Association of Mandatory Bundled Payments for Joint Replacement With Use of Postacute Care Among Medicare Advantage Enrollees

Physical and Cognitive Function Trends in Post-acute Care After Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018

OBJECTIVES

Physical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018.

DESIGN

Observational study using Medicare enrollment, claims, and assessment data from 2013-2018.

SETTING AND PARTICIPANTS

1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018.

METHODS

Medicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013-2018) by estimating multivariable models that controlled for patient- and hospital-level covariates.

RESULTS

Multivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)-21.57% (2018), P < .001], HHA increased (46.72%-72.47%, P < .001), and IRF decreased (9.13%-5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)-14.23 (2018), P < .001] and cognitive impairment (13.25%-12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09-3.94, P < .001) and cognitive impairment (13.95%-16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81-37.78, P < .001) and cognitive dependence increased (39.08%-46.36%, P < .001), indicating greater dependence.

CONCLUSIONS AND IMPLICATIONS

From 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Employer-Sponsored Medicare Advantage Plans and the 2018 Therapy Cap Repeal: Reduced Overall Spending Does Not Constrain Out-of-Pocket Costs

BACKGROUND

Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning.

METHODS

The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed.

RESULTS

No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans.

CONCLUSIONS

Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.

Medicare Advantage and Home Health Care: A Systematic Review

OBJECTIVES

Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees.

METHODS

A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist.

RESULTS

Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits.

CONCLUSIONS

Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes.

Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review

OBJECTIVES

To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions.

BACKGROUND SUMMARY

Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear.

METHODS

A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion.

RESULTS

Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited.

CONCLUSIONS

Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.

Is there an advantage? Considerations for researchers studying the effects of the type of Medicare coverage

OBJECTIVE

To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within-MA studies and provide suggestions of how researchers can address these issues.

STUDY SETTING

Published research evaluating Medicare coverage options in the United States.

STUDY DESIGN

We considered key conceptual challenges and promising solutions that have been used thus far and suggest additional directions.

DATA COLLECTION

Not available.

PRINCIPAL FINDINGS

Many existing studies of MA versus TM include significant limitations, such as failing to account for unobserved confounders driving both beneficiary coverage choice and health outcomes once enrolled, not accounting for variation in benefit generosity, provider networks, or plan design across MA plans, and/or having been conducted at a time when MA enrollment was less than a third of all Medicare beneficiaries. We provide a review of methods that can help researchers to overcome these weaknesses and suggest additional methods and data sources that may aid future research.

CONCLUSIONS

The MA program is becoming an essential part of the US healthcare system. By accounting for non-random movement into and out of MA and studying the heterogeneity of beneficiary experience across plan and market characteristics, researchers can provide the high-quality evidence necessary for policymakers to design the program and reform TM in ways that maximize beneficiary outcomes.

Trading spaces: Medicare's regulatory spillovers on treatment setting for non-Medicare patients

Medicare pricing is known to indirectly influence provider prices and care provision for non-Medicare patients; however, Medicare's regulatory externalities beyond fee-setting are less well understood. We study how physicians' outpatient surgery choices for non-Medicare patients responded to Medicare removing a ban on ambulatory surgery center (ASC) use for a specific procedure. Following the rule change, surgeons began reallocating both Medicare and commercially insured patients to ASCs. Specifically, physicians became 70% more likely to use ASCs for the policy-targeted procedure among their non-Medicare patients. These novel findings demonstrate that Medicare rulemaking affects physician behavior beyond the program's statutory scope.

Risk assessment, consequences, and epidemiology of electric scooter accidents admitted to an emergency department: a prospective observational study

PURPOSE

This study aimed to describe the demographic and clinical characteristics of individuals involved in electric scooter (E-scooter) accidents and the factors associated with these incidents.

METHODS

We conducted a prospective observational study of individuals involved in E-scooter accidents admitted to the emergency department of Saint-Pierre Hospital. The highest abbreviated injury score above or equal to two classified the injury as significant. Injuries during working hours were compared to those during off-working hours.

