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Waddell KJ, Goel K, Park SH, Linn KA, Navathe AS, Liao JM, McDonald C, Reitz C, Moore J, Hyland S, Mehta SJ. Association of Electronic Self-Scheduling and Screening Mammogram Completion. Am J Prev Med 2024; 66:399-407. [PMID: 38085196 PMCID: PMC10922640 DOI: 10.1016/j.amepre.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 01/29/2024]
Abstract
INTRODUCTION The purpose of this study was to evaluate if an electronic health record (EHR) self-scheduling function was associated with changes in mammogram completion for primary care patients who were eligible for a screening mammogram using U.S. Preventive Service Task Force recommendations. METHODS This was a retrospective cohort study (September 1, 2014-August 31, 2019, analyses completed in 2022) using a difference-in-differences design to examine mammogram completion before versus after the implementation of self-scheduling. The difference-in-differences estimate was the interaction between time (pre-versus post-implementation) and group (active EHR patient portal versus inactive EHR patient portal). The primary outcome was mammogram completion among all eligible patients, with completion defined as receiving a mammogram within 6 months post-visit. The secondary outcome was mammogram completion among patients who received a clinician order during their visit. RESULTS The primary analysis included 35,257 patient visits. The overall mammogram completion rate in the pre-period was 22.2% and 49.7% in the post-period. EHR self-scheduling was significantly associated with increased mammogram completion among those with an active EHR portal, relative to patients with an inactive portal (adjusted difference 13.2 percentage points [95% CI 10.6-15.8]). For patients who received a clinician mammogram order at their eligible visit, self-scheduling was significantly associated with increased mammogram completion among patients with an active EHR portal account (adjusted difference 14.7 percentage points, [95% CI 10.9-18.5]). CONCLUSIONS EHR-based self-scheduling was associated with a significant increase in mammogram completion among primary care patients. Self-scheduling can be a low-cost, scalable function for increasing preventive cancer screenings.
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Affiliation(s)
- Kimberly J Waddell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Cresencz VA Medical Center, Philadelphia, PA.
| | - Keshav Goel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sae-Hwan Park
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Kristin A Linn
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Amol S Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Cresencz VA Medical Center, Philadelphia, PA
| | - Joshua M Liao
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medicine, University of Washington, Seattle, WA
| | - Caitlin McDonald
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA
| | - Catherine Reitz
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA
| | - Jake Moore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steve Hyland
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shivan J Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, PA
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Crowley AP, Neville S, Sun C, Huang QE, Cousins D, Shirk T, Zhu J, Kilaru A, Liao JM, Navathe AS. Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations. J Gen Intern Med 2024:10.1007/s11606-024-08655-4. [PMID: 38319498 DOI: 10.1007/s11606-024-08655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. OBJECTIVE Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). DESIGN Cross-sectional study using ordinary least squares regression controlling for patient and community factors. PARTICIPANTS Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. MAIN MEASURES Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022. KEY RESULTS Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). CONCLUSIONS Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.
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Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Sarah Neville
- The Commonwealth Fund, New York, NY, USA
- Independent Health and Aged Care Pricing Authority, Sydney, Australia
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Qian Erin Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Torrey Shirk
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Kilaru
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Program on Policy Evaluation and Learning, UT Southwestern, Dallas, TX, USA
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
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Klaiman T, Steckel J, Hearn C, Diana A, Ferrell WJ, Emanuel EJ, Navathe AS, Parikh RB. Clinician Perspectives on Virtual Specialty Palliative Care for Patients With Advanced Illnesses. J Palliat Med 2024. [PMID: 38197852 DOI: 10.1089/jpm.2023.0521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.
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Affiliation(s)
- Tamar Klaiman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jenna Steckel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caleb Hearn
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amaya Diana
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William J Ferrell
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ezekiel J Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Ravi B Parikh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Eschliman BH, Pham HH, Navathe AS, Dale KM, Harris J. The role of payment and financing in achieving health equity. Health Serv Res 2023; 58 Suppl 3:311-317. [PMID: 38015860 PMCID: PMC10684035 DOI: 10.1111/1475-6773.14219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms. DATA SOURCES AND STUDY SETTING AHRQ convened a payment and financing workgroup-the authors of this paper-as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity. STUDY DESIGN The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants. DATA COLLECTION/EXTRACTION METHODS This paper did not require novel data collection; the authors collected the data from the existing evidence base. PRINCIPAL FINDINGS The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools. CONCLUSIONS Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity.
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Affiliation(s)
- Brede H. Eschliman
- Medicare Drug Rebate and Negotiations GroupCenters for Medicare and Medicaid ServicesWindsor MillMarylandUSA
| | | | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Corporal Michael J. Cresencz VA Medical CenterPhiladelphiaPennsylvaniaUSA
| | | | - Julian Harris
- Deerfield ManagementNew YorkNew YorkUSA
- ConcertoCareNew YorkNew YorkUSA
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List JM, Palevsky P, Tamang S, Crowley S, Au D, Yarbrough WC, Navathe AS, Kreisler C, Parikh RB, Wang-Rodriguez J, Klutts JS, Conlin P, Pogach L, Meerwijk E, Moy E. Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration. Health Equity 2023; 7:809-816. [PMID: 38076213 PMCID: PMC10698768 DOI: 10.1089/heq.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 01/29/2024] Open
Abstract
The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.
