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Kilaru AS, Liao JM, Wang E, Zhao Y, Zhu J, Ng G, Shirk T, Cousins DS, Kanter GP, Ibrahim S, Navathe AS. Association between mandatory bundled payments and changes in socioeconomic disparities for joint replacement outcomes. Health Serv Res 2024; 59:e14369. [PMID: 39128893 PMCID: PMC11366957 DOI: 10.1111/1475-6773.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
OBJECTIVE To determine whether mandatory participation by hospitals in bundled payments for lower extremity joint replacement (LEJR) was associated with changes in outcome disparities for patients dually eligible for Medicare and Medicaid. DATA SOURCES AND STUDY SETTING We used Medicare claims data for beneficiaries undergoing LEJR in the United States between 2011 and 2017. STUDY DESIGN We conducted a retrospective observational study using a differences-in-differences method to compare changes in outcome disparities between dual-eligible and non-dual eligible beneficiaries after hospital participation in the Comprehensive Care for Joint Replacement (CJR) program. The primary outcome was LEJR complications. Secondary outcomes included 90-day readmissions and mortality. DATA EXTRACTION METHODS We identified hospitals in the US market areas eligible for CJR. We included beneficiaries in the intervention group who received joint replacement at hospitals in markets randomized to participate in CJR. The comparison group included patients who received joint replacement at hospitals in markets who were eligible for CJR but randomized to control. PRINCIPAL FINDINGS The study included 1,603,555 Medicare beneficiaries (mean age, 74.6 years, 64.3% women, 11.0% dual-eligible). Among participant hospitals, complications decreased between baseline and intervention periods from 11.0% to 10.1% for dual-eligible and 7.0% to 6.4% for non-dual-eligible beneficiaries. Among nonparticipant hospitals, complications decreased from 10.3% to 9.8% for dual-eligible and 6.7% to 6.0% for non-dual-eligible beneficiaries. In adjusted analysis, CJR participation was associated with a reduced difference in complications between dual-eligible and non-dual-eligible beneficiaries (-0.9 percentage points, 95% CI -1.6 to -0.1). The reduction in disparities was observed among hospitals without prior experience in a voluntary LEJR bundled payment model. There were no differential changes in 90-day readmissions or mortality. CONCLUSIONS Mandatory participation in a bundled payment program was associated with reduced disparities in joint replacement complications for Medicare beneficiaries with low income. To our knowledge, this is the first evidence of reduced socioeconomic disparities in outcomes under value-based payments.
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MESH Headings
- Humans
- United States
- Female
- Male
- Aged
- Retrospective Studies
- Medicare/statistics & numerical data
- Medicare/economics
- Socioeconomic Factors
- Healthcare Disparities/statistics & numerical data
- Patient Care Bundles/economics
- Arthroplasty, Replacement/economics
- Arthroplasty, Replacement/statistics & numerical data
- Patient Readmission/statistics & numerical data
- Aged, 80 and over
- Medicaid/statistics & numerical data
- Medicaid/economics
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Socioeconomic Disparities in Health
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Affiliation(s)
- Austin S. Kilaru
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Joshua M. Liao
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal Medicine, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Erkuan Wang
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yueming Zhao
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jingsan Zhu
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Grace Ng
- Department of NeurosurgeryMassachusetts General HospitalBostonMassachusettsUSA
| | - Torrey Shirk
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Deborah S. Cousins
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Genevieve P. Kanter
- Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Said Ibrahim
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Amol S. Navathe
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of MedicineCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA
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Siddiqi A, Pasqualini I, Tidd J, Rullán PJ, Klika AK, Murray TG, Johnson JK, Piuzzi NS. Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future. J Bone Joint Surg Am 2024; 106:1521-1528. [PMID: 38652757 DOI: 10.2106/jbjs.23.00422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
ABSTRACT The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.