RESULTS

During the study period from June 1, 2019, to June 30, 2020, 170 individuals were admitted to the emergency department following an E-scooter accident. In 73.5% of the accidents, rented E-scooters were involved. Of the patients, 68.2% were male, 6.4% wore helmets, and 30% were under the influence of alcohol. Upper limb and cranial injuries were more frequently severe (abbreviated injury score ≥ 2) than other injuries (p < 0.05). Accidents during off-working hours were significantly related to alcohol consumption (p < 0.001), non-usage of helmets (p < 0.01), head and neck injuries (p < 0.01), and rented E-scooters (p < 0.01). Alcohol consumption was itself associated with the non-usage of helmets (p < 0.05) and major head and neck injuries (p < 0.001).

CONCLUSION

Given the increasing popularity of E-scooters as an alternative mode of transportation, our study can inform public policy on patterns of injuries associated with E-scooter utilization for future injury prevention policies. Using helmets, avoiding alcohol consumption, and regulating use at night can improve outcomes in E-scooter accidents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04778332.

The Spillover Effect of the Medicare Mandatory Bundled Payment Program on Joint Replacement Outcomes: Analysis of Patients with Commercial Insurance and Medicare Advantage

BACKGROUND

To improve the value and efficiency of care among traditional Medicare enrollees, the Centers for Medicare & Medicaid Services has implemented alternative payment models designed to control health-care spending and improve quality. These models may affect care beyond traditional Medicare enrollees, "spilling over" into other populations. Established in April 2016, the Medicare mandatory bundled payment program, called the Comprehensive Care for Joint Replacement (CJR) model, holds hospitals accountable for spending and quality of care for traditional Medicare joint-replacement patients during care episodes that span from the index hospitalization to 90 days post-discharge. We assessed the extent to which the CJR model was associated with outcomes for patients enrolled in commercial insurance and Medicare Advantage plans.

METHODS

With use of Health Care Cost Institute claims data from 2012 through 2017, we assessed the association of the CJR model with total expenditures, discharges to institutional post-acute care, and readmissions among commercial insurance and Medicare Advantage joint-replacement patients. The exposure variable was the implementation of the CJR model in 67 randomly selected metropolitan statistical areas compared with 103 similar areas without CJR implementation. We utilized difference-in-differences models to estimate the spillover effects of the CJR model by comparing outcomes between these areas before and after CJR implementation.

RESULTS

The study included 174,893 joint-replacement episodes of care in commercial insurance enrollees and 202,070 episodes in Medicare Advantage enrollees. Among both commercial insurance and Medicare Advantage enrollees, CJR implementation was associated with no meaningful changes in total episode expenditures, discharges to institutional post-acute care, or readmissions.

CONCLUSIONS

We found no evidence for spillover effects of the CJR model on commercial insurance and Medicare Advantage patients, suggesting that alternative payment models targeting traditional Medicare patients may have limited effects on the cost and quality of care for patients outside of the traditional Medicare system.

Measuring resource use in Medicare Advantage using Encounter data

OBJECTIVE

To check the completeness of Medicare Advantage (MA) Encounter data and to illustrate a process to measure resource use among MA enrollees using Encounter data.

DATA SOURCES

2015 Preliminary MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and 2013 Traditional Medicare (TM) claims data.

STUDY DESIGN

Secondary data analysis.

DATA COLLECTION/EXTRACTION METHODS

We calculated the percentage of each contract's total hospitalizations in Encounter data after identifying total inpatient stays from Encounter and MedPAR data. We constructed each contract's ambulatory visits and emergency department (ED) visits per 1000 enrollees using Encounter data and compared those visit counts with the counts from HEDIS. We defined high data completeness as having less than 10% missing hospital stays and less than ±10% difference in ambulatory and ED visits between Encounter and HEDIS data. We used TM payments as standardized prices of services to examine resource use among MA enrollees with cancer in the contracts with high data completeness.

PRINCIPAL FINDINGS

We identified 83 of 380 MA contracts with high data completeness. Total resource use per enrollee with cancer in the 83 contracts was $14,715 in 2015. Service-specific resource use was $5342 for inpatient care, $5932 for professional services and $3441 for outpatient facility services. These represent what an MA enrollee with cancer would have cost on average if MA plans paid providers at TM payment rates, holding the observed utilization constant.

