The Promise and Challenge of Value-Based Payment

This Viewpoint discusses the benefits and challenges of transitioning to a value-based payment design for health care rather than a fee-for-service system.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

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.

Association of Electronic Self-Scheduling and Screening Mammogram Completion

INTRODUCTION

The purpose of this study was to evaluate if an electronic health record (EHR) self-scheduling function was associated with changes in mammogram completion for primary care patients who were eligible for a screening mammogram using U.S. Preventive Service Task Force recommendations.

METHODS

This was a retrospective cohort study (September 1, 2014-August 31, 2019, analyses completed in 2022) using a difference-in-differences design to examine mammogram completion before versus after the implementation of self-scheduling. The difference-in-differences estimate was the interaction between time (pre-versus post-implementation) and group (active EHR patient portal versus inactive EHR patient portal). The primary outcome was mammogram completion among all eligible patients, with completion defined as receiving a mammogram within 6 months post-visit. The secondary outcome was mammogram completion among patients who received a clinician order during their visit.

RESULTS

The primary analysis included 35,257 patient visits. The overall mammogram completion rate in the pre-period was 22.2% and 49.7% in the post-period. EHR self-scheduling was significantly associated with increased mammogram completion among those with an active EHR portal, relative to patients with an inactive portal (adjusted difference 13.2 percentage points [95% CI 10.6-15.8]). For patients who received a clinician mammogram order at their eligible visit, self-scheduling was significantly associated with increased mammogram completion among patients with an active EHR portal account (adjusted difference 14.7 percentage points, [95% CI 10.9-18.5]).

CONCLUSIONS

EHR-based self-scheduling was associated with a significant increase in mammogram completion among primary care patients. Self-scheduling can be a low-cost, scalable function for increasing preventive cancer screenings.

Clinician Perspectives on Virtual Specialty Palliative Care for Patients With Advanced Illnesses

Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.

The role of payment and financing in achieving health equity

OBJECTIVE

The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms.

DATA SOURCES AND STUDY SETTING

AHRQ convened a payment and financing workgroup-the authors of this paper-as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity.

STUDY DESIGN

The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants.

DATA COLLECTION/EXTRACTION METHODS

This paper did not require novel data collection; the authors collected the data from the existing evidence base.

PRINCIPAL FINDINGS

The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools.

CONCLUSIONS

Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity.

Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration

The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.

Pneumonia is not just pneumonia: Differences in utilization and costs with common comorbidities

We sought to explore the heterogeneity among patients hospitalized with pneumonia, a condition targeted in payment reform. In a retrospective cohort study of Medicare beneficiaries hospitalized for pneumonia, we compared postacute care utilization and costs of 90-day episodes of care among patients with and without comorbidities of chronic obstructive pulmonary disease (COPD) and/or heart failure. Of the 1,926,674 discharges, 28.1% had COPD, 14.3% had heart failure, and 14.6% carried both diagnoses. Patients with pneumonia were more likely to be discharged to a facility than those with pneumonia and COPD with or without heart failure, though less likely than those with pneumonia and heart failure only. Compared to patients with pneumonia only, patients with COPD and/or heart failure had higher episode payments. Acute conditions such as pneumonia may hold promise for episode-based care payment reform; however, the heterogeneity within this diagnosis indicates the need to consider other patient characteristics in interventions to improve value-based care.

Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease

Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.

Spending patterns among commercially insured individuals during the COVID-19 pandemic

OBJECTIVES

To describe trends in US health care spending in a large, national, and commercially insured population during the COVID-19 pandemic.

STUDY DESIGN

Cross-sectional study of commercially insured members enrolled between May 1, 2018, and December 31, 2021.

METHODS

The study utilized a population-based sample of continuously enrolled members in a geographically diverse federation of Blue Cross Blue Shield plans across the United States. Our sample excluded Medicare and Medicare Advantage beneficiaries. The COVID-19 exposure period was defined as 2020-2021; 2018-2019 were pre-COVID-19 years. We defined 4 post-COVID-19 periods: March 1 to April 30, 2020; May 1 to December 31, 2020; January 1 to March 31, 2021; and April 1 to December 31, 2021. The primary outcome was inflation-adjusted overall per-member per-month (PMPM) medical spending adjusted for age, sex, Elixhauser comorbidities, area-level racial composition, income, and education.

