The Affordable Care Act at 10 Years - Payment and Delivery System Reforms

Impact of Ethno-racial Factors on Clinical Outcomes and Health Care Utilization in Chronic Pancreatitis

BACKGROUND

Healthcare disparities adversely affect clinical outcomes in racial and ethnic minorities. Chronic pancreatitis (CP) is a complex disorder, and pressures for time and cost-containment may amplify the disparity for minorities in this condition. This study aimed to assess ethno-racial differences in the clinical outcomes of CP patients cared for at our institution.

METHODS

This is a study of CP patients with available ethno-racial information followed at our pancreas center. We reviewed their demographics, comorbidities, clinical outcomes, and resource utilization: pain, frequent flares (≥ 2/year), local complications, psychosocial variables, exocrine, and endocrine insufficiency, imaging, endoscopic procedures, and surgeries. The outcomes underwent logistic regression to ascertain association(s) with covariates and were expressed as odds ratio (95% confidence intervals).

RESULTS

Of the 445 CP patients, there were 23 Hispanics, 330 Non-Hispanic Whites, 47 Non-Hispanic Blacks, 16 Asian Americans, and 29 patients from Other/mixed races. Over a median follow-up of 7 years, no significant differences in the pain profile (p = 0.36), neuromodulator use (p = 0.94), and opioid use for intermittent (p = 0.34) and daily pain (p = 0.80) were observed. Frequent flares were associated with Hispanic ethnicity [2.98(1.20-7.36); p = 0.02], despite adjustment for smoking [2.21(1.11-4.41); p = 0.02)] and alcohol [1.88(1.06-3.35); p = 0.03]. Local complications (pseudocysts, mesenteric thrombosis, and biliary obstruction), exocrine and endocrine dysfunction, and healthcare resource utilization (cross-sectional imaging, endoscopic procedures, celiac blocks, or surgeries) were comparable across all ethno-racial groups.

CONCLUSIONS

Although no significant differences in clinical outcomes, and health resource utilization were noted across ethno-racial groups, Hispanic ethnicity had significant association with CP flares. This study calls for further investigation of an understudied minority population with CP.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Performance measurement part I: Foundational knowledge for measure development

As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.

Value-Based Health Care in Perioperative Medicine: Process Maps and Costing to Determine Best Practices

Perioperative care in the United States is largely based on current fee-for-service models. Fee-for-service models are not based on the true cost of services provided, charges do not equal costs, and reimbursement varies based on insurer. Value-based health care is defined as patient-centered outcomes over cost of providing these services. Process mapping and time-driven activity-based costing can be used to define actual cost of services provided. Outcomes after discharge can be measured, so that the overall value of care provided can be assessed and improved based on the outcomes and costs identified.

Patients Hospitalized for Complications of Cirrhosis may Have Benefited From Medicaid Expansion Under the Affordable Care Act

Objective

The benefit of the Affordable Care Act (ACA) for patients with cirrhosis is unclear. We determined the impact of ACA expansion on outcomes in patients hospitalized for complications of cirrhosis.

Patients and Methods

We compared hospitalizations; in-hospital outcomes; and readmissions among patients with cirrhosis identified using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, 10th Revision, codes in states that expanded Medicaid under ACA (expanded [E] states) and those that did not (nonexpanded [NE] states). Data from the State Inpatient Databases were obtained for 3 pairs of contiguous E and NE states with both pre-ACA expansion and post-ACA expansion data. The difference-in-difference analysis was performed to compare the pre- and post-ACA data between the E and NE states. The outcomes were admission rates, hospital complications, resource utilization, length of stay, in-hospital mortality, discharge destination, cost of initial hospitalization, and readmission characteristics.

Results

There were 228,349 admissions (E states, 149,705; NE states, 78,644). After ACA implementation, the E states had lower rates of admission increase per 100,000 population (22.9 in E states vs 25.5 in NE states, P=.005), sepsis (relative risk, 0.884; P=.0084), and hepatic coma (relative risk, 0.763; P<.001) than the NE states. The length of stay was lower by 0.21 days (P=.00028), with a $587.40 lower cost per hospitalization (P=.00091), in the E states than in the NE states. The readmission rates within 30, 60, and 90 days decreased in the E states after ACA implementation but increased in the NE states after ACA implementation.

Conclusion

Among patients hospitalized for cirrhosis, quality indicators, such as the rate of admission increase, complications, costs, and readmissions, were more favorable in the states that expanded Medicaid. Medicaid expansion under ACA may have benefited patients with cirrhosis.

Catastrophic Health Expenditures With Pregnancy and Delivery in the United States

OBJECTIVE

To describe prevalence, trends, and risk factors for catastrophic health expenditures in the year of delivery among birth parents (delivering people).

