Impact of reimbursement systems on patient care - a systematic review of systematic reviews

BACKGROUND

There is not yet sufficient scientific evidence to answer the question of the extent to which different reimbursement systems influence patient care and treatment quality. Due to the asymmetry of information between physicians, health insurers and patients, market-based mechanisms are necessary to ensure the best possible patient care. The aim of this study is to investigate how reimbursement systems influence multiple areas of patient care in form of structure, process and outcome indicators.

METHODS

For this purpose, a systematic literature review of systematic reviews is conducted in the databases PubMed, Web of Science and the Cochrane Library. The reimbursement systems of salary, bundled payment, fee-for-service and value-based reimbursement are examined. Patient care is divided according to the three dimensions of structure, process, and outcome and evaluated in eight subcategories.

RESULTS

A total of 34 reviews of 971 underlying primary studies are included in this article. International studies identified the greatest effects in categories resource utilization and quality/health outcomes. Pay-for-performance and bundled payments were the most commonly studied models. Among the systems examined, fee-for-service and value-based reimbursement systems have the most positive impact on patient care.

CONCLUSION

Patient care can be influenced by the choice of reimbursement system. The factors for successful implementation need to be further explored in future research.

Health-Care Patterns for Three Common Elective Surgeries: Implications for Bundled Payment Models

INTRODUCTION

The study objectives were to assess the timing, duration, and nature of health-care service utilization before and after three common elective surgical procedures not currently included in federal episode-based bundled payment programs.

METHODS

We performed a retrospective cohort study of patients undergoing one of three low-risk surgical procedures (breast reduction, upper extremity nerve decompression, and panniculectomy) between 2010 and 2017 using a private insurer's national claims database. All professional and facility billing claims for health-care services were identified during the 12-mo preoperative and 12-mo postoperative periods for each patient. We compared trends in monthly utilization of health-care services to estimate surgery-related utilization patterns with interrupted time series analyses.

RESULTS

The cohort included 7885 patients receiving breast reduction, 99,404 patients receiving upper extremity nerve decompression, and 955 patients receiving panniculectomy. The mean monthly encounters gradually increased before each procedure, with a gradual decline in services postoperatively. Claims in the preoperative period for all procedures were primarily diagnostic testing and outpatient evaluation and management. There was limited use of postacute care services across the surgical procedures. There were notable differences in service utilization between the three surgeries, including differing inflection points for preoperative services (approximately 7 mo for breast reduction and panniculectomy, compared with at least 9 mo for nerve decompression) and postoperative services (up to 3 mo for panniculectomy and 4 mo for nerve decompression, compared with 6 mo for breast reduction).

CONCLUSIONS

This study highlights important differences in utilization of health-care services by type of surgery. These findings suggest that prior to expanding episode-based bundled payment models to surgical conditions with limited utilization of postacute care services and fewer complications, the Centers for Medicare and Medicaid Services and private payers should consider tailoring the timing and duration of clinical episodes to individual surgical procedures.

SF-36 physical function and general health domains are independent predictors of acute hospital length of stay after hip fracture surgery

OBJECTIVE

The demographics and co-morbidities of individuals may impact healthcare consumption, but it is less understood how premorbid physical and mental function may influence these effects. The aim of this study is to determine patient's pre-fracture quality of life and mobility affect acute hospital burden in the management of hip fracture, using length of stay (LOS) as a proxy for healthcare resource.

MATERIALS AND METHODS

This is a retrospective study which investigated hip fracture patients who underwent surgery over the period of 2017-2020. Variables collected include LOS, age, gender, race, marital status, payer type, ASA score, time to surgery (TTS), type of surgery, fracture type, POD1 mobilization, discharge disposition, pre-fracture SF-36, EQ-5D and Parker mobility score (PMS) based on patient's recollection on admission. These variables were correlated with LOS using binary logistic regression on SAS.

RESULTS

There were 1045 patients, and mean age was 79.5 + 8.57 (range 60-105) years with an average LOS 13.64 + 10.0 days (range 2-114). On univariate analysis, PMS, EQ-5D and all domains of SF-36 except bodily pain (BP), emotional role and mental health were associated significantly with LOS. Amongst the QOL and PMS scores, only the domains of SF-36 Physical Function (PF) (OR = 0.993, p = 0.0068) and General Health perception (GH) (OR 0.992, p = 0.0230) remained significant on the multivariate model.

CONCLUSION

Our study showed that poor premorbid scores of SF36 PF and GH are independent factors associated with longer LOS in hip fracture patients after surgery, regardless of fracture type, age and ASA status. Hence, premorbid SF36 PF and GH can be used to identify patients that are at risk of prolonged hospital stay and employ targeted strategies to facilitate rehabilitation and discharge planning.

Outpatient physical therapy bundled payment models are feasible for total hip arthroplasty patients: an evaluation of utilization, cost and outcomes

BACKGROUND

Various episode-of-care bundled payment models for patients undergoing total joint arthroplasty have been implemented. However, participation in bundled payment programs has dropped given the challenges of meeting continually lower target prices. The purpose of our study is to investigate the cost of outpatient physical therapy (PT) and the potential for stand-alone outpatient PT bundled payments for patients undergoing total hip arthroplasty (THA).