RESULTS

Our sample included 97,319,130 individuals. Mean PMPM medical spending decreased from $370.92 in January-February 2020 to $281.00 in March-April 2020. Between May and December 2020, mean PMPM medical spending recovered to-but did not exceed-prepandemic levels. Mean PMPM medical spending stayed below prepandemic levels between January and March 2021, rose above prepandemic baselines between April and June 2021, and decreased below baseline between July and December 2021.

CONCLUSIONS

The COVID-19 pandemic induced a spending shock in 2020, and health care spending did not recover to near baseline until mid-2021, with some emerging evidence of pent-up demand. The observed spending below baseline through the end of 2021 will pose challenges to setting spending benchmarks for alternative payment and shared savings models.

Principles to Inform Risk Adjustment Policy: Reflection From the Front Lines

This Viewpoint discusses the benefits and drawbacks of current risk adjustment tools, outlines the pressures clinicians may face to use these tools, and proposes principles and policy solutions to ensure that risk adjustment is clinically meaningful and to minimize gaming and waste.

Growth of Medicare Advantage After Plan Payment Reductions

Importance

Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program.

Objective

To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth.

Design, Setting, and Participants

This retrospective cohort study examined the MA market before and after the ACA, which mandated cuts to MA benchmark payment rates. Using 2008 to 2019 county-level enrollment and payment data, a difference-in-differences analysis was conducted comparing MA enrollment changes between counties with larger vs smaller benchmark reductions, before vs after the ACA.

Main Outcomes and Measures

The primary outcome was the MA enrollment rate, defined as the proportion of a county's Medicare beneficiaries enrolled in MA. A secondary analysis examined MA plan payments per member per month.

Results

Among 3138 counties with 37 639 county-year observations, ACA-induced benchmark cuts were sizeable and varied, ranging from 0% to 42.9% (mean [SD], 5.9% [6.6%]). Counties with benchmark cuts above the 75th percentile had population-weighted average benchmark cuts of 14.9% compared with 4.4% in other counties. In the 8 years following the ACA, there was no differential change in MA enrollment between counties with larger vs smaller benchmark cuts (difference-in-differences estimate, 0.02 [95% CI, -1.18 to 1.21] percentage points; P = .98). Plan payments differentially fell in counties with larger benchmark cuts by $78.35 (95% CI, $62.21-$94.48) per member per month (P < .001).

Conclusion and Relevance

This cohort study found no evidence that the MA benchmark and ensuing payment cuts imposed by the ACA were associated with reduced MA enrollment, compromising access to MA. This evidence can inform ongoing policy debates regarding the growth of MA, concerns about excess payments to MA plans, and proposed Medicare reforms, including further reductions in MA payments.

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries

Importance

Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality.

Objective

To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery.

Design, Setting, and Participants

Cross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022.

Exposures

Physician practice participation in the bundled payment program.

Main Outcomes and Measures

The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions).

Results

The final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]).

Conclusions and Relevance

In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

Hospital Consolidation: The Rise of Geographically Distant Mergers

This Viewpoint discusses how and why cross-market hospital mergers are different than prototypical within-market mergers in their effects on patients and communities, why the trend may be accelerating, and future policy and research directions.

How Physician Self-Perceptions Affect the Impact of Peer Comparison Feedback on Opioid Prescribing

Peer comparison feedback is a promising strategy for reducing opioid prescribing and opioid-related harms. Such comparisons may be particularly impactful among underestimating clinicians who do not perceive themselves as high prescribers relative to their peers. But peer comparisons could also unintentionally increase prescribing among overestimating clinicians who do not perceive themselves as lower prescribers than peers. The objective of this study was to assess if the impact of peer comparisons varied by clinicians' preexisting opioid prescribing self-perceptions. Subgroup analysis of a randomized trial of peer comparison interventions among emergency department and urgent care clinicians was used. Generalized mixed-effects models were used to assess whether the impact of peer comparisons, alone or combined with individual feedback, varied by underestimating or overestimating prescriber status. Underestimating and overestimating prescribers were defined as those who self-reported relative prescribing amounts that were lower and higher, respectively, than actual relative baseline amounts. The primary outcome was pills per opioid prescription. Among 438 clinicians, 54% (n = 236) provided baseline prescribing self-perceptions and were included in this analysis. Overall, 17% (n = 40) were underestimating prescribers whereas 5% (n = 11) were overestimating prescribers. Underestimating prescribers exhibited a differentially greater decrease in pills per prescription compared to nonunderestimating clinicians when receiving peer comparison feedback (1.7 pills, 95% CI, -3.2 to -0.2 pills) or combined peer and individual feedback (2.8 pills, 95% CI, -4.8 to -0.8 pills). In contrast, there were no differential changes in pills per prescription for overestimating versus nonoverestimating prescribers after receiving peer comparison (1.5 pills, 95% CI, -0.9 to 3.9 pills) or combined peer and individual feedback (3.0 pills, 95% CI, -0.3 to 6.2 pills). Peer comparisons were more impactful among clinicians who underestimated their prescribing compared to peers. By correcting inaccurate self-perceptions, peer comparison feedback can be an effective strategy for influencing opioid prescribing.

