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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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Zhang Y, Leifheit KM, Lee KT, Thorpe RJ, Gaskin DJ, Dean LT. The Association of Oncology Provider Density With Black-White Disparities in Cancer Mortality in US Counties. Cancer Control 2024; 31:10732748241244929. [PMID: 38607968 PMCID: PMC11015762 DOI: 10.1177/10732748241244929] [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: 02/29/2024] [Accepted: 02/08/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Black-White racial disparities in cancer mortality are well-documented in the US. Given the estimated shortage of oncologists over the next decade, understanding how access to oncology care might influence cancer disparities is of considerable importance. We aim to examine the association between oncology provider density in a county and Black-White cancer mortality disparities. METHODS An ecological study of 1048 US counties was performed. Oncology provider density was estimated using the 2013 National Plan and Provider Enumeration System data. Black:White cancer mortality ratio was calculated using 2014-2018 age-standardized cancer mortality rates from State Cancer Profiles. Linear regression with covariate adjustment was constructed to assess the association of provider density with (1) Black:White cancer mortality ratio, and (2) cancer mortality rates overall, and separately among Black and White persons. RESULTS The mean Black:White cancer mortality ratio was 1.12, indicating that cancer mortality rate among Black persons was on average 12% higher than that among White persons. Oncology provider density was significantly associated with greater cancer mortality disparities: every 5 additional oncology providers per 100 000 in a county was associated with a .02 increase in the Black:White cancer mortality ratio (95% CI: .007 to .03); however, the unexpected finding may be explained by further analysis showing that the relationship between oncology provider density and cancer mortality was different by race group. Every 5 additional oncologists per 100 000 was associated with a 1.6 decrease per 100 000 in cancer mortality rates among White persons (95% CI: -3.0 to -.2), whereas oncology provider density was not associated with cancer mortality among Black persons. CONCLUSION Greater oncology provider density was associated with significantly lower cancer mortality among White persons, but not among Black persons. Higher oncology provider density alone may not resolve cancer mortality disparities, thus attention to ensuring equitable care is critical.
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Affiliation(s)
- Yuehan Zhang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn M. Leifheit
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Kimberley T. Lee
- Departments of Breast Oncology and Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Roland J. Thorpe
- Hopkins Center for Health Disparities Solutions, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Darrell J. Gaskin
- Hopkins Center for Health Disparities Solutions, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Carey K, Lin M. Safety-net hospital performance under Comprehensive Care for Joint Replacement. Health Serv Res 2023; 58:101-106. [PMID: 35904218 PMCID: PMC9836942 DOI: 10.1111/1475-6773.14042] [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: 02/03/2023] Open
Abstract
OBJECTIVE To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016-2020 and to identify the contributors to SNHs' realization of success under the program. DATA SOURCES/STUDY SETTING Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association. STUDY DESIGN We addressed whether SNHs can achieve progress in financial performance under CJR by focusing on the relative change in reconciliation payments or the difference between episode spending and target prices. We applied the method of dominance analysis to ordinary least squares regression to determine the relative importance of predictors of change in reconciliation payments over time. PRINCIPAL FINDINGS Compared to CJR hospitals overall, SNHs were less successful in meeting episode spending targets. Hospital factors dominated socioeconomic factors in explaining progress among SNHs, but not among non-SNHs. The contribution of nurse staffing was negligible across all CJR hospitals. CONCLUSIONS The formula used by CMS to determine spending targets may not be sufficient to address disparities in SNH financial performance under mandatory bundled payment.
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Affiliation(s)
- Kathleen Carey
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
| | - Meng‐Yun Lin
- Department of Social Sciences and Health Policy, Medical Center BoulevardWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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Ying M, Thirukumaran CP, Temkin-Greener H, Joynt Maddox KE, Holloway RG, Li Y. Association of Skilled Nursing Facility Participation in Voluntary Bundled Payments With Postacute Care Outcomes for Joint Replacement. Med Care 2023; 61:109-116. [PMID: 36630561 DOI: 10.1097/mlr.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. OBJECTIVE To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). DESIGN, SETTING, AND PARTICIPANTS Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. RESULTS Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. CONCLUSIONS Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.