METHODS

A retrospective review of 501 patients who underwent primary unilateral THA from November 2017 to February 2020 was performed. All patients included in this study received postoperative PT care at a single hospital-affiliated PT practice. Patients above the 75th percentile of therapy visits were then classified as high-PT utilizers and compared with the rest of the population using univariate statistics. Stepwise multivariate logistic regression was used to assess the predictors of high therapy utilization.

RESULTS

Patients averaged 65 ± 10 years of age and a BMI of 29 ± 5 kg/m². Overall, 80% of patients were white and 53% were female. The average patient had 11 ± 8 total therapy sessions in 42 days: one initial evaluation, one re-evaluation and 9 standard sessions. High-PT utilizers incurred estimated average costs of $1934 ± 431 per patient, compared to $783 ± 432 (P < 0.001) in the rest of the population. Further, no significant differences in 90-day outcomes including lower extremity functional scale scores, emergency department returns, readmissions, or returns to the operating room were observed between high utilizers and the rest of the population (all P > 0.08). In the multivariate analysis, women (OR = 1.68, P = 0.017) and those with sleep apnea (OR = 2.02, P = 0.012) were nearly twice as likely to be high utilizers, while white patients were 42% less likely to be high utilizers than patients of other races (OR = 0.58, P = 0.028).

CONCLUSIONS

Outpatient PT utilization is highly variable in patients undergoing THA. However, despite using more services and incurring increased cost, patients in the top quartile of utilization experienced similar outcomes to the rest of the population. If outpatient therapy bundles are to be developed, 16 visits appear to be a reasonable target for pricing, given this provides adequate coverage for 75% of THA patients.

Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery

BACKGROUND

As healthcare costs rise, there is an increasing emphasis on alternative payment models to improve care efficiency. The bundled payment represents an alternative reimbursement model gaining popularity within the surgical sphere. We aimed to assess where the largest opportunities for care improvement lay and how best to identify patients at high risk of suffering costly complications.

METHODS

We utilized itemized CMS claims data for a retrospective cohort of patients between 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Based on the results of this cost analysis, we identified readmissions as a target for improvement. We then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within our bundled payment population who were at high risk of readmission using a logistic regression model.

RESULTS

Our study cohort included 252 patients. Readmissions accounted for 12.8% of the average total care episode cost with a coefficient of variation of 2.72, thereby representing the most substantial, non-fixed cost for our bundled payment patients. Patients readmitted within their 90-day care episode were 2.53 times more likely to be high-cost (>$60,000) than patients not readmitted. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days with an AUROC of 0.58.

CONCLUSIONS

Our study highlights the importance of reducing readmissions as a central component of improving care for bowel surgery bundled payment patients. Preventing such readmissions requires accurate identification of patients at high risk of readmission; however, current risk prediction models lack the adaptability necessary for this task.

Robotic-assisted TKA reduces surgery duration, length of stay and 90-day complication rate of complex TKA to the level of noncomplex TKA

INTRODUCTION

Complex primary total knee arthroplasties (TKA) are reported to be associated with excessive episode of care (EOC) costs as compared to noncomplex procedures. The impact of robotic assistance (rTKA) on economic outcome parameters in greater case complexity has not been described yet. The purpose of this study was to investigate economic outcome parameters in the 90-days postoperative EOC in robotic-assisted complex versus noncomplex procedures.

MATERIALS AND METHODS

This study is a retrospective, single-center review of 341 primary rTKAs performed between 2017 and 2020. Patient collective was stratified into complex (n = 218) and noncomplex TKA (n = 123) based on the presence of the following criteria: Obese BMI, coronal malalignment, flexion contracture > 10°, posttraumatic status, previous correction osteotomy, presence of hardware requiring removal during surgery, severe rheumatoid arthritis. Group comparison included surgery duration, length of stay (LOS), surgical site complications, readmissions, and revision procedures in the 90-days EOC following rTKA.

RESULTS

The mean surgery duration was marginally longer in complex rTKA, but showed no significant difference (75.26 vs. 72.24 min, p = 0.258), neither did the mean LOS, which was 8 days in both groups (p = 0.605). No differences between complex and noncomplex procedures were observed regarding 90-days complication rates (7.34 vs. 4.07%, p = 0.227), readmission rates (3.67 vs. 3.25%, p = 0.841), and revision rates (2.29 vs. 0.81%, p = 0.318).

CONCLUSIONS

Robotic-assisted primary TKA reduces the surgical time, inpatient length of stay as well as 90-days complication and readmission rates of complex TKA to the level of noncomplex TKA. Greater case complexity does not seem to have a negative impact on economic outcome parameters when surgery is performed with robotic assistance.

Recent Trends in Medicare Utilization and Reimbursement for Spinal Cord Stimulators: 2000-2019

OBJECTIVE

Spinal cord stimulators (SCS) allow spine surgeons to provide relief for patients who suffer from chronic pain due to several disorders, such as failed back surgery syndrome, complex regional pain syndrome, and neuropathy. Despite this, there remains a paucity of data regarding the utilization and reimbursement of SCS. Therefore, the purpose of this study is to evaluate the monetary and procedural trends of spinal cord stimulators among the Medicare database from 2000 to 2019.