Performance drift in a mortality prediction algorithm among patients with cancer during the SARS-CoV-2 pandemic

Sudden changes in health care utilization during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic may have impacted the performance of clinical predictive models that were trained prior to the pandemic. In this study, we evaluated the performance over time of a machine learning, electronic health record-based mortality prediction algorithm currently used in clinical practice to identify patients with cancer who may benefit from early advance care planning conversations. We show that during the pandemic period, algorithm identification of high-risk patients had a substantial and sustained decline. Decreases in laboratory utilization during the peak of the pandemic may have contributed to drift. Calibration and overall discrimination did not markedly decline during the pandemic. This argues for careful attention to the performance and retraining of predictive algorithms that use inputs from the pandemic period.

Clinician Perceptions of Receiving Different Forms of Feedback on their Opioid Prescribing

Opioid misuse represents a major public health issue in the United States. One driver is overprescription for acute pain, with the size of initial prescription associated with subsequent long-term use. However, little work has been done to elicit clinician feedback about interventions to reduce opioid prescribing. To address this knowledge gap, qualitative analyses were conducted with clinicians who participated in a randomized controlled trial in which clinicians received monthly emailed feedback notifications about their opioid prescribing behaviors. Semistructured telephone interviews were conducted (N = 12) with urgent care (N = 7) and emergency department (N = 5) clinicians who participated in the trial between November 2020 and April 2021. Clinicians appreciated feedback about their prescribing behavior and found comparative data with peer clinicians to be most useful. Sharing opioid prescribing feedback data with clinicians can be an acceptable way to address opioid prescribing among emergency and urgent care clinicians.

Performance of Physician Groups and Hospitals Participating in Bundled Payments Among Medicare Beneficiaries

Importance

Hospital participation in bundled payment initiatives has been associated with financial savings and stable quality of care. However, how physician group practices (PGPs) perform in bundled payments compared with hospitals remains unknown.

Objectives

To evaluate the association of PGP participation in the Bundled Payments for Care Improvement (BPCI) initiative with episode outcomes and to compare these with outcomes for participating hospitals.

Design, Settings, and Participants

This cohort study with a difference-in-differences analysis used 2011 to 2018 Medicare claims data to compare the association of BPCI participation with episode outcomes for PGPs vs hospitals providing medical and surgical care to Medicare beneficiaries. Data analyses were conducted from January 1, 2020, to May 31, 2022.

Exposures

Hospitalization for any of the 10 highest-volume episodes (5 medical and 5 surgical) included in the BPCI initiative for Medicare patients of participating PGPs and hospitals.

Main Outcomes and Measures

The primary outcome was 90-day total episode spending. Secondary outcomes were 90-day readmissions and mortality.

Results

The total sample comprised data from 1 288 781 Medicare beneficiaries, of whom 696 710 (mean [SD] age, 76.2 [10.8] years; 432 429 [59.7%] women; 619 655 [85.5%] White individuals) received care through 379 BPCI-participating hospitals and 1441 propensity-matched non-BPCI-participating hospitals, and 592 071 (mean [SD] age, 75.4 [10.9] years; 527 574 [86.6%] women; 360 835 [59.3%] White individuals) received care from 6405 physicians in BPCI-participating PGPs and 24 758 propensity-matched physicians in non-BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical (difference, -$1368; 95% CI, -$1648 to -$1088) but not for medical episodes (difference, -$101; 95% CI, -$410 to $206). Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical (-$1010; 95% CI, -$1345 to -$675) and medical (-$763; 95% CI, -$1139 to -$386) episodes.

Conclusions and Relevance

This cohort study and difference-in-differences analysis of PGPs and hospital participation in BPCI found that bundled payments were associated with cost savings for surgical episodes for PGPs, and savings for both surgical and medical episodes for hospitals. Policy makers should consider the comparative performance of participant types when designing and evaluating bundled payment models.