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Affiliation(s)
- Ahmed Siddiqi
- Orthopedic Institute Brielle Orthopedics (OrthoNJ) Wall, Manasquan, New Jersey
- Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
| | | | - Joshua Tidd
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Pedro J Rullán
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Trevor G Murray
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joshua K Johnson
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio
- Center for Value-Based Care Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
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Burke RE, Roy I, Hutchins F, Zhong S, Patel S, Rose L, Kumar A, Werner RM. Trends in Post-Acute Care use in Medicare Advantage Versus Traditional Medicare: A Retrospective Cohort Analysis. J Am Med Dir Assoc 2024; 25:105202. [PMID: 39155043 DOI: 10.1016/j.jamda.2024.105202] [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: 03/15/2024] [Revised: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 08/20/2024]
Abstract
OBJECTIVES We sought to describe national trends in hospitalization and post-acute care utilization rates in skilled nursing facilities (SNFs) and home health (HH) for both Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries, reaching up to the COVID-19 pandemic (2015-2019). DESIGN Retrospective, observational using 100% sample of Medicare Provider Analysis and Review file (MedPAR), the Medicare Beneficiary Summary File, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS). SETTING AND PARTICIPANTS Medicare beneficiaries aged 66 and older enrolled in MA or TM who were hospitalized and discharged alive. METHODS We first calculated the proportions of MA and TM beneficiaries who were hospitalized and who used any post-acute care, as well as the total number of days of post-acute care used. We also calculated the size of the post-acute care network used by TM and MA beneficiaries within each hospital in our sample and the measured quality (star ratings) of the post-acute care providers used. RESULTS We found hospitalizations, SNF stays, and HH stays were all decreasing over time in both populations. Although similar proportions of MA and TM beneficiaries received SNF or HH care, MA beneficiaries received fewer days. The largest difference we found was in the number of post-acute care providers used in TM and MA, with MA using far fewer; however, quality ratings were similar among post-acute care providers used in each program. CONCLUSIONS AND IMPLICATIONS Together, these results suggest MA beneficiaries have fewer days in post-acute care, receive care from fewer providers of similar measured quality to TM, but have a similar number of days outside the hospital or SNF in the first 100 days after hospital discharge.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA; Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Indrakshi Roy
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA; Affiliated Research Scientist, Regenstrief Institute, Indianapolis, IN, USA
| | - Franya Hutchins
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Song Zhong
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Syama Patel
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Liam Rose
- Health Economics Resource Center, Palo Alto VA Medical Center, Palo Alto, CA, USA; Stanford Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, CA, USA
| | - Amit Kumar
- Department of Physical Therapy, College of Health, University of Utah, Salt Lake City, UT, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA; Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Lin MY, Hanchate AD, Frakt AB, Burgess JF, Carey K. Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis. Health Serv Res 2024. [PMID: 38654539 DOI: 10.1111/1475-6773.14311] [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: 04/26/2024] Open
Abstract
OBJECTIVE To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure. DATA SOURCES The primary data were Massachusetts All-Payer Claims Database (2009-2013). STUDY SETTING Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013. STUDY DESIGN Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate. CONCLUSIONS Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.
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Affiliation(s)
- Meng-Yun Lin
- Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Austin B Frakt
- Boston University School of Public Health, Boston, Massachusetts, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Kathleen Carey
- Boston University School of Public Health, Boston, Massachusetts, USA
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Patel UJ, Shaikh HJF, Brodell JD, Coon M, Ketz JP, Soin SP. Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries. J Bone Joint Surg Am 2023; 105:1972-1979. [PMID: 37725686 DOI: 10.2106/jbjs.23.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures. METHODS A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05. RESULTS There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay. CONCLUSIONS Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Urvi J Patel
- Department of Orthopaedic Surgery & Physical Performance, University of Rochester Medical Center, Rochester, New York