METHODS

Medicare Part B National Summary Data files, which are publicly available, were used. These files contain data from the years 2000-2019 on all services billed to Medicare within that time frame. Each service is given a Current Procedural Terminology (CPT) code and the number of times that service was performed, as well as the total physician Medicare charges and reimbursements for each service annually are included in that data set. The CPT codes for percutaneous and open placement of spinal cord stimulators were identified: 63650 and 63655, respectively. The total allowed services allowed charges and actual payments were isolated from the data set for each year for each CPT code. The total allowed charges and actual payments for the year were then divided by the total allowed services to find and trend the allowed charges and actual payment for each individual service performed for both percutaneous and open placement of spinal cord stimulators.

RESULTS

There were 992,372 Medicare-approved total percutaneous spinal cord stimulator operations and 99,736 Medicare-approved total open spinal cord stimulator operations from 2000 to 2019. Medicare paid $1.02 billion (2019 U.S. dollars) in reimbursement to physicians for percutaneous spinal cord stimulator operations and nearly $145 million (2019 U.S. dollars) in reimbursement to physicians for open spinal cord stimulator operations. From the years 2000 to 2019, there was an average 21.9% increase annually in Medicare-approved percutaneous spinal stimulator placement operations and a 18.4% increase annually in Medicare-approved open spinal stimulator placement operations. During this time, there was also an average 8.7% increase annually in Medicare reimbursement per each percutaneous spinal stimulator placement operation and a 9.1% increase annually in Medicare reimbursement per each open spinal stimulator placement operation.

CONCLUSIONS

The results of this study show that the number of percutaneous and open procedures have steadily increased from 2000 to 2019. Reimbursement per procedure has also increased steadily over this time. Identifying these trends is important to promote research into costs of these surgeries and ensure adequate resource allocation.

A Comprehensive Monetary Analysis of Inpatient Total Hip and Knee Arthroplasties Billed to Medicare by Hospitals: 2011-2017

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.

Cost analysis and complication rate comparing open, mini-open, and all arthroscopic rotator cuff repair

Hypothesis/Background

Value-based healthcare delivery models are becoming increasingly common and are driving cost effectiveness initiatives. Rotator cuff repair (RCR) is a commonly performed procedure with some variations on the specific surgical technique. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 categories of RCR techniques (open [oRCR], combined arthroscopically assisted and mini-open [CRCR], and all arthroscopic [ARCR]) at a high-volume institution.

Methods

All RCR procedures performed by 2 fellowship-trained shoulder surgeons at a single institution between 2012 and 2017 were retrospectively identified. These consisted of oRCR, CRCR, and ARCR repair techniques. One surgeon performed oRCR and CRCR, and the second surgeon performed ARCR. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation.

Results

The cohort consisted of 95 oRCR, 233 CRCR, and 287 ARCR. Median standardized costs were as follows: preoperative evaluation $486.03; index surgical hospitalization oRCR $9,343.10, CRCR $10,057.20, and ARCR $10,330.60; and postoperative care $875.02. Preoperative and postoperative costs did not vary based on the type of RCR performed. However, significant differences were observed among index surgical costs (P = .0008). The highest standardized cost for hospitalization for both the CRCR group and the ARCR group was related to the cost of the operating room and the implants. The 90-day complication, reoperation, and readmission rates were 1.1%, 1.1%, and 2.1% in the open group; 0.8%, 0.8%, and 1.7% in the combination group; 0%, 0%, and 1.7% in the all arthroscopic group, respectively. There were no significant differences among the 3 surgical procedures with respect to complication (P = .26), reoperation (P = .26), and readmission rates (P = .96).

Discussion/Conclusions

In this investigation, the median standardized costs for RCR inclusive of 60-day workup and 90-day postoperative care were $10,704.15, $11,418.25, and $11,691.65 for oRCR, CRCR (average added cost $714.10), and ARCR (added cost $987.50), respectively. The group complication, reoperation, and readmission rate were 0.5%, 0.5%, and 1.8% with no significant differences between the varying techniques, respectively. This retrospective cost analysis and complication profile may serve as a useful reference as surgeons consider engaging in bundled payment for RCR. As value based initiatives continue to progress, implant cost may serve as an actionable area for cost reduction.

As predicted by theory: choice and competition in a publicly funded and regulated regional health system yield improved access and cost control

BACKGROUND

New Public Management (NPM) has been widely used to introduce competition into public healthcare. Results have been mixed, and there has been much controversy about the appropriateness of a private sector-mimicking governance model in a public service. One voice in the debate suggested that rather than discussing whether competition is "good" or "bad" the emphasis should be on exploring the conditions for a successful implementation.

METHODS

We report a longitudinal case study of the introduction of patient choice and allowing private providers to enter a publicly funded market. Patients in need of hip or knee replacement surgery are allowed to choose provider, and those are paid a fixed reimbursement for the full care episode (bundled payment). Providers are financially accountable for complications. Data on number of patients, waiting lists and times, costs to the public purchaser, and complications were collected from public registries. Providers were interviewed at three points in time during a nine-year follow-up period. Time-series of the quantitative data were exhibited and the views of actors involved were explored in a thematic analysis of the interviews.