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Affiliation(s)
- Justin M. List
- VA Office of Health Equity, Washington, District of Columbia, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul Palevsky
- Kidney Medicine Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Suzanne Tamang
- Department of Veterans Affairs, Palo Alto, California, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Susan Crowley
- Nephrology Section, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - David Au
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - William C. Yarbrough
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- VA North Texas Health Care System, Dallas, Texas, USA
| | - Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig Kreisler
- Analytics and Performance Integration (API), Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Ravi B. Parikh
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica Wang-Rodriguez
- VA National Pathology and Laboratory Medicine Service, Washington, District of Columbia, USA
- Department of Pathology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - J. Stacey Klutts
- National VHA Diagnostics Office, Washington, District of Columbia, USA
- Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Paul Conlin
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonard Pogach
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey, USA
| | | | - Ernest Moy
- VA Office of Health Equity, Washington, District of Columbia, USA
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Lee JT, Navathe AS, Werner RM. Pneumonia is not just pneumonia: Differences in utilization and costs with common comorbidities. J Hosp Med 2023; 18:1004-1007. [PMID: 37815324 DOI: 10.1002/jhm.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023]
Abstract
We sought to explore the heterogeneity among patients hospitalized with pneumonia, a condition targeted in payment reform. In a retrospective cohort study of Medicare beneficiaries hospitalized for pneumonia, we compared postacute care utilization and costs of 90-day episodes of care among patients with and without comorbidities of chronic obstructive pulmonary disease (COPD) and/or heart failure. Of the 1,926,674 discharges, 28.1% had COPD, 14.3% had heart failure, and 14.6% carried both diagnoses. Patients with pneumonia were more likely to be discharged to a facility than those with pneumonia and COPD with or without heart failure, though less likely than those with pneumonia and heart failure only. Compared to patients with pneumonia only, patients with COPD and/or heart failure had higher episode payments. Acute conditions such as pneumonia may hold promise for episode-based care payment reform; however, the heterogeneity within this diagnosis indicates the need to consider other patient characteristics in interventions to improve value-based care.
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Affiliation(s)
- Jessica T Lee
- Department of Medicine, Perelman School of Medicine, Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gupta R, Yang L, Lewey J, Navathe AS, Groeneveld PW, Khatana SAM. Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease. J Am Heart Assoc 2023; 12:e030730. [PMID: 37750565 PMCID: PMC10727247 DOI: 10.1161/jaha.123.030730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Hopkins Business of Health Initiative, Johns Hopkins UniversityBaltimoreMD
| | - Lin Yang
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Peter W. Groeneveld
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
| | - Sameed Ahmed M. Khatana
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
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Parikh RB, Emanuel EJ, Zhao Y, Pagnotti DR, Hagen S, Pizza DA, Navathe AS. Spending patterns among commercially insured individuals during the COVID-19 pandemic. Am J Manag Care 2023; 29:517-521. [PMID: 37870545 DOI: 10.37765/ajmc.2023.89440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVES To describe trends in US health care spending in a large, national, and commercially insured population during the COVID-19 pandemic. STUDY DESIGN Cross-sectional study of commercially insured members enrolled between May 1, 2018, and December 31, 2021. METHODS The study utilized a population-based sample of continuously enrolled members in a geographically diverse federation of Blue Cross Blue Shield plans across the United States. Our sample excluded Medicare and Medicare Advantage beneficiaries. The COVID-19 exposure period was defined as 2020-2021; 2018-2019 were pre-COVID-19 years. We defined 4 post-COVID-19 periods: March 1 to April 30, 2020; May 1 to December 31, 2020; January 1 to March 31, 2021; and April 1 to December 31, 2021. The primary outcome was inflation-adjusted overall per-member per-month (PMPM) medical spending adjusted for age, sex, Elixhauser comorbidities, area-level racial composition, income, and education. RESULTS Our sample included 97,319,130 individuals. Mean PMPM medical spending decreased from $370.92 in January-February 2020 to $281.00 in March-April 2020. Between May and December 2020, mean PMPM medical spending recovered to-but did not exceed-prepandemic levels. Mean PMPM medical spending stayed below prepandemic levels between January and March 2021, rose above prepandemic baselines between April and June 2021, and decreased below baseline between July and December 2021. CONCLUSIONS The COVID-19 pandemic induced a spending shock in 2020, and health care spending did not recover to near baseline until mid-2021, with some emerging evidence of pent-up demand. The observed spending below baseline through the end of 2021 will pose challenges to setting spending benchmarks for alternative payment and shared savings models.
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Affiliation(s)
- Ravi B Parikh
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley 1102, Philadelphia, PA 19104.
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Abstract
This Viewpoint discusses the benefits and drawbacks of current risk adjustment tools, outlines the pressures clinicians may face to use these tools, and proposes principles and policy solutions to ensure that risk adjustment is clinically meaningful and to minimize gaming and waste.
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Affiliation(s)
- Daniel M Horn
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania
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Abstract
Importance Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program. Objective To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth. Design, Setting, and Participants This retrospective cohort study examined the MA market before and after the ACA, which mandated cuts to MA benchmark payment rates. Using 2008 to 2019 county-level enrollment and payment data, a difference-in-differences analysis was conducted comparing MA enrollment changes between counties with larger vs smaller benchmark reductions, before vs after the ACA. Main Outcomes and Measures The primary outcome was the MA enrollment rate, defined as the proportion of a county's Medicare beneficiaries enrolled in MA. A secondary analysis examined MA plan payments per member per month. Results Among 3138 counties with 37 639 county-year observations, ACA-induced benchmark cuts were sizeable and varied, ranging from 0% to 42.9% (mean [SD], 5.9% [6.6%]). Counties with benchmark cuts above the 75th percentile had population-weighted average benchmark cuts of 14.9% compared with 4.4% in other counties. In the 8 years following the ACA, there was no differential change in MA enrollment between counties with larger vs smaller benchmark cuts (difference-in-differences estimate, 0.02 [95% CI, -1.18 to 1.21] percentage points; P = .98). Plan payments differentially fell in counties with larger benchmark cuts by $78.35 (95% CI, $62.21-$94.48) per member per month (P < .001). Conclusion and Relevance This cohort study found no evidence that the MA benchmark and ensuing payment cuts imposed by the ACA were associated with reduced MA enrollment, compromising access to MA. This evidence can inform ongoing policy debates regarding the growth of MA, concerns about excess payments to MA plans, and proposed Medicare reforms, including further reductions in MA payments.
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Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, US Department of Veterans Affairs, Philadelphia, Pennsylvania
| | - Seyoun Kim
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, US Department of Veterans Affairs, Philadelphia, Pennsylvania
| | - Atul Gupta
- The Wharton School, University of Pennsylvania, Philadelphia
- National Bureau of Economic Research, Cambridge, Massachusetts
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Sutherland A, Boudreau E, Bowe A, Huang Q, Liao JM, Flagg M, Cousins D, Antol DD, Shrank WH, Powers BW, Navathe AS. Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries. JAMA Health Forum 2023; 4:e231495. [PMID: 37355996 DOI: 10.1001/jamahealthforum.2023.1495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023] Open
Abstract
Importance Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality. Objective To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery. Design, Setting, and Participants Cross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022. Exposures Physician practice participation in the bundled payment program. Main Outcomes and Measures The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions). Results The final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]). Conclusions and Relevance In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.
