1
|
Boulanger MC, Krasne MD, Gough EK, Myers S, Browner IS, Feliciano JL. Outpatient Embedded Palliative Care for Patients with Advanced Thoracic Malignancy: A Retrospective Cohort Study. Curr Oncol 2024; 31:1389-1399. [PMID: 38534938 PMCID: PMC10968799 DOI: 10.3390/curroncol31030105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 05/26/2024] Open
Abstract
Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.
Collapse
Affiliation(s)
- Mary C. Boulanger
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute/Massachusetts General Brigham, Boston, MA 02114, USA
| | - Margaret D. Krasne
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Ethan K. Gough
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Samantha Myers
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
| | - Ilene S. Browner
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Josephine L. Feliciano
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
- Johns Hopkins Bayview, 301 Lord Mason Drive, Baltimore, MD 21224, USA
| |
Collapse
|
2
|
Milstein R, Schreyögg J. The end of an era? Activity-based funding based on diagnosis-related groups: A review of payment reforms in the inpatient sector in 10 high-income countries. Health Policy 2024; 141:104990. [PMID: 38244342 DOI: 10.1016/j.healthpol.2023.104990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 12/19/2023] [Accepted: 12/31/2023] [Indexed: 01/22/2024]
Abstract
CONTEXT Across the member countries of the Organisation for Economic Co-Operation and Development, policy makers are searching for new ways to pay hospitals for inpatient care to move from volume to value. This paper offers an overview of the latest reforms and their evidence to date. METHODS We reviewed reforms to DRG payment systems in 10 high-income countries: Australia, Austria, Canada (Ontario), Denmark, France, Germany, Norway, Poland, the United Kingdom (England), and the United States. FINDINGS We identified four reform trends among the observed countries, them being (1) reductions in the overall share of inpatient payments based on DRGs, (2) add-on payments for rural hospitals or their exclusion from the DRG system, (3) episode-based payments, which use one joint price to pay providers for all services delivered along a patient pathway, and (4) financial incentives to shift the delivery of care to less costly settings. Some countries have combined some or all of these measures with financial adjustments for quality of care. These reforms demonstrate a shift away from activity and efficiency towards a diversified set of targets, and mirror efforts to slow the rise in health expenditures while improving quality of care. Where evaluations are available, the evidence indicates mixed success in improving quality of care and reducing costs and expenditures.
Collapse
Affiliation(s)
- Ricarda Milstein
- Universität Hamburg, Hamburg Center for Health Economics, Esplanade 36, 20354 Hamburg, Germany.
| | - Jonas Schreyögg
- Universität Hamburg, Hamburg Center for Health Economics, Esplanade 36, 20354 Hamburg, Germany
| |
Collapse
|
3
|
Bourne DS, Roberts ET, Sabik LM. Early impacts of the Pennsylvania Rural Health Model on potentially avoidable utilization. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae002. [PMID: 38313868 PMCID: PMC10836154 DOI: 10.1093/haschl/qxae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 02/06/2024]
Abstract
The Pennsylvania Rural Health Model (PARHM) is a novel alternative payment model for rural hospitals that aims to test whether hospital-based global budgets, coupled with delivery transformation plans, improve the quality of health care and health outcomes in rural communities. Eighteen hospitals joined PARHM in 3 cohorts between 2019 and 2021. This study assessed PARHM's impact on changes in potentially avoidable utilization (PAU)-a measure of admission rates policymakers explicitly targeted for improvement in PARHM. Using a difference-in-differences analysis and all-payer hospital discharge data for Pennsylvania hospitals from 2016 through 2022, we found no significant overall reduction in community-level PAU rates up to 4 years post-PARHM implementation, relative to changes in rural Pennsylvania communities whose hospitals did not join PARHM. However, heterogeneous treatment effects were observed across cohorts that joined PARHM in different years, and between critical access vs prospective payment system hospitals. These findings offer insight into how alternative payment models in rural health care settings may have heterogeneous impacts based on contextual factors and highlight the importance of accounting for these factors in proposed expansions of alternative payment models for rural health systems.
Collapse
Affiliation(s)
- Donald S Bourne
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA 15261, United States
| | - Eric T Roberts
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, and Leonard Davis Institute of Health Economics, Philadelphia, PA 19104, United States
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA 15261, United States
| |
Collapse
|
4
|
Gondi S, Joynt Maddox K, Wadhera RK. Looking AHEAD to State Global Budgets for Health Care. N Engl J Med 2024; 390:197-199. [PMID: 38226845 DOI: 10.1056/nejmp2313194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Affiliation(s)
- Suhas Gondi
- From the Department of Medicine, Brigham and Women's Hospital (S.G.), and the Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, and the Center for Health Economics and Policy, Washington University in St. Louis - both in St. Louis (K.J.M.)
| | - Karen Joynt Maddox
- From the Department of Medicine, Brigham and Women's Hospital (S.G.), and the Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, and the Center for Health Economics and Policy, Washington University in St. Louis - both in St. Louis (K.J.M.)
| | - Rishi K Wadhera
- From the Department of Medicine, Brigham and Women's Hospital (S.G.), and the Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (S.G., R.K.W.) - both in Boston; and the Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, and the Center for Health Economics and Policy, Washington University in St. Louis - both in St. Louis (K.J.M.)
| |
Collapse
|
5
|
Roberts ET, Xue L, Lovelace J, Kypriotis C, Connor KL, Liang Q, Grabowski DC. Changes in Care Associated With Integrating Medicare and Medicaid for Dual-Eligible Individuals. JAMA HEALTH FORUM 2023; 4:e234583. [PMID: 38127588 PMCID: PMC10739174 DOI: 10.1001/jamahealthforum.2023.4583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/23/2023] [Indexed: 12/23/2023] Open
Abstract
Importance There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated dual-eligible special needs plans (FIDE-SNPs) are one of the largest integrated models, but evidence about their performance is limited. Objective To evaluate changes in care associated with integrating Medicare and Medicaid coverage in a FIDE-SNP in Pennsylvania. Design, Setting, and Participants This cohort study using a difference-in-differences analysis compared changes in care between 2 cohorts of dual-eligible individuals: (1) an integration cohort composed of Medicare Dual Eligible Special Needs Plan enrollees who joined a companion Medicaid plan following a 2018 state reform mandating Medicaid managed care (leading to integration), and (2) a comparison cohort with nonintegrated coverage before and after the start of Medicaid managed care. Analyses were conducted between February 2022 and June 2023. Main Outcomes and Measures Analyses examined outcomes in 4 domains: use of home- and community-based services (HCBS), care management and coordination, hospital stays and postacute care, and long-term nursing home stays. Results The study included 7967 individuals in the integration cohort and 3832 individuals in the comparison cohort. In the integration cohort, the mean (SD) age at baseline was 63.3 (14.7) years, and 5268 individuals (66.1%) were female and 2699 (33.9%) were male. In the comparison cohort, the mean (SD) age at baseline was 64.8 (18.6) years, and 2341 individuals (61.1%) were female and 1491 (38.9%) were male. At baseline, integration cohort members received a mean (SD) of 2.83 (8.70) days of HCBS per month and 3.34 (3.56) medications for chronic conditions per month, and the proportion with a follow-up outpatient visit after a hospital stay was 0.47. From baseline through 3 years after integration, HCBS use increased differentially in the integration vs comparison cohorts by 0.61 days/person-month (95% CI, 0.28-0.94; P < .001). However, integration was not associated with changes in care management and coordination, including medication use for chronic conditions (-0.02 fills/person-month; 95% CI, -0.10 to 0.06; P = .65) or follow-up outpatient care after a hospital stay (-0.01 visits/hospital stay; 95% CI, -0.04 to 0.03; P = .61). Hospital stays did not change differentially between the cohorts. Unmeasured factors contributing to differential mortality limited the ability to identify changes in long-term nursing home stays associated with integration. Conclusions and Relevance In this cohort study with a difference-in-differences analysis of 2 cohorts of individuals dually eligible for Medicare and Medicaid, integration was associated with greater HCBS use but not with other changes in care patterns. The findings highlight opportunities to strengthen how integrated programs manage care and a need to further evaluate their performance.