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Affiliation(s)
- Meiling Ying
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Caroline P Thirukumaran
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Helena Temkin-Greener
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Manner PA. Editor's Spotlight/Take 5: Does Hypothetical Centralization of Revision THA and TKA Exacerbate Existing Geographic or Demographic Disparities in Access to Care by Increased Patient Travel Distances or Times? A Large-database Study. Clin Orthop Relat Res 2022; 480:1028-1032. [PMID: 35512061 PMCID: PMC9263470 DOI: 10.1097/corr.0000000000002232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Paul A Manner
- Senior Editor, Clinical Orthopaedics and Related Research ®, Philadelphia, PA, USA
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Ying M, Temkin-Greener H, Thirukumaran CP, Maddox KEJ, Holloway RG, Li Y. Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance. Med Care 2022; 60:83-92. [PMID: 34812788 PMCID: PMC8665005 DOI: 10.1097/mlr.0000000000001659] [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] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.
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Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY
| | - Karen E. Joynt Maddox
- Cardiovascular Division, School of Medicine, Washington University in St. Louis, St. Louis, MO
- Center for Health Economics and Policy, Washington University Institute for Public Health, St. Louis, MO
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
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7
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Habchi KM, Weinberg RY, White RS. How the use of standardized protocols may paradoxically worsen disparities for safety-net hospitals. J Comp Eff Res 2021; 11:65-66. [PMID: 34879744 DOI: 10.2217/cer-2021-0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Karam M Habchi
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, NY 10065, USA
| | - Roniel Y Weinberg
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, NY 10065, USA
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8
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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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Nerenz DR, Austin JM, Deutscher D, Maddox KEJ, Nuccio EJ, Teigland C, Weinhandl E, Glance LG. Adjusting Quality Measures For Social Risk Factors Can Promote Equity In Health Care. Health Aff (Millwood) 2021; 40:637-644. [PMID: 33819097 DOI: 10.1377/hlthaff.2020.01764] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Risk adjustment of quality measures using clinical risk factors is widely accepted; risk adjustment using social risk factors remains controversial. We argue here that social risk adjustment is appropriate and necessary in defined circumstances and that social risk adjustment should be the default option when there are valid empirical arguments for and against adjustment for a given measure. Social risk adjustment is an important way to avoid exacerbating inequity in the health care system.
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Affiliation(s)
- David R Nerenz
- David R. Nerenz is the director emeritus of the Center for Health Policy and Health Services Research, Henry Ford Health System, in Detroit, Michigan
| | - J Matthew Austin
- J. Matthew Austin is an assistant professor at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Daniel Deutscher
- Daniel Deutscher is a senior research scientist at Net Health Systems, Inc., in Pittsburgh, Pennsylvania, and the director of patient reported outcome measures at the MaccabiTech Institute for Research and Innovation, Maccabi Healthcare Services, in Tel Aviv, Israel
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine in the Department of Internal Medicine, Washington University School of Medicine, in St. Louis, Missouri
| | - Eugene J Nuccio
- Eugene J. Nuccio is an assistant professor of medicine at the University of Colorado, Anschutz Medical Campus, in Denver, Colorado
| | - Christie Teigland
- Christie Teigland is a principal in the health economics and advanced analytics practice at Avalere Health, in Washington, D.C
| | - Eric Weinhandl
- Eric Weinhandl is a senior epidemiologist in the Chronic Disease Research Group at the Hennepin Healthcare Research Institute, in Minneapolis, Minnesota
| | - Laurent G Glance
- Laurent G. Glance is vice chair for research and a professor in the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, in Rochester, New York
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/05/2021] [Indexed: 12/19/2022] Open
Abstract
Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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11
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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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12
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Liao JM, Shan EZ, Zhao Y, Shah Y, Cousins DS, Navathe AS. Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations. J Arthroplasty 2021; 36:1-5. [PMID: 32792203 DOI: 10.1016/j.arth.2020.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Overlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels. METHODS We conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap). RESULTS We studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net. CONCLUSION CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Eric Z Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yueming Zhao