RESULTS

The policy goals of improving access to care and care quality while controlling total costs were achieved in a sustained way. Six themes were identified among actors interviewed and those were consistent over time. The design of the patient choice model was accepted, although all providers were discontent with the level of reimbursement. Providers felt that quality, timeliness of service and staff satisfaction had improved. Public and private providers differed in terms of patient-mix and developed different strategies to adjust to the reimbursement system. Private providers were more active in marketing and improving operation room efficiency. All providers intensified cooperation with referring physicians. Close attention was paid to following the rules set by the purchaser.

DISCUSSION AND CONCLUSIONS

The sustained cost control was an effect of bundled payment. What this study shows is that both public and private providers adhere long-term to regulations by a public purchaser that also controls entrance to the market. The compensation was fixed and led to competition on quality, as predicted by theory.

The effects of competition and bundled payment on patient reported outcome measures after hip replacement surgery

BACKGROUND

Competition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery. This study considers such a reform which was initiated in 2009 for elective hip replacement surgery in Stockholm, Sweden. The reform involved patient choice of provider, free establishment of new providers and a bundled payment model. The study aimed to examine its effects on hip replacement surgery quality as captured by patient reported outcome measures (PROMs) of health gain (as indicated by the EQ-5D index and a visual analogue scale (VAS)), pain reduction (VAS) and patient satisfaction (VAS) one and six years after the surgery.

METHODS

Using patient-level data collected from multiple national registers, we applied a quasi-experimental research design. Data were collected for elective primary total hip replacements that were carried out between 2008 and 2012, and contain information on patient demography, the surgery and PROMs at baseline and at one- and six-years follow-up. In total, 36,627 observations were included in the analysis. First, entropy balancing was applied in order to reduce differences in observable characteristics between treatment groups. Second, difference-in-difference analyses were conducted to eliminate unobserved time-invariant differences between treatment groups and to estimate the causal treatment effects.

RESULTS

The entropy balancing was successful in creating balance in all covariates between treatment groups. No significant effects of the reform were found on any of the included PROMs at one- and six-years follow-up. The sensitivity analyses showed that the results were robust.

CONCLUSIONS

Competition and bundled payment had no effects on the quality of hip replacement surgery as captured by post-surgery PROMs of health gain, pain reduction and patient satisfaction. The study provides important insights to the limited knowledge on the effects of competition and economic incentives on PROMs.

Bundled payments for chronic diseases increased health care expenditure in the Netherlands, especially for multimorbid patients

Bundled payments aim to stimulate the integration of healthcare services and ultimately reduce healthcare expenditure growth through improved quality of care. The Netherlands introduced bundled payments for chronic diseases in 2010 by reimbursing providers annually for a bundle of primary care services related to COPD, Diabetes, or Vascular Risk Management. We aimed to assess the long-term effects of these bundled payments on healthcare expenditure. We used health insurance claims data from 2008 to 2015 to compare the healthcare expenditure between everyone who was included in bundled payments and a control group. We performed a difference-in-difference analysis in combination with propensity score matching and found that bundled payments consistently increased health care expenditure over seven years. The average half-year increase was €233 (95%CI: 204-262) for DM2, €609 (95%CI: 533-686) for COPD, and €231 (95%CI: 208-254) for VRM, representing 13%, 52%, and 20% of 2008 half-year cost. The increase was higher for those with multimorbidity compared to those without multimorbidity. This suggests that the expectations of the bundled payments are yet to be fulfilled.

Development and validation of a novel scoring tool for predicting facility discharge after elective posterior lumbar fusion

BACKGROUND CONTEXT

Discharge to acute/intermediate care facilities is a common occurrence after posterior lumbar fusion and can be associated with increased costs and complications after these procedures. This is particularly relevant with the growing popularity of bundled payment plans, creating a need to identify patients at greatest risk.

PURPOSE

To develop and validate a risk-stratification tool to identify patients at greatest risk for facility discharge after open posterior lumbar fusion.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Patients were queried using separate databases from the institution of study and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for all patients undergoing open lumbar fusion between 2011 and 2018.

OUTCOME MEASURES

Discharge to intermediate care and/or rehabilitation facilities.

METHODS

Using an 80:20 training and testing NSQIP data split, collected preoperative demographic and operative variables were used in a multivariate logistic regression to identify potential risk factors for postoperative facility discharge, retaining those with a p value <.05. A nomogram was generated to develop a scoring system from this model, with probability cutoffs determined for facility discharge. This model was subsequently validated within the NSQIP database, in addition to external validation at the institution of study. Overall model performance and calibration was assessed using the Brier score and calibration plots, respectively.

RESULTS

A total of 11,486 patients (10,453 NSQIP, 1,033 local cohort) were deemed eligible for study, of which 16.1% were discharged to facilities (16.7% NSQIP, 9.6% local cohort). Utilizing training data, age (p<.001), body mass index (p<.001), female sex (p<.001), diabetes (p=.043), peripheral vascular disease (p=.001), cancer (p=.010), revision surgery (p<.001), number of levels fused (p<.001), and spondylolisthesis (p=.049) were identified as significant risk factors for facility discharge. The area under the receiver operating characteristic curve (AUC) indicated a strong predictive model (AUC=0.750), with similar predictive ability in the testing (AUC=0.757) and local data sets (AUC=0.773). Using this tool, patients identified as low- and high-risk had a 7.94% and 33.28% incidence of facility discharge in the testing data set, while rates of 4.44% and 16.33% were observed at the institution of study.