Collapse
Affiliation(s)
- Eric T. Roberts
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lingshu Xue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - John Lovelace
- UPMC Insurance Services Division, Pittsburgh, Pennsylvania
| | - Chris Kypriotis
- Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Qingfeng Liang
- Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
6
|
Homauni A, Markazi-Moghaddam N, Mosadeghkhah A, Noori M, Abbasiyan K, Jame SZB. Budgeting in Healthcare Systems and Organizations: A Systematic Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2023; 52:1889-1901. [PMID: 38033850 PMCID: PMC10682572 DOI: 10.18502/ijph.v52i9.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/16/2023] [Indexed: 12/02/2023]
Abstract
Background Budgeting is the process resource allocation to produce the best output according to the revenue levels involved. Among the constraints that healthcare organizations, including hospitals, both in the public and private sectors, grapple with is budgetary constraints. Therefore, cost control and resource management should be considered in healthcare organizations under such circumstances. Methods We aimed to identify methods of budgeting in healthcare systems and organizations as a systematic review. To extract and analyze the data, a form was designed by the researcher to define budgeting methods proposed in the literature and to identify their strengths, weaknesses, and dimensions. The search was conducted in Google Scholar, Web of science, Pub med and Scopus databases covering the period 1990-2022. Results Overall, 33 articles were included in the study for extraction and final analysis. The study results were reported in four main themes: healthcare system budgeting, capital budgeting, global budgeting, and performance-based budgeting. Conclusion Each budgeting approach has its own pros and cons and requires meeting certain requirements. These approaches are selected and implemented depending on each country's infrastructure and conditions as well as its organizations. These infrastructures need to be thoroughly examined before implementing any budgeting method, and then a budgeting method should be selected accordingly.
Collapse
Affiliation(s)
- Abbas Homauni
- Department of Health Management and Economics, School of Medicine, Aja University of Medical Sciences, Tehran, Iran
| | - Nader Markazi-Moghaddam
- Department of Health Management and Economics, School of Medicine, Aja University of Medical Sciences, Tehran, Iran
- Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Mosadeghkhah
- Department of Endocrinology, Aja University of Medical Science, Tehran, Iran
| | - Majid Noori
- Infectious Diseases Research Center, Aja University of Medical Sciences, Tehran, Iran
| | - Kourosh Abbasiyan
- Department of Health Management and Economics, School of Medicine, Aja University of Medical Sciences, Tehran, Iran
| | - Sanaz Zargar Balaye Jame
- Department of Health Management and Economics, School of Medicine, Aja University of Medical Sciences, Tehran, Iran
| |
Collapse
|
7
|
Yesantharao PS, Etchill EW, Zhou AL, Ong CS, Metkus TS, Canner JK, Alejo DE, Aliu O, Czarny MJ, Hasan RK, Resar JR, Schena S. The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions. Catheter Cardiovasc Interv 2023; 101:1193-1202. [PMID: 37102376 DOI: 10.1002/ccd.30670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/07/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.
Collapse
Affiliation(s)
- Pooja S Yesantharao
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric W Etchill
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alice L Zhou
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas S Metkus
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Diane E Alejo
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Oluseyi Aliu
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Matthew J Czarny
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rani K Hasan
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Medical College of Wisconsin, Milwaukee, Wisconsin, 53226, USA
| |
Collapse
|
8
|
McGINTY BETH. The Future of Public Mental Health: Challenges and Opportunities. Milbank Q 2023; 101:532-551. [PMID: 37096616 PMCID: PMC10126977 DOI: 10.1111/1468-0009.12622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/30/2022] [Accepted: 01/06/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points Social policies such as policies advancing universal childcare to expand Medicaid coverage of home- and community-based care for seniors and people with disabilities and for universal preschool are the types of policies needed to address social determinants of poor mental health. Population-based global budgeting approaches like accountable care and total cost of care models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve. Policies expanding reimbursement for services delivered by peer support specialists are needed. People with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services.
Collapse
|
9
|
Pai DR. Complexities of Simultaneously Improving Quality and Lowering Costs in Hospitals Comment on "Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies". Int J Health Policy Manag 2022; 12:7442. [PMID: 36404505 PMCID: PMC10125090 DOI: 10.34172/ijhpm.2022.7442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/02/2022] [Indexed: 11/21/2022] Open
Abstract
As health systems transition to value-based care delivery models, reducing costs and improving quality of care without sacrificing either remains a challenge for many healthcare organizations. There is extensive research on hospital costs, however, works addressing the complex relationship between hospital costs and the quality of care have been limited. In this commentary, I expound on the scoping review on integrated hospital strategies by Wackers et al that aim to improve quality while lowering costs. Specifically, I reiterate the complexity of the relationship between cost and quality and delve into major interdependent themes identified by the authors as relevant for the implementation of hospitals' integrated strategy.
Collapse
Affiliation(s)
- Dinesh R. Pai
- School of Business Administration, Penn State Harrisburg, Middletown, PA, USA
| |
Collapse
|
10
|
Remers TE, Wackers EM, van Dulmen SA, Jeurissen PP. Towards population-based payment models in a multiple-payer system: the case of the Netherlands. Health Policy 2022; 126:1151-1156. [DOI: 10.1016/j.healthpol.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/10/2022] [Accepted: 09/21/2022] [Indexed: 11/04/2022]
|
11
|
Offodile AC, Lin YL, Melamed A, Rauh-Hain JA, Kinzer D, Keating NL. Association of Maryland Global Budget Revenue With Spending and Outcomes Related to Surgical Care for Medicare Beneficiaries With Cancer. JAMA Surg 2022; 157:e220135. [PMID: 35385085 PMCID: PMC8988019 DOI: 10.1001/jamasurg.2022.0135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care. Objective To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states. Design, Setting, and Participants Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011-2013) to after (2015-2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection). Main Outcomes and Measures Thirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. Results Relative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, -4.3 to -0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures. Conclusions and Relevance Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.
Collapse
Affiliation(s)
- Anaeze C Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston.,Baker Institute for Public Policy, Rice University, Houston, Texas.,Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Yu-Li Lin
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - J Alejandro Rauh-Hain
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston.,Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
12
|
Kilaru AS, Crider CR, Chiang J, Fassas E, Sapra KJ. Health Care Leaders' Perspectives on the Maryland All-Payer Model. JAMA HEALTH FORUM 2022; 3:e214920. [PMID: 35977273 PMCID: PMC8903109 DOI: 10.1001/jamahealthforum.2021.4920] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2023] Open
Abstract
IMPORTANCE Since 2014, all hospitals in Maryland have operated under an all-payer global budget system. Hospital global budgets have gained renewed attention as a strategy for constraining cost growth, improving patient outcomes, and preserving health care access in rural and underserved communities. Lessons from the implementation of the Maryland All-Payer Model (MDAPM) may have implications for policy makers, payers, and hospitals in other settings seeking to adopt global budgets or other value-based payment models. OBJECTIVE To examine perspectives on the implementation of the MDAPM among health care leaders who participated in its design and execution. DESIGN SETTING AND PARTICIPANTS This qualitative study with semistructured telephone interviews was conducted from November 1, 2019, to February 11, 2020. The purposive sample of Maryland health care leaders represents diverse stakeholder groups, including hospitals, state government and regulatory agencies, the federal government, and payers. MAIN OUTCOMES AND MEASURES Key high-level themes were extracted from interviews using qualitative content analysis, with barriers and facilitators to implementation specified within each theme. RESULTS A total of 20 interviews were conducted with hospital leaders (n = 6), state regulators (n = 4), federal regulators (n = 4), payer representatives (n = 3), and state leaders (n = 3). Key themes were labeled as (1) expectations (setting bold yet achievable goals), (2) autonomy (allowing hospitals to follow individual strategies within MDAPM parameters), (3) communication (encouraging early and ongoing communication between stakeholders), (4) actionable data (sharing useful hospital and patient-level data between stakeholders), (5) global budget calibration (anticipating technical challenges when negotiating budgets for individual hospitals), and (6) shared commitment to change (harnessing collective motivation for system change). Together, these themes suggest that implementing the payment model followed an evolving and collaborative process that requires stakeholder communication, data to guide decisions, and commitment to operating within the new payment system. CONCLUSIONS AND RELEVANCE The implementation of hospital global budgets in the state of Maryland offers generalizable lessons that can inform the evolution and expansion of this approach to value-based payment in other states and settings.