Characteristics of Hospitals Eligible for Rural Emergency Hospital Designation

This cross-sectional study compares the characteristics, finances, services, and challenges at hospitals that are eligible vs not eligible to become rural emergency hospitals.

Organizational capacity among hospitals in Medicare and commercial bundled payments

OBJECTIVES

Hospitals must strategically build organizational capacities to succeed in bundled payment arrangements. Given differences between Medicare and commercial arrangements, capacities may vary between hospitals in Medicare vs both Medicare and commercial bundled payment programs. This study compared organizational capacities between these 2 hospital groups.

STUDY DESIGN

National survey of American Hospital Association (AHA) member hospitals with experience in bundled payment programs.

METHODS

We analyzed data from October 31, 2017, to April 30, 2018, collected from AHA member hospitals with bundled payment experience in only Medicare (Medicare-only hospitals) or in both Medicare and commercial insurers (multipayer hospitals). Survey questions examined capacity in 4 areas: (1) physician performance feedback, (2) care management, (3) postacute care provider utilization, and (4) health information technology.

RESULTS

Our sample included 114 hospitals reporting experience in Medicare or commercial bundled payment programs. Both Medicare-only and multipayer hospitals reported high organizational capacities in performance measurement of physician-level quality and cost feedback and in incorporation of health information technology. More multipayer hospitals reported high capacity for coordinating hospital to postacute care settings (88% vs 52%). Although nearly all hospitals in both groups reported formalized relationships with skilled nursing facilities (98%), fewer hospitals reported such relationships with long-term acute care hospitals (83%) and inpatient rehabilitation facilities (80%).

CONCLUSIONS

Although they have similar capacity in a number of areas, Medicare-only and multipayer hospitals differed with respect to other aspects of organizational capacity.

Characteristics, utilization, and concentration of outpatient care for dual-eligible Medicare beneficiaries

OBJECTIVES

To characterize the (1) distribution of outpatient care for dual-eligible Medicare beneficiaries ("duals") and (2) intensity of outpatient care utilization of duals vs non-dual-eligible beneficiaries ("nonduals").

STUDY DESIGN

Using data preceding the introduction of several outpatient alternative payment models, as well as Medicaid expansion, we evaluated the distribution of outpatient care across physician practices using a Lorenz curve and compared utilization of different outpatient services between duals and nonduals.

METHODS

We defined practices that did (high dual) and did not (low dual and no dual) account for the large majority of visits based on the Lorenz curve and then performed descriptive statistics between these groups of practices. Practice-level outcomes included patient demographics, practice characteristics, and county measures of structural disadvantage and population health. Patient-level outcomes included number of outpatient visits and unique outpatient physicians, primary vs subspecialty care visits, and expenditures.

RESULTS

Nearly 80% of outpatient visits for duals were provided by 35% of practices. Compared with low-dual and no-dual practices, high-dual practices served more patients (1117.6 patients per high-dual practice vs 683.8 patients per low-dual practice and 447.5 patients per no-dual practice; P < .001) with more comorbidities (3.9 mean total Elixhauser comorbidities among patients served by high-dual practices vs 3.6 among low-dual practices and 3.3 among no-dual practices; P < .001). With regard to utilization, duals had 2 fewer outpatient visits per year compared with nonduals (13.3 vs 15.2; P < .001), with particularly fewer subspecialty care visits (6.5 vs 7.9; P < .001) despite having more comorbidities (3.5 vs 2.7; P < .001).

CONCLUSIONS

Outpatient care for duals was concentrated among a small number of practices. Despite having more chronic conditions, duals had fewer outpatient visits. Duals and the practices that serve them may benefit from targeted policies to promote access and improve outcomes.

Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries

Question

Do rates of low-value care differ between traditional Medicare (TM) and Medicare Advantage (MA), and, if so, what elements of insurance design are associated with the differences?

Findings

In this cross-sectional study of 2 470 199 Medicare beneficiaries, those enrolled in MA received 9.2% fewer low-value services than those in TM (23.1 vs 25.4 total low-value services per 100 beneficiaries). The MA beneficiaries in health maintenance organizations and those in primary care organizations reimbursed within advanced value-based payment models had the lowest rates of low-value care.

Meaning

The study results suggest that low-value care is less common in MA than TM, with elements of insurance design present in MA associated with fewer low-value services.