CONCLUSIONS

Using preoperative variables as predictors, this scoring system demonstrated high efficiency in risk-stratifying patients with an approximate four to fivefold difference in rates of facility discharge after posterior lumbar fusion. This tool may help inform medical decision-making and guide reimbursement under bundled-care repayment plans.

Medicare's Bundled Payment Initiatives for Hospital-Initiated Episodes: Evidence and Evolution

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment.

CONTEXT

Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.

METHODS

We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs.

FINDINGS

Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change.

CONCLUSIONS

Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.

A pain relieving reimbursement program? Effects of a value-based reimbursement program on patient reported outcome measures

Background

Value-based reimbursement programs have become increasingly common. However, little is known about the effect of such programs on patient reported outcomes. Thus, the aim of this study was to analyze the effect of introducing a value-based reimbursement program on patient reported outcome measures and to explore whether a selection bias towards less complicated patients occurred.

Methods

This is a retrospective observational study with a before and after design based on the introduction of a value-based reimbursement program in Region Stockholm, Sweden. We analyzed patient level data from inpatient and outpatient care of patients undergoing lumbar spine surgery during 2006–2015. Patient reported outcome measures used was Global Assessment, EQ-5D-3L and Oswestry Disability Index. The case-mix of surgically treated patients was analyzed using medical and socioeconomic factors.

Results

The value-based reimbursement program did not have any effect on targeted or non-targeted patient reported outcome measures. Moreover, the share of surgically treated patients with risk factors such as having comorbidities and being born outside of Europe increased after the introduction. Hence, the value-based reimbursement program did not encourage discrimination against sicker patients. However, the income was higher among patients surgically treated after the introduction of the value-based reimbursement. This indicates that a value-based reimbursement program may contribute to increased inequalities in access to healthcare.

Conclusions

The value-based reimbursement program did not have any effect on patient reported outcome measures. Our study contributes to the understanding of the effects of a value-based reimbursement program on patient reported outcome measures and to what extent cherry-picking arises.

Economics of the Management of Craniospinal Chordoma and Chondrosarcoma and the feasibility of the bundled payment model

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) created a new reimbursement model "Bundled Payment for Care Improvement (BPCI)" which reimburses providers a predetermined payment in advance to cover all possible services rendered within a certain time window. Chordoma and Chondrosarcoma are locally aggressive malignant primary bony tumors. Treatment includes surgical resection and radiotherapy with substantial risk for recurrence which necessitates monitoring and further treatment. We assessed the feasibility of the BPCI model in these neurosurgical diseases.

METHODS

We selected patients with chordoma/chondrosarcoma from inpatient admission table using the International Classification of Disease, 9th (ICD-9), and 10th (ICD-10) revision codes. We collected the patients' demographics and insurance type at the index hospitalization. We recorded the following outcomes length of stay, total payment, discharge disposition, and complications for the index hospitalization. For post-discharge, we collected the 30 days and 3/6/12 months inpatient admission, outpatient service, and medication refills. Continuous variables were summarized by means with standard deviations, median with interquartile and full ranges (minimum-maximum); Continuous outcomes were compared by nonparametric Wilcoxson rank-sum test. All tests were 2-sided with a significance level of 0.05. Statistical data analysis was performed in SAS 9.4 (SAS Institute, Inc, Cary, NC).

RESULTS

The population size was 2041 patients which included 1412 patients with cranial (group1), 343 patients with a mobile spine (group 2), and 286 patients with sacrococcygeal (group 3) chordoma and chondrosarcoma. For index hospitalization, the median length of stay (days) was 4, 6, and 7 for groups 1, 2, and 3 respectively (P<.001). The mean payments were ($58,130), ($84,854), and ($82,440), for groups 1, 2, and 3 respectively (P=.02). The complication rates were 30%, 35%, and 43% for groups 1, 2, and 3 respectively (P<.001). Twelve months post-discharge, the hospital readmission rates were 44%, 53%, and 65% for groups 1, 2, and 3, respectively (P<.001). The median payments for this period were ($72,294), ($76,827), and ($101,474), for groups 1, 2, and 3, respectively (P <.001).

CONCLUSION

The management of craniospinal chordoma and chondrosarcoma is costly and may extend over a prolonged period. The success of BPCI requires a joint effort between insurers and hospitals. Also, it should consider patients' comorbidities, the complexity of the disease. Finally, the adoptionof quality improvement programs by hospitals can help with cost reduction.

Defining the 90-day cost structure of lower extremity revascularization for alternative payment model assessment

BACKGROUND

The U.S. healthcare system is undergoing a broad transformation from the traditional fee-for-service model to value-based payments. The changes introduced by the Medicare Quality Payment Program, including the establishment of Alternative Payment Models, ensure that the practice of vascular surgery is likely to face significant reimbursement changes as payments transition to favor these models. The Society for Vascular Surgery Alternative Payment Model taskforce was formed to explore the opportunities to develop a physician-focused payment model that will allow vascular surgeons to continue to deliver the complex care required for peripheral arterial disease (PAD).