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Affiliation(s)
| | | | | | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
| | | | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | | | - Brian W Powers
- Humana Inc, Louisville, Kentucky
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Navathe AS, Connolly JE. Hospital Consolidation: The Rise of Geographically Distant Mergers. JAMA 2023; 329:1547-1548. [PMID: 37052898 DOI: 10.1001/jama.2023.5391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
This Viewpoint discusses how and why cross-market hospital mergers are different than prototypical within-market mergers in their effects on patients and communities, why the trend may be accelerating, and future policy and research directions.
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Affiliation(s)
- Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - John E Connolly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Liao JM, Sun C, Yan XS, Patel MS, Small DS, Isenberg WM, Landa HM, Bond BL, Rareshide CAL, Volpp KG, Delgado MK, Lei VJ, Shen Z, Navathe AS. How Physician Self-Perceptions Affect the Impact of Peer Comparison Feedback on Opioid Prescribing. Am J Med Qual 2023; 38:129-136. [PMID: 37017283 DOI: 10.1097/jmq.0000000000000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Peer comparison feedback is a promising strategy for reducing opioid prescribing and opioid-related harms. Such comparisons may be particularly impactful among underestimating clinicians who do not perceive themselves as high prescribers relative to their peers. But peer comparisons could also unintentionally increase prescribing among overestimating clinicians who do not perceive themselves as lower prescribers than peers. The objective of this study was to assess if the impact of peer comparisons varied by clinicians' preexisting opioid prescribing self-perceptions. Subgroup analysis of a randomized trial of peer comparison interventions among emergency department and urgent care clinicians was used. Generalized mixed-effects models were used to assess whether the impact of peer comparisons, alone or combined with individual feedback, varied by underestimating or overestimating prescriber status. Underestimating and overestimating prescribers were defined as those who self-reported relative prescribing amounts that were lower and higher, respectively, than actual relative baseline amounts. The primary outcome was pills per opioid prescription. Among 438 clinicians, 54% (n = 236) provided baseline prescribing self-perceptions and were included in this analysis. Overall, 17% (n = 40) were underestimating prescribers whereas 5% (n = 11) were overestimating prescribers. Underestimating prescribers exhibited a differentially greater decrease in pills per prescription compared to nonunderestimating clinicians when receiving peer comparison feedback (1.7 pills, 95% CI, -3.2 to -0.2 pills) or combined peer and individual feedback (2.8 pills, 95% CI, -4.8 to -0.8 pills). In contrast, there were no differential changes in pills per prescription for overestimating versus nonoverestimating prescribers after receiving peer comparison (1.5 pills, 95% CI, -0.9 to 3.9 pills) or combined peer and individual feedback (3.0 pills, 95% CI, -0.3 to 6.2 pills). Peer comparisons were more impactful among clinicians who underestimated their prescribing compared to peers. By correcting inaccurate self-perceptions, peer comparison feedback can be an effective strategy for influencing opioid prescribing.
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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
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | - Dylan S Small
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Charles A L Rareshide
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kevin G Volpp
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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14
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Parikh RB, Zhang Y, Kolla L, Chivers C, Courtright KR, Zhu J, Navathe AS, Chen J. Performance drift in a mortality prediction algorithm among patients with cancer during the SARS-CoV-2 pandemic. J Am Med Inform Assoc 2023; 30:348-354. [PMID: 36409991 PMCID: PMC9846686 DOI: 10.1093/jamia/ocac221] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/22/2022] Open
Abstract
Sudden changes in health care utilization during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic may have impacted the performance of clinical predictive models that were trained prior to the pandemic. In this study, we evaluated the performance over time of a machine learning, electronic health record-based mortality prediction algorithm currently used in clinical practice to identify patients with cancer who may benefit from early advance care planning conversations. We show that during the pandemic period, algorithm identification of high-risk patients had a substantial and sustained decline. Decreases in laboratory utilization during the peak of the pandemic may have contributed to drift. Calibration and overall discrimination did not markedly decline during the pandemic. This argues for careful attention to the performance and retraining of predictive algorithms that use inputs from the pandemic period.
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Affiliation(s)
- Ravi B Parikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Yichen Zhang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Likhitha Kolla
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corey Chivers
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine R Courtright
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amol S Navathe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Jinbo Chen
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Klaiman T, Nelson MN, Yan XS, Navathe AS, Patel MS, Refai F, Delgado MK, Pagnotti DR, Liao JM. Clinician Perceptions of Receiving Different Forms of Feedback on their Opioid Prescribing. Am J Med Qual 2023; 38:1-8. [PMID: 36579960 DOI: 10.1097/jmq.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Opioid misuse represents a major public health issue in the United States. One driver is overprescription for acute pain, with the size of initial prescription associated with subsequent long-term use. However, little work has been done to elicit clinician feedback about interventions to reduce opioid prescribing. To address this knowledge gap, qualitative analyses were conducted with clinicians who participated in a randomized controlled trial in which clinicians received monthly emailed feedback notifications about their opioid prescribing behaviors. Semistructured telephone interviews were conducted (N = 12) with urgent care (N = 7) and emergency department (N = 5) clinicians who participated in the trial between November 2020 and April 2021. Clinicians appreciated feedback about their prescribing behavior and found comparative data with peer clinicians to be most useful. Sharing opioid prescribing feedback data with clinicians can be an acceptable way to address opioid prescribing among emergency and urgent care clinicians.
