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Richard P. Menger, Bharat Guthikonda, Christopher M. Storey, Anil Nanda, Matthew McGirt and Anthony Asher

T he Affordable Care Act (ACA) represents a direct and aggressive expansion of government-controlled health care delivery. This legislation will ultimately lead to wide-ranging governmental oversight and determination of health care value (i.e., quality and cost). 24 According to the Kaiser Family Foundation, 270 million (of 313 million total) Americans have health insurance. Fifty-four percent have private insurance; public insurance is roughly split between Medicare (46 million, or 15%), Medicaid (49 million, or 16%), and “other” public insurance (2

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Rachel F. Groman and Koryn Y. Rubin

W ith the signing of the Patient Protection and Affordable Care Act of 2010 (ACA or Pub.L. 111–148), the US health system entered a new era in which health care professionals will be held to an unprecedented level of accountability for both the quality and efficiency of the care they provide. Although health care quality assessment and improvement have been integral elements of the practice of medicine for much of the past 2 centuries, historically these efforts have been mostly voluntary, internally driven by organized medicine, and rarely focused on cost

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Edie E. Zusman

CER has been used by government fairly broadly since then, its policy potential was not fully realized until 2009, when President Obama signed into law the American Recovery and Reimbursement Act, the stimulus bill that included a $1.1 billion allotment for CER. The funds were divided among 3 federal agencies: the Office of the Secretary of Health and Human Services ($400 million), the National Institutes of Health ($400 million), and the AHRQ ($300 million). 6 The Patient Protection and Affordable Care Act, the health care reform legislation passed in 2010

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Laura P. D'Arcy and Eugene C. Rich

historical changes in the definition and funding of CER, the article explores the mission, priorities, and research agenda of the Patient-Centered Outcomes Research Institute (PCORI), which is an independent, nonprofit corporation established in 2010 by the Patient Protection and Affordable Care Act (ACA). Evolving Conceptions of CER Researchers who systematically review the clinical literature have recognized for decades the need for better evidence regarding “what works best for whom” in health care, but the specific terminology regarding CER has evolved as policy

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Joshua M. Rosenow and Katie O. Orrico

somewhat open to interpretation. Possible Implications of Health Care Reform The Patient Protection and Affordable Care Act of 2010 is intended to enable millions more Americans to have health insurance. However, the possession of individual health insurance does not necessarily guarantee access to health care. The results of this survey indicate that while it may be possible to find a neurosurgeon who accepts Medicare, it may be very difficult to actually obtain care, at least in part because of the poor reimbursement rates under the program. The problem

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Nicolas W. Villelli, Rohit Das, Hong Yan, Wei Huff, Jian Zou and Nicholas M. Barbaro

W ith the passage of the federal Patient Protection and Affordable Care Act (ACA) in 2009, an estimated 30 million uninsured individuals obtained access to medical insurance. 4 , 10 The ACA was developed on principles similar to the 2006 Massachusetts state health care insurance reform statute, “An Act Providing Access to Affordable, Quality, Accountable Health Care,” also known as Chapter 58. 9 The primary goal of both laws is to extend insurance coverage to nonelderly individuals who do not qualify for subsidized programs at either the state or federal

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Nicolas W. Villelli, Hong Yan, Jian Zou and Nicholas M. Barbaro

W ith the passage of the Affordable Care Act (ACA) in 2009, significant debate has developed as to the financial implications of this policy. This bill has many similarities to the Massachusetts health care reform law of 2006, including subsidies for lower-income families, individual and business mandates, and state-based exchanges. 1 Because of these parallels, prior research has used Massachusetts as a predictor of the ACA’s impact on the future of the US health care system. 3 , 5 , 8 , 10 Our prior analysis showed that neurosurgical procedure volume and

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Praveen V. Mummaneni, Mohamad Bydon, Mohammed Ali Alvi, Andrew K. Chan, Steven D. Glassman, Kevin T. Foley, Eric A. Potts, Christopher I. Shaffrey, Mark E. Shaffrey, Domagoj Coric, John J. Knightly, Paul Park, Michael Y. Wang, Kai-Ming Fu, Jonathan R. Slotkin, Anthony L. Asher, Michael S. Virk, Panagiotis Kerezoudis, Jian Guan, Regis W. Haid and Erica F. Bisson

