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Crowley AP, Neville S, Sun C, Huang QE, Cousins D, Shirk T, Zhu J, Kilaru A, Liao JM, Navathe AS. Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations. J Gen Intern Med 2024; 39:1180-1187. [PMID: 38319498 PMCID: PMC11116315 DOI: 10.1007/s11606-024-08655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. OBJECTIVE Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). DESIGN Cross-sectional study using ordinary least squares regression controlling for patient and community factors. PARTICIPANTS Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. MAIN MEASURES Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022. KEY RESULTS Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). CONCLUSIONS Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.
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Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Sarah Neville
- The Commonwealth Fund, New York, NY, USA
- Independent Health and Aged Care Pricing Authority, Sydney, Australia
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Qian Erin Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Torrey Shirk
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Kilaru
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Program on Policy Evaluation and Learning, UT Southwestern, Dallas, TX, USA
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
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Roy I, Karmarkar AM, Lininger MR, Jain T, Martin BI, Kumar A. Association Between Hospital Participation in Value-Based Programs and Timely Initiation of Post-Acute Home Health Care, Functional Recovery, and Hospital Readmission After Joint Replacement. Phys Ther 2023; 103:pzad123. [PMID: 37694820 PMCID: PMC10715680 DOI: 10.1093/ptj/pzad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/08/2023] [Accepted: 07/05/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. METHOD This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. RESULTS Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20-1.26), mobility (OR = 1.15; 95% CI = 1.13-1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15-1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13-1.20) and mobility (OR = 1.26; 95% CI = 1.22-1.30) for hip replacement. CONCLUSION Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. IMPACT Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models.
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Affiliation(s)
- Indrakshi Roy
- Department of Health Sciences, Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Sheltering Arms Institute, Richmond, Virginia, USA
| | - Monica R Lininger
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona, USA
| | - Tarang Jain
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona, USA
| | - Brook I Martin
- Department of Orthopedics, University of Utah, Salt Lake City, Utah, USA
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
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DeKeyser GJ, Martin BI, Ko H, Kahn TL, Haller JM, Anderson LA, Gililland JM. Increased Complications and Cost Associated With Hip Arthroplasty for Femoral Neck Fracture: Evaluation of 576,119 Medicare Patients Treated With Hip Arthroplasty. J Arthroplasty 2022; 37:742-747.e2. [PMID: 34968650 DOI: 10.1016/j.arth.2021.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The benefit of total hip arthroplasty (THA) for treatment of osteoarthritis (OA) and femoral neck fractures (FNFs) in the geriatric population is well established. We compare perioperative complications and cost of THA for treatment of OA to hemiarthroplasty (HA) and THA for treatment of FNF. METHODS Data from the Centers for Medicare & Medicaid Services were used to identify all patients 65 years and older undergoing primary hip arthroplasty between 2013 and 2017. Patients were divided into 3 cohorts: THA for OA (n = 326,313), HA for FNF (n = 223,811), and THA for FNF (n = 25,995). Generalized regressions were used to compare group mortality, 90-day readmission, thromboembolic events, and 90-day episode costs, controlling for age, gender, race, and comorbidities. RESULTS Compared to patients treated for OA, FNF patients were older and had significantly more comorbidities (all P < .001). Even among the youngest age group (65-69 years) without comorbidities, FNF was associated with a greater risk of mortality at 90 days (THA-FNF odds ratio [OR] 9.3, HA-FNF OR 27.0, P < .001), 1 year (THA-FNF OR 7.8, HA-FNF OR 19.0, P < .001) and 5 years (THA-FNF hazard ratio 4.5, HA-FNF hazard ratio 10.0, P < .001). The average 90-day direct cost was $12,479 and $14,036 greater among THA and HA for FNF respectively compared to THA for OA (all P < .001). CONCLUSION Among Centers for Medicare & Medicaid Services hip arthroplasty patients, those with an FNF had significantly higher rates of mortality, thromboembolic events, readmission, and greater direct cost. Reimbursement models for arthroplasty should account for the distinctly different perioperative complication and resource utilization for FNF patients.