METHODS

A financial analysis was performed based on Medicare beneficiaries who had undergone qualifying index procedures during fiscal year 2016 through the third quarter of 2017. Index procedures were defined using a list of Healthcare Common Procedural Coding (HCPC) procedure codes that represent open and endovascular PAD interventions. Inpatient procedures were mapped to three diagnosis-related group (DRG) families consistent with PAD conditions: other vascular procedures (codes, 252-254), aortic and heart assist procedures (codes, 268, 269), and other major vascular procedures (codes, 270-272). Patients undergoing outpatient or office-based procedures were included if the claims data were inclusive of the HCPC procedure codes. Emergent procedures, patients with end-stage renal disease, and patients undergoing interventions within the 30 days preceding the index procedure were excluded. The analysis included usage of postacute care services (PACS) and 90-day postdischarge events (PDEs). PACS are defined as rehabilitation, skilled nursing facility, and home health services. PDEs included emergency department visits, observation stays, inpatient readmissions, and reinterventions.

RESULTS

A total of 123,180 cases were included. Of these 123,180 cases, 82% had been performed in the outpatient setting. The Medicare expenditures for all periprocedural services provided at the index procedure (ie, professional, technical, and facility fees) were higher in the inpatient setting, with an average reimbursement per index case of $18,755, $34,600, and $25,245 for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility interventions had an average reimbursement of $11,458, and office-based index procedures had costs of $11,533. PACS were more commonly used after inpatient index procedures. In the inpatient setting, PACS usage and reimbursement were 58.6% ($5338), 57.2% ($4192), and 55.9% ($5275) for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility cases required PACS for 13.7% of cases (average cost, $1352), and office-based procedures required PACS in 15% of cases (average cost, $1467). The 90-day PDEs were frequent across all sites of service (range, 38.9%-50.2%) and carried significant costs. Readmission was associated with the highest average PDE expenditure (range, $13,950-$18.934). The average readmission Medicare reimbursement exceeded that of the index procedures performed in the outpatient setting.

CONCLUSIONS

The cost of PAD interventions extends beyond the index procedure and includes relevant spending during the long postoperative period. Despite the analysis challenges related to the breadth of vascular procedures and the site of service variability, the data identified potential cost-saving opportunities in the management of costly PDEs. Because of the vulnerability of the PAD patient population, alternative payment modeling using a bundled value-based approach will require reallocation of resources to provide longitudinal patient care extending beyond the initial intervention.

Refining risk adjustment for bundled payment models in cervical fusions-an analysis of Medicare beneficiaries

BACKGROUND CONTEXT

The current Bundled Payment for Care Improvement model relies on the use of "Diagnosis Related Groups" (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1-3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology).

PURPOSE

To understand factors responsible for cost variation in a 90-day episode of care following cervical fusions.

STUDY DESIGN

Retrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5).

OUTCOME MEASURES

To calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473.

METHODS

The 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement.

RESULTS

Following application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (-$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (-$7,492) and Iowa (-$3,393) having the lowest reimbursements, as compared with Michigan.

CONCLUSIONS

The current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.

Feasibility of Bundled Payments in Anterior, Middle, and Posterior Cranial Fossa Skull Base Meningioma Surgery: MarketScan Analysis of Health Care Utilization and Outcomes

BACKGROUND

The aim of our study was to compare the health care utilization and outcomes after surgery for anterior cranial fossa skull base meningioma (AFM), middle cranial fossa skull base meningioma (MFM), and posterior cranial fossa skull base meningioma (PFM) across the United States.

METHODS

We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had at least 24 months of enrollment after the surgical procedure. The outcome of interest was length of hospital stay, disposition, complications, and reoperation after the procedure.

RESULTS

A cohort of 1191 patients was identified from the database. Less than half of patients (43.66%) were in the AFM cohort, 32.24% were in the MFM cohort, and only 24.1% were in the PFM cohort. Patients who underwent surgery for PFM had longer hospital stay (P = 0.0009), high complication rate (P = 0.0011), and less likely to be discharged home (P = 0.0013) during index hospitalization. There were no differences in overall payments at 12 months and 24 months among the cohorts. There was no significant difference in 90-day median payments among the groups ($66,212 [AFM] vs. $65,602 [MFM] and $71,837 [PFM]; P = 0.198). Male gender, commercial insurance (compared with Medicare), and higher comorbidity scores (score 3 compared with score 0) were associated with higher 90-day payments in the PFM cohort.

CONCLUSIONS

Overall payments (at 12 months and 24 months) and 90-day payments were not different among the cohorts. Patients with PFM had longer hospital stay and higher complication rate and were less likely to be discharged home with higher utilization of outpatient services at 12 months and 24 months.

A validated preoperative score for predicting 30-day readmission after 1-2 level elective posterior lumbar fusion

PURPOSE

To develop a model to predict 30-day readmission rates in elective 1-2 level posterior lumbar spine fusion (PSF) patients.