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Liao JM, Huang Q, Wang E, Linn K, Shirk T, Zhu J, Cousins D, Navathe AS. Performance of Physician Groups and Hospitals Participating in Bundled Payments Among Medicare Beneficiaries. JAMA HEALTH FORUM 2022; 3:e224889. [PMID: 36580325 PMCID: PMC9856773 DOI: 10.1001/jamahealthforum.2022.4889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Importance Hospital participation in bundled payment initiatives has been associated with financial savings and stable quality of care. However, how physician group practices (PGPs) perform in bundled payments compared with hospitals remains unknown. Objectives To evaluate the association of PGP participation in the Bundled Payments for Care Improvement (BPCI) initiative with episode outcomes and to compare these with outcomes for participating hospitals. Design, Settings, and Participants This cohort study with a difference-in-differences analysis used 2011 to 2018 Medicare claims data to compare the association of BPCI participation with episode outcomes for PGPs vs hospitals providing medical and surgical care to Medicare beneficiaries. Data analyses were conducted from January 1, 2020, to May 31, 2022. Exposures Hospitalization for any of the 10 highest-volume episodes (5 medical and 5 surgical) included in the BPCI initiative for Medicare patients of participating PGPs and hospitals. Main Outcomes and Measures The primary outcome was 90-day total episode spending. Secondary outcomes were 90-day readmissions and mortality. Results The total sample comprised data from 1 288 781 Medicare beneficiaries, of whom 696 710 (mean [SD] age, 76.2 [10.8] years; 432 429 [59.7%] women; 619 655 [85.5%] White individuals) received care through 379 BPCI-participating hospitals and 1441 propensity-matched non-BPCI-participating hospitals, and 592 071 (mean [SD] age, 75.4 [10.9] years; 527 574 [86.6%] women; 360 835 [59.3%] White individuals) received care from 6405 physicians in BPCI-participating PGPs and 24 758 propensity-matched physicians in non-BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical (difference, -$1368; 95% CI, -$1648 to -$1088) but not for medical episodes (difference, -$101; 95% CI, -$410 to $206). Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical (-$1010; 95% CI, -$1345 to -$675) and medical (-$763; 95% CI, -$1139 to -$386) episodes. Conclusions and Relevance This cohort study and difference-in-differences analysis of PGPs and hospital participation in BPCI found that bundled payments were associated with cost savings for surgical episodes for PGPs, and savings for both surgical and medical episodes for hospitals. Policy makers should consider the comparative performance of participant types when designing and evaluating bundled payment models.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristin Linn
- Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Torrey Shirk
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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The Association between Bundled Payment Participation and Changes in Medical Episode Outcomes among High-Risk Patients. Healthcare (Basel) 2022; 10:healthcare10122510. [PMID: 36554035 PMCID: PMC9778756 DOI: 10.3390/healthcare10122510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Bundled payments for medical conditions are associated with stable quality and savings through shorter skilled nursing facility (SNF) length of stay. However, effects among clinically higher-risk patients remain unknown. Objective: To evaluate whether the association between participation in bundled payments for medical conditions and episode outcomes differed for clinically high-risk versus other patients. Design: Retrospective difference-in-differences analysis; Participants: 471,421 Medicare patients hospitalized at bundled payment and propensity-matched non-participating hospitals. Exposures were 5 measures of clinically high-risk groups: advanced age (>85 years old), high case-mix, disabled, frail, and prior institutional post-acute care provider utilization. Main Measures: Primary outcomes were SNF length of stay and 90-day unplanned readmissions. Secondary outcomes included quality, utilization, and spending measures. Key Results: SNF length of stay was differentially lower among frail patients (aDID −0.4 days versus non-frail patients, 95% CI −0.8 to −0.1 days), patients with advanced age (aDID −0.8 days versus younger patients, 95% CI −1.2 to −0.3 days), and those with prior institutional post-acute care provider utilization (aDID −1.1 days versus patients without prior utilization, 95% CI −1.6 to −0.6 days), compared to non-frail, younger, and patients without prior utilization, respectively. BPCI participation was also associated with differentially greater SNF LOS among disabled patients (aDID 0.8 days versus non-disabled patients, 95% CI 0.4 to 1.2 days, p < 0.001). Bundled payment participation was not associated with differential changes in readmissions in any high-risk group but was associated with changes in secondary outcomes for some groups. Conclusions: Changes under medical bundles affected, but did not indiscriminately apply to, high-risk patient groups.