Collapse
Affiliation(s)
- Austin S. Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Christina R. Crider
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Joshua Chiang
- currently a medical student at Perelman School of Medicine, University of Pennsylvania, Philadelpia
| | - Elisabeth Fassas
- currently a medical student at University of Maryland School of Medicine, Baltimore
| | - Katherine J. Sapra
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| |
Collapse
|
13
|
Wu Y, Fung H, Shum HM, Zhao S, Wong ELY, Chong KC, Hung CT, Yeoh EK. Evaluation of Length of Stay, Care Volume, In-Hospital Mortality, and Emergency Readmission Rate Associated With Use of Diagnosis-Related Groups for Internal Resource Allocation in Public Hospitals in Hong Kong. JAMA Netw Open 2022; 5:e2145685. [PMID: 35119464 PMCID: PMC8817200 DOI: 10.1001/jamanetworkopen.2021.45685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hong Kong's internal resource allocation system for public inpatient care changed from a global budget system to one based on diagnosis-related groups (DRGs) in 2009 and returned to a global budget system in 2012. Changes in patient and hospital outcomes associated with moving from a DRG-based system to a global budget system for inpatient care have rarely been evaluated. OBJECTIVE To examine associations between the introduction and discontinuation of DRGs and changes in length of stay, volume of care, in-hospital mortality rates, and emergency readmission rates in the inpatient population in acute care hospitals overall, stratified by age group, and across 5 medical conditions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data from patients aged 45 years or older who were hospitalized in public acute care settings in Hong Kong before the introduction (April 2006 to March 2009), during implementation (April 2009 to March 2012), and after discontinuation (April 2012 to November 2014) of the DRG scheme. Data analysis was conducted from January to June 2021. EXPOSURES Public hospitals transitioned from a global budget payment system to a DRG-based system in April 2009 and returned to a global budget system in April 2014. MAIN OUTCOMES AND MEASURES The main outcome was the association of use of DRGs with patient-level length of stay, in-hospital mortality rate, 1-month emergency readmission rate, and population-level number of admissions per month. An interrupted time series design was used to estimate changes in the level and slope of outcome variables after introduction and discontinuation of DRGs, accounting for pretrends. RESULTS This study included 7 604 390 patient episodes. Overall, the mean (SD) age of patients was 68.97 (13.20) years, and 52.17% were male. The introduction of DRGs was associated with a 1.77% (95% CI, 1.23%-2.32%) decrease in the mean length of stay, a 2.90% (95% CI, 2.52%-3.28%) increase in the number of patients admitted, a 4.12% (95% CI, 1.89%-6.35%) reduction in in-hospital mortality, and a 2.37% (95% CI, 1.28%-3.46%) decrease in emergency readmissions. Discontinuation of the DRG scheme was associated with a 0.93% (95% CI, 0.42%-1.44%) increase in the mean length of stay and a 1.82% (95% CI, 1.47%-2.17%) reduction in the number of patients treated after adjusting for covariates; no statistically significant change was observed in in-hospital mortality (-0.14%; 95% CI, -2.29% to 2.01%) or emergency readmission rate (-0.29%; 95% CI, -1.30% to 0.71%). CONCLUSIONS AND RELEVANCE In this cross-sectional study, the introduction of DRGs was associated with shorter lengths of stay and increased hospital volume, and discontinuation was associated with longer lengths of stay and decreased hospital volume. In-hospital mortality and emergency readmission rates did not significantly change after discontinuation of DRGs.
Collapse
Affiliation(s)
- Yushan Wu
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Hong Fung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Chinese University of Hong Kong Medical Centre, Hong Kong Special Administrative Region, Hong Kong, China
| | - Ho-Man Shum
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Shi Zhao
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Eliza Lai-Yi Wong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Ka-Chun Chong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Chi-Tim Hung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Eng-Kiong Yeoh
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| |
Collapse
|
14
|
Galarraga JE, DeLia D, Huang J, Woodcock C, Fairbanks RJ, Pines JM. Effects of Maryland's global budget revenue model on emergency department utilization and revisits. Acad Emerg Med 2022; 29:83-94. [PMID: 34288254 DOI: 10.1111/acem.14351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/28/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. METHODS We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. RESULTS ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. CONCLUSIONS GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.
Collapse
Affiliation(s)
- Jessica E. Galarraga
- Health Care Delivery Research MedStar Health Research Institute Hyattsville Maryland USA
- Department of Emergency Medicine MedStar Washington Hospital Center Washington DC USA
- Georgetown University School of Medicine Washington DC USA
| | - Derek DeLia
- Health Care Delivery Research MedStar Health Research Institute Hyattsville Maryland USA
- Georgetown University School of Medicine Washington DC USA
| | - Jim Huang
- Health Care Delivery Research MedStar Health Research Institute Hyattsville Maryland USA
| | - Cynthia Woodcock
- The Hilltop Institute University of Maryland Baltimore County Baltimore Maryland USA
| | - Rollin J. Fairbanks
- Department of Emergency Medicine MedStar Washington Hospital Center Washington DC USA
- Georgetown University School of Medicine Washington DC USA
- Quality and Safety MedStar Health Columbia Maryland USA
| | - Jesse M. Pines
- US Acute Care Solutions Canton Ohio USA
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| |
Collapse
|
15
|
Yesantharao PS, Jenny HE, Lopez J, Chen J, Lopez CD, Aliu O, Redett RJ, Yang R, Steinberg JP. The Impact of Payment Reform on Pediatric Craniofacial Fracture Care in Maryland. Craniomaxillofac Trauma Reconstr 2021; 14:308-316. [PMID: 34707791 PMCID: PMC8543597 DOI: 10.1177/1943387520983634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective, quasi-experimental difference-in-differences investigation. OBJECTIVE Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland's All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. METHODS Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid's Inpatient Database (Healthcare Cost and Utilization Project). RESULTS Between 2009-2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals (p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: -1.1 fewer admissions, 95% confidence interval: -2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. CONCLUSIONS Maryland's APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.
Collapse
Affiliation(s)
- Pooja S. Yesantharao
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hillary E. Jenny
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Lopez
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonlin Chen
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher D. Lopez
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oluseyi Aliu
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J. Redett
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robin Yang
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jordan P. Steinberg
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
16
|
Rodriguez MI, Skye M, Lindner S, Caughey AB, Lopez-DeFede A, Darney BG, McConnell KJ. Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care. JAMA Netw Open 2021; 4:e2138983. [PMID: 34910148 PMCID: PMC8674744 DOI: 10.1001/jamanetworkopen.2021.38983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid. OBJECTIVE To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception. DESIGN, SETTING, AND PARTICIPANTS This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021. EXPOSURES Medicaid coverage of postpartum care. MAIN OUTCOMES AND MEASURES Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery. RESULTS The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.
Collapse
Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Megan Skye
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Ana Lopez-DeFede
- Institute for Families in Society, University of South Carolina, Columbia
| | - Blair G. Darney
- Divisionof Complex Family Planning, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| |
Collapse
|
17
|
Bhardwaj V, Spaulding EM, Marvel FA, LaFave S, Yu J, Mota D, Lorigiano TJ, Huynh PP, Shan R, Yesantharao PS, Lee MA, Yang WE, Demo R, Ding J, Wang J, Xun H, Shah L, Weng D, Wongvibulsin S, Carter J, Sheidy J, McLin R, Flowers J, Majmudar M, Elgin E, Vilarino V, Lumelsky D, Leung C, Allen JK, Martin SS, Padula WV. Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery. Med Care 2021; 59:1023-1030. [PMID: 34534188 PMCID: PMC8516712 DOI: 10.1097/mlr.0000000000001636] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone. METHODS A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty. RESULTS The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone. CONCLUSIONS Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.