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Affiliation(s)
| | - Brook I Martin
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Hyunkyu Ko
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Timothy L Kahn
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Justin M Haller
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Lucas A Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
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Lin E, Uhler LM, Finley EP, Jayakumar P, Rathouz PJ, Bozic KJ, Tsevat J. Incorporating patient-reported outcomes into shared decision-making in the management of patients with osteoarthritis of the knee: a hybrid effectiveness-implementation study protocol. BMJ Open 2022; 12:e055933. [PMID: 35190439 PMCID: PMC8860037 DOI: 10.1136/bmjopen-2021-055933] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Osteoarthritis (OA) is a major clinical and public health concern. The primary surgical treatment of knee OA is total knee replacement (TKR), a procedure that aims to alleviate pain and restore physical function. TKR is expensive, however, and based on professional guidelines, inappropriately performed in up to a third of patients. Patient-reported outcome measures (PROMs) help evaluate treatment options by quantifying health outcomes that matter to patients and can thus inform shared decision-making (SDM) between patients and health professionals. METHODS AND ANALYSIS This is a US-based 2-year, two-site hybrid type 1 study to assess clinical effectiveness and implementation of a machine learning-based patient decision aid (PDA) integrating patient-reported outcomes and clinical variables to support SDM for patients with knee OA considering TKR. Substudy 1: At one study site, a randomised controlled trial is evaluating the clinical effectiveness of the PDA and SDM process on decision quality as measured after the baseline consultation and treatment choice measured 3 and 6 months after the baseline visit among 200 patients with knee OA. Substudy 2: At a second study site, a qualitative assessment using principles of behaviour design and intervention mapping is evaluating the feasibility and acceptability of the PROMs, PDA and SDM process by interviewing seven health professionals and 25 patients before and 25 patients after PDA implementation. ETHICS AND DISSEMINATION Ethics approval has been obtained from The University of Texas at Austin Institutional Review Board (protocol number: 2018-11-0042). Informed consent will be obtained from all participants. Study results will be disseminated through conference presentations, publications and professional societies. TRIAL REGISTRATION NUMBER NCT04805554.
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Affiliation(s)
- Eugenia Lin
- Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Lauren M Uhler
- Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Erin P Finley
- Research Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
- Center for Research to Advance Community Health, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Division of General and Hospital Medicine, Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Prakash Jayakumar
- Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Paul J Rathouz
- Population Health, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kevin J Bozic
- Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Joel Tsevat
- Center for Research to Advance Community Health, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Division of General and Hospital Medicine, Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Population Health, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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Kumar A, Roy I, Warren M, Shaibi SD, Fabricant M, Falvey JR, Vashist A, Karmarkar AM. Impact of Hospital-Based Rehabilitation Services on Discharge to the Community by Value-Based Payment Programs After Joint Replacement Surgery. Phys Ther 2022; 102:6506306. [PMID: 35079829 PMCID: PMC9190306 DOI: 10.1093/ptj/pzab313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 10/13/2021] [Accepted: 12/15/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models. METHODS A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65 years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics. RESULTS Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose-response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR) = 1.28 (95% CI = 1.17 to 1.41), and the high category had OR = 1.90 (95% CI = 1.71 to 2.11). For those who received a knee replacement, there was a dose-response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR = 1.21 (95% CI = 1.15 to 1.28), and the high category had OR = 1.56 (95% CI = 1.46 to 1.66). CONCLUSION Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery. IMPACT In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement.
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Affiliation(s)
- Amit Kumar
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Meghan Warren
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Stefany D Shaibi
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Maximilian Fabricant
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Sciences, School of Medicine, University of Maryland, Baltimore, Maryland, USA,Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | | | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA,Sheltering Arms Institute, Richmond, Virginia, USA,Address all correspondence to Dr Karmarkarat at:
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Haglin JM, Arthur JR, Deckey DG, Moore ML, Makovicka JL, Spangehl MJ. A Comprehensive Monetary Analysis of Inpatient Total Hip and Knee Arthroplasties Billed to Medicare by Hospitals: 2011-2017. J Arthroplasty 2021; 36:S134-S140. [PMID: 33339635 DOI: 10.1016/j.arth.2020.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) has been a recent target of reimbursement reform. As such, the purpose of this study was to evaluate trends in Medicare reimbursement to hospitals for TJA patients from 2011 to 2017. METHODS The Inpatient Utilization and Payment Public Use File was queried for all primary total hip and knee arthroplasty episodes. This file includes all services billed to Medicare via the Inpatient Prospective Payment System. Extracted data included hospital charges and amount paid by Medicare. All data were adjusted for inflation to 2017 US dollars. Multiple linear mixed-model regression analyses were conducted to assess change over time, and geo-modelling was used to represent reimbursement by location. RESULTS A total of 3,368,924 primary TJA procedures were billed to Medicare by hospitals from 2011 to 2017 and included in the study. The mean inflation-adjusted Medicare payment to hospitals for DRG 469 decreased from $22,783.66 to $19,604.62 per procedure (-$3179.04; -14.0%; P < .001) and decreased from $13,290.79 to $11,771.54 for DRG 470 (-$1519.25; -11.4%, P = .011) from 2011 to 2017. Meanwhile, the mean charge submitted by hospitals increased by $6483.39 and $5115.60 for DRGs 469 and 470, respectively (+7.4% for 469, +9.3% for 470; P < .001). Medicare reimbursement to hospitals varied by state. CONCLUSION During the study period, the mean Medicare reimbursement to hospitals decreased for TJA from 2011 to 2017. Meanwhile, the average charge submitted by hospitals increased. As alternative payment models continue to undergo evaluation and development, these data are important for the advancement of more agreeable reimbursement models in arthroplasty care.