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Liao JM, Chatterjee P, Wang E, Connolly J, Zhu J, Cousins DS, Navathe AS. The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes. J Hosp Med 2021; 16:716-723. [PMID: 34798000 PMCID: PMC8626055 DOI: 10.12788/jhm.3722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Under Medicare's Bundled Payments for Care Improvement (BPCI) program, hospitals have maintained quality and achieved savings for medical conditions. However, safety net hospitals may perform differently owing to financial constraints and organizational challenges. OBJECTIVE To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes. DESIGN, SETTING, AND PARTICIPANTS This observational difference-in-differences analysis was conducted in safety net and non-safety net hospitals participating in BPCI for medical episodes (BPCI hospitals) using data from 2011-2016 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. EXPOSURE(S) Hospital BPCI participation and safety net status. MAIN OUTCOME(S) AND MEASURE(S) The primary outcome was postdischarge spending. Secondary outcomes included quality and post-acute care utilization measures. RESULTS Our sample consisted of 803 safety net and 2263 non-safety net hospitals. Safety net hospitals were larger and located in areas with more low-income individuals than non-safety net hospitals. Among BPCI hospitals, safety net status was not associated with differential postdischarge spending (adjusted difference-in-differences [aDID], $40; 95% CI, -$254 to $335; P = .79) or quality (mortality, readmissions). However, BPCI safety net hospitals had differentially greater discharge to institutional post-acute care (aDID, 1.06 percentage points; 95% CI, 0.37-1.76; P = .003) and lower discharge home with home health (aDID, -1.15 percentage points; 95% CI, -1.73 to -0.58; P < .001) than BPCI non-safety net hospitals. CONCLUSIONS Under medical condition bundles, safety net hospitals perform differently from other hospitals in terms of post-acute care utilization, but not spending. Policymakers could support safety net hospitals and consider safety net status when evaluating bundled payment programs.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corresponding Author: Joshua M Liao, MD, MSc; ; Telephone: 206-616-6934. Twitter: @JoshuaLiaoMD
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Connolly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah S Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Navathe AS, Liao JM, Wang E, Isidro U, Zhu J, Cousins DS, Werner RM. Association of Patient Outcomes With Bundled Payments Among Hospitalized Patients Attributed to Accountable Care Organizations. JAMA HEALTH FORUM 2021; 2:e212131. [PMID: 35977188 PMCID: PMC8796940 DOI: 10.1001/jamahealthforum.2021.2131] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/17/2021] [Indexed: 01/23/2023] Open
Abstract
Question Is receiving care simultaneously under a Medicare accountable care organization (ACO) and bundled payments associated with better patient outcomes compared with bundled payments alone? Findings In this cohort study of 9 850 080 Medicare beneficiaries, simultaneous inclusion in both ACOs and bundled payments was associated with lower spending on institutional postacute care, fewer readmissions for medical episodes, and fewer readmissions only for surgical episodes compared with inclusion in bundled payments alone. Meaning These findings suggest that receiving care under models such as ACOs may improve patient outcomes under bundled payments. Importance It is unknown how outcomes are affected when patients receive care under bundled payment and accountable care organization (ACO) programs simultaneously. Objective To evaluate whether outcomes in the Medicare Bundled Payments for Care Improvement (BPCI) program differed depending on whether patients were attributed to ACOs in the Medicare Shared Savings Program. Design, Setting, and Participants This cohort study was conducted using Medicare claims data from January 1, 2011, to September 30, 2016, and difference-in-differences analysis to compare episode outcomes for patients admitted to BPCI vs non-BPCI hospitals. Outcomes were stratified for patients who were and were not attributed to an ACO. Participants included Medicare fee-for-service beneficiaries receiving care for medical and surgical episodes at US hospitals. Data were analyzed between October 1, 2018, and June 10, 2021. Exposures Hospitalization for any of the 48 episodes (24 medical, 24 surgical) included in the BPCI at US hospitals participating in the BPCI for those episodes. Main Outcomes and Measures The primary outcome was change in 90-day postdischarge institutional spending, and secondary outcomes included changes in quality and utilization. Results A total of 7 108 146 beneficiaries (mean [SD] age, 76.9 [12.2] years; 4 101 081 women [58%]) received care for medical episodes, and 3 675 962 beneficiaries (mean [SD] age, 74.8 [10.1] years; 2 074 921 women [56%]) received care for surgical episodes. Compared with patients who were not attributed to ACOs, the association between bundled payments and changes in postdischarge institutional spending was larger among patients attributed to ACOs (–$323 difference; 95% CI, –$607 to –$39; P = .03) for medical episodes, but not surgical episodes. Attribution to an ACO also increased the strength of the association between bundled payments and changes in 90-day readmissions for both medical episodes (−0.98 percentage point difference; 95% CI, –1.55 to –0.41; P = .001) and surgical episodes (−0.84 percentage point difference; 95% CI, −1.32 to −0.35; P = .001). Conclusions and Relevance In this cohort study, compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes. Receiving care under models such as ACOs may improve episode outcomes under bundled payments.