Importance

Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.

Objectives

To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.

Design, Setting, and Participants

This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.

Exposures

Enrollment in MA vs TM.

Main Outcomes and Measures

Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.

Results

Among a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.

Conclusions and Relevance

In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.

Trends in Enrollment in Employer-Sponsored Health Insurance in the US Before and During the COVID-19 Pandemic, January 2019 to June 2021

This cross-sectional study compares trends in employer-sponsored health insurance coverage in the US before and during the COVID-19 pandemic.

Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

IMPORTANCE

The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk.

OBJECTIVE

To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022.

EXPOSURES

Enrollment in MA or attribution to an accountable care organization in the MSSP program.

MAIN OUTCOMES AND MEASURES

Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending.

RESULTS

The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts.

CONCLUSIONS AND RELEVANCE

In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.

The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments

Hospitals have demonstrated the benefits of both voluntary and mandatory bundled payments for joint replacement surgery. However, given generalizability and disparities concerns, it is critical to understand the availability of care through bundled payments to historically marginalized groups, such as racial and ethnic minorities and individuals with lower socioeconomic status (SES). This cross-sectional analysis of 3880 US communities evaluated the relationship between the proportion of Black and Hispanic individuals (minority share) or Medicare/Medicaid dual-eligible individuals (low SES share) and community-level participation in Bundled Payments for Care Improvement initiative (BPCI) (being a BPCI community) and Comprehensive Care for Joint Replacement (CJR) model (being a CJR community). An increase from the lowest to highest quartile of minority share was not associated with differences in the probability of being a BPCI community (3.5 percentage point [pp] difference, 95% confidence interval [CI] -1.2% to 8.3%, P = 0.15), but was associated with a 16.1 pp higher probability of being a CJR community (95% CI 10.3% to 22.0%, P < 0.0001). An increase from the lowest to highest quartile of low SES share was associated with a 6.0 pp lower probability of being a BPCI community (95% CI -10.9% to -1.2%, P = 0.02) and 19.0 pp lower probability of being a CJR community (95% CI -24.9% to -13.0%, P < 0.0001). These findings highlight that the greater the proportion of lower SES individuals in a community, the lower the likelihood that its hospitals participated in either voluntary or mandatory bundled payments. Policymakers should consider community socioeconomic characteristics when designing participation mechanisms for future bundled payment programs.

Value-Based Payment Models In The Commercial Insurance Sector: A Systematic Review

Value-based payment models are a prominent strategy in health reform. Although Medicare payment models have been extensively evaluated, much less is known about value-based payment models in the commercial insurance sector. We performed the first systematic review of the quality, spending, and utilization effects of commercial models, extracting results from fifty-nine studies. Forty-one of these studies evaluated outcomes. More studies had positive results for quality outcomes (81 percent of studies) than for spending (56 percent) and utilization (58 percent). Less rigorous studies were more likely to find positive results. Given the mixed nature of the findings, commercial insurers should identify ways to strengthen value-based payment programs or leverage other strategies to improve health care value.

The Effect Of Clinician Feedback Interventions On Opioid Prescribing

An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians' prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician's outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (-0.8) and for the combination of peer comparison and individual audit feedback (-1.2). This decrease was sustained during follow-up. There were no significant changes for individual audit feedback alone, and no interventions changed the proportion of encounters with an opioid prescription.

Performance Drift in a Mortality Prediction Algorithm during the SARS-CoV-2 Pandemic

Research Objective

Health systems use clinical predictive algorithms to allocate resources to high-risk patients. Such algorithms are trained using historical data and are later implemented in clinical settings. During this implementation period, predictive algorithms are prone to performance changes ("drift") due to exogenous shocks in utilization or shifts in patient characteristics. Our objective was to examine the impact of sudden utilization shifts during the SARS-CoV-2 pandemic on the performance of an electronic health record (EHR)-based prognostic algorithm.

Study Design

We studied changes in the performance of Conversation Connect, a validated machine learning algorithm that predicts 180-day mortality among outpatients with cancer receiving care at medical oncology practices within a large academic cancer center. Conversation Connect generates mortality risk predictions before each encounter using data from 159 EHR variables collected in the six months before the encounter. Since January 2019, Conversation Connect has been used as part of a behavioral intervention to prompt clinicians to consider early advance care planning conversations among patients with ≥10% mortality risk. First, we descriptively compared encounter-level characteristics in the following periods: January 2019-February 2020 ("pre-pandemic"), March-May 2020 ("early-pandemic"), and June-December 2020 ("later-pandemic"). Second, we quantified changes in high-risk patient encounters using interrupted time series analyses that controlled for pre-pandemic trends and demographic, clinical, and practice covariates. Our primary metric of performance drift was false negative rate (FNR). Third, we assessed contributors to performance drift by comparing distributions of key EHR inputs across periods and predicting later pandemic utilization using pre-pandemic inputs.