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Affiliation(s)
- Jack M Haglin
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | | | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | - Michael L Moore
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
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The Impact of Simultaneous Hospital Participation in Accountable Care Organizations and Bundled Payments on Episode Outcomes. Am J Med Qual 2021; 37:173-179. [PMID: 34225274 DOI: 10.1097/01.jmq.0000754532.72567.c9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among hospitals accepting bundled payments, simultaneous "co-participation" in accountable care organizations (ACOs) could impact episode outcomes compared to bundled payment participation alone. Difference-in-differences (DID) analysis of 1 857 653 ACO-attributed Medicare beneficiaries. The study exposure was hospitalization for 24 procedure-based and 24 condition-based episodes at hospitals participating in bundled payments and ACOs (co-participant) versus only bundled payments. Study outcomes included episode quality, postacute utilization, and spending. For procedure-based episodes, patients hospitalized at co-participant and bundled payment hospitals did not exhibit differential changes in risk-adjusted mortality (DID 0.04 percentage points [p.p.], 95% confidence interval [CI] -0.28 p.p. to 0.37 p.p., P = 0.79), readmissions (DID -0.32 p.p., 95% CI -1.5 p.p. to 0.82 p.p., P = 0.59), postdischarge institutional spending (DID $119, 95% CI -$216 to $455, P = 0.49), or postacute utilization. Similarly, outcomes for condition-based episodes did not vary between co-participant and bundled payment hospitals. Payment model co-participation may produce neither synergistic benefits nor negative effects for patients.
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Liao JM, Zhou L, Navathe AS. Nationwide Hospital Performance on Publicly Reported Episode Spending Measures. J Hosp Med 2021; 16:204-210. [PMID: 32195657 DOI: 10.12788/jhm.3377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Medicare has implemented strategies to improve value by containing hospital spending for episodes of care. Compared with payment models, publicly reported episode-based spending measures are underrecognized strategies. OBJECTIVE To provide the first nationwide description of hospitals' episode-based spending based on publicly reported Clinical Episode-Based Payment (CEBP) measures. DESIGN, SETTING, AND PARTICIPANTS We used 2017 Hospital Compare data to assess spending on six CEBPs among 1,778 hospitals. We examined spending variation and its drivers, correlation between CEBPs, and spending by cost performance categories (for individual CEBPs, below vs above average spending; for across-CEBP comparisons, high vs low vs mixed cost). We also compared hospital spending performance on CEBPs with a global Medicare Spending Per Beneficiary measure. MAIN OUTCOMES AND MEASURES Episode spending. RESULTS Episode spending varied by CEBP type, with skilled nursing facility (SNF) care accounting for the majority of spending variation for procedural episodes but not for condition episodes. Across CEBPs, greater proportions of episode spending were attributed to SNF care at high-(18.1%) vs mixed-(10.7%) vs low-cost (9.2%) hospitals (P > .001). There was low within-hospital CEBP correlation and low correlation and concordance between hospitals' CEBP and Medicare Spending Per Beneficiary performance. CONCLUSIONS Variation reduction and savings opportunities in SNF care for procedural episodes suggest that they may be better suited for existing payment models than condition episodes are. Spending performance was not hospital specific, which highlights the potential utility of episode spending measures beyond global measures.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Value & Systems Science Lab, University of Washington School of Medicine, Seattle, Washington
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lingmei Zhou
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Value & Systems Science Lab, University of Washington School of Medicine, Seattle, Washington
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Whaley CM, Dankert C, Richards M, Bravata D. An Employer-Provider Direct Payment Program Is Associated With Lower Episode Costs. Health Aff (Millwood) 2021; 40:445-452. [PMID: 33646875 PMCID: PMC9939257 DOI: 10.1377/hlthaff.2020.01488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Bundled payment has shown promise in reducing medical spending while maintaining quality. However, its impact among commercially insured populations has not been well studied. We examined the impacts on episode cost and patient cost sharing of a program that applies bundled payments for orthopedic and surgical procedures in a commercially insured population. The program we studied negotiates preferred prices for selected providers that cover the procedure and all related care within a thirty-day period after the procedure and waives cost sharing for patients who receive care from these providers. After implementation, episode prices for three selected surgical procedures declined by $4,229, a 10.7 percent relative reduction. Employers captured approximately 85 percent of the savings, or $3,582 per episode (a 9.5 percent relative decrease), and patient cost-sharing payments decreased by $498 per episode (a 27.7 percent relative decrease).