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yash Shah
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah S Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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13
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Kim H, Meath THA, Dobbertin K, Quiñones AR, Ibrahim SA, McConnell KJ. Association of the Mandatory Medicare Bundled Payment With Joint Replacement Outcomes in Hospitals With Disadvantaged Patients. JAMA Netw Open 2019; 2:e1914696. [PMID: 31693127 PMCID: PMC6865278 DOI: 10.1001/jamanetworkopen.2019.14696] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/16/2019] [Indexed: 11/21/2022] Open
Abstract
Importance Medicare's Comprehensive Care for Joint Replacement (CJR) model rewards or penalizes hospitals on the basis of meeting spending benchmarks that do not account for patients' preexisting social and medical complexity or high expenses associated with serving disadvantaged populations such as dual-eligible patients (ie, those enrolled in both Medicare and Medicaid). The CJR model may have different implications for hospitals serving a high percentage of dual-eligible patients (termed high-dual) and hospitals serving a low percentage of dual-eligible patients (termed low-dual). Objective To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017. Design, Setting, and Participants This cohort study comprised 3 analyses of high-dual or low-dual hospitals (n = 1165) serving patients with hip or knee joint replacements (n = 768 224) in 67 treatment metropolitan statistical areas (MSAs) selected for CJR participation and 103 control MSAs. The study used Medicare claims data and public reports from 2012 to 2017. Data analysis was conducted from February 1, 2019, to August 31, 2019. Exposures The CJR model holds participating hospitals accountable for the spending and quality of care during care episodes for patients with hip or knee joint replacement, including hospitalization and 90 days after discharge. Main Outcomes and Measures The primary outcomes were total episode spending, discharge to institutional postacute care facility, and readmission within the 90-day postdischarge period; bonus and penalty payments for each hospital; and reductions in per-episode spending required to receive a bonus for each hospital. Results In total, 1165 hospitals (291 high-dual and 874 low-dual) and 768 224 patients with joint replacement (494 013 women [64.3%]; mean [SD] age, 76 [7] years) were included. An episode-level triple-difference analysis indicated that total spending under the CJR model decreased at high-dual hospitals (by $851; 95% CI, -$1556 to -$146; P = .02) and low-dual hospitals (by $567; 95% CI, -$933 to -$202; P = .003). The size of decreases did not differ between the 2 groups (difference, -$284; 95% CI, -$981 to $413; P = .42). Discharge to institutional postacute care settings and readmission did not change among both hospital groups. High-dual hospitals were less likely to receive a bonus compared with low-dual hospitals (40.3% vs 59.1% in 2016; 56.9% vs 76.0% in 2017). To receive a bonus, high-dual hospitals would be required to reduce spending by $887 to $2231 per episode, compared with only $89 to $215 for low-dual hospitals. Conclusions and Relevance The study found that high- and low-dual hospitals made changes in care after CJR implementation, and the magnitude of these changes did not differ between the 2 groups. However, high-dual hospitals were less likely to receive a bonus for spending cuts. Spending benchmarks for CJR would require high-dual hospitals to reduce spending more substantially to receive a financial incentive.
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Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Thomas H. A. Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Konrad Dobbertin
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Ana R. Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Said A. Ibrahim
- Department of Healthcare Policy and Research, Weill Cornell Medicine/New York-Presbyterian, New York, New York
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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14
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CORR Insights®: What Preoperative Factors are Associated With Not Achieving a Minimum Clinically Important Difference After sTHA? Findings from an International Multicenter Study. Clin Orthop Relat Res 2019; 477:1313-1314. [PMID: 31136426 PMCID: PMC6554140 DOI: 10.1097/corr.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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15
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Thirukumaran CP, Glance LG, Cai X, Kim Y, Li Y. Penalties and Rewards for Safety Net vs Non-Safety Net Hospitals in the First 2 Years of the Comprehensive Care for Joint Replacement Model. JAMA 2019; 321:2027-2030. [PMID: 31135838 PMCID: PMC6547113 DOI: 10.1001/jama.2019.5118] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study compared monetary penalties and rewards among safety net vs non–safety net hospitals under Medicare’s Comprehensive Care for Joint Replacement (CJR) model, a bundled payment plan for hip and knee replacements intended to incentivize health care quality and savings, in 2016 and 2017.
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Affiliation(s)
| | - Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
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