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Affiliation(s)
- Tamar Klaiman
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Maria N Nelson
- CIO Peer and Practitioner Research and Analytics Department, Gartner, Philadelphia, PA
| | - Xiaowei S Yan
- Sutter Health, Center for Health System Research, Walnut Creek, CA
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Mitesh S Patel
- Department of Clinical Transformation, Ascension, St. Louis, MO
| | - Farah Refai
- Gilead Sciences, Research Department (Virology), Foster City, CA
| | - M Kit Delgado
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - David R Pagnotti
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Joshua M Liao
- School of Medicine, University of Washington, Seattle, WA
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16
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Liao JM, Huang Q, Wang E, Linn K, Shirk T, Zhu J, Cousins D, Navathe AS. Performance of Physician Groups and Hospitals Participating in Bundled Payments Among Medicare Beneficiaries. JAMA Health Forum 2022; 3:e224889. [PMID: 36580325 PMCID: PMC9856773 DOI: 10.1001/jamahealthforum.2022.4889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Importance Hospital participation in bundled payment initiatives has been associated with financial savings and stable quality of care. However, how physician group practices (PGPs) perform in bundled payments compared with hospitals remains unknown. Objectives To evaluate the association of PGP participation in the Bundled Payments for Care Improvement (BPCI) initiative with episode outcomes and to compare these with outcomes for participating hospitals. Design, Settings, and Participants This cohort study with a difference-in-differences analysis used 2011 to 2018 Medicare claims data to compare the association of BPCI participation with episode outcomes for PGPs vs hospitals providing medical and surgical care to Medicare beneficiaries. Data analyses were conducted from January 1, 2020, to May 31, 2022. Exposures Hospitalization for any of the 10 highest-volume episodes (5 medical and 5 surgical) included in the BPCI initiative for Medicare patients of participating PGPs and hospitals. Main Outcomes and Measures The primary outcome was 90-day total episode spending. Secondary outcomes were 90-day readmissions and mortality. Results The total sample comprised data from 1 288 781 Medicare beneficiaries, of whom 696 710 (mean [SD] age, 76.2 [10.8] years; 432 429 [59.7%] women; 619 655 [85.5%] White individuals) received care through 379 BPCI-participating hospitals and 1441 propensity-matched non-BPCI-participating hospitals, and 592 071 (mean [SD] age, 75.4 [10.9] years; 527 574 [86.6%] women; 360 835 [59.3%] White individuals) received care from 6405 physicians in BPCI-participating PGPs and 24 758 propensity-matched physicians in non-BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical (difference, -$1368; 95% CI, -$1648 to -$1088) but not for medical episodes (difference, -$101; 95% CI, -$410 to $206). Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical (-$1010; 95% CI, -$1345 to -$675) and medical (-$763; 95% CI, -$1139 to -$386) episodes. Conclusions and Relevance This cohort study and difference-in-differences analysis of PGPs and hospital participation in BPCI found that bundled payments were associated with cost savings for surgical episodes for PGPs, and savings for both surgical and medical episodes for hospitals. Policy makers should consider the comparative performance of participant types when designing and evaluating bundled payment models.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristin Linn
- Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Torrey Shirk
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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17
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Chatterjee P, Klebanoff MJ, Huang Q, Navathe AS. Characteristics of Hospitals Eligible for Rural Emergency Hospital Designation. JAMA Health Forum 2022; 3:e224613. [PMID: 36484999 PMCID: PMC9856250 DOI: 10.1001/jamahealthforum.2022.4613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This cross-sectional study compares the characteristics, finances, services, and challenges at hospitals that are eligible vs not eligible to become rural emergency hospitals.
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Affiliation(s)
- Paula Chatterjee
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew J. Klebanoff
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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18
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Urwin J, Navathe AS, Zhou L, Bhatt J, Kralovec PD, Liao JM. Organizational capacity among hospitals in Medicare and commercial bundled payments. Am J Manag Care 2022; 28:678-683. [PMID: 36525660 DOI: 10.37765/ajmc.2022.89276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Hospitals must strategically build organizational capacities to succeed in bundled payment arrangements. Given differences between Medicare and commercial arrangements, capacities may vary between hospitals in Medicare vs both Medicare and commercial bundled payment programs. This study compared organizational capacities between these 2 hospital groups. STUDY DESIGN National survey of American Hospital Association (AHA) member hospitals with experience in bundled payment programs. METHODS We analyzed data from October 31, 2017, to April 30, 2018, collected from AHA member hospitals with bundled payment experience in only Medicare (Medicare-only hospitals) or in both Medicare and commercial insurers (multipayer hospitals). Survey questions examined capacity in 4 areas: (1) physician performance feedback, (2) care management, (3) postacute care provider utilization, and (4) health information technology. RESULTS Our sample included 114 hospitals reporting experience in Medicare or commercial bundled payment programs. Both Medicare-only and multipayer hospitals reported high organizational capacities in performance measurement of physician-level quality and cost feedback and in incorporation of health information technology. More multipayer hospitals reported high capacity for coordinating hospital to postacute care settings (88% vs 52%). Although nearly all hospitals in both groups reported formalized relationships with skilled nursing facilities (98%), fewer hospitals reported such relationships with long-term acute care hospitals (83%) and inpatient rehabilitation facilities (80%). CONCLUSIONS Although they have similar capacity in a number of areas, Medicare-only and multipayer hospitals differed with respect to other aspects of organizational capacity.
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Affiliation(s)
- John Urwin
- Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Deaconess 3, Boston, MA 02215.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Value and Systems Science Lab, Seattle
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania
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Tummalapalli SL, Navathe AS, Ibrahim SA. Early Findings From Medicare's End-Stage Renal Disease Treatment Choices Model. JAMA Health Forum 2022; 3:e223500. [PMID: 36206008 PMCID: PMC10133989 DOI: 10.1001/jamahealthforum.2022.3500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science and Innovation, Department of Population Health Sciences and Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Said A Ibrahim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York.,Associate Editor, JAMA Health Forum
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Chatterjee P, Liao JM, Wang E, Feffer D, Navathe AS. Characteristics, utilization, and concentration of outpatient care for dual-eligible Medicare beneficiaries. Am J Manag Care 2022; 28:e370-e377. [PMID: 36252177 PMCID: PMC10084394 DOI: 10.37765/ajmc.2022.89189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To characterize the (1) distribution of outpatient care for dual-eligible Medicare beneficiaries ("duals") and (2) intensity of outpatient care utilization of duals vs non-dual-eligible beneficiaries ("nonduals"). STUDY DESIGN Using data preceding the introduction of several outpatient alternative payment models, as well as Medicaid expansion, we evaluated the distribution of outpatient care across physician practices using a Lorenz curve and compared utilization of different outpatient services between duals and nonduals. METHODS We defined practices that did (high dual) and did not (low dual and no dual) account for the large majority of visits based on the Lorenz curve and then performed descriptive statistics between these groups of practices. Practice-level outcomes included patient demographics, practice characteristics, and county measures of structural disadvantage and population health. Patient-level outcomes included number of outpatient visits and unique outpatient physicians, primary vs subspecialty care visits, and expenditures. RESULTS Nearly 80% of outpatient visits for duals were provided by 35% of practices. Compared with low-dual and no-dual practices, high-dual practices served more patients (1117.6 patients per high-dual practice vs 683.8 patients per low-dual practice and 447.5 patients per no-dual practice; P < .001) with more comorbidities (3.9 mean total Elixhauser comorbidities among patients served by high-dual practices vs 3.6 among low-dual practices and 3.3 among no-dual practices; P < .001). With regard to utilization, duals had 2 fewer outpatient visits per year compared with nonduals (13.3 vs 15.2; P < .001), with particularly fewer subspecialty care visits (6.5 vs 7.9; P < .001) despite having more comorbidities (3.5 vs 2.7; P < .001). CONCLUSIONS Outpatient care for duals was concentrated among a small number of practices. Despite having more chronic conditions, duals had fewer outpatient visits. Duals and the practices that serve them may benefit from targeted policies to promote access and improve outcomes.
