus Post DiDP valueINTERPRETATIONAdjusted RR post-ACASEP valueAdjusted RR post-ACASEP valueAAA0.950.11.640.800.09.01.36No significant differences in AAA occurrence post-ACAAVF/AVG0.490.04<.0010.510.04<.001<.001Significantly larger decrease in AVF/AVG in the West post-ACACEA2.370.05<.0011.440.04<.001<.001Significantly greater increase in CEA in the West post-ACACAS1.350.11.0051.170.09.06.49No significant differences in CAS occurrence post-ACAEVAR3.460.13<.0014.770.09<.001.18No significant difference in the increase of EVAR post-ACALER0.970.05.461.010.03.71.23No significant differences in LER occurrence post-ACAMinor AMP1.170.03<.0010.880.03<.001<.001Significantly greater increase in minor AMP in the West post-ACAMajor AMP1.030.04.430.790.03<.001.58No significant changes in major AMP post-ACAPVI0.850.03<.0011.240.02<.001<.001PVI decreased in the West but increased in the South post-ACATEVAR1.350.17.071.450.14.009.008Significantly greater increase in TEVAR in the West post-ACAAAA, Abdominal aortic aneurysm; AMP, amputation; AVF, arteriovenous fistula; AVG, arteriovenous graft; CAS, carotid artery stenting; CEA, carotid endarterectomy; DiD, difference-in-difference; EVAR, endovascular aortic aneurysm repair; LER, lower extremity revascularization; PVI, peripheral vascular intervention; RR, relative risk; TEVAR, thoracic endovascular aortic repair.ARR of undergoing the procedure in the West compared to the South and least squares means estimates describing difference-in-differences for Medicaid patients pre- and post-ACA expansion are reported. 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Leadership Perceptions and Practices of Hospitality in Senior Care.

Senior care providers are increasingly focused on hospitality to distinguish themselves from competitors. A mixed-methods approach was used to examine perceptions of hospitality from leadership (i.e., administrators of nursing homes and assisted living facilities) and use of hospitality practices across settings and lines of service. Results indicated that hospitality practices readily exist in senior care settings (i.e., nursing homes, assisted living facilities), but may be referred to by names other than hospitality. There also appear to be more similarities than differences in practices across long-term care service lines (i.e., short- and long-stay nursing home residents, assisted living), suggesting that, regardless of provider type, hospitality in senior care is becoming part of the expected culture and cadre of services for residents. Overall, findings suggest hospitality practices are related to providers' census, payer mix, and organizational performance.