METHODS

We conducted a retrospective, cross-sectional study of the Medical Expenditure Panel Survey from 2008-2016. We identified newborn birth parents and a 2:1 nearest-neighbor propensity-matched control cohort of nonpregnant reproductive-aged individuals, then assessed for catastrophic health expenditures (spending greater than 10% of family income) in the delivery year. We applied survey weights to extrapolate to the noninstitutionalized U.S. population and used the adjusted Wald test for significance testing. We compared risk of catastrophic health expenditures between birth parents and the control cohort and described time trends and risk factors for catastrophic spending with subgroup comparisons.

RESULTS

We analyzed 4,056 birth parents and 7,996 reproductive-aged females without pregnancy in a given year. Birth parents reported higher rates of unemployment (52.6% vs 46.6%, P<.001), and high rates of gaining (22.4%) and losing (25.6%) Medicaid in the delivery year. Birth parents were at higher risk of catastrophic health expenditures (excluding premiums: 9.2% vs 6.8%, odds ratio [OR] 1.95, 95% CI 1.61-2.34; including premiums: 21.3% vs 18.4%, OR 1.53, 95% CI 1.32-1.82). Birth parents living on low incomes had the highest risk of catastrophic health expenditures (18.8% vs 0.7% excluding premiums for 138% or less vs greater than 400% of the federal poverty level, relative risk [RR] 26.9; 29.8% vs 5.9% including premiums, RR 5.1). For birth parents living at low incomes, public insurance was associated with lower risks of catastrophic health expenditures than private insurance, particularly when including premium spending (incomes 138% of the federal poverty level or lower: 18.8% public vs 67.9% private, RR 0.28; incomes 139-250% of the federal poverty level: 6.5% public vs 41.1% private, RR 0.16). The risk of catastrophic spending for birth parents did not change significantly over time from before to after Affordable Care Act implementation.

CONCLUSION

Pregnancy and delivery are associated with increased risk of catastrophic health expenditures in the delivery year. Medicaid and public coverage were more protective from high out-of-pocket costs than private insurance, particularly among low-income families.

Trends in Orthopedic Surgeon Practice Consolidation From 2008 to 2019

BACKGROUND

In the past decade, physician practices have merged into larger group practices (ie, horizontal consolidation) and have been acquired by hospitals and health systems (ie, vertical consolidation), leaving fewer practices independent. The implications of these changes can be profound, affecting the prices for and spending on physician services, access to care, patients' choice of providers, and quality of care.

METHODS

We used IQVIA data on orthopedic surgeon practice sites that included information on health system or hospital ownership, group medical practice participation, and average patient volume. We calculated the number and size of group medical practices as measures of horizontal consolidation and the percentage of practice sites owned by a health system or hospital as a measure of vertical consolidation. We also calculated the Herfindahl-Hirschman Index to measure market concentration.

RESULTS

We found significant horizontal and vertical consolidation nationally and across all regions of the United States. This consolidation has led to much more concentrated markets, as measured by Herfindahl-Hirschman Index, for orthopedic surgeon services. These trends are consistent with studies looking at consolidation of other types of providers.

CONCLUSION

Orthopedic surgeon practices, like other provider types, have consolidated at a rapid rate over the past decade. A variety of factors may have contributed, including the move away from fee-for-service to alternative payment arrangements, changes in Medicare payment policies, private equity activity, and evolving physician preferences. Due to the potential impacts of this consolidation, more research is needed to examine some of these contributing factors.

[10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?]

GOAL OF THE STUDY

An intent of the Patient Protection and Affordable Care Acts (ACA), also know as Obama Care, was to slow the expenditure growth in the public Medicare-System by shifting the accountability for health care outcomes and costs to the provider. For this purpose, provider were allowed to form networks, which would then take accountability for a defined population - Accountable Care Organizations (ACOs). Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany.

METHODS

In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed. This was supported with further papers identified using the snowballing-technique. After screening the abstracts, we included articles containing information on cost- and/or quality impact of US-Medicare-ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA.

RESULTS

In total, we included 60 publications which incorporated 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved.

CONCLUSION

ACOs contributed to slowing the cost growth in US Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between US Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken.

Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems

Question

Do health system physician compensation arrangements primarily incentivize volume or value?

Findings

This cross-sectional mixed-methods study of 31 physician organizations affiliated with 22 US health systems found that volume was a component of primary care and specialist compensation for most POs (83.9% and 93.3%, respectively), representing a substantial portion of compensation when included (mean, 68.2% and 73.7%, respectively). While most primary care and specialist compensation arrangements included performance-based incentives, they averaged less than 10% of compensation.