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Navathe AS, Liao JM, Linn KA, Zhang Y, Mishra A, Wang R, Dinh CT, Zhu J, Cousins DS, Lindner J, Emanuel EJ. Spillover Effects of Medicare's Voluntary Bundled Payments for Joint Replacement Surgery to Patients Insured by Commercial Health Plans. Ann Intern Med 2021; 174:200-208. [PMID: 33347769 DOI: 10.7326/m19-3792] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries. OBJECTIVE To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA). DESIGN Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016. SETTING LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals. PATIENTS 184 922 patients with MA or commercial insurance. MEASUREMENTS Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers. RESULTS Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; P = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; P = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status. LIMITATION Nonrandomized studies are subject to residual confounding and selection. CONCLUSION Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage. PRIMARY FUNDING SOURCE Leonard Davis Institute of Health Economics at the University of Pennsylvania.
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Affiliation(s)
- Amol S Navathe
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (A.S.N.)
| | - Joshua M Liao
- University of Washington School of Medicine, Seattle, Washington, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (J.M.L.)
| | - Kristin A Linn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Yi Zhang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Akriti Mishra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Robin Wang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Claire T Dinh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Jingsan Zhu
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (J.Z., E.J.E.)
| | - Deborah S Cousins
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Jacob Lindner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (K.A.L., Y.Z., A.M., R.W., C.T.D., D.S.C., J.L.)
| | - Ezekiel J Emanuel
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (J.Z., E.J.E.)
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11
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Risk-Adjusted Cost Performance for 90-Day Total Hip Arthroplasty Episodes: Comparing US Hospitals Nationwide Before CJR. J Arthroplasty 2020; 35:3452-3463. [PMID: 32713725 DOI: 10.1016/j.arth.2020.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We characterize variation in total hip arthroplasty (THA) episode payments in the United States. Medicare population immediately preceding implementation of the comprehensive care for joint replacement (CJR) bundled care model and propose a model for ongoing evaluation of hospital performance. METHODS We identified THA episodes in Medicare part A 2014-2016 (n = 366,380) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed and region-level and hospital-level random effects. Random effects estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3218) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high-performing and low-performing hospitals. RESULTS Mean part A episode payments declined from 2014 to 2016 throughout the United States ($19,925-$17,775; P < .001), primarily attributable to decreased postacute care payments. Ninety-day readmission rates fell by a percentage point (from 7.9% to 6.8%; P < .001). We found significant variation in risk-adjusted episode payments, postacute care utilization, and readmission rates across regions, and ever greater variation at the hospital level. CONCLUSION Medicare part A payments decreased for THA episodes between 2014 and 2016. The time frame for this decrease is notable for preceding full implementation of CJR, thus suggesting a more universal embrace of value-based care principles before the start date of CJR. These decreases were primarily because of decreased postacute care utilization and possibly related to falling readmission rates. Yet, significant variation in hospital cost performance remains, even after risk adjustment.
