1
|
Ryan AM, Markovitz AA. Estimated Savings From the Medicare Shared Savings Program. JAMA Health Forum 2023; 4:e234449. [PMID: 38100095 PMCID: PMC10724775 DOI: 10.1001/jamahealthforum.2023.4449] [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] [Received: 05/02/2023] [Accepted: 10/09/2023] [Indexed: 12/18/2023] Open
Abstract
Importance The Medicare Shared Savings Program (MSSP) is the largest and most important alternative payment model that has been implemented by the Centers for Medicare & Medicaid Services (CMS). Its budgetary impact to CMS is not well understood. Objective To evaluate the association between the MSSP and net savings to CMS for performance years 2013 to 2021. Design, Setting, and Participants The economic evaluation used publicly reported data on the MSSP from April 1, 2012, to December 31, 2021, and estimates extracted from 2 prior studies. Main Outcomes and Measures Net savings to CMS, calculated as the difference between incentive payments to MSSP accountable care organizations and gross spending reductions. Incentive payments were calculated using the publicly reported data. The association of the MSSP with gross medical spending in traditional Medicare was extracted from 2 prior studies. Spillovers of the MSSP to Medicare Advantage (MA) were estimated by evaluating how gross spending reductions from the MSSP impacted benchmark payments to MA plans. Savings from traditional Medicare and MA were then combined. Results The MSSP was associated with net losses to traditional Medicare of between $584 million and $1.423 billion over the study period. Savings from MSSP-related reductions to MA benchmarks totaled between $4.480 billion and $4.923 billion. Across traditional Medicare and MA, the MSSP was associated with savings of between $3.057 billion and $4.339 billion. This represents approximately 0.075% of combined spending for traditional Medicare and MA over the study period. Conclusions and Relevance This economic evaluation found that the MSSP was associated with net losses to traditional Medicare, net savings to MA, and overall net savings to CMS. The total budget impact of the MSSP to CMS was small and continues to be uncertain due to challenges in estimating the effects of the MSSP on gross spending, particularly in recent years.
Collapse
Affiliation(s)
- Andrew M. Ryan
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | | |
Collapse
|
2
|
Ryan AM, Gulseren B, Ayanian JZ, Markovitz AA, Meyers DJ, Brown EF. Association Between Double Bonuses and Clinical and Administrative Performance in Medicare Advantage. JAMA Health Forum 2022; 3:e223301. [PMID: 36218947 PMCID: PMC9508651 DOI: 10.1001/jamahealthforum.2022.3301] [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: 01/28/2023] Open
Abstract
This cross-sectional study compares double bonuses with clinical and administrative performance in Medicare Advantage facilities.
Collapse
Affiliation(s)
- Andrew M. Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor,University of Michigan Center for Evaluating Health Reform, Ann Arbor
| | - Baris Gulseren
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor,University of Michigan Center for Evaluating Health Reform, Ann Arbor
| | - John Z. Ayanian
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor,University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Adam A. Markovitz
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - David J. Meyers
- Department of Health Services, Policy & Practice, Brown School of Public Health, Providence, Rhode Island
| | | |
Collapse
|
3
|
Markovitz AA, Murray RC, Ryan AM. Comprehensive Primary Care Plus Did Not Improve Quality Or Lower Spending For The Privately Insured. Health Aff (Millwood) 2022; 41:1255-1262. [PMID: 36067428 DOI: 10.1377/hlthaff.2021.01982] [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: 11/05/2022]
Abstract
Comprehensive Primary Care Plus (CPC+) was a multipayer payment reform model that provided incentives for primary care practices to lower spending and improve quality performance. Although CPC+ has been evaluated in Medicare, little is known about its impact in the private sector. Using claims and enrollment data from the period 2013-20 from two large insurers in Michigan, we performed difference-in-differences analyses and found that CPC+ was not associated with changes in total spending (-$44.70 per year) or overall quality performance (-0.1 percentage point). These changes did not vary systematically across CPC+ cohorts, tracks, regions, or participation in prior primary care innovations. We conclude that CPC+ did not improve spending or quality for private-plan enrollees in Michigan, even before accounting for payouts to providers. This analysis adds to existing evidence that CPC+ may cost payers money in the short term, without concomitant improvements to care quality.