Population Studied

237,336 in-person and telemedicine medical oncology encounters.

Principal Findings

Age, race, average patient encounters per month, insurance type, comorbidity counts, laboratory values, and overall mortality were similar among encounters in the pre-, early-, and later-pandemic periods. Relative to the pre-pandemic period, the later-pandemic period was characterized by a 6.5-percentage-point decrease (28.2% vs. 34.7%) in high-risk encounters (p<0.001). FNR increased from 41.0% (95% CI 38.0-44.1%) in the pre-pandemic period to 57.5% (95% CI 51.9-63.0%) in the later pandemic period. Compared to the pre-pandemic period, the early and later pandemic periods had higher proportions of telemedicine encounters (0.01% pre-pandemic vs. 20.0% early-pandemic vs. 26.4% later-pandemic) and encounters with no preceding laboratory draws (17.7% pre-pandemic vs. 19.8% early-pandemic vs. 24.1% later-pandemic). In the later pandemic period, observed laboratory utilization was lower than predicted (76.0% vs 81.2%, p<0.001). In the later-pandemic period, mean 180-day mortality risk scores were lower for telemedicine encounters vs. in-person encounters (10.3% vs 11.2%, p<0.001) and encounters with no vs. any preceding laboratory draws (1.5% vs. 14.0%, p<0.001).

Conclusions

During the SARS-CoV-2 pandemic period, the performance of a machine learning prognostic algorithm used to prompt advance care planning declined substantially. Increases in telemedicine and declines in laboratory utilization contributed to lower performance.

Implications for Policy or Practice

This is the first study to show algorithm performance drift due to SARS-CoV-2 pandemic-related shifts in telemedicine and laboratory utilization. These mechanisms of performance drift could apply to other EHR clinical predictive algorithms. Pandemic-related decreases in care utilization may negatively impact the performance of clinical predictive algorithms and warrant assessment and possible retraining of such algorithms.

The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes

BACKGROUND

Under Medicare's Bundled Payments for Care Improvement (BPCI) program, hospitals have maintained quality and achieved savings for medical conditions. However, safety net hospitals may perform differently owing to financial constraints and organizational challenges.

OBJECTIVE

To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This observational difference-in-differences analysis was conducted in safety net and non-safety net hospitals participating in BPCI for medical episodes (BPCI hospitals) using data from 2011-2016 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease.

EXPOSURE(S)

Hospital BPCI participation and safety net status.

MAIN OUTCOME(S) AND MEASURE(S)

The primary outcome was postdischarge spending. Secondary outcomes included quality and post-acute care utilization measures.

RESULTS

Our sample consisted of 803 safety net and 2263 non-safety net hospitals. Safety net hospitals were larger and located in areas with more low-income individuals than non-safety net hospitals. Among BPCI hospitals, safety net status was not associated with differential postdischarge spending (adjusted difference-in-differences [aDID], $40; 95% CI, -$254 to $335; P = .79) or quality (mortality, readmissions). However, BPCI safety net hospitals had differentially greater discharge to institutional post-acute care (aDID, 1.06 percentage points; 95% CI, 0.37-1.76; P = .003) and lower discharge home with home health (aDID, -1.15 percentage points; 95% CI, -1.73 to -0.58; P < .001) than BPCI non-safety net hospitals.

CONCLUSIONS

Under medical condition bundles, safety net hospitals perform differently from other hospitals in terms of post-acute care utilization, but not spending. Policymakers could support safety net hospitals and consider safety net status when evaluating bundled payment programs.

Group Practice Performance in the Second Year of Medicare's Merit-Based Incentive Payment System

This cross-sectional study describes performance among group practices in the second year of the Medicare Merit-Based Incentive Payment System (MIPS) program.

Association of Patient Outcomes With Bundled Payments Among Hospitalized Patients Attributed to Accountable Care Organizations

Question

Is receiving care simultaneously under a Medicare accountable care organization (ACO) and bundled payments associated with better patient outcomes compared with bundled payments alone?