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Liao JM, Wang R, Mishra A, Emanuel EJ, Zhu J, Cousins DS, Navathe AS. Spillover effects of mandatory hip and knee replacement surgery bundles in medicare. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100447. [PMID: 33129181 DOI: 10.1016/j.hjdsi.2020.100447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking. OBJECTIVE To evaluate the association between CJR participation and changes in outcomes among privately insured individuals. DESIGN, SETTING, PARTICIPANTS We used 2013-2017 Health Care Cost Institute claims for 418,016 privately insured individuals undergoing joint replacement in 75 CJR and 121 Non-CJR markets. Multivariable generalized linear models with hospital and market random effects and time fixed effects were used to analyze the association between CJR participation and changes in outcomes. MAIN OUTCOMES AND MEASURES Total episode spending, discharge to institutional post-acute care, and quality (e.g., surgical complications, readmissions). RESULTS Patients in CJR and Non-CJR markets did not differ in total episode spending (difference of -$157, 95% CI -$1043 to $728, p = 0.73) or discharge to institutional post-acute care (difference of -1.1%, 95% CI -3.2%-1.0%, p = 0.31). Similarly, patients in the two groups did not differ in quality or other utilization outcomes. Findings were generally similar in stratified and sensitivity analyses. CONCLUSIONS There was a lack of evidence of cost or utilization spillovers from CJR to privately insured individuals. There may be limits in the ability of certain value-based payment reforms to drive broad changes in care delivery and patient outcomes.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Robin Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Akriti Mishra
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ezekiel J Emanuel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deborah S Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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13
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Berlin NL, Gulseren B, Nuliyalu U, Ryan AM. Target Prices Influence Hospital Participation And Shared Savings In Medicare Bundled Payment Program. Health Aff (Millwood) 2020; 39:1479-1485. [DOI: 10.1377/hlthaff.2020.00104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Nicholas L. Berlin
- Nicholas L. Berlin is a National Clinician Scholar in the Institute for Healthcare Policy and Innovation at the University of Michigan, in Ann Arbor, Michigan
| | - Baris Gulseren
- Baris Gulseren is a health policy analyst in the Institute for Healthcare Policy and Innovation, University of Michigan
| | - Ushapoorna Nuliyalu
- Ushapoorna Nuliyalu is a statistician in the Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan
| | - Andrew M. Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
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14
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Rolnick JA, Liao JM, Emanuel EJ, Huang Q, Ma X, Shan EZ, Dinh C, Zhu J, Wang E, Cousins D, Navathe AS. Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study. BMJ 2020; 369:m1780. [PMID: 32554705 PMCID: PMC7298619 DOI: 10.1136/bmj.m1780] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. DESIGN Quasi-experimental difference-in-differences analysis. SETTING US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. PARTICIPANTS 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. MAIN OUTCOME MEASURES Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. RESULTS In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points). CONCLUSIONS In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.
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Affiliation(s)
- Joshua A Rolnick
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- National Clinician Scholars Program,Philadelphia, PA, USA
| | - Joshua M Liao
- University of Washington School of Medicine, Seattle, WA USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Ezekiel J Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Xinshuo Ma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Eric Z Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Claire Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Amol S Navathe
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
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15
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A Model to Improve the Workflow for Radiation Treatments in the Era of Bundled Payments: A Quality Improvement Project Report. Adv Radiat Oncol 2020; 5:490-494. [PMID: 32529145 PMCID: PMC7276685 DOI: 10.1016/j.adro.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/26/2019] [Accepted: 12/27/2019] [Indexed: 12/04/2022] Open
Abstract
The Centers for Medicare and Medicaid Services has proposed alternate payment models to improve the efficiency and decrease the redundancy of health care. Bundled payments or episode-based care is one example. Herein, we report on the successful implementation of a quality improvement project in which changing the clinical workflow for postoperative radiation treatment to the hip to prevent heterotopic ossification improved the efficiency of patient care and decreased cost by eliminating redundant imaging through multidisciplinary participation. This project is a model for interdisciplinary collaboration to improve patient care and reduce unnecessary health care spending in the era of bundled payment/episodes of care program implementation.
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16
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Schilling PL, He J, Chen S, Placzek H, Bini S. Risk-Adjusted Cost Performance for 90-Day Total Knee Arthroplasty Episodes: Data and Methods for Comparing U.S. Hospitals Nationwide. J Bone Joint Surg Am 2020; 102:971-982. [PMID: 32251141 DOI: 10.2106/jbjs.19.01017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We propose a model to characterize the variation in total knee arthroplasty (TKA) episode payments in the U.S. Medicare population to establish a baseline prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model. METHODS We identified TKA episodes in Medicare Part A (100% sample) from 2014 to 2016 (n = 717,690) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed effects (age, sex, race, comorbidities) and region-level (U.S. Census Regions) and hospital-level random effects. Random-effect estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3,217) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high and low-performing hospitals. RESULTS During this period, the mean Part A episode payments declined throughout the United States ($18,665 to $16,978; p < 0.001), primarily because of decreased post-acute care payments ($6,401 to $4,873; p < 0.0001). The 90-day readmission rates fell by nearly 20% (7.2% to 5.8%; p < 0.001). We found significant variation (p < 0.05) in risk-adjusted episode payments, post-acute care utilization, and readmission rates across regions and even hospitals. The share of hospitals in each geographic region that were low-performance outliers for episode payments ranged from 13% to 31% and those that were high-performance outliers ranged from 16% to 30%. CONCLUSIONS Medicare Part A payments for TKA episodes were decreasing prior to the CJR model because of decreases in both post-acute care utilization and hospital readmissions. A significant variation in risk-adjusted hospital cost performance remained. Our results provide a baseline against which to measure the impact of alternative payment models and a methodology by which to measure hospital-level performance, which can be compared with peer hospitals and national benchmarks.
