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Zhang X, Tang S, Wang R, Qian M, Ying X, Maciejewski ML. Hospital response to a new case-based payment system in China: the patient selection effect. Health Policy Plan 2024; 39:519-527. [PMID: 38581671 PMCID: PMC11095269 DOI: 10.1093/heapol/czae022] [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] [Received: 09/14/2023] [Revised: 03/06/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024] Open
Abstract
Providers have intended and unintended responses to payment reforms, such as China's new case-based payment system, i.e. Diagnosis-Intervention Packet (DIP) under global budget, that classified patients based on the combination of principal diagnosis and procedures. Our study explores the impact of DIP payment reform on hospital selection of patients undergoing total hip/knee arthroplasty (THA/TKA) or with arteriosclerotic heart disease (AHD) from July 2017 to June 2021 in a large city. We used a difference-in-differences approach to compare the changes in patient age, severity reflected by the Charlson Comorbidity Index (CCI), and a measure of treatment intensity [relative weight (RW)] in hospitals that were and were not subject to DIP incentives before and after the DIP payment reform in July 2019. Compared with non-DIP pilot hospitals, trends in patient age after the DIP reform were similar for DIP and non-DIP hospitals for both conditions, while differences in patient severity grew because severity in DIP hospitals increased more for THA/TKA (P = 0.036) or dropped in non-DIP hospitals for AHD (P = 0.011) following DIP reform. Treatment intensity (measured via RWs) for AHD patients in DIP hospitals increased 5.5% (P = 0.015) more than in non-DIP hospitals after payment reform, but treatment intensity trends were similar for THA/TKA patients in DIP and non-DIP hospitals. When the DIP payment reform in China was introduced just prior to the pandemic, hospitals subject to this reform responded by admitting sicker patients and providing more treatment intensity to their AHD patients. Policymakers need to balance between cost containment and the unintended consequences of prospective payment systems, and the DIP payment could also be a new alternative payment system for other countries.
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Affiliation(s)
- Xinyu Zhang
- School of Public Health, Fudan University, 130 Dong’an Road, Shanghai 200030, China
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27710, United States
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27710, United States
- Global Health Research Center, Duke Kunshan University, No. 8 Duke Avenue, Kunshan, Jiangsu 215316, China
- SingHealth Duke-NUS Global Health Institute, Duke-NUS, 8 College Road, Singapore 169857, Singapore
| | - Ruixin Wang
- School of Public Health, Fudan University, 130 Dong’an Road, Shanghai 200030, China
| | - Mengcen Qian
- School of Public Health, Fudan University, 130 Dong’an Road, Shanghai 200030, China
- Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), 130 Dong’an Road, Shanghai 200030, China
| | - Xiaohua Ying
- School of Public Health, Fudan University, 130 Dong’an Road, Shanghai 200030, China
- Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), 130 Dong’an Road, Shanghai 200030, China
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705, United States
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC 27701, United States
- Division of General Internal Medicine, Department of Medicine, Duke University, 40 Duke Medicine Circle, Durham, NC 27710, United States
- Duke-Margolis Health Policy Center, Duke University, 230 Science Drive, Durham, NC 27708, United States
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Hider AM, Gomez-Rexrode AE, Agius J, MacEachern MP, Ibrahim AM, Regenbogen SE, Berlin NL. Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review. Am J Surg 2024; 229:83-91. [PMID: 38148257 DOI: 10.1016/j.amjsurg.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/17/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023]
Abstract
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.