Findings

In this cohort study of 9 850 080 Medicare beneficiaries, simultaneous inclusion in both ACOs and bundled payments was associated with lower spending on institutional postacute care, fewer readmissions for medical episodes, and fewer readmissions only for surgical episodes compared with inclusion in bundled payments alone.

Meaning

These findings suggest that receiving care under models such as ACOs may improve patient outcomes under bundled payments.

Importance

It is unknown how outcomes are affected when patients receive care under bundled payment and accountable care organization (ACO) programs simultaneously.

Objective

To evaluate whether outcomes in the Medicare Bundled Payments for Care Improvement (BPCI) program differed depending on whether patients were attributed to ACOs in the Medicare Shared Savings Program.

Design, Setting, and Participants

This cohort study was conducted using Medicare claims data from January 1, 2011, to September 30, 2016, and difference-in-differences analysis to compare episode outcomes for patients admitted to BPCI vs non-BPCI hospitals. Outcomes were stratified for patients who were and were not attributed to an ACO. Participants included Medicare fee-for-service beneficiaries receiving care for medical and surgical episodes at US hospitals. Data were analyzed between October 1, 2018, and June 10, 2021.

Exposures

Hospitalization for any of the 48 episodes (24 medical, 24 surgical) included in the BPCI at US hospitals participating in the BPCI for those episodes.

Main Outcomes and Measures

The primary outcome was change in 90-day postdischarge institutional spending, and secondary outcomes included changes in quality and utilization.

Results

A total of 7 108 146 beneficiaries (mean [SD] age, 76.9 [12.2] years; 4 101 081 women [58%]) received care for medical episodes, and 3 675 962 beneficiaries (mean [SD] age, 74.8 [10.1] years; 2 074 921 women [56%]) received care for surgical episodes. Compared with patients who were not attributed to ACOs, the association between bundled payments and changes in postdischarge institutional spending was larger among patients attributed to ACOs (–$323 difference; 95% CI, –$607 to –$39; P = .03) for medical episodes, but not surgical episodes. Attribution to an ACO also increased the strength of the association between bundled payments and changes in 90-day readmissions for both medical episodes (−0.98 percentage point difference; 95% CI, –1.55 to –0.41; P = .001) and surgical episodes (−0.84 percentage point difference; 95% CI, −1.32 to −0.35; P = .001).

Conclusions and Relevance

In this cohort study, compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes. Receiving care under models such as ACOs may improve episode outcomes under bundled payments.

Comparing Medicare Advantage And Traditional Medicare: A Systematic Review

Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.

When Should Medicare Mandate Participation In Alternative Payment Models?

The Centers for Medicare and Medicaid Services continues to propose and implement alternative payment models (APMs) to shift Medicare payment away from fee-for-service and toward approaches that emphasize health care value. As APMs expand in scope, one critical question is whether they should engage providers on a voluntary or a mandatory basis. Clinicians and policy makers may view the benefits and drawbacks of these two modes of participation differently. In this Analysis we compare the benefits and drawbacks of mandatory and voluntary participation, based on clinical versus policy perspectives, and we argue that both modes are necessary for APMs to achieve the goal of improving value. Policy makers should match the mode of participation and related financial incentives to each clinical scenario in which an APM is implemented. We propose ways to coordinate mandatory and voluntary APMs based on clinical scenarios.

The Beneficial Effects Of Medicare Advantage Special Needs Plans For Patients With End-Stage Renal Disease

Patients with end-stage renal disease (ESRD) are a vulnerable population with high rates of morbidity, mortality, and acute care use. Medicare Advantage Special Needs Plans (SNPs) are an alternative financing and delivery model designed to improve care and reduce costs for patients with ESRD, but little is known about their impact. We used detailed clinical, demographic, and claims data to identify fee-for-service Medicare beneficiaries who switched to ESRD SNPs offered by a single health plan (SNP enrollees) and similar beneficiaries who remained enrolled in fee-for-service Medicare plans (fee-for-service controls). We then compared three-year mortality and twelve-month utilization rates. Compared with fee-for-service controls, SNP enrollees had lower mortality and lower rates of utilization across the care continuum. These findings suggest that SNPs may be an effective alternative care financing and delivery model for patients with ESRD.

The Impact of Medicare's Alternative Payment Models on the Value of Care

Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.

Nationwide Hospital Performance on Publicly Reported Episode Spending Measures

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.