Collapse
|
4
|
Markovitz AA, Montás MC, Warrier A, Ayanian JZ, Ryan AM. Hispanic-White Differences in Double Bonuses for Quality of Care in Medicare Advantage. JAMA Health Forum 2022; 3:e215281. [PMID: 35977290 PMCID: PMC8903100 DOI: 10.1001/jamahealthforum.2021.5281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/27/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Adam A. Markovitz
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Marie C. Montás
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- University of Michigan Center for Evaluating Health Reform, Ann Arbor
| | - Anupama Warrier
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- University of Michigan Center for Evaluating Health Reform, Ann Arbor
| | - John Z. Ayanian
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Andrew M. Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- University of Michigan Center for Evaluating Health Reform, Ann Arbor
| |
Collapse
|
5
|
Markovitz AA, Ryan AM, Peterson TA, Rozier MD, Ayanian JZ, Hollingsworth JM. ACO Awareness and Perceptions Among Specialists Versus Primary Care Physicians: a Survey of a Large Medicare Shared Savings Program. J Gen Intern Med 2022; 37:492-494. [PMID: 33501534 PMCID: PMC8811095 DOI: 10.1007/s11606-020-06556-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/22/2020] [Indexed: 02/03/2023]
Affiliation(s)
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Timothy A Peterson
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael D Rozier
- Department of Health Management and Policy, Saint Louis University, St. Louis, MO, USA
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - John M Hollingsworth
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
6
|
Abstract
In 2012 Medicare introduced the quality bonus program, linking financial bonuses to commercial insurers' quality performance in Medicare Advantage (MA). Despite large investments in the program, evidence of its effectiveness is limited. We analyzed insurance claims from the period 2009-2018 from the nation's largest MA claims database for 3,753,117 MA beneficiaries (treatment group) and 4,025,179 commercial enrollees (control group). Using a difference-in-differences framework, we evaluated changes in performance on nine claims-based measures of quality in both groups before and after the start of the bonus program and with adjustment for differential pre-period trends. We observed no consistent differential improvement in quality for MA versus commercial enrollees under the quality bonus program. Program participation was associated with significant quality improvements among MA beneficiaries on four measures, significant declines on four other measures, and no significant change in overall quality performance (+0.6 percentage points). Together, these results suggest that the quality bonus program did not produce the intended improvement in overall quality performance of MA plans.
Collapse
Affiliation(s)
- Adam A Markovitz
- Adam A. Markovitz is a resident in the Department of Internal Medicine, University of Michigan Medical School, and a research fellow in the Department of Health Management and Policy, University of Michigan School of Public Health, both in Ann Arbor, Michigan
| | - John Z Ayanian
- John Z. Ayanian is the Alice Hamilton Collegiate Professor of Medicine in the Department of Internal Medicine, University of Michigan Medical School, and director of the Institute for Healthcare Policy and Innovation, University of Michigan
| | - Devraj Sukul
- Devraj Sukul is a clinical lecturer in internal medicine, University of Michigan Medical School
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| |
Collapse
|
7
|
Markovitz AA, Ayanian JZ, Warrier A, Ryan AM. Medicare Advantage Plan Double Bonuses Drive Racial Disparity In Payments, Yield No Quality Or Enrollment Improvements. Health Aff (Millwood) 2021; 40:1411-1419. [PMID: 34495734 DOI: 10.1377/hlthaff.2021.00349] [Citation(s) in RCA: 3] [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: 11/05/2022]
Abstract
Under the Medicare Advantage (MA) quality bonus payment program, initiated in 2012, MA plans with relatively high quality performance that are located in "double bonus"-eligible counties-metropolitan areas with high MA enrollment and low fee-for-service Medicare spending-receive quality bonuses twice as large as those received by equivalently high-quality plans in double-bonus-ineligible counties. Using national data for 2008-18, we found that double bonuses were not associated with either improvements in plan quality or increased MA enrollment. Additionally, because Black beneficiaries were less likely to reside in eligible counties, double bonuses increased payments to plans to care for Black beneficiaries by $60 per year, compared with $91 for White beneficiaries. Our findings suggest that double bonuses not only fail to improve quality and enrollment but also foster a racially inequitable distribution of Medicare funds that disfavors Black beneficiaries. Our study supports eliminating double bonuses, thereby saving Medicare an estimated $1.8 billion per year.