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Affiliation(s)
- Peter L Schilling
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Jason He
- Clarify Health Solutions, San Francisco, California
| | - Sarah Chen
- Clarify Health Solutions, San Francisco, California
| | | | - Stefano Bini
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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17
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Finch DJ, Pellegrini VD, Franklin PD, Magder LS, Pelt CE, Martin BI. The Effects of Bundled Payment Programs for Hip and Knee Arthroplasty on Patient-Reported Outcomes. J Arthroplasty 2020; 35:918-925.e7. [PMID: 32001083 PMCID: PMC8218221 DOI: 10.1016/j.arth.2019.11.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/10/2019] [Accepted: 11/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes after hip and knee arthroplasty based on hospital participation in Medicare's bundled payment programs. METHODS We performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively. RESULTS Relative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (-1.8 point relative difference at 6 months; 95% confidence interval -3.2 to -0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (-2.3 point relative difference at 6 months; 95% confidence interval -4.0 to -0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference. CONCLUSIONS Patients receiving care at hospitals participating in Medicare's bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty.
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Affiliation(s)
- Daniel J Finch
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT; Tufts University School of Medicine, Boston, MA
| | | | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Christopher E Pelt
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT
| | - Brook I Martin
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT
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18
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Navathe AS, Emanuel EJ, Venkataramani AS, Huang Q, Gupta A, Dinh CT, Shan EZ, Small D, Coe NB, Wang E, Ma X, Zhu J, Cousins DS, Liao JM. Spending And Quality After Three Years Of Medicare’s Voluntary Bundled Payment For Joint Replacement Surgery. Health Aff (Millwood) 2020; 39:58-66. [DOI: 10.1377/hlthaff.2019.00466] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Amol S. Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center, in Philadelphia, and an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and a senior fellow at the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
| | - Ezekiel J. Emanuel
- Ezekiel J. Emanuel is the Diane V. S. Levy and Robert M. Levy University Professor, chair of the Department of Medical Ethics and Health Policy, and vice provost for global initiatives, all at the University of Pennsylvania
| | - Atheendar S. Venkataramani
- Atheendar S. Venkataramani is an assistant professor of medical ethics and of health policy at the Perelman School of Medicine, University of Pennsylvania
| | - Qian Huang
- Qian Huang is a statistical analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Atul Gupta
- Atul Gupta is an assistant professor in the Department of Health Care Management, Wharton School, University of Pennsylvania
| | - Claire T. Dinh
- Claire T. Dinh is a medical student at Harvard Medical School, in Boston, Massachusetts. She was a research coordinator in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, when this work was completed
| | - Eric Z. Shan
- Eric Z. Shan is a research assistant in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Dylan Small
- Dylan Small is a professor in the Department of Statistics, University of Pennsylvania
| | - Norma B. Coe
- Norma B. Coe is an associate professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Erkuan Wang
- Erkuan Wang is a data analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Xinshuo Ma
- Xinshuo Ma is a data analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Jingsan Zhu
- Jingsan Zhu is associate director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Deborah S. Cousins
- Deborah S. Cousins is a project manager in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Joshua M. Liao
- Joshua M. Liao is medical director of payment strategy, director of the Value and Systems Science Lab, and an assistant professor in the Department of Medicine, all at the University of Washington, in Seattle, and an adjunct senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania
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19
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Do Bundled Payment Programs in Joint Replacement Care Hold Promise for Improving Patient Outcomes? J Healthc Qual 2019; 42:83-90. [PMID: 31834002 DOI: 10.1097/jhq.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Centers for Medicare and Medicaid Services (CMS) Innovation Center offers two alternative payment models for joint replacement: the voluntary Bundled Payment for Care Improvement (BPCI) model and the mandatory Comprehensive Care for Joint Replacement (CJR) model. As CMS considers methods for cost reduction, research is needed to understand patient-level outcomes and organizational-level success factors. A retrospective cross-sectional study of hospitals was performed, using regression models to evaluate an aggregate patient satisfaction score, complication rates, and operational differences among BPCI, CJR, and nonparticipating hospitals. Results show that BPCI hospitals received significantly better patient satisfaction scores (88.6) than CJR hospitals (86.0), but complication rates were not significantly different between CJR and BPCI hospitals (2.83 and 2.77, respectively). Factors associated with BPCI participation include academic affiliation, a Northeast region locale, and having a higher CMS efficiency score. Thus, requiring more hospitals to participate in CMS-bundled payment programs as a federal policy may not be the optimal way to improve patient satisfaction and outcomes. Rather, the CJR and BPCI programs should be further studied, and the results generalized for use by nonparticipating hospitals to encourage preparation and participation in CMS value-based initiatives.