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Affiliation(s)
- Paula Chatterjee
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Rm 1318, Philadelphia, PA 19104.
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Affiliation(s)
- Amol S Navathe
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Washington, Seattle
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23
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Affiliation(s)
- Amol S Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
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24
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Boudreau E, Schwartz R, Schwartz AL, Navathe AS, Caplan A, Li Y, Blink A, Racsa P, Antol DD, Erwin CJ, Shrank WH, Powers BW. Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries. JAMA Health Forum 2022; 3:e222935. [PMID: 36218933 PMCID: PMC9463603 DOI: 10.1001/jamahealthforum.2022.2935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Question Do rates of low-value care differ between traditional Medicare (TM) and Medicare Advantage (MA), and, if so, what elements of insurance design are associated with the differences? Findings In this cross-sectional study of 2 470 199 Medicare beneficiaries, those enrolled in MA received 9.2% fewer low-value services than those in TM (23.1 vs 25.4 total low-value services per 100 beneficiaries). The MA beneficiaries in health maintenance organizations and those in primary care organizations reimbursed within advanced value-based payment models had the lowest rates of low-value care. Meaning The study results suggest that low-value care is less common in MA than TM, with elements of insurance design present in MA associated with fewer low-value services. Importance Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care. Objectives To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care. Design, Setting, and Participants This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022. Exposures Enrollment in MA vs TM. Main Outcomes and Measures Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries. Results Among a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.
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Affiliation(s)
| | | | - Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Yong Li
- Humana Inc, Louisville, Kentucky
| | | | | | | | | | | | - Brian W. Powers
- Humana Inc, Louisville, Kentucky
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
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Navathe AS, Crowley A, Liao JM. Remote Patient Monitoring-Will More Data Lead to More Health? JAMA Intern Med 2022; 182:1007-1008. [PMID: 35913717 DOI: 10.1001/jamainternmed.2022.3040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Aidan Crowley
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle.,Value & Systems Science Lab, Seattle, Washington
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Parikh RB, Navathe AS, Zhao Y, Pagnotti D, Emanuel EJ. Trends in Enrollment in Employer-Sponsored Health Insurance in the US Before and During the COVID-19 Pandemic, January 2019 to June 2021. JAMA Netw Open 2022; 5:e2234174. [PMID: 36178690 PMCID: PMC9526087 DOI: 10.1001/jamanetworkopen.2022.34174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This cross-sectional study compares trends in employer-sponsored health insurance coverage in the US before and during the COVID-19 pandemic.
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Affiliation(s)
- Ravi B. Parikh
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Yueming Zhao
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - David Pagnotti
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Parikh RB, Emanuel EJ, Brensinger CM, Boyle CW, Price-Haywood EG, Burton JH, Heltz SB, Navathe AS. Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program. JAMA Netw Open 2022; 5:e2228529. [PMID: 35997977 PMCID: PMC9399862 DOI: 10.1001/jamanetworkopen.2022.28529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk. OBJECTIVE To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records. DESIGN, SETTING, AND PARTICIPANTS This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. EXPOSURES Enrollment in MA or attribution to an accountable care organization in the MSSP program. MAIN OUTCOMES AND MEASURES Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending. RESULTS The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts. CONCLUSIONS AND RELEVANCE In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.
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Affiliation(s)
- Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Ezekiel J. Emanuel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | | | - Connor W. Boyle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | | | - Amol S. Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Navathe AS, Chandrashekar P, Chen C. Making Value-Based Payment Work for Federally Qualified Health Centers: Toward Equity in the Safety Net. JAMA 2022; 327:2081-2082. [PMID: 35575800 DOI: 10.1001/jama.2022.8285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amol S Navathe
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Milad MA, Murray RC, Navathe AS, Ryan AM. Errata. Health Aff (Millwood) 2022; 41:925. [PMID: 35666978 DOI: 10.1377/hlthaff.2022.00590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liao JM, Ibrahim SA, Huang Q, Connolly J, Cousins DS, Zhu J, Navathe AS. The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments. Popul Health Manag 2022; 25:501-508. [PMID: 35532549 PMCID: PMC9419980 DOI: 10.1089/pop.2021.0334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Hospitals have demonstrated the benefits of both voluntary and mandatory bundled payments for joint replacement surgery. However, given generalizability and disparities concerns, it is critical to understand the availability of care through bundled payments to historically marginalized groups, such as racial and ethnic minorities and individuals with lower socioeconomic status (SES). This cross-sectional analysis of 3880 US communities evaluated the relationship between the proportion of Black and Hispanic individuals (minority share) or Medicare/Medicaid dual-eligible individuals (low SES share) and community-level participation in Bundled Payments for Care Improvement initiative (BPCI) (being a BPCI community) and Comprehensive Care for Joint Replacement (CJR) model (being a CJR community). An increase from the lowest to highest quartile of minority share was not associated with differences in the probability of being a BPCI community (3.5 percentage point [pp] difference, 95% confidence interval [CI] -1.2% to 8.3%, P = 0.15), but was associated with a 16.1 pp higher probability of being a CJR community (95% CI 10.3% to 22.0%, P < 0.0001). An increase from the lowest to highest quartile of low SES share was associated with a 6.0 pp lower probability of being a BPCI community (95% CI -10.9% to -1.2%, P = 0.02) and 19.0 pp lower probability of being a CJR community (95% CI -24.9% to -13.0%, P < 0.0001). These findings highlight that the greater the proportion of lower SES individuals in a community, the lower the likelihood that its hospitals participated in either voluntary or mandatory bundled payments. Policymakers should consider community socioeconomic characteristics when designing participation mechanisms for future bundled payment programs.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Said A. Ibrahim
- Department of Medicine, Northwell Health, New York, New York, USA
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Connolly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Abstract
Value-based payment models are a prominent strategy in health reform. Although Medicare payment models have been extensively evaluated, much less is known about value-based payment models in the commercial insurance sector. We performed the first systematic review of the quality, spending, and utilization effects of commercial models, extracting results from fifty-nine studies. Forty-one of these studies evaluated outcomes. More studies had positive results for quality outcomes (81 percent of studies) than for spending (56 percent) and utilization (58 percent). Less rigorous studies were more likely to find positive results. Given the mixed nature of the findings, commercial insurers should identify ways to strengthen value-based payment programs or leverage other strategies to improve health care value.