Collapse
Affiliation(s)
- Vinayak Bhardwaj
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
| | - Erin M. Spaulding
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Francoise A. Marvel
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Sarah LaFave
- Johns Hopkins University School of Nursing, Baltimore, MD, US
| | - Jeffrey Yu
- Johns Hopkins Health System, Baltimore, MD, US
- Dept. of Pharmaceutical & Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, US
| | - Daniel Mota
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Dimock Center, Baltimore, MD, US
| | | | - Pauline P. Huynh
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Rongzi Shan
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Pooja S. Yesantharao
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Matthias A. Lee
- Johns Hopkins University Whiting School of Engineering, Baltimore, MD, US
| | - William E. Yang
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Ryan Demo
- Johns Hopkins University Whiting School of Engineering, Baltimore, MD, US
| | - Jie Ding
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Jane Wang
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Helen Xun
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Lochan Shah
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Daniel Weng
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Shannon Wongvibulsin
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | | | | | | | | | - Maulik Majmudar
- Massachusetts General Hospital, Boston, MA, US
- Harvard Medical School, Boston, MA, US
| | | | - Valerie Vilarino
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University Krieger School of Arts and Sciences, Baltimore, MD, US
| | - David Lumelsky
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University Krieger School of Arts and Sciences, Baltimore, MD, US
| | | | - Jerilyn K. Allen
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Seth S. Martin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University Whiting School of Engineering, Baltimore, MD, US
| | - William V. Padula
- Dept. of Pharmaceutical & Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, US
- Leonard D. Schaeffer Center for Health Economics & Policy, University of Southern California, Los Angeles, CA
| |
Collapse
|
18
|
Delanois RE, Wilkie WA, Mohamed NS, Remily EA, Pollak AN, Mont MA. Maryland's Global Budget Revenue Model: How Do Costs and Readmission Rates Fare for Patients Undergoing Total Knee Arthroplasty? J Knee Surg 2021; 34:1421-1428. [PMID: 32369838 DOI: 10.1055/s-0040-1709677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011-2013) and post-GBR (2014-2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges (p < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets.
Collapse
Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Wayne A Wilkie
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ethan A Remily
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, New York
| |
Collapse
|
19
|
Masters SH, Rutledge RI, Morrison M, Beil HA, Haber SG. Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland. Med Care Res Rev 2021; 79:535-548. [PMID: 34698554 DOI: 10.1177/10775587211052748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White.
Collapse
|
20
|
Yesantharao PS, He W, Shetty P, Aravind P, Quan A, Fadavi D, Aliu O. The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures. Ann Plast Surg 2021; 87:e40-e50. [PMID: 33346555 DOI: 10.1097/sap.0000000000002608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services like reconstructive surgery. This study evaluated the impact of 2 healthcare reform policies, Medicaid expansion and global hospital budgeting, on utilization of reconstructive surgery by Medicaid patients. METHODS Utilization of reconstructive surgery by Medicaid patients in New Jersey (Medicaid expansion/no global budget), Maryland (Medicaid expansion/with global budgets), and Florida (no Medicaid expansion/no global budget) between 2012 and 2016 was compared using quasi-experimental, interrupted time-series modeling. Subgroup analyses by procedure type and urgency were also undertaken. RESULTS During the study period, the likelihood of Medicaid patients using reconstructive surgery significantly increased in expansion states (Maryland: 0.3% [95% confidence interval = 0.17% to 0.42%] increase per quarter, P < 0.001; New Jersey: 0.4% [0.31% to 0.52%] increase per quarter, P = 0.004) when compared with Florida (nonexpansion state). Global budgeting did not significantly impact overall utilization of reconstructive procedures by Medicaid beneficiaries. Upon subgroup analyses, there was a greater increase in utilization of elective procedures than emergent procedures by Medicaid beneficiaries after Medicaid expansion (elective: 0.9% [0.8% to 1.3%] increase per quarter, P = 0.04; emergent/urgent: 0.2% [0.1% to 0.4%] increase per quarter, P = 0.02). In addition, Medicaid expansion had the greatest absolute effect on breast reconstruction (1.0% [95% confidence interval = 0.7% to 1.3%] increase per quarter) compared with other procedure types. CONCLUSIONS Medicaid expansion increased access to reconstructive surgery for Medicaid beneficiaries, especially for elective procedures. Encouragingly, although cost-constrictive, global hospital budgeting did not limit longitudinal utilization of reconstructive surgery by Medicaid patients, who are traditionally at higher risk for complications/readmissions.
Collapse
Affiliation(s)
- Pooja S Yesantharao
- From the Department of Plastic & Reconstructive Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | | | | | | | | | | |
Collapse
|
21
|
Giannouchos TV, Kum HC, Gary J, Ohsfeldt R, Morrisey M. The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York. J Emerg Med 2021; 61:749-762. [PMID: 34518044 DOI: 10.1016/j.jemermed.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use. OBJECTIVES To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York. METHODS We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years. RESULTS Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95-0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86-0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08-1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years. CONCLUSION The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.
Collapse
Affiliation(s)
- Theodoros V Giannouchos
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Population Informatics Lab
| | - Hye-Chung Kum
- Population Informatics Lab; Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Jodie Gary
- College of Nursing, Texas A&M University, Bryan, Texas
| | - Robert Ohsfeldt
- Population Informatics Lab; Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Michael Morrisey
- Population Informatics Lab; Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, Texas
| |
Collapse
|
22
|
Schwartzman DA, Sheetz KH, Fendrick AM. Refining the Recipe for Alternative Payment Models for Surgical Care-Importance of Patient Mix and Venue Match. JAMA Netw Open 2021; 4:e2128258. [PMID: 34559234 DOI: 10.1001/jamanetworkopen.2021.28258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Kyle H Sheetz
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - A Mark Fendrick
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| |
Collapse
|
23
|
Aliu O, Lee AWP, Efron JE, Higgins RSD, Butler CE, Offodile AC. Assessment of Costs and Care Quality Associated With Major Surgical Procedures After Implementation of Maryland's Capitated Budget Model. JAMA Netw Open 2021; 4:e2126619. [PMID: 34559228 PMCID: PMC8463941 DOI: 10.1001/jamanetworkopen.2021.26619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland's all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. OBJECTIVE To examine the association between the implementation of Maryland's all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. EXPOSURES All-payer model. MAIN OUTCOMES AND MEASURES Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). RESULTS Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P < .001), sex (22.7% male vs 21.4% male; P < .001), and race (0.3% vs 0.4% American Indian, 2.8% vs 4.5% Asian or Pacific Islander, 25.9% vs 12.7% Black, 4.7% vs 11.9% Hispanic, and 63.5% vs 63.4% White; P < .001). After implementation of the all-payer model in Maryland, significantly lower rates of avoidable complications were found among patients who underwent CABG (-11.3%; 95% CI, -13.8% to -8.7%; P < .001), CEA (-1.6%; 95% CI, -2.9% to -0.3%; P = .02), hip arthroplasty (-0.8%; 95% CI, -1.0% to -0.5%; P < .001), knee arthroplasty (-0.4%; 95% CI, -0.7% to -0.1%; P = .01), and cesarean delivery (-1.0%; 95% CI, -1.3% to -0.7%; P < .001). In addition, there were significantly lower increases in index hospital costs in Maryland among patients who underwent CABG (-$6236; 95% CI, -$7320 to -$5151; P < .001), CEA (-$730; 95% CI, -$1367 to -$94; P = .03), spinal fusion (-$3253; 95% CI, -$3879 to -$2627; P < .001), hip arthroplasty (-$328; 95% CI, -$634 to -$21; P = .04), knee arthroplasty (-$415; 95% CI, -$643 to -$187; P < .001), cesarean delivery (-$300; 95% CI, -$380 to -$220; P < .001), and hysterectomy (-$745; 95% CI, -$974 to -$517; P < .001). Significant changes in patient mix consistent with a younger population (eg, a shift toward private/commercial insurance for orthopedic procedures, such as spinal fusion [4.3%; 95% CI, 3.4%-5.2%; P < .001] and knee arthroplasty [1.6%; 95% CI, 1.0%-2.3%; P < .001]) and a lower comorbidity burden across surgical procedures (eg, CABG: -0.7% [95% CI, -0.1% to -0.5%; P < .001]; hip arthroplasty: -3.0% [95% CI, -3.6% to -2.3%; P < .001]) were also observed. CONCLUSIONS AND RELEVANCE In this study, patients who underwent common surgical procedures had significantly fewer avoidable complications and lower hospital costs, as measured against the rate of increase throughout the study, after implementation of the all-payer model in Maryland. These findings may be associated with changes in the patient mix.
Collapse
Affiliation(s)
- Oluseyi Aliu
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Jonathan E. Efron
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Charles E. Butler
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Anaeze C. Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
- Baker Institute for Public Policy, Rice University, Houston, Texas
| |
Collapse
|
24
|
Lindner S, Kaufman MR, Marino M, O'Malley J, Angier H, Cottrell EK, McConnell KJ, DeVoe JE, Heintzman JR. A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services. Health Aff (Millwood) 2021; 39:1194-1201. [PMID: 32634361 DOI: 10.1377/hlthaff.2019.01656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.