CONCLUSIONS

Checking the completeness of Encounter data is an important step to ensure the validity of research on MA resource use. Using Encounter data to measure MA resource use is feasible. It can compensate for the lack of payment information in Encounter data. It will be important to identify and refine ways to best use Encounter data to learn about care provision to MA enrollees.

Beyond Causality: Additional Benefits of Randomized Controlled Trials for Improving Health Care Delivery

Policy Points Policymakers at federal and state agencies, health systems, payers, and providers need rigorous evidence for strategies to improve health care delivery and population health. This is all the more urgent now, during the COVID-19 pandemic and its aftermath, especially among low-income communities and communities of color. Randomized controlled trials (RCTs) are known for their ability to produce credible causal impact estimates, which is why they are used to evaluate the safety and efficacy of drugs and, increasingly, to evaluate health care delivery and policy. But RCTs provide other benefits, allowing policymakers and researchers to: 1) design studies to answer the question they want to answer, 2) test theory and mechanisms to help enrich understanding beyond the results of a single study, 3) examine potentially subtle, indirect effects of a program or policy, and 4) collaborate closely to generate policy-relevant findings. Illustrating each of these points with examples of recent RCTs in health care, we demonstrate how policymakers can utilize RCTs to solve pressing challenges.

Comparing Receipt of Prescribed Post-acute Home Health Care Between Medicare Advantage and Traditional Medicare Beneficiaries: an Observational Study

BACKGROUND

Medicare Advantage (MA) covers more than 1/3rd of all Medicare beneficiaries. MA plans are required to provide the same benefits as Traditional Medicare (TM), but can impose utilization management tools to control costs.

OBJECTIVE

To assess differences between TM and MA enrollees in the probability of receiving prescribed post-acute home health (HH) care and to describe MA plan characteristics associated with HH receipt.

DESIGN

Retrospective cross-sectional analysis of claims data, HH patient assessment data, and MA plan data from 2011 to 2017.

PARTICIPANTS

Medicare beneficiaries aged 66 and older with an incident hospitalization for joint replacement, pneumonia, chronic obstructive pulmonary disease, stroke, urinary tract infection, septicemia, acute renal failure, or congestive heart failure.

MAIN MEASURES

Receipt of prescribed HH as indicated by a HH discharge code and corresponding HH patient assessment within 14 days of hospital discharge.

KEY RESULTS

There were 2,723,245 beneficiaries prescribed HH at discharge (68% TM, 32% MA). About 75% of TM enrollees and 62% of MA enrollees received prescribed post-acute HH. In adjusted analyses, MA enrollees had an -11.7 percentage point (pp) (95% confidence interval (CI): -16.8, -6.5) lower probability of receiving HH compared with TM enrollees. In adjusted analyses, HMO enrollees in plans with cost sharing (- 8.4 pp; 95% CI: - 14.3, - 2.5), referrals (- 3.7 pp; 95% CI: - 6.1, - 1.2), and pre-authorization (- 5.1 pp; 95% CI: - 8.3, - 2.0) were less likely to receive prescribed HH. In adjusted analyses, PPO enrollees in plans with cost sharing were -7.0 pp (95% CI: - 12.7, - 1.4) less likely to receive HH, but there was no difference for those with referrals (1.1 pp; 95% CI, - 1.5, 3.7) or pre-authorization (1.6 pp; 95% CI: - 0.6, - 3.9).

CONCLUSIONS

Among Medicare beneficiaries, MA enrollees were less likely to receive prescribed post-acute HH compared with TM. As enrollment in MA continues to grow, it is important to examine how differences in utilization relate to outcomes.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients

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.

Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform

Changes in the way health insurers pay healthcare providers may not only directly affect the insurer's patients but may also affect patients covered by other insurers. We provide evidence of such spillovers in the context of a nationwide Medicare bundled payment reform that was implemented in some areas of the country but not in others, via random assignment. We estimate that the payment reform-which targeted traditional Medicare patients-had effects of similar magnitude on the healthcare experience of nontargeted, privately insured Medicare Advantage patients. We discuss the implications of these findings for estimates of the impact of healthcare payment reforms and more generally for the design of healthcare policy.