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Affiliation(s)
- Ahmad M Hider
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Josh Agius
- University of Michigan, Ann Arbor, MI, USA
| | - Mark P MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ibrahim
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
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Sylvester CB, Ryan CT, Frankel WC, Asokan S, Zea-Vera R, Zhang Q, Wall MJ, Coselli JS, Rosengart TK, Chatterjee S, Ghanta RK. Readmission After Bioprosthetic vs Mechanical Mitral Valve Replacement in the United States. Ann Thorac Surg 2024; 117:113-118. [PMID: 35803331 DOI: 10.1016/j.athoracsur.2022.05.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/17/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Choosing between a bioprosthetic and a mechanical mitral valve is an important decision for both patients and surgeons. We compared patient outcomes and readmission rates after bioprosthetic mitral valve replacement (Bio-MVR) vs mechanical mitral valve replacement (Mech-MVR). METHODS The Nationwide Readmissions Database was queried to identify 31 474 patients who underwent isolated MVR (22 998 Bio-MVR, 8476 Mech-MVR) between January 1, 2016, and December 31, 2018. Propensity score matching by age, sex, elective status, and comorbidities was used to compare outcomes between matched cohorts by prosthesis type. Freedom from readmission within the first calendar year was estimated by Kaplan-Meier analysis and compared between matched cohorts. RESULTS Bio-MVR patients were older (median age, 69 vs 57 years; P < .001) and had more comorbidities (median Elixhauser score, 14 vs 11; P < .001) compared with Mech-MVR patients. After propensity score matching (n = 15 549), Bio-MVR patients had similar operative mortality (3.5% vs 3.4%; P = .97) and costs ($50 958 vs $49 782; P = .16) but shorter lengths of stay (8 vs 9 days; P < .001) and fewer 30-day (16.0% vs 18.1%; P = .04) and 90-day (23.8% vs 26.8%; P = .01) readmissions compared with Mech-MVR patients. The difference in readmissions persisted at 1 year (P = .045). Readmission for bleeding or coagulopathy complications was less common with Bio-MVR (5.7% vs 10.1%; P < .001). CONCLUSIONS Readmission was more common after Mech-MVR than after Bio-MVR. Identifying and closely observing patients at high risk for bleeding complications may bridge the readmissions gap between Bio-MVR and Mech-MVR.
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Affiliation(s)
- Christopher B Sylvester
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas; Department of Bioengineering, Rice University, Houston, Texas
| | - Christopher T Ryan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sainath Asokan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Qianzi Zhang
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Wall
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Todd K Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ravi K Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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Shashikumar SA, Zheng J, Orav EJ, Epstein AM, Joynt Maddox KE. Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement - Advanced. Circulation 2023; 148:1074-1083. [PMID: 37681315 PMCID: PMC10540757 DOI: 10.1161/circulationaha.123.065109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model. METHODS In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for cardiac medical and procedural conditions at BPCI-A hospitals compared with controls. Secondary outcomes included changes in patient complexity, care utilization, healthy days at home, readmissions, and mortality. RESULTS Baseline spending for cardiac medical episodes at BPCI-A hospitals was $25 606. The differential change in spending for cardiac medical episodes at BPCI-A versus control hospitals was $16 (95% CI, -$228 to $261; P=0.90). Baseline spending for cardiac procedural episodes at BPCI-A hospitals was $37 961. The differential change in spending for cardiac procedural episodes was $171 (95% CI, -$429 to $772; P=0.58). There were minimal differential changes in physicians' care patterns such as the complexity of treated patients or in their care utilization. At BPCI-A versus control hospitals, there were no significant differential changes in rates of 90-day readmissions (differential change, 0.27% [95% CI, -0.25% to 0.80%] for medical episodes; differential change, 0.31% [95% CI, -0.98% to 1.60%] for procedural episodes) or mortality (differential change, -0.14% [95% CI, -0.50% to 0.23%] for medical episodes; differential change, -0.36% [95% CI, -1.25% to 0.54%] for procedural episodes). CONCLUSIONS Participation in BPCI-A was not associated with spending reductions, changes in care utilization, or quality improvements for the cardiovascular medical events or procedures offered in the model.
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Affiliation(s)
- Sukruth A. Shashikumar
- Department of Medicine (S.A.S.), Brigham and Women’s Hospital, Boston, MA
- Center for Advancing Health Services, Policy & Economics Research, Washington University, St. Louis, MO (S.A.S., K.E.J.M.)
| | - Jie Zheng
- Department of Health Policy and Management (J.Z., A.M.E.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine (E.J.O., A.M.E.), Brigham and Women’s Hospital, Boston, MA
- Department of Biostatistics (E.J.O.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Arnold M. Epstein
- Division of General Internal Medicine and Primary Care, Department of Medicine (E.J.O., A.M.E.), Brigham and Women’s Hospital, Boston, MA
- Department of Health Policy and Management (J.Z., A.M.E.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Karen E. Joynt Maddox
- Center for Advancing Health Services, Policy & Economics Research, Washington University, St. Louis, MO (S.A.S., K.E.J.M.)
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (K.E.J.M.)