D egenerative lumbar spondylolisthesis is one of the most common causes of low-back pain, with a reported prevalence of 11.5% in the United States. 27 Surgical intervention may be considered for carefully selected patients in whom conservative management has failed, and it has been found to be associated with superior outcomes compared to nonsurgical therapy for this subset of patients. 41 However, it remains unclear what factors are associated with optimum patient-reported outcomes (PROs). Since the enactment of the Patient Protection and the Affordable Care

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W. Lee Titsworth, Justine Abram, Peggy Guin, Mary A. Herman, Jennifer West, Nicolle W. Davis, Jennifer Bushwitz, Robert W. Hurley and Christoph N. Seubert

, this study has broad implications for the continuum of care model proposed in the Affordable Care Act. 22 Acknowledgments This study received funding from the W. Martin Smith Interdisciplinary Patient Quality and Safety Awards Program. References 1 Amtmann D , Cook KF , Jensen MP , Chen WH , Choi S , Revicki D , : Development of a PROMIS item bank to measure pain interference . Pain 150 : 173 – 182 , 2010 2 Barakzoy AS , Moss AH : Efficacy of the world health organization analgesic ladder to treat pain in end-stage renal

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Owoicho Adogwa, Aladine A. Elsamadicy, Jing L. Han, Joseph Cheng, Isaac Karikari and Carlos A. Bagley

OBJECTIVE

With the recent passage of the Patient Protection and Affordable Care Act, there has been a dramatic shift toward critical analyses of quality and longitudinal assessment of subjective and objective outcomes after lumbar spine surgery. Accordingly, the emergence and routine use of real-world institutional registries have been vital to the longitudinal assessment of quality. However, prospectively obtaining longitudinal outcomes for patients at 24 months after spine surgery remains a challenge. The aim of this study was to assess if 12-month measures of treatment effectiveness accurately predict long-term outcomes (24 months).

METHODS

A nationwide, multiinstitutional, prospective spine outcomes registry was used for this study. Enrollment criteria included available demographic, surgical, and clinical outcomes data. All patients had prospectively collected outcomes measures and a minimum 2-year follow-up. Patient-reported outcomes instruments (Oswestry Disability Index [ODI], SF-36, and visual analog scale [VAS]-back pain/leg pain) were completed before surgery and then at 3, 6, 12, and 24 months after surgery. The Health Transition Index of the SF-36 was used to determine the 1- and 2-year minimum clinically important difference (MCID), and logistic regression modeling was performed to determine if achieving MCID at 1 year adequately predicted improvement and achievement of MCID at 24 months.

RESULTS

The study group included 969 patients: 300 patients underwent anterior lumbar interbody fusion (ALIF), 606 patients underwent transforaminal lumbar interbody fusion (TLIF), and 63 patients underwent lateral interbody fusion (LLIF). There was a significant correlation between the 12- and 24-month ODI (r = 0.82; p < 0.0001), SF-36 Physical Component Summary score (r = 0.89; p < 0.0001), VAS-back pain (r = 0.90; p < 0.0001), and VAS-leg pain (r = 0.85; p < 0.0001). For the ALIF cohort, patients achieving MCID thresholds for ODI at 12 months were 13-fold (p < 0.0001) more likely to achieve MCID at 24 months. Similarly, for the TLIF and LLIF cohorts, patients achieving MCID thresholds for ODI at 12 months were 13-fold and 14-fold (p < 0.0001) more likely to achieve MCID at 24 months. Outcome measures obtained at 12 months postoperatively are highly predictive of 24-month outcomes, independent of the surgical procedure.

CONCLUSIONS

In a multiinstitutional prospective study, patient-centered measures of surgical effectiveness obtained at 12 months adequately predict long-term (24-month) outcomes after lumbar spine surgery. Patients achieving MCID at 1 year were more likely to report meaningful and durable improvement at 24 months, suggesting that the 12-month time point is sufficient to identify effective versus ineffective patient care.