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Affiliation(s)
| | - Roslyn C Murray
- Roslyn C. Murray, University of Michigan, Ann Arbor, Michigan
| | - Amol S Navathe
- Amol S. Navathe, Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
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Navathe AS, Liao JM, Yan XS, Delgado MK, Isenberg WM, Landa HM, Bond BL, Small DS, Rareshide CAL, Shen Z, Pepe RS, Refai F, Lei VJ, Volpp KG, Patel MS. The Effect Of Clinician Feedback Interventions On Opioid Prescribing. Health Aff (Millwood) 2022; 41:424-433. [PMID: 35254932 DOI: 10.1377/hlthaff.2021.01407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians' prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician's outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (-0.8) and for the combination of peer comparison and individual audit feedback (-1.2). This decrease was sustained during follow-up. There were no significant changes for individual audit feedback alone, and no interventions changed the proportion of encounters with an opioid prescription.
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Affiliation(s)
- Amol S Navathe
- Amol S. Navathe , Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Liao
- Joshua M. Liao, University of Washington, Seattle, Washington, and University of Pennsylvania
| | - Xiaowei S Yan
- Xiaowei S. Yan, Sutter Health, Walnut Creek, California
| | | | | | | | - Barbara L Bond
- Barbara L. Bond, Sutter Health, Castro Valley, California
| | | | | | - Zijun Shen
- Zijun Shen, Sutter Health, San Francisco
| | | | | | | | | | - Mitesh S Patel
- Mitesh S. Patel, Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania
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Parikh RB, Zhang Y, Chivers C, Courtright KR, Zhu J, Hearn CM, Navathe AS, Chen J. Performance Drift in a Mortality Prediction Algorithm during the SARS-CoV-2 Pandemic. medRxiv 2022:2022.02.28.22270996. [PMID: 35262088 PMCID: PMC8902871 DOI: 10.1101/2022.02.28.22270996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Research Objective Health systems use clinical predictive algorithms to allocate resources to high-risk patients. Such algorithms are trained using historical data and are later implemented in clinical settings. During this implementation period, predictive algorithms are prone to performance changes ("drift") due to exogenous shocks in utilization or shifts in patient characteristics. Our objective was to examine the impact of sudden utilization shifts during the SARS-CoV-2 pandemic on the performance of an electronic health record (EHR)-based prognostic algorithm. Study Design We studied changes in the performance of Conversation Connect, a validated machine learning algorithm that predicts 180-day mortality among outpatients with cancer receiving care at medical oncology practices within a large academic cancer center. Conversation Connect generates mortality risk predictions before each encounter using data from 159 EHR variables collected in the six months before the encounter. Since January 2019, Conversation Connect has been used as part of a behavioral intervention to prompt clinicians to consider early advance care planning conversations among patients with ≥10% mortality risk. First, we descriptively compared encounter-level characteristics in the following periods: January 2019-February 2020 ("pre-pandemic"), March-May 2020 ("early-pandemic"), and June-December 2020 ("later-pandemic"). Second, we quantified changes in high-risk patient encounters using interrupted time series analyses that controlled for pre-pandemic trends and demographic, clinical, and practice covariates. Our primary metric of performance drift was false negative rate (FNR). Third, we assessed contributors to performance drift by comparing distributions of key EHR inputs across periods and predicting later pandemic utilization using pre-pandemic inputs. Population Studied 237,336 in-person and telemedicine medical oncology encounters. Principal Findings Age, race, average patient encounters per month, insurance type, comorbidity counts, laboratory values, and overall mortality were similar among encounters in the pre-, early-, and later-pandemic periods. Relative to the pre-pandemic period, the later-pandemic period was characterized by a 6.5-percentage-point decrease (28.2% vs. 34.7%) in high-risk encounters (p<0.001). FNR increased from 41.0% (95% CI 38.0-44.1%) in the pre-pandemic period to 57.5% (95% CI 51.9-63.0%) in the later pandemic period. Compared to the pre-pandemic period, the early and later pandemic periods had higher proportions of telemedicine encounters (0.01% pre-pandemic vs. 20.0% early-pandemic vs. 26.4% later-pandemic) and encounters with no preceding laboratory draws (17.7% pre-pandemic vs. 19.8% early-pandemic vs. 24.1% later-pandemic). In the later pandemic period, observed laboratory utilization was lower than predicted (76.0% vs 81.2%, p<0.001). In the later-pandemic period, mean 180-day mortality risk scores were lower for telemedicine encounters vs. in-person encounters (10.3% vs 11.2%, p<0.001) and encounters with no vs. any preceding laboratory draws (1.5% vs. 14.0%, p<0.001). Conclusions During the SARS-CoV-2 pandemic period, the performance of a machine learning prognostic algorithm used to prompt advance care planning declined substantially. Increases in telemedicine and declines in laboratory utilization contributed to lower performance. Implications for Policy or Practice This is the first study to show algorithm performance drift due to SARS-CoV-2 pandemic-related shifts in telemedicine and laboratory utilization. These mechanisms of performance drift could apply to other EHR clinical predictive algorithms. Pandemic-related decreases in care utilization may negatively impact the performance of clinical predictive algorithms and warrant assessment and possible retraining of such algorithms.