Collapse
Affiliation(s)
- Stephan Lindner
- Stephan Lindner is an assistant professor in the Center for Health Systems Effectiveness and in the Department of Emergency Medicine, both at Oregon Health & Science University, in Portland, Oregon
| | - Menolly R Kaufman
- Menolly R. Kaufman is a research associate in the Center for Health Systems Effectiveness, Oregon Health & Science University
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health & Science University, and at the OHSU-Portland State University School of Public Health, in Portland
| | - Jean O'Malley
- Jean O'Malley is a biostatistician in the Research Department at Ochin, Inc., in Portland
| | - Heather Angier
- Heather Angier is an assistant professor in the Department of Family Medicine, Oregon Health & Science University
| | - Erika K Cottrell
- Erika K. Cottrell is an assistant professor in the Department of Family Medicine, Oregon Health & Science University, and an investigator at OCHIN, Inc
| | - K John McConnell
- K. John McConnell is director of the Center for Health Systems Effectiveness and a professor in the Department of Emergency Medicine, both at Oregon Health & Science University
| | - Jennifer E DeVoe
- Jennifer E. DeVoe is professor and chair in the Department of Family Medicine, Oregon Health & Science University
| | - John R Heintzman
- John R. Heintzman is an associate professor in the Department of Family Medicine, Oregon Health & Science University
| |
Collapse
|
25
|
Zeldow B, Hatfield LA. Confounding and regression adjustment in difference-in-differences studies. Health Serv Res 2021; 56:932-941. [PMID: 33978956 PMCID: PMC8522571 DOI: 10.1111/1475-6773.13666] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective To define confounding bias in difference‐in‐difference studies and compare regression‐ and matching‐based estimators designed to correct bias due to observed confounders. Data sources We simulated data from linear models that incorporated different confounding relationships: time‐invariant covariates with a time‐varying effect on the outcome, time‐varying covariates with a constant effect on the outcome, and time‐varying covariates with a time‐varying effect on the outcome. We considered a simple setting that is common in the applied literature: treatment is introduced at a single time point and there is no unobserved treatment effect heterogeneity. Study design We compared the bias and root mean squared error of treatment effect estimates from six model specifications, including simple linear regression models and matching techniques. Data collection Simulation code is provided for replication. Principal findings Confounders in difference‐in‐differences are covariates that change differently over time in the treated and comparison group or have a time‐varying effect on the outcome. When such a confounding variable is measured, appropriately adjusting for this confounder (ie, including the confounder in a regression model that is consistent with the causal model) can provide unbiased estimates with optimal SE. However, when a time‐varying confounder is affected by treatment, recovering an unbiased causal effect using difference‐in‐differences is difficult. Conclusions Confounding in difference‐in‐differences is more complicated than in cross‐sectional settings, from which techniques and intuition to address observed confounding cannot be imported wholesale. Instead, analysts should begin by postulating a causal model that relates covariates, both time‐varying and those with time‐varying effects on the outcome, to treatment. This causal model will then guide the specification of an appropriate analytical model (eg, using regression or matching) that can produce unbiased treatment effect estimates. We emphasize the importance of thoughtful incorporation of covariates to address confounding bias in difference‐in‐difference studies.
Collapse
Affiliation(s)
- Bret Zeldow
- Department of Mathematics and Statistics, Colby College, Waterville, Maine, USA
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
26
|
Viganego F, Um EK, Ruffin J, Fradley MG, Prida X, Friebel R. Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis. Circ Cardiovasc Qual Outcomes 2021; 14:e007110. [PMID: 33622052 DOI: 10.1161/circoutcomes.120.007110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Global budget payments (GBP) are considered effective in containing health care expenditures; however, information on their impact on quality of cardiovascular care is limited. We aimed to evaluate the effects of GBP on utilization, outcomes, and costs for 3 major cardiovascular conditions. Methods We analyzed claims data of hospital admissions in Maryland from fiscal year 2013 to 2018. Using segmented regression, we evaluated temporal trends in hospitalizations, length of stay, percutaneous coronary intervention and coronary artery bypass grafting volumes, case mix-adjusted 30-day readmission rates, risk-standardized mortality rates, and hospitalization charges in patients with principal diagnosis of heart failure, acute ischemic stroke, and acute myocardial infarction (AMI) in relation to GBP implementation. Trends in global cardiovascular procedure charges/volumes were also studied. Results Hospitalization rates for congestive heart failure and AMI remained unaffected by GBP, while the gradient of ischemic stroke admissions decreased (Ptrend <0.0001). Length of stay slightly increased for patients with congestive heart failure (Ptrend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (Ptrend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (Ptrend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (Ptrend <0.0001), remained constant for congestive heart failure (Ptrend=0.1), and decreased for AMI (Ptrend=0.0005). We observed a significant increase in electrocardiography rate charges (Ptrend <0.0001), coincidentally with a reduction in volumes (Ptrend=0.0003). Conclusions Introducing GBP in Maryland had no perceivable adverse effects on inpatient outcomes and quality indicators for 3 major cardiovascular conditions. Savings were observed in the AMI cohort, possibly due to reduced unnecessary readmissions, efficiency improvements, or shifts to outpatient care. Reduced cardiovascular procedure volumes were counterbalanced by a proportional rise in charges. State-level adoption of GBP with pay-for-performance incentives may be effective for cost containment without adversely impacting quality of cardiovascular care.
Collapse
Affiliation(s)
| | - Eun K Um
- AMSTAT Consulting, LLC, Bethesda, MD (A.E.K.U., J.R.)
| | | | - Michael G Fradley
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia (M.G.F.)
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa (X.P.)
| | - Rocco Friebel
- Department of Health Policy, London School of Economics and Political Science, United Kingdom (R.F.)
| |
Collapse
|
27
|
Mafi JN, Reid RO, Baseman LH, Hickey S, Totten M, Agniel D, Fendrick AM, Sarkisian C, Damberg CL. Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018. JAMA Netw Open 2021; 4:e2037328. [PMID: 33591365 PMCID: PMC7887655 DOI: 10.1001/jamanetworkopen.2020.37328] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/09/2020] [Indexed: 12/11/2022] Open
Abstract
Importance Low-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown. Objective To assess national trends in low-value care use and spending. Design, Setting, and Participants In this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020. Exposure Being enrolled in fee-for-service Medicare for a period of time, in years. Main Outcomes and Measures The Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation. Results Among 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level. Conclusions and Relevance This cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.
Collapse
Affiliation(s)
- John N. Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles
- RAND Health Care, RAND Corporation, Santa Monica, California
| | - Rachel O. Reid
- RAND Health Care, RAND Corporation, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Scot Hickey
- RAND Health Care, RAND Corporation, Santa Monica, California
| | - Mark Totten
- RAND Health Care, RAND Corporation, Santa Monica, California
| | - Denis Agniel
- RAND Health Care, RAND Corporation, Santa Monica, California
| | - A. Mark Fendrick
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine at the University of California, Los Angeles
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | |
Collapse
|
28
|
Zhang H, Cowling DW, Graham JM, Taylor E. Impact of a commercial accountable care organization on prescription drugs. Health Serv Res 2021; 56:592-603. [PMID: 33508877 DOI: 10.1111/1475-6773.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To determine the long-run impact of a commercial accountable care organization (ACO) on prescription drug spending, utilization, and related quality of care. DATA SOURCES/STUDY SETTING California Public Employees' Retirement System (CalPERS) health maintenance organization (HMO) member enrollment data and pharmacy benefit claims, including both retail and mail-order generic and brand-name prescription drugs. STUDY DESIGN We applied a longitudinal retrospective cohort study design and propensity-weighted difference-in-differences regression models. We examined the relative changes in outcome measures between two ACO cohorts and one non-ACO cohort before and after the ACO implementation in 2010. The ACO directed provider prescribing patterns toward generic substitution for brand-name prescription drugs to maximize shared savings in pharmacy spending. DATA COLLECTION/EXTRACTION METHODS The study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area. PRINCIPAL FINDINGS The cohort differences in baseline characteristics of 40 483 study participants were insignificant after propensity-weighting adjustment. The ACO enrollees had no significant differential changes in either all or most of the five years of the ACO operation for the following measures: (1) average total spending and (2) average total scripts filled and days supplied on either generic or brand-name prescription drugs, or the two combined; (3) average generic shares of total prescription drug spending, scripts filled or days supplied; (4) annual rates of 10 outpatient process quality of care metrics for medication prescribing or adherence. CONCLUSIONS Participation in the commercial ACO was associated with negligible differential changes in prescription drug spending, utilization, and related quality of care measures. Capped financial risk-sharing and increased generics substitution for brand names are not enough to produce tangible performance improvement in ACOs. Measures to increase provider financial risk-sharing shares and lower brand-name drug prices are needed.