Collapse
Affiliation(s)
- Adam A Markovitz
- Adam A. Markovitz is an internal medicine resident at the University of Michigan, in Ann Arbor, Michigan
| | - John Z Ayanian
- John Z. Ayanian is the Alice Hamilton Collegiate Professor of Medicine in the Department of Internal Medicine, University of Michigan Medical School, and director of the Institute for Healthcare Policy and Innovation, University of Michigan
| | - Anupama Warrier
- Anupama Warrier is a PhD student in the Department of Health Management and Policy, University of Michigan School of Public Health
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| |
Collapse
|
8
|
Kerr EA, Klamerus ML, Markovitz AA, Sussman JB, Bernstein SJ, Caverly TJ, Chou R, Min L, Saini SD, Lohman SE, Skurla SE, Goodrich DE, Froehlich W, Hofer TP. Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care. JAMA Intern Med 2020; 180:1500-1508. [PMID: 32926088 DOI: 10.1001/jamainternmed.2020.4001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 01/23/2023]
Abstract
IMPORTANCE Much of health care involves established, routine use of medical services for chronic conditions or prevention. Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing. OBJECTIVE To develop a systematic, transparent, and reproducible approach for identifying, specifying, and validating deintensification recommendations associated with routine adult primary care. DESIGN, SETTING, AND PARTICIPANTS A focused review of existing guidelines and recommendations was completed to identify and prioritize potential deintensification indications. Then, 2 modified virtual Delphi expert panels examined the synthesized evidence, suggested ways that the candidate recommendations could be improved, and assessed the validity of the recommendations using the RAND/UCLA Appropriateness Method. Twenty-five physicians from Veterans Affairs and US academic institutions with knowledge in relevant clinical areas (eg, geriatrics, primary care, women's health, cardiology, and endocrinology) served as panel members. MAIN OUTCOMES AND MEASURES Validity of the recommendations, defined as high-quality evidence that deintensification is likely to improve patient outcomes, evidence that intense testing and/or treatment could cause harm in some patients, absence of evidence on the benefit of continued or repeated intense treatment or testing, and evidence that deintensification is consistent with high-quality care. RESULTS A total of 409 individual recommendations were identified representing 178 unique opportunities to stop or scale back routine services (eg, stopping population-based screening for vitamin D deficiency and decreasing concurrent use of opioids and benzodiazepines). Thirty-seven recommendations were prioritized and forwarded to the expert panels. Panelists reviewed the evidence and suggested modifications, resulting in 44 recommendations being rated. Overall, 37 recommendations (84%) were considered to be valid, as assessed by the RAND/UCLA Appropriateness Method. CONCLUSIONS AND RELEVANCE In this study, a total of 178 unique opportunities to deintensify routine primary care services were identified, and 37 of these were validated as high-priority deintensification recommendations. To date, this is the first study to develop a model for identifying, specifying, and validating deintensification recommendations that can be implemented and tracked in clinical practice.
Collapse
Affiliation(s)
- Eve A Kerr
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Mandi L Klamerus
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Adam A Markovitz
- Medical student, University of Michigan Medical School, Ann Arbor
| | - Jeremy B Sussman
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Steven J Bernstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Tanner J Caverly
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Learning Health Sciences, University of Michigan, Ann Arbor
| | - Roger Chou
- Pacific Northwest Evidence-Based Practice Center, Oregon Health & Science University, Portland.,Division of General Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Lillian Min
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Shannon E Lohman
- Medical student, Wayne State University, School of Medicine, Detroit, Michigan
| | - Sarah E Skurla
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - David E Goodrich
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Veterans Affairs Quality Enhancement Research Initiative Center for Evaluation and Implementation Research, Ann Arbor, Michigan
| | - Whit Froehlich
- Medical student, University of Michigan Medical School, Ann Arbor
| | - Timothy P Hofer
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| |
Collapse
|
9
|
Markovitz AA, Rozier MD, Ryan AM, Goold SD, Ayanian JZ, Norton EC, Peterson TA, Hollingsworth JM. Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians. J Gen Intern Med 2020; 35:133-141. [PMID: 31705479 PMCID: PMC6957659 DOI: 10.1007/s11606-019-05511-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 06/03/2019] [Accepted: 10/01/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care. OBJECTIVE To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care. DESIGN Cross-sectional survey of ACO clinicians in 2018. PARTICIPANTS 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%. MAIN MEASURES Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care. RESULTS Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation. CONCLUSIONS Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.