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Affiliation(s)
- Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Corresponding Author: Ravi B. Parikh, MD, MPP, 423 Guardian Drive, Blockley 1102, Philadelphia, PA 19104, Tel: 352-422-4285, Fax: 215-615-5888
| | - Yichen Zhang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Corey Chivers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Jingsan Zhu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Caleb M. Hearn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amol S. Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Jinbo Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Shrank WH, Chernew ME, Navathe AS. Hierarchical Payment Models-A Path for Coordinating Population- and Episode-Based Payment Models. JAMA 2022; 327:423-424. [PMID: 35029652 DOI: 10.1001/jama.2021.23786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Powers BW, Shrank WH, Navathe AS. Private Equity and Health Care Delivery-Reply. JAMA 2021; 326:2534-2535. [PMID: 34962533 DOI: 10.1001/jama.2021.20434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Liao JM, Zhou L, Navathe AS. Group Practice Performance in the Second Year of Medicare's Merit-Based Incentive Payment System. JAMA Netw Open 2021; 4:e2128267. [PMID: 34609498 PMCID: PMC8493433 DOI: 10.1001/jamanetworkopen.2021.28267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study describes performance among group practices in the second year of the Medicare Merit-Based Incentive Payment System (MIPS) program.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Value and Systems Science Lab, University of Washington School of Medicine, Seattle
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Lingmei Zhou
- Department of Medicine, University of Washington School of Medicine, Seattle
- Value and Systems Science Lab, University of Washington School of Medicine, Seattle
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Affiliation(s)
- Brian W Powers
- Humana Inc, Louisville, Kentucky
- Mass General Brigham, Boston, Massachusetts
| | | | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Navathe AS, Liao JM, Wang E, Isidro U, Zhu J, Cousins DS, Werner RM. Association of Patient Outcomes With Bundled Payments Among Hospitalized Patients Attributed to Accountable Care Organizations. JAMA Health Forum 2021; 2:e212131. [PMID: 35977188 PMCID: PMC8796940 DOI: 10.1001/jamahealthforum.2021.2131] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/17/2021] [Indexed: 01/23/2023] Open
Abstract
Question Is receiving care simultaneously under a Medicare accountable care organization (ACO) and bundled payments associated with better patient outcomes compared with bundled payments alone? Findings In this cohort study of 9 850 080 Medicare beneficiaries, simultaneous inclusion in both ACOs and bundled payments was associated with lower spending on institutional postacute care, fewer readmissions for medical episodes, and fewer readmissions only for surgical episodes compared with inclusion in bundled payments alone. Meaning These findings suggest that receiving care under models such as ACOs may improve patient outcomes under bundled payments. Importance It is unknown how outcomes are affected when patients receive care under bundled payment and accountable care organization (ACO) programs simultaneously. Objective To evaluate whether outcomes in the Medicare Bundled Payments for Care Improvement (BPCI) program differed depending on whether patients were attributed to ACOs in the Medicare Shared Savings Program. Design, Setting, and Participants This cohort study was conducted using Medicare claims data from January 1, 2011, to September 30, 2016, and difference-in-differences analysis to compare episode outcomes for patients admitted to BPCI vs non-BPCI hospitals. Outcomes were stratified for patients who were and were not attributed to an ACO. Participants included Medicare fee-for-service beneficiaries receiving care for medical and surgical episodes at US hospitals. Data were analyzed between October 1, 2018, and June 10, 2021. Exposures Hospitalization for any of the 48 episodes (24 medical, 24 surgical) included in the BPCI at US hospitals participating in the BPCI for those episodes. Main Outcomes and Measures The primary outcome was change in 90-day postdischarge institutional spending, and secondary outcomes included changes in quality and utilization. Results A total of 7 108 146 beneficiaries (mean [SD] age, 76.9 [12.2] years; 4 101 081 women [58%]) received care for medical episodes, and 3 675 962 beneficiaries (mean [SD] age, 74.8 [10.1] years; 2 074 921 women [56%]) received care for surgical episodes. Compared with patients who were not attributed to ACOs, the association between bundled payments and changes in postdischarge institutional spending was larger among patients attributed to ACOs (–$323 difference; 95% CI, –$607 to –$39; P = .03) for medical episodes, but not surgical episodes. Attribution to an ACO also increased the strength of the association between bundled payments and changes in 90-day readmissions for both medical episodes (−0.98 percentage point difference; 95% CI, –1.55 to –0.41; P = .001) and surgical episodes (−0.84 percentage point difference; 95% CI, −1.32 to −0.35; P = .001). Conclusions and Relevance In this cohort study, compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes. Receiving care under models such as ACOs may improve episode outcomes under bundled payments.
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Affiliation(s)
- Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joshua M. Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ulysses Isidro
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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40
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Shah S, Navathe AS, Kocher RP. Strategies to Overcome the Market Dominance of Hospitals-Reply. JAMA 2021; 326:278-279. [PMID: 34283186 DOI: 10.1001/jama.2021.6895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Soleil Shah
- Stanford University School of Medicine, Stanford, California
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert P Kocher
- Stanford University School of Medicine, Stanford, California
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Abstract
Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.