Collapse
Affiliation(s)
- Hui Zhang
- Health Policy Research Division, California Public Employees' Retirement System, Sacramento, California, USA
| | - David W Cowling
- Health Policy Research Division, California Public Employees' Retirement System, Sacramento, California, USA
| | - Joanne M Graham
- Health Policy Research Division, California Public Employees' Retirement System, Sacramento, California, USA
| | - Erik Taylor
- Health Policy Research Division, California Public Employees' Retirement System, Sacramento, California, USA
| |
Collapse
|
29
|
Lindner S, Levy A, Horner-Johnson W. The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon. Disabil Health J 2020; 14:101010. [PMID: 33419718 DOI: 10.1016/j.dhjo.2020.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/02/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion. OBJECTIVE To examine the association of the ACA expansion on health care access and utilization for adults ages 18-64 years who have qualified for Supplemental Security Income (SSI) in Oregon. METHODS We used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits. RESULTS The Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon's counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association. CONCLUSIONS We did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.
Collapse
Affiliation(s)
- Stephan Lindner
- OHSU Center for Health System Effectiveness (CHSE), Department of Emergency Medicine, School of Medicine, 3030 SW Moody Ave, Portland, 97201, OR, USA; OHSU-PSU School of Public Health, Portland 97239, OR, USA.
| | - Anna Levy
- OHSU Center for Health System Effectiveness (CHSE), Department of Emergency Medicine, School of Medicine, 3030 SW Moody Ave, Portland, 97201, OR, USA
| | - Willi Horner-Johnson
- OHSU-PSU School of Public Health, Portland 97239, OR, USA; OHSU Institute on Development and Disability, Department of Pediatrics, School of Medicine, Portland, 97239, OR, USA
| |
Collapse
|
30
|
Oakes AH, Sen AP, Segal JB. The impact of global budget payment reform on systemic overuse in Maryland. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100475. [PMID: 33027725 DOI: 10.1016/j.hjdsi.2020.100475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/13/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Medical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending. OBJECTIVE To assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services. METHODS We conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index. RESULTS Global budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses. CONCLUSIONS We did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.
Collapse
Affiliation(s)
- Allison H Oakes
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA; Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA.
| | - Aditi P Sen
- Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
| |
Collapse
|
31
|
The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes. Med Care 2020; 58 Suppl 6 Suppl 1:S22-S30. [PMID: 32412950 DOI: 10.1097/mlr.0000000000001276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear. METHODS A quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015. Difference-in-differences multivariable logistic regression models that incorporated 4-group propensity score weighting were estimated. Heterogeneity of SIM effects by grantee state and for CMS populations were assessed. RESULTS In adjusted difference-in-difference analyses, SIM was associated with an increase in odds of 30-day hospital readmission among patients in SIM states in the post-SIM versus pre-SIM period relative to the ratio in odds of readmission among patients in the comparison states post-SIM versus pre-SIM (ratio of adjusted odds ratio=1.057, P=0.01). Restricting the analyses to CMS populations (Medicare and Medicaid beneficiaries), resulted in consistent findings (ratio of adjusted odds ratio=1.057, P=0.034). SIM did not have different effects on 30-day readmissions by state. CONCLUSIONS We found no evidence that SIM reduced 30-day readmission rates among adults with diabetes during the first 2 years of round 1 implementation, even among CMS beneficiaries. It may be difficult to reduce readmissions statewide without greater investment in health information exchange and more intensive use of payment models that promote interorganizational coordination.
Collapse
|
32
|
Mazzeffi MA, Gammie JS, Tanaka K, Holmes SD, Salenger R, Alejo D, Galvagno S, Rock P, Taylor B. Maryland’s Global Budget Revenue Program and Coronary Artery Bypass Surgery. Ann Thorac Surg 2020; 110:592-597. [DOI: 10.1016/j.athoracsur.2019.10.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/07/2019] [Accepted: 10/28/2019] [Indexed: 11/29/2022]
|
33
|
Comfort LN, Fulton BD, Shortell SM. Assessing the Short-Term Association Between Rural Hospitals' Participation in Accountable Care Organizations and Changes in Utilization and Financial Performance. J Rural Health 2020; 37:334-346. [PMID: 32657481 DOI: 10.1111/jrh.12494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Although much research has been done on accountable care organizations (ACOs), little is known about their impact on rural hospitals. We examine the association between rural hospitals' participation in an ACO and their performance on utilization and financial measures. METHODS This quasi-experimental study estimates the relationship between voluntary ACO participation and hospital metrics using propensity score-matched, longitudinal regression models with year and hospital fixed effects. Regression models controlled for secular trends and time-varying hospital and county characteristics. Hospital measures were from the American Hospital Association, RAND Hospital Data, and Leavitt Partners. The initial population comprises 643 rural hospitals that participated in an ACO for at least one year during the 2011 to 2018 study period and 1,541 rural hospitals that did not participate in an ACO. From this population we created a sample of propensity score-matched hospitals consisting of 525 ACO-participating and 525 comparable non-ACO hospitals. RESULTS Rural hospitals' participation in an ACO is not associated with changes in hospital utilization or financial measures, nor is there an association between these performance metrics and whether another within-county hospital participated in an ACO. A secondary analysis limited to Critical Access Hospitals provides some evidence that inpatient utilization increases in the second year of ACO participation, though the increases are not significant in year 3 and beyond. CONCLUSION We find no evidence that rural hospitals experience substantive changes in outpatient visits, inpatient utilization, or operating margin in the years immediately after joining an ACO.