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20
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Padilla JA, Gabor JA, Kalkut GE, Pazand L, Zuckerman JD, Macaulay W, Bosco JA, Slover JD. Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program. J Bone Joint Surg Am 2019; 101:1948-1954. [PMID: 31567678 DOI: 10.2106/jbjs.19.00238] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jorge A Padilla
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - Jonathan A Gabor
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - Gary E Kalkut
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - Lily Pazand
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - Joseph D Zuckerman
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - William Macaulay
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - Joseph A Bosco
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
| | - James D Slover
- Departments of Orthopedic Surgery (J.A.P., J.A.G., J.D.Z., W.M., J.A.B., and J.D.S.) and Medicine (G.E.K. and L.P.), NYU Langone Health, New York, NY
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21
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Liao JM, Emanuel EJ, Venkataramani AS, Huang Q, Dinh CT, Shan EZ, Wang E, Zhu J, Cousins DS, Navathe AS. Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations. JAMA Netw Open 2019; 2:e1912270. [PMID: 31560389 PMCID: PMC6777392 DOI: 10.1001/jamanetworkopen.2019.12270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/11/2019] [Indexed: 11/14/2022] Open
Abstract
Importance An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models. Objective To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. Design, Setting, and Participants This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States. Exposures Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants). Main Outcomes and Measures Changes in clinical outcomes and mean LEJR episode spending. Results A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants. Conclusions and Relevance Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Claire T. Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric Z. Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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22
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Sankaran R, Sukul D, Nuliyalu U, Gulseren B, Engler TA, Arntson E, Zlotnick H, Dimick JB, Ryan AM. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. BMJ 2019; 366:l4109. [PMID: 31270062 PMCID: PMC6607204 DOI: 10.1136/bmj.l4109] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes. DESIGN Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims. SETTING 3238 acute care hospitals in the United States. PARTICIPANTS Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334). INTERVENTION Hospital receipt of a penalty in the first year of the HACRP. MAIN OUTCOME MEASURES Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality. RESULTS Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics. CONCLUSIONS Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.
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Affiliation(s)
- Roshun Sankaran
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Devraj Sukul
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ushapoorna Nuliyalu
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Baris Gulseren
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Tedi A Engler
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
| | - Emily Arntson
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hanna Zlotnick
- University of Michigan Gerald R Ford School of Public Policy, Ann Arbor, MI, USA
| | - Justin B Dimick
- University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Andrew M Ryan
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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23
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Affiliation(s)
- Prakash Jayakumar
- UK Harkness Fellow in Health Care Policy & Practice, The Commonwealth Fund, The University of Texas at Austin.,Value Institute for Health and Care, Dell Medical School, The University of Texas at Austin.,Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin
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24
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Haas DA, Zhang X, Kaplan RS, Song Z. Evaluation of Economic and Clinical Outcomes Under Centers for Medicare & Medicaid Services Mandatory Bundled Payments for Joint Replacements. JAMA Intern Med 2019; 179:924-931. [PMID: 31157819 PMCID: PMC6547121 DOI: 10.1001/jamainternmed.2019.0480] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE In 2016, the Centers for Medicare & Medicaid Services (CMS) launched its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, by randomizing metropolitan statistical areas (MSAs) into the payment model. OBJECTIVE To evaluate changes in key economic and clinical outcomes associated with the CJR model. DESIGN, SETTING, AND PARTICIPANTS A retrospective, national, population-based analysis of Medicare fee-for-service beneficiaries undergoing lower extremity joint replacement was conducted using 100% Medicare Part A data and 5% Medicare Part B data. Within an intention-to-treat framework, a difference-in-differences approach was used to compare Medicare spending, quality of care, volume of episodes, and patient selection in episodes of lower extremity joint replacements in the first 2 years of the