Meaning

The study results suggest that despite growth in value-based payment arrangements from payers, health systems currently incentivize physicians to maximize volume, thereby maximizing health system revenues.

Importance

Public and private payers continue to expand use of alternative payment models, aiming to use value-based payment to affect the care delivery of their contracted health system partners. In parallel, health systems and their employment of physicians continue to grow. However, the degree to which health system physician compensation reflects an orientation toward value, rather than volume, is unknown.

Objective

To characterize primary care physician (PCP) and specialist compensation arrangements among US health system–affiliated physician organizations (POs) and measure the portion of total physician compensation based on quality and cost performance.

Design, Setting, and Participants

This study was a cross-sectional mixed-methods analysis of in-depth multimodal data (compensation document review, interviews with 40 PO leaders, and surveys conducted between November 2017 and July 2019) from 31 POs affiliated with 22 purposefully selected health systems in 4 states. Data were analyzed from June 2019 to September 2020.

Main Outcomes and Measures

The frequency of PCP and specialist compensation types and the percentage of compensation when included, including base compensation incentives, quality and cost performance incentives, and other financial incentives. The top 3 actions physicians could take to increase their compensation. The association between POs’ percentage of revenue from fee-for-service and their physicians’ volume-based compensation percentage.

Results

Volume-based compensation was the most common base compensation incentive component for PCPs (26 POs [83.9%]; mean, 68.2% of compensation; median, 81.4%; range, 5.0%-100.0% when included) and specialists (29 POs [93.3%]; mean, 73.7% of compensation; median, 90.5%; range, 2.5%-100.0% when included). While quality and cost performance incentives were common (included by 83.9%-56.7% of POs for PCPs and specialists, respectively), the percentage of compensation based on quality and cost performance was modest (mean, 9.0% [median, 8.3%; range, 1.0%-25.0%] for PCPs and 5.3% [median, 4.5%; range, 0.5%-16.0%] for specialists when included). Increasing the volume of services was the most commonly cited action for physicians to increase compensation, reported as the top action by 22 POs (70.0%) for PCPs and specialists. We observed a very weak, nonsignificant association between the percentage of revenue of POs from fee for service and the PCP and specialist volume-based compensation percentage (r = 0.08; P = .78 and r = −0.04; P = .89, respectively).

Conclusions and Relevance

The results of this cross-sectional study suggest that PCPs and specialists despite receiving value-based reimbursement incentives from payers, the compensation of health system PCPs and specialists was dominated by volume-based incentives designed to maximize health systems revenue.

Innovation, value and reimbursement in radiation and complex surgical oncology: Time to rethink

BACKGROUND AND PURPOSE

Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews.

MATERIAL AND METHODS

A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models.

RESULTS

Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy.

CONCLUSION

A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.

Innovation, value and reimbursement in radiation and complex surgical oncology: time to rethink

BACKGROUND AND PURPOSE

Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews.

MATERIAL AND METHODS

A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models.

RESULTS

Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy.

CONCLUSION

A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.

US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019

BACKGROUND

Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized.

OBJECTIVE

We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care.

METHODS

Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system.

RESULTS

Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22).

CONCLUSIONS

We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.

Minimally important difference in cost savings: Is it possible to identify an MID for cost savings?

As healthcare costs continue to increase, studies assessing costs are becoming increasingly common, but researchers planning for studies that measure costs differences (savings) encounter a lack of literature or consensus among researchers on what constitutes "small" or "large" cost savings for common measures of resource use.  Other fields of research have developed approaches to solve this type of problem. Researchers measuring improvement in quality of life or clinical assessments have defined minimally important differences (MID) which are then used to define magnitudes when planning studies. Also, studies that measure cost effectiveness use benchmarks, such as cost/QALY, but do not provide benchmarks for cost differences. In a review of the literature, we found no publications identifying indicators of magnitude for costs. However, the literature describes three approaches used to identify minimally important outcome differences: (1) anchor-based, (2) distribution-based, and (3) a consensus-based Delphi methods. In this exploratory study, we used these three approaches to derive MID for two types of resource measures common in costing studies for: (1) hospital admissions (high cost); and (2) clinic visits (low cost). We used data from two (unpublished) studies to implement the MID estimation. Because the distributional characteristics of cost measures may require substantial samples, we performed power analyses on all our estimates to illustrate the effect that the definitions of "small" and "large" costs may be expected to have on power and sample size requirements for studies. The anchor-based method, while logical and simple to implement, may be of limited value in cases where it is difficult to identify appropriate anchors. We observed some commonalities and differences for the distribution and consensus-based approaches, which require further examination. We recommend that in cases where acceptable anchors are not available, both the Delphi and the distribution-method of MID for costs be explored for convergence.