Collapse
Affiliation(s)
- Leeann N Comfort
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Brent D Fulton
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California
| | - Stephen M Shortell
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California
| |
Collapse
|
34
|
Galarraga JE, Black B, Pimentel L, Venkat A, Sverha JP, Frohna WJ, Lemkin DL, Pines JM. The Effects of Global Budgeting on Emergency Department Admission Rates in Maryland. Ann Emerg Med 2020; 75:370-381. [DOI: 10.1016/j.annemergmed.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 05/24/2019] [Accepted: 06/11/2019] [Indexed: 11/27/2022]
|
35
|
Chernew ME, Conway PH, Frakt AB. Transforming Medicare’s Payment Systems: Progress Shaped By The ACA. Health Aff (Millwood) 2020; 39:413-420. [DOI: 10.1377/hlthaff.2019.01410] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Michael E. Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy and director of the Healthcare Markets and Regulation Lab in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Patrick H. Conway
- Patrick H. Conway was the president and CEO of Blue Cross and Blue Shield of North Carolina, in Durham, when this work was performed
| | - Austin B. Frakt
- Austin B. Frakt is director of the Partnered Evidence-Based Policy Resource Center at the Veterans Affairs Boston Healthcare System; an associate professor at the Boston University School of Public Health; and a senior research scientist at the Harvard T. H. Chan School of Public Health, all in Boston
| |
Collapse
|
36
|
Roberts ET. Response to "The effects of global budget payments on hospital utilization in rural Maryland". Health Serv Res 2020; 54:523-525. [PMID: 31066466 DOI: 10.1111/1475-6773.13161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Eric T Roberts
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| |
Collapse
|
37
|
Delanois RE, Etcheson JI, Dávila Castrodad IM, Mohamed NS, Pollak AN, Mont MA. Influence of the Maryland All-Payer Model on Primary Total Knee Arthroplasties. JB JS Open Access 2019; 4:e0041. [PMID: 32043062 PMCID: PMC6959916 DOI: 10.2106/jbjs.oa.19.00041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In 2014, Maryland received a waiver for the Global Budget Revenue (GBR) program. We evaluated GBR's impact on patient and hospital trends for total knee arthroplasty (TKA) in Maryland compared with the U.S. Specifically, we examined (1) patient characteristics, (2) inpatient course, and (3) costs and charges associated with TKAs from 2014 through 2016. METHODS A comparative analysis of TKA-treated patients in the Maryland State Inpatient Database (n = 36,985) versus those in the National Inpatient Sample (n = 2,117,191) was performed. Patient characteristics included race, Charlson Comorbidity Index (CCI), morbid obesity, patient income status, and primary payer. Inpatient course included length of hospital stay (LOS), discharge disposition, and complications. RESULTS In the Maryland TKA cohort, the proportion of minorities increased from 2014 to 2016 while the proportion of whites decreased (p = 0.001). The proportion of patients with a CCI of ≥3 decreased (p = 0.014), that of low-income patients increased (p < 0.001), and that of patients covered by Medicare or Medicaid increased (p < 0.001). In the U.S. TKA cohort, the proportion of blacks increased (p < 0.001), that of patients with a CCI score of ≥3 decreased (p < 0.001), and the proportions of low-income patients (p < 0.001) and those covered by Medicare or Medicaid increased (p < 0.001). In both Maryland and the U.S., the LOS (p < 0.001) and complication rate (p < 0.001) decreased while home-routine discharges increased (p < 0.001). Costs and charges decreased in Maryland (p < 0.001 for both) whereas charges in the U.S. increased (p < 0.001) and costs decreased (p < 0.001). CONCLUSIONS While the U.S. health reform and GBR achieved similar patient and hospital-specific outcomes and broader inclusion of minority patients, Maryland experienced decreased hospital charges while hospital charges increased in the U.S. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Iciar M Dávila Castrodad
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | | |
Collapse
|
38
|
Fulton BD, Hong N, Rodriguez HP. Early Impact of the State Innovation Models Initiative on Diagnosed Diabetes Prevalence Among Adults and Hospitalizations Among Diagnosed Adults. Med Care 2019; 57:710-717. [PMID: 31295167 PMCID: PMC6690748 DOI: 10.1097/mlr.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The State Innovation Models (SIM) Initiative invested $254 million in 6 states in Round 1 to accelerate delivery system and payment reforms. OBJECTIVE The objective of this study was to examine the association of early SIM implementation and diagnosed diabetes prevalence among adults and hospitalization rates among diagnosed adults. RESEARCH DESIGN Quasi-experimental design compares diagnosed diabetes prevalence and hospitalization rates before SIM (2010-2013) and during early implementation (2014) in 6 SIM states versus 6 comparison states. County-level, difference-in-differences regression models were estimated. SUBJECTS The annual average of 4.5 million adults aged 20+ diagnosed with diabetes with 1.4 million hospitalizations in 583 counties across 12 states. MEASURES Diagnosed diabetes prevalence among adults and hospitalization rates per 1000 diagnosed adults. RESULTS Compared with the pre-SIM period, diagnosed diabetes prevalence increased in SIM counties by 0.65 percentage points (from 10.22% to 10.87%) versus only 0.10 percentage points (from 9.64% to 9.74%) in comparison counties, a difference-in-differences of 0.55 percentage points. The difference-in-differences regression estimates ranged from 0.49 to 0.53 percentage points (P<0.01). Regression results for ambulatory care-sensitive condition and all-cause hospitalization rates were inconsistent across models with difference-in-differences estimates ranging from -5.34 to -0.37 and from -13.16 to 0.92, respectively. CONCLUSIONS SIM Round 1 was associated with higher diagnosed diabetes prevalence among adults after a year of implementation, likely because of SIM's emphasis on detection and care management. SIM was not associated with lower hospitalization rates among adults diagnosed with diabetes, but the SIM's long-term impact on hospitalizations should be assessed.
Collapse
Affiliation(s)
- Brent D. Fulton
- School of Public Health, University of California, Berkeley, Berkeley, California, United States
| | - Nianyi Hong
- School of Public Health, University of California, Berkeley, Berkeley, California, United States
| | - Hector P. Rodriguez
- Henry J. Kaiser Endowed Chair in Organized Health Systems. School of Public Health, University of California, Berkeley, Berkeley, California, United States
| |
Collapse
|
39
|
Abstract
BACKGROUND Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk). METHODS Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States. RESULTS During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets. CONCLUSIONS During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).
Collapse
Affiliation(s)
- Zirui Song
- From the Department of Health Care Policy, Harvard Medical School (Z.S., M.E.C.), the Department of Medicine, Massachusetts General Hospital (Z.S.), the Department of Medicine, Tufts University School of Medicine, and Haven (D.G.S.), Boston, and the Graduate School of Arts and Sciences, Harvard University, Cambridge (Y.J.) - all in Massachusetts
| | - Yunan Ji
- From the Department of Health Care Policy, Harvard Medical School (Z.S., M.E.C.), the Department of Medicine, Massachusetts General Hospital (Z.S.), the Department of Medicine, Tufts University School of Medicine, and Haven (D.G.S.), Boston, and the Graduate School of Arts and Sciences, Harvard University, Cambridge (Y.J.) - all in Massachusetts
| | - Dana G Safran
- From the Department of Health Care Policy, Harvard Medical School (Z.S., M.E.C.), the Department of Medicine, Massachusetts General Hospital (Z.S.), the Department of Medicine, Tufts University School of Medicine, and Haven (D.G.S.), Boston, and the Graduate School of Arts and Sciences, Harvard University, Cambridge (Y.J.) - all in Massachusetts
| | - Michael E Chernew
- From the Department of Health Care Policy, Harvard Medical School (Z.S., M.E.C.), the Department of Medicine, Massachusetts General Hospital (Z.S.), the Department of Medicine, Tufts University School of Medicine, and Haven (D.G.S.), Boston, and the Graduate School of Arts and Sciences, Harvard University, Cambridge (Y.J.) - all in Massachusetts
| |
Collapse
|
40
|
Jencks SF, Schuster A, Dougherty GB, Gerovich S, Brock JE, Kind AJH. Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland's All-Payer Program: An Observational Study. Ann Intern Med 2019; 171:91-98. [PMID: 31261378 PMCID: PMC6736732 DOI: 10.7326/m16-2671] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Safety-net hospitals have higher-than-expected readmission rates. The relative roles of the mean disadvantage of neighborhoods the hospitals serve and the disadvantage of individual patients in predicting a patient's readmission are unclear. OBJECTIVE To examine the independent contributions of the patient's neighborhood and the hospital's service area to risk for 30-day readmission. DESIGN Retrospective observational study. SETTING Maryland. PARTICIPANTS All Maryland residents discharged from a Maryland hospital in 2015. MEASUREMENTS Predictors included the disadvantage of neighborhoods for each Maryland resident (area disadvantage index) and the mean disadvantage of each hospital's discharged patients (safety-net index). The primary outcome was unplanned 30-day hospital readmission. Generalized estimating equations and marginal modeling were used to estimate readmission rates. Results were adjusted for clinical readmission risk. RESULTS 13.4% of discharged patients were readmitted within 30 days. Patients living in neighborhoods at the 90th percentile of disadvantage had a readmission rate of 14.1% (95% CI, 13.6% to 14.5%) compared with 12.5% (CI, 11.8% to 13.2%) for similar patients living in neighborhoods at the 10th percentile. Patients discharged from hospitals at the 90th percentile of safety-net status had a readmission rate of 14.8% (CI, 13.4% to 16.1%) compared with 11.6% (CI, 10.5% to 12.7%) for similar patients discharged from hospitals at the 10th percentile of safety-net status. The association of readmission risk with the hospital's safety-net index was approximately twice the observed association with the patient's neighborhood disadvantage status. LIMITATIONS Generalizability outside Maryland is unknown. Confounding may be present. CONCLUSION In Maryland, residing in a disadvantaged neighborhood and being discharged from a hospital serving a large proportion of disadvantaged neighborhoods are independently associated with increased risk for readmission. PRIMARY FUNDING SOURCE National Institute on Minority Health and Health Disparities and Maryland Health Services Cost Review Commission.