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Affiliation(s)
- Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joshua M. Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ulysses Isidro
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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10
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Organizational Capacity of Hospitals Co-Participating in Accountable Care Organizations and Bundled Payments. Am J Med Qual 2021; 37:39-45. [PMID: 34310377 DOI: 10.1097/01.jmq.0000741980.70096.ce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Building organizational capacity is critical for hospitals participating in payment models such as bundled payments and accountable care organizations, particularly "co-participant" hospitals with experience in both models. This study used a national survey of American Hospital Association member hospitals with bundled payment experience, with (co-participant hospitals) or without (bundled payment hospitals) accountable care organization experience. Questions examined capacity in 4 domains: performance feedback, postacute care provider utilization, care management, and health information technology. Of 424 hospitals, 38% responded. Both co-participant and bundled payment hospitals reported high capacity for performance feedback and risk stratification and predictive risk assessment using health information technology systems. The hospital groups did not differ in care management capacity, but bundled payment hospitals reported higher postacute care provider utilization capacity. Experience with multiple payment models may prompt hospitals to make different investments or adopt different strategies than hospitals with experience in a single model.
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11
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The Impact of Simultaneous Hospital Participation in Accountable Care Organizations and Bundled Payments on Episode Outcomes. Am J Med Qual 2021; 37:173-179. [PMID: 34225274 DOI: 10.1097/01.jmq.0000754532.72567.c9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among hospitals accepting bundled payments, simultaneous "co-participation" in accountable care organizations (ACOs) could impact episode outcomes compared to bundled payment participation alone. Difference-in-differences (DID) analysis of 1 857 653 ACO-attributed Medicare beneficiaries. The study exposure was hospitalization for 24 procedure-based and 24 condition-based episodes at hospitals participating in bundled payments and ACOs (co-participant) versus only bundled payments. Study outcomes included episode quality, postacute utilization, and spending. For procedure-based episodes, patients hospitalized at co-participant and bundled payment hospitals did not exhibit differential changes in risk-adjusted mortality (DID 0.04 percentage points [p.p.], 95% confidence interval [CI] -0.28 p.p. to 0.37 p.p., P = 0.79), readmissions (DID -0.32 p.p., 95% CI -1.5 p.p. to 0.82 p.p., P = 0.59), postdischarge institutional spending (DID $119, 95% CI -$216 to $455, P = 0.49), or postacute utilization. Similarly, outcomes for condition-based episodes did not vary between co-participant and bundled payment hospitals. Payment model co-participation may produce neither synergistic benefits nor negative effects for patients.
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12
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Dreyer T, Wilfong LS, Patel K, Gamble B, Polite BN. Oncology Care Model: A Herculean Effort With Fixable Fatal Flaws. JCO Oncol Pract 2021; 17:173-176. [PMID: 33539172 DOI: 10.1200/op.20.00852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Bo Gamble
- Community Oncology Alliance, Washington, DC
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Li Y, Ying M, Cai X, Thirukumaran CP. Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients. Med Care 2021; 59:101-110. [PMID: 33273296 PMCID: PMC7855778 DOI: 10.1097/mlr.0000000000001473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.
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Affiliation(s)
- Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
- Department of Orthopaedics, University of Rochester Medical Center
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14
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Staloff JA, Navathe AS, Liao JM. It’s Time to Advance Payment Reform Using the Principle of Policy Equipoise. JAMA HEALTH FORUM 2020; 1:e201323. [DOI: 10.1001/jamahealthforum.2020.1323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jonathan A. Staloff
- Department of Family Medicine, University of Washington, Seattle
- Value and Systems Science Lab, University of Washington, Seattle
| | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania
| | - Joshua M. Liao
- Department of Family Medicine, University of Washington, Seattle
- Value and Systems Science Lab, University of Washington, Seattle
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15
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Rolnick JA, Liao JM, Emanuel EJ, Huang Q, Ma X, Shan EZ, Dinh C, Zhu J, Wang E, Cousins D, Navathe AS. Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study. BMJ 2020; 369:m1780. [PMID: 32554705 PMCID: PMC7298619 DOI: 10.1136/bmj.m1780] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. DESIGN Quasi-experimental difference-in-differences analysis. SETTING US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. PARTICIPANTS 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. MAIN OUTCOME MEASURES Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. RESULTS In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points). CONCLUSIONS In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.
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Affiliation(s)
- Joshua A Rolnick
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- National Clinician Scholars Program,Philadelphia, PA, USA
| | - Joshua M Liao
- University of Washington School of Medicine, Seattle, WA USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Ezekiel J Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Xinshuo Ma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Eric Z Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Claire Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Amol S Navathe
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
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