METHODS

In this retrospective case control study, patients were identified in the State Inpatient Database using ICD-9 codes. Data were queried for 30-day readmission, as well as demographic and surgical data. Patients were randomly assigned to either the derivation or the validation cohort. Stepwise multivariate analysis was conducted on the derivation cohort to predict 30-day readmission. Readmission after posterior spinal fusion (RAPSF) score was created by including variables with odds ratio (OR) > 1.1 and p < 0.01; value assigned to each variable was based on the OR and calibrated to 100. Linear regression was performed between readmission rate and RAPSF score to test correlation in both cohorts.

RESULTS

There were 92,262 and 90,257 patients in the derivation and validation cohorts. Thirty-day readmission rates were 10.9% and 11.1%, respectively. Variables in RAPSF included: age, female gender, race, insurance, anterior approach, cerebrovascular disease, chronic pulmonary disease, congestive heart failure, diabetes, hemiplegia/paraplegia, rheumatic disease, drug abuse, electrolyte disorder, osteoporosis, depression, obesity, and morbid obesity. Linear regression between readmission rate and RAPSF fits the derivation cohort and validation cohort with an adjusted r² of 0.92 and 0.94, respectively, and a coefficient of 0.011 (p < 0.001) in both cohorts.

CONCLUSION

The RAPSF can accurately predict readmission rates in PSF patients and may be used to guide an evidence-based approach to preoperative optimization and risk adjustment within alternative payment models for elective spine surgery.

LEVEL OF EVIDENCE

3. These slides can be retrieved under Electronic Supplementary Material.

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature

BACKGROUND

Strategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing.

METHODS

A structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management.

RESULTS

The majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce.

CONCLUSION

There is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.

Effects of episode-based payment on health care spending and utilization: Evidence from perinatal care in Arkansas

We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment Improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments

PURPOSE

To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs.

METHODS

Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided.

RESULTS

Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care.

CONCLUSIONS

Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs.

CLINICAL RELEVANCE

This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

Bundled Payments and Hidden Costs

In a fee-for-service environment, anesthesiologists are paid for the volume of services billed, with little relation to the cost of delivering the services. In bundled payments, anesthesiologists are paid a set fee for an episode of care inclusive of all the anesthesia, pain medicine, and related services for the surgical episode and a period of time after the initial procedure to cover complications and redo procedures. When calculating a bundled payment, all the services typically used by a patient must be counted when calculating both the costs and expected payment.

Medical oncologists' willingness to participate in bundled payment programs

Background

Bundled payment programs play an increasingly important role in transforming reimbursement for oncologic care. We assessed determinants of oncologists’ willingness to participate in bundled payment programs for breast cancer. We hypothesized that providers would be more likely to participate in bundled payment programs if offered higher levels of reimbursement for each episode of care.

Methods

Oncologists from Florida, New Jersey, New York, and Pennsylvania were identified in the AMA database or by patients listed in state cancer registries. Providers were randomized to receive one of four versions of a survey describing bundled payment programs offering different levels of compensation for the first year of localized breast cancer treatment ($5000, $10,000, $15,000, or $20,000). Physicians rated their likelihood of participation in a bundled program on a Likert scale. Logistic regression was used to analyze determinants of likelihood of participation in bundling.

Results

Among 460 respondents, only 17% of oncologists were highly likely to participate in a bundled program paying $5000 for the first year of care, rising to 41% for the $15,000 program, but falling to 34% for the $20,000 program. Likelihood of participation was higher among oncologists who were male, older, and believed that cancer patients should not be offered high-cost drugs with minimal survival benefit.

Conclusion

Our results suggest that medical oncologists have limited enthusiasm for bundled payments, and higher payments may not overcome resistance to bundling among a substantial proportion of physicians.

'Heart Team' Concept - A reality or a 'Platonic Illusion'

Post Syntax Trial, 'Heart Team' Concept has been ensconsed class I recommendation in both the European and ACC/AHA guidelines and has gained increasing traction in context of complex and multi modality procedures. Despite an arrray of advantages including the much touted - 'the patient is central', there are a plethora of un-addressed issues, some of which sentinel to our country, which threaten to make the 'Heart Team' concept a perfunctory exercise. As it stands today, 'Heart Team' is more of a fictional euphemism, a kind of 'Platonic Illusion' rather than a pragmatic reality.

Design and impact of bundled payment for detox and follow-up care

INTRODUCTION

Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues.

METHODS

Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010-April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session.

RESULTS

The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs.

CONCLUSIONS

Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care.

Preoperative Education for Hip and Knee Replacement: Never Stop Learning

PURPOSE OF REVIEW

Participation in alternative payment models has focused efforts to improve outcomes and patient satisfaction while also lowering cost for elective hip and knee replacement. The purpose of this review is to determine if preoperative education classes for elective hip and knee replacement achieve these goals.

RECENT FINDINGS

Recent literature demonstrates that patients who attend education classes prior to surgery have decreased anxiety, better post-operative pain control, more realistic expectations of surgery, and a better understanding of their surgery. As a result, comprehensive clinical pathways incorporating a preoperative education program for elective hip and knee replacement lead to lower hospital length of stay, higher home discharge, lower readmission, and improved cost. In summary, we report convincing evidence that preoperative education classes are an essential element to successful participation in alternative payment models such as the Bundle Payment Care Initiative.