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Treffalls JA, Shah AM, Worrell CM, Treffalls RN, Das NA, Hui DS, Calhoon JH. Two Decades of Declining Medicare Reimbursement in Cardiac Surgery. Ann Thorac Surg 2023; 116:845-852. [PMID: 37423345 DOI: 10.1016/j.athoracsur.2023.06.023] [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] [Received: 01/18/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Given the uncertainty of US health care finances, an understanding of reimbursement trends has become increasingly important in the field of cardiac surgery. We aimed to assess Medicare reimbursement trends for common cardiac surgical procedures from 2000 to 2022. METHODS Reimbursement data were extracted from the Centers for Medicare and Medicaid Services Physician Fee Schedule Look-Up Tool during the study period for 6 common cardiac operations: aortic valve replacement, mitral valve repair and replacement, tricuspid valve replacement, Bentall procedure, and coronary artery bypass grafting. Reimbursement rates were adjusted for inflation to 2022 US dollars using the Consumer Price Index. Total percentage change and compound annual growth rate were calculated. A split-time analysis was performed to assess trends before and after 2015. Least squares and linear regressions were performed. The R2 value was calculated for each procedure, and slope was used to determine change in reimbursements over time. RESULTS Inflation-adjusted reimbursement decreased by 34.1% during the study period. The overall compound annual growth rate was -1.8%. Reimbursement trends differed by procedure (P < .001), with all reimbursements trending down (R2 > 0.62), except for mitral valve replacement (P = .21) and tricuspid valve replacement (P = .43). Coronary artery bypass grafting decreased the most (-44.4%), followed by aortic valve replacement (-40.1%), mitral valve repair (-38.5%), mitral valve replacement (-29.8%), Bentall procedure (-28.5%), and tricuspid valve replacement (-25.3%). In split-time analysis, reimbursement rates did not significantly change from 2000 to 2015 (P = .24) but decreased significantly from 2016 to 2022 (P = .001). CONCLUSIONS Medicare reimbursement significantly decreased for most cardiac surgical procedures. These trends justify further advocacy by The Society of Thoracic Surgeons to maintain access to quality cardiac surgical care.
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Affiliation(s)
- John A Treffalls
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Aakash M Shah
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Christopher M Worrell
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Rebecca N Treffalls
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas.
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, San Antonio, Texas
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Fliegner M, Yaser JM, Stewart J, Nathan H, Likosky DS, Theurer PF, Clark MJ, Prager RL, Thompson MP. Area Deprivation and Medicare Spending for Coronary Artery Bypass Grafting: Insights from Michigan. Ann Thorac Surg 2022; 114:1291-1297. [PMID: 35300953 DOI: 10.1016/j.athoracsur.2022.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prior work has established that high socioeconomic deprivation is associated with worse short- and long-term outcomes for coronary artery bypass graft (CABG) patients. The relationship between socioeconomic status and 90-day episode spending is poorly understood. In this observational cohort analysis, we evaluated whether socioeconomically disadvantaged patients were associated with higher expenditures during 90-day episodes of care following isolated CABG. METHODS We linked clinical registry data from 8,728 isolated CABG procedures from January 1st, 2012 to December 31st, 2018 to Medicare fee-for-service claims data. Our primary exposure variable was patients in the top decile of the Area Deprivation Index. Linear regression was used to compare risk-adjusted, price-standardized 90-day episode spending for deprived against non-deprived patients, as well as component spending categories: index hospitalization, professional services, post-acute care, and readmissions. RESULTS A total of 872 patients were categorized as being in the top decile. Mean 90-day episode spending for the 8,728 patients in the sample was $55,258 (standard deviation = $26,252). Socioeconomically deprived patients had higher overall 90-day spending compared to non-deprived patients ($61,579 vs. $54,557, difference = $3,003, p = 0.001). Spending was higher in socioeconomically deprived patients for index hospitalizations (difference = $1,284, p = 0.005), professional services (difference = $379, p = 0.002) and readmissions (difference = $1,188, p = 0.008). Inpatient rehabilitation was the only significant difference in post-acute care spending (difference = $469, p = 0.011). CONCLUSIONS Medicare spending was higher for socioeconomically deprived CABG in Michigan, indicating systemic disparities over and above patient demographic factors.
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Affiliation(s)
- Maximilian Fliegner
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan; Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | | | - James Stewart
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Hari Nathan
- Michigan Value Collaborative, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; Michigan Value Collaborative, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Patricia F Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Richard L Prager
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Michael P Thompson
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Value Collaborative, Ann Arbor, Michigan.
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