program between propensity score-matched CJR and non-CJR hospitals (episodes initiated from April 1, 2016, through December 31, 2017, with the latter completed by March 31, 2018). Lower extremity joint replacement episodes in MSAs randomly assigned to the CJR model were compared with those in MSAs not assigned to the CJR model. EXPOSURES Random assignment of MSAs into the CJR model within prespecified strata. MAIN OUTCOMES AND MEASURES Spending and its components, quality of care, volume of episodes, and patient characteristics were the main outcomes. RESULTS After propensity score matching, there were 157 828 primary lower extremity joint replacement cases across 684 hospitals in the CJR (treatment) group (101 641 [64.4%] women; mean [SD] age, 72.8 [8.9] years) and 180 594 cases across 726 hospitals in the non-CJR (control) group (115 580 women [64.0%] women; mean [SD] age, 72.6 [8.8] years). The CJR was associated with a decrease of $582 per episode in Medicare Part A spending, a 2.5% savings on claims (95% CI, -$873 to -$290; P < .001) driven by a 5.5% decline in 90-day postacute care spending, concentrated in skilled nursing facilities (-4.5% change from baseline; 95% CI, -$460 to -$26; P = .03) and inpatient rehabilitation facilities (-22.9% change from baseline; 95% CI,-$497 to -$176; P < .001). Estimated savings on claims, while consistent with changes in practice patterns, may not have exceeded the reconciliation payments to hospitals reported by CMS to date. No significant changes in hospital length of stay, readmissions, complications, 30- or 90-day mortality, volume of episodes, or patient characteristics relative to control were found. CONCLUSIONS AND RELEVANCE The CJR was associated with reduced Medicare Part A spending on claims over 2 years, largely through lower postacute spending. Mandatory bundled payments may serve as a useful model for policy efforts to change clinicians' and facilities' behavior without harming quality.
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Affiliation(s)
| | | | | | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Massachusetts General Hospital, Boston
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25
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Zhu JM, Navathe A, Yuan Y, Dykstra S, Werner RM. Medicare's bundled payment model did not change skilled nursing facility discharge patterns. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:329-334. [PMID: 31318505 PMCID: PMC6788623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration. STUDY DESIGN Retrospective observational study using difference-in-differences analysis. METHODS We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals. RESULTS Our analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups. CONCLUSIONS Hospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.
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Affiliation(s)
- Jane M Zhu
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
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26
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Liao JM, Emanuel EJ, Polsky DE, Huang Q, Shah Y, Zhu J, Lyon ZM, Dykstra SE, Dinh CT, Cousins DS, Navathe AS. National Representativeness Of Hospitals And Markets In Medicare’s Mandatory Bundled Payment Program. Health Aff (Millwood) 2019; 38:44-53. [DOI: 10.1377/hlthaff.2018.05177] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joshua M. Liao
- Joshua M. Liao is associate medical director for contracting and value-based care, director of the UW Medicine Value and Systems Science Lab, and an assistant professor in the Department of Medicine, University of Washington, in Seattle, and an adjunct senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, in Philadelphia
| | - Ezekiel J. Emanuel
- Ezekiel J. Emanuel is the Diane V. S. Levy and Robert M. Levy University Professor, chair of the Department of Medical Ethics and Health Policy, and vice provost for global initiatives, all at the University of Pennsylvania
| | - Daniel E. Polsky
- Daniel E. Polsky is the Robert D. Eilers Professor in Health Care Management and Policy and executive director of the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
| | - Qian Huang
- Qian Huang is a statistical analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Yash Shah
- Yash Shah is a research assistant in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, and a medical student at Rutgers New Jersey Medical School, in Newark
| | - Jingsan Zhu
- Jingsan Zhu is assistant director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Zoe M. Lyon
- Zoe M. Lyon is a medical student at the University of California San Francisco. At the time this study was conducted, she was a senior research coordinator in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Sarah E. Dykstra
- Sarah E. Dykstra is a PhD candidate in the Department of Health Care Management, University of Pennsylvania
| | - Claire T. Dinh
- Claire T. Dinh is a senior research coordinator in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Deborah S. Cousins
- Deborah S. Cousins is a project manager in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Amol S. Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center, in Philadelphia, and an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, and a senior fellow at the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
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