Collapse
Affiliation(s)
| | - Alyson Schuster
- Maryland Health Services Cost Review Commission, Baltimore, Maryland (A.S., G.B.D.)
| | - Geoff B Dougherty
- Maryland Health Services Cost Review Commission, Baltimore, Maryland (A.S., G.B.D.)
| | - Sule Gerovich
- Mathematica Policy Research, Woodlawn, Maryland (S.G.)
| | - Jane E Brock
- Telligen Colorado, Greenwood Village, Colorado (J.E.B.)
| | - Amy J H Kind
- University of Wisconsin School of Medicine and Public Health and Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, U.S. Department of Veterans Affairs, Madison, Wisconsin (A.J.K.)
| |
Collapse
|
41
|
Done N, Herring B, Xu T. The effects of global budget payments on hospital utilization in rural Maryland. Health Serv Res 2019; 54:526-536. [PMID: 31066468 PMCID: PMC6505416 DOI: 10.1111/1475-6773.13162] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation. DATA SOURCES/STUDY SETTING Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File. STUDY DESIGN We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization. DATA COLLECTION Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census. PRINCIPAL FINDINGS We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department. CONCLUSIONS We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.
Collapse
Affiliation(s)
- Nicolae Done
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMaryland
- Department of Veterans AffairsCenter for Access Policy, Evaluation, and ResearchBostonMassachusetts
| | - Bradley Herring
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMaryland
| | - Tim Xu
- McKinsey and Co. Inc.BostonMassachusetts
| |
Collapse
|
42
|
|
43
|
Srivastava MC, Varricchio C, Gupta A. Same-Day Discharge After Percutaneous Coronary Intervention-An Elusive Bargain. JAMA Cardiol 2019; 4:495-496. [PMID: 30865213 DOI: 10.1001/jamacardio.2019.0306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mukta C Srivastava
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore
| | | | - Anuj Gupta
- University of Maryland School of Medicine, Baltimore
| |
Collapse
|
44
|
Mandel SR, Langan S, Mathioudakis NN, Sidhaye AR, Bashura H, Bie JY, Mackay P, Tucker C, Demidowich AP, Simonds WF, Jha S, Ebenuwa I, Kantsiper M, Howell EE, Wachter P, Golden SH, Zilbermint M. Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital. J Community Hosp Intern Med Perspect 2019; 9:64-73. [PMID: 31044034 PMCID: PMC6484466 DOI: 10.1080/20009666.2019.1593782] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/07/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown. Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR). Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models. Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048). Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.
Collapse
Affiliation(s)
| | - Susan Langan
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Nicolas Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aniket R Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Holly Bashura
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jun Y Bie
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Periwinkle Mackay
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cynthia Tucker
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Andrew P Demidowich
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA.,Department of Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
| | - William F Simonds
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Smita Jha
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Ifechukwude Ebenuwa
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Melinda Kantsiper
- Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Eric E Howell
- Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Patricia Wachter
- Hospitalist Division, Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| |
Collapse
|
45
|
Pines JM, Vats S, Zocchi MS, Black B. Maryland’s Experiment With Capitated Payments For Rural Hospitals: Large Reductions In Hospital-Based Care. Health Aff (Millwood) 2019; 38:594-603. [DOI: 10.1377/hlthaff.2018.05366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jesse M. Pines
- Jesse M. Pines is national director of clinical innovation at US Acute Care Solutions, in Canton, Ohio
| | - Sonal Vats
- Sonal Vats is vice president and health care economist at Daddyo, Inc., in Queens, New York
| | - Mark S. Zocchi
- Mark S. Zocchi is a PhD student at the Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts
| | - Bernard Black
- Bernard Black is the Nicholas J. Chabraja Professor at the Pritzer School of Law and Kellogg School of Management, Northwestern University, in Evanston, Illinois
| |
Collapse
|
46
|
Wijesekera TP, Kim M, Moore EZ, Sorenson O, Ross DA. All Other Things Being Equal: Exploring Racial and Gender Disparities in Medical School Honor Society Induction. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:562-569. [PMID: 30234509 DOI: 10.1097/acm.0000000000002463] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE A large body of literature has demonstrated racial and gender disparities in the physician workforce, but limited data are available regarding the potential origins of these disparities. To that end, the authors evaluated the effects of race and gender on Alpha Omega Alpha Honor Medical Society (AOA) and Gold Humanism Honor Society (GHHS) induction. METHOD In this retrospective cohort study, the authors examined data from 11,781 Electronic Residency Application Service applications from 133 U.S. MD-granting medical schools to 12 residency programs in the 2014-2015 application cycle and to all 15 residency programs in the 2015-2016 cycle at Yale-New Haven Hospital. They estimated the odds of induction into AOA and GHHS using logistic regression models, adjusting for Step 1 score, research publications, citizenship status, training interruptions, and year of application. They used gender- and race-matched samples to account for differences in clerkship grades and to test for bias. RESULTS Women were more likely than men to be inducted into GHHS (odds ratio 1.84, P < .001) but did not differ in their likelihood of being inducted into AOA. Black medical students were less likely to be inducted into AOA (odds ratio 0.37, P < .05) but not into GHHS. CONCLUSIONS These findings demonstrate significant differences between groups in AOA and GHHS induction. Given the importance of honor society induction in residency applications and beyond, these differences must be explored further.
Collapse
Affiliation(s)
- Thilan P Wijesekera
- T.P. Wijesekera is instructor, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut. M. Kim is a doctoral student, Yale School of Management, New Haven, Connecticut. E.Z. Moore is associate professor, Department of Engineering, Central Connecticut State University, New Britain, Connecticut. O. Sorenson is professor, Yale School of Management, New Haven, Connecticut. D.A. Ross is associate professor, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | | |
Collapse
|
47
|
Affiliation(s)
- Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
48
|
Gaskin DJ, Vazin R, McCleary R, Thorpe RJ. The Maryland Health Enterprise Zone Initiative Reduced Hospital Cost And Utilization In Underserved Communities. Health Aff (Millwood) 2018; 37:1546-1554. [DOI: 10.1377/hlthaff.2018.0642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Darrell J. Gaskin
- Darrell J. Gaskin is the William C. and Nancy F. Richardson Professor in Health Policy in the Department of Health Policy and Management and director of the Hopkins Center for Health Disparities Solutions, both at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Roza Vazin
- Roza Vazin was a graduate student research assistant in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, at the time this research was conducted
| | - Rachael McCleary
- Rachael McCleary is a research data analyst in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | - Roland J. Thorpe
- Roland J. Thorpe Jr. is an associate professor in the Department of Health, Behavior, and Society and deputy director of the Hopkins Center for Health Disparities Solutions, both at the Johns Hopkins Bloomberg School of Public Health
| |
Collapse
|
49
|
Affiliation(s)
- Joshua M Sharfstein
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | |
Collapse
|
50
|
Roberts ET, Hatfield LA, McWilliams JM, Chernew ME, Done N, Gerovich S, Gilstrap L, Mehrotra A. Changes In Hospital Utilization Three Years Into Maryland's Global Budget Program For Rural Hospitals. Health Aff (Millwood) 2018; 37:644-653. [PMID: 29608370 PMCID: PMC5993431 DOI: 10.1377/hlthaff.2018.0112] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a substantial shift in payment policy, the State of Maryland implemented a global budget program for acute care hospitals in 2010. Goals of the program include controlling hospital use and spending. Eight rural hospitals entered the program in 2010, while urban and suburban hospitals joined in 2014. Prior analyses, which focused on urban and suburban hospitals, did not find consistent evidence that Maryland's program had contributed to changes in hospital use after two years. However, these studies were limited by short follow-up periods, may have failed to isolate impacts of Maryland's payment change from other state trends, and had limited generalizability to rural settings. To understand the effects of Maryland's global budget program on rural hospitals, we compared changes in hospital use among Medicare beneficiaries served by affected rural hospitals versus an in-state control population from before to after 2010. By 2013-three years after the rural program began-there were no differential changes in acute hospital use or price-standardized hospital spending among beneficiaries served by the affected hospitals, versus the within-state control group. Our results suggest that among Medicare beneficiaries, global budgets in rural Maryland hospitals did not reduce hospital use or price-standardized spending as policy makers had anticipated.
Collapse
Affiliation(s)
- Eric T Roberts
- Eric T. Roberts ( ) is an assistant professor in the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, in Pennsylvania
| | - Laura A Hatfield
- Laura A. Hatfield is an associate professor in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - J Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School
| | - Michael E Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School
| | - Nicolae Done
- Nicolae Done is a postdoctoral fellow at Boston University School of Medicine
| | - Sule Gerovich
- Sule Gerovich is a senior researcher at Mathematica Policy Research in Baltimore, Maryland
| | - Lauren Gilstrap
- Lauren Gilstrap is a research fellow in the Department of Health Care Policy, Harvard Medical School
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor in the Department of Health Care Policy, Harvard Medical School
| |
Collapse
|