Bundled payments in total joint arthroplasty and spine surgery

PURPOSE OF REVIEW

The goal of this manuscript is to provide an overview and analysis of bundled payment models for joint replacement and select spine procedures. Advantages and disadvantages of bundled payment models will be discussed.

RECENT FINDINGS

In select populations, bundled payment models have been shown to reduce costs while maintaining satisfactory outcomes. These models have not been tested with complex patient cohorts, such as older adults with fragility hip fractures, and limited data exist with bundled payment analysis in spine procedures. The reduction of healthcare costs, satisfactory patient outcomes, and favorable payments to healthcare systems can be achieved through bundled payments. Modifications of existing bundled payment models should be critically tested prior to implementation across higher risk populations. Bundled payment models will also require healthcare systems to define what services are necessary for an episode of care regarding a specific condition or disease.

Using Health Information Technology to Enhance Care Outcome Accountability Through Bundled Payments

Eventhough the US expenditure on health care is almost twice of the Organization for Economic Co-operation and Development (OECD) average, the care quality indicators in the US unfortunately are not reflective of such extra spending (Baird, 2016). To revise this cost and quality imbalance, new models have been recommended (and partially implemented) that will tie health care reimbursement with efficient utcomes. This study offers a technology enabled solution to calcualting approraite bundles.

New pricing approaches for bundled payments: Leveraging clinical standards and regional variations to target avoidable utilization

OBJECTIVES

Develop pricing models for bundled payments that draw inputs from clinician-defined best practice standards and benchmarks set from regional variations in utilization.

DATA

Health care utilization and claims data for a cohort of incident Ontario ischemic and hemorrhagic stroke episodes. Episodes of care are created by linking incident stroke hospitalizations with subsequent health service utilization across multiple datasets.

STUDY DESIGN

Costs are estimated for episodes of care and constituent service components using setting-specific case mix methodologies and provincial fee schedules. Costs are estimated for five areas of potentially avoidable utilization, derived from best practice standards set by an expert panel of stroke clinicians. Alternative approaches for setting normative prices for stroke episodes are developed using measures of potentially avoidable utilization and benchmarks established by the best performing regions.

PRINCIPAL FINDINGS

There are wide regional variations in the utilization of different health services within episodes of stroke care. Reconciling the best practice standards with regional utilization identifies significant amounts of potentially avoidable utilization. Normative pricing models for stroke episodes result in increasingly aggressive redistributions of funding.

CONCLUSIONS

Bundled payment pilots to date have been based on the costs of historical service patterns, which effectively 'bake in' unwarranted and inefficient variations in utilization. This study demonstrates the feasibility of novel clinically informed episode pricing approaches that leverage these variations to target reductions in potentially avoidable utilization.

Post-acute referral patterns for hospitals and implications for bundled payment initiatives

BACKGROUND

Under new bundled payment models, hospitals are financially responsible for post-acute care delivered by providers such as skilled nursing facilities (SNFs) and home health agencies (HHAs). The hope is that hospitals will use post-acute care more prudently and better coordinate care with post-acute providers. However, little is known about existing patterns in hospitals׳ referrals to post-acute providers.

METHODS

Post-acute provider referrals were identified using SNF and HHA claims within 14 days following hospital discharge. Hospital post-acute care network size and concentration were estimated across hospital types and regions. The 2008 Medicare Provider Analysis and Review claims for acute hospitals and SNFs, and the 100% HHA Standard Analytic Files were used.

RESULTS

The mean post-acute care network size for U.S. hospitals included 57.9 providers with 37.5 SNFs and 23.4 HHAs. The majority of these providers (65.7% of SNFs, 60.9% of HHAs) accounted for 1 percent or less of a hospital׳s referrals and classified as "low-volume". Other post-acute providers we classified as routine. The mean network size for routine providers was greater for larger hospitals, teaching hospitals and in regions with higher per capita post-acute care spending.

CONCLUSIONS

The average hospital works with over 50 different post-acute providers. Moreover, the size of post-acute care networks varies considerably geographically and by hospital characteristics. These results provide context on the complex task hospitals will face in coordinating care with post-acute providers and cutting costs under new bundled payment models.

Accountable care organizations and the allergist: challenges and opportunities

For decades, health care policy experts have wrestled with ways to solve problems of access, cost, and quality in US health care. The current consensus is that the solution to all three lies in changing financial incentives for providers and delivering care through integrated systems. The currently favored vehicle for this, both in the public and private sectors, is through Accountable Care Organizations (ACOs). Medicare has several models and has fostered rapid growth in the number of operative ACOs. At least an equal number of private ACOs are in operation. Whether or not these organizations will fulfill their promise is unknown but there is reason for cautious optimism. Allergists can and should be part of the process of this transformation in our health care system. They can be integral to helping these organizations save money by reducing hospitalizations and improving the quality of allergy and asthma care in the populations served. In order to accomplish this, allergists must become more involved in their medical communities and hospitals.