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Affiliation(s)
- Rajender Agarwal
- Rajender Agarwal is director of the Center for Health Reform, in Southlake, Texas
| | - John Connolly
- John Connolly is a medical student in the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Shweta Gupta
- Shweta Gupta is the fellowship director of the Oncology Program, Department of Medicine, John H. Stroger Jr. Hospital of Cook County, in Chicago, Illinois
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Risa J Lavizzo-Mourey
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Lei VJ, Navathe AS, Seki SM, Neuman MD. Perioperative benzodiazepine administration among older surgical patients. Br J Anaesth 2021; 127:e69-e71. [PMID: 34144785 DOI: 10.1016/j.bja.2021.05.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Victor J Lei
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Corporal Michael J. Cresencz VA Medical Center, Department of Veterans Affairs, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott M Seki
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Liao JM, Gupta A, Zhao Y, Zhu J, Martinez J, Cousins DS, Navathe AS. Association Between Hospital Voluntary Participation, Mandatory Participation, or Nonparticipation in Bundled Payments and Medicare Episodic Spending for Hip and Knee Replacements. JAMA 2021; 326:2781198. [PMID: 34133709 PMCID: PMC8209556 DOI: 10.1001/jama.2021.10046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/02/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington, Seattle
| | - Atul Gupta
- Wharton School, University of Pennsylvania, Philadelphia
| | - Yueming Zhao
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | | | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Affiliation(s)
- Ezekiel J Emanuel
- Healthcare Transformation Institute, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Amol S Navathe
- Healthcare Transformation Institute, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Cresencz VA Medical Center, Philadelphia, Pennsylvania
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Abstract
The Centers for Medicare and Medicaid Services continues to propose and implement alternative payment models (APMs) to shift Medicare payment away from fee-for-service and toward approaches that emphasize health care value. As APMs expand in scope, one critical question is whether they should engage providers on a voluntary or a mandatory basis. Clinicians and policy makers may view the benefits and drawbacks of these two modes of participation differently. In this Analysis we compare the benefits and drawbacks of mandatory and voluntary participation, based on clinical versus policy perspectives, and we argue that both modes are necessary for APMs to achieve the goal of improving value. Policy makers should match the mode of participation and related financial incentives to each clinical scenario in which an APM is implemented. We propose ways to coordinate mandatory and voluntary APMs based on clinical scenarios.
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Affiliation(s)
- Joshua M Liao
- Joshua M. Liao is medical director of payment strategy, director of the Value and Systems Science Lab, and an assistant professor in the Department of Medicine, University of Washington, in Seattle, and an adjunct senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, in Philadelphia
| | - Mark V Pauly
- Mark V. Pauly is the Bendheim Professor in the Health Care Management Department at the Wharton School, University of Pennsylvania
| | - Amol S Navathe
- Amol S. Navathe ( amol. navathe@gmail. com ) is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center, in Philadelphia; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania; and codirector of the Healthcare Transformation Institute, associate director of the Center for Health Incentives and Behavioral Economics, and senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania
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47
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Powers BW, Yan J, Zhu J, Linn KA, Jain SH, Kowalski J, Navathe AS. The Beneficial Effects Of Medicare Advantage Special Needs Plans For Patients With End-Stage Renal Disease. Health Aff (Millwood) 2021; 39:1486-1494. [PMID: 32897788 DOI: 10.1377/hlthaff.2019.01793] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients with end-stage renal disease (ESRD) are a vulnerable population with high rates of morbidity, mortality, and acute care use. Medicare Advantage Special Needs Plans (SNPs) are an alternative financing and delivery model designed to improve care and reduce costs for patients with ESRD, but little is known about their impact. We used detailed clinical, demographic, and claims data to identify fee-for-service Medicare beneficiaries who switched to ESRD SNPs offered by a single health plan (SNP enrollees) and similar beneficiaries who remained enrolled in fee-for-service Medicare plans (fee-for-service controls). We then compared three-year mortality and twelve-month utilization rates. Compared with fee-for-service controls, SNP enrollees had lower mortality and lower rates of utilization across the care continuum. These findings suggest that SNPs may be an effective alternative care financing and delivery model for patients with ESRD.
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Affiliation(s)
- Brian W Powers
- Brian W. Powers is deputy chief medical officer at Humana in Boston, Massachusetts
| | - Jiali Yan
- Jiali Yan is a data analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Jingsan Zhu
- Jingsan Zhu is assistant director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Kristin A Linn
- Kristin A. Linn is an assistant professor of biostatistics in the Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Sachin H Jain
- Sachin H. Jain is president and CEO, SCAN Group and Health Plan, and an adjunct professor of medicine, Stanford University School of Medicine, in Stanford, California
| | - Jennifer Kowalski
- Jennifer Kowalski is vice president of the Anthem Public Policy Institute, in Washington, D.C
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
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48
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Abstract
Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington 98195, USA; .,Value and Systems Science Lab, School of Medicine, University of Washington, Seattle, Washington 98195, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Abstract
BACKGROUND Medicare has implemented strategies to improve value by containing hospital spending for episodes of care. Compared with payment models, publicly reported episode-based spending measures are underrecognized strategies. OBJECTIVE To provide the first nationwide description of hospitals' episode-based spending based on publicly reported Clinical Episode-Based Payment (CEBP) measures. DESIGN, SETTING, AND PARTICIPANTS We used 2017 Hospital Compare data to assess spending on six CEBPs among 1,778 hospitals. We examined spending variation and its drivers, correlation between CEBPs, and spending by cost performance categories (for individual CEBPs, below vs above average spending; for across-CEBP comparisons, high vs low vs mixed cost). We also compared hospital spending performance on CEBPs with a global Medicare Spending Per Beneficiary measure. MAIN OUTCOMES AND MEASURES Episode spending. RESULTS Episode spending varied by CEBP type, with skilled nursing facility (SNF) care accounting for the majority of spending variation for procedural episodes but not for condition episodes. Across CEBPs, greater proportions of episode spending were attributed to SNF care at high-(18.1%) vs mixed-(10.7%) vs low-cost (9.2%) hospitals (P > .001). There was low within-hospital CEBP correlation and low correlation and concordance between hospitals' CEBP and Medicare Spending Per Beneficiary performance. CONCLUSIONS Variation reduction and savings opportunities in SNF care for procedural episodes suggest that they may be better suited for existing payment models than condition episodes are. Spending performance was not hospital specific, which highlights the potential utility of episode spending measures beyond global measures.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Value & Systems Science Lab, University of Washington School of Medicine, Seattle, Washington
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lingmei Zhou
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Value & Systems Science Lab, University of Washington School of Medicine, Seattle, Washington
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Affiliation(s)
- Robert P Kocher
- Stanford University School of Medicine, Stanford, California
| | - Soleil Shah
- Stanford University School of Medicine, Stanford, California
| | - Amol S Navathe
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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