Collapse
Affiliation(s)
- Adam A Markovitz
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Michael D Rozier
- Department of Health Management and Policy, Saint Louis University, St. Louis, MO, USA
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Susan D Goold
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John Z Ayanian
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Economics, University of Michigan, Ann Arbor, MI, USA.,National Bureau of Economic Research, Cambridge, MA, USA
| | - Timothy A Peterson
- Physician Organization of Michigan Accountable Care Organization, Ann Arbor, MI, USA.,Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John M Hollingsworth
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
10
|
Sinha SS, Moloci NM, Ryan AM, Markovitz AA, Colla CH, Lewis VA, Hollenbeck BK, Nallamothu BK, Hollingsworth JM. The Effect of Medicare Accountable Care Organizations on Early and Late Payments for Cardiovascular Disease Episodes. Circ Cardiovasc Qual Outcomes 2019; 11:e004495. [PMID: 30354375 DOI: 10.1161/circoutcomes.117.004495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Initial evaluations of the Pioneer and Shared Savings Programs have shown modest savings associated with care receipt in a Medicare accountable care organization (ACO). Whether these savings are affected by disease chronicity and the mechanisms through which they occur are unclear. In this context, we examined the association between Medicare ACO implementation and episode spending for 2 different cardiovascular conditions. METHODS AND RESULTS We analyzed a 20% sample of national Medicare data, identifying fee-for-service beneficiaries aged ≥65 years admitted for acute myocardial infarction (AMI) or congestive heart failure (CHF) between January 2010 and October 2014. We distinguished admissions to hospitals participating in a Medicare ACO from those to hospitals that were not. We calculated 365-day, price-standardized episode spending made on behalf of these beneficiaries, differentiating between early (index admission to 90 days postdischarge) and late payments (91-365 days postdischarge). Using an interrupted time series design, we fit longitudinal multivariable models to estimate the association between hospital ACO participation and episode spending. Our study included 153 476 beneficiaries admitted for AMI to 401 ACO participating hospitals and 2597 nonparticipating hospitals and 260 420 beneficiaries admitted for CHF to 412 ACO participating hospitals and 2796 nonparticipating hospitals. On multivariable analysis, admission to an ACO participating hospital was not associated with changes in early episode spending (AMI, $95 per beneficiary; 95% CI, -$481 to $671; CHF, $158; 95% CI, -$290 to $605). However, it was associated with significant reductions in late episode spending for both cohorts (AMI, -$680; 95% CI, -$1348 to -$11; CHF, -$889; 95% CI, -$1465 to -$313). CONCLUSIONS For beneficiaries with AMI or CHF, admission to ACO participating hospitals was not associated with changes in early episode spending, but it was associated with significant savings during the late episode. ACO effects on late episode spending may complement other value-based payment reforms that target the early episode.
Collapse
Affiliation(s)
- Shashank S Sinha
- Division of Cardiovascular Medicine, Department of Internal Medicine (S.S.S., B.K.N.).,Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor
| | - Nicholas M Moloci
- Dow Division of Health Services Research, Department of Urology (N.M.M., B.K.H., J.M.H.).,Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor
| | - Andrew M Ryan
- Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R., A.A.M.)
| | - Adam A Markovitz
- Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R., A.A.M.)
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (C.H.C., V.A.L.)
| | - Valerie A Lewis
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH (C.H.C., V.A.L.)
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology (N.M.M., B.K.H., J.M.H.).,Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Internal Medicine (S.S.S., B.K.N.).,Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor.,Center for Clinical Management and Research, Ann Arbor Veterans Affairs Healthcare System, MI (B.K.N.)
| | - John M Hollingsworth
- Dow Division of Health Services Research, Department of Urology (N.M.M., B.K.H., J.M.H.)
| |
Collapse
|
11
|
Markovitz AA, Hollingsworth JM, Ayanian JZ, Norton EC, Yan PL, Ryan AM. Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis. Ann Intern Med 2019; 171:27-36. [PMID: 31207609 PMCID: PMC8757576 DOI: 10.7326/m18-2539] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs. OBJECTIVE To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit. DESIGN Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants. SETTING Fee-for-service Medicare, 2008 through 2014. PATIENTS A 20% sample (97 204 192 beneficiary-quarters). MEASUREMENTS Total spending, 4 quality indicators, and hospitalization for hip fracture. RESULTS In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile). LIMITATION The study used an observational design and administrative data. CONCLUSION After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP. PRIMARY FUNDING SOURCE Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.
Collapse
Affiliation(s)
- Adam A Markovitz
- University of Michigan Medical School and School of Public Health, Ann Arbor, Michigan (A.A.M.)
| | - John M Hollingsworth
- University of Michigan Medical School and Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan (J.M.H.)
| | - John Z Ayanian
- University of Michigan Medical School, School of Public Health, Gerald R. Ford School of Public Policy, and Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan (J.Z.A.)
| | - Edward C Norton
- University of Michigan School of Public Health, and Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, and National Bureau of Economic Research, Cambridge, Massachusetts (E.C.N.)
| | - Phyllis L Yan
- University of Michigan Medical School, Ann Arbor, Michigan (P.L.Y.)
| | - Andrew M Ryan
- University of Michigan School of Public Health, Center for Evaluating Health Reform, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan (A.M.R.)
| |
Collapse
|
12
|
Markovitz AA, Mullangi S, Hollingsworth JM, Nuliyalu U, Ryan AM. ACOs and the 1%: Changes in Spending Among High-Cost Patients Following the Medicare Shared Savings Program. J Gen Intern Med 2019; 34:1116-1118. [PMID: 31065949 PMCID: PMC6614231 DOI: 10.1007/s11606-019-04963-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/28/2022]
Affiliation(s)
- Adam A Markovitz
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - John M Hollingsworth
- University of Michigan Medical School, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Ushapoorna Nuliyalu
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ryan
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
13
|
Markovitz AA, Hollingsworth JM, Ayanian JZ, Norton EC, Moloci NM, Yan PL, Ryan AM. Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries. Health Aff (Millwood) 2019; 38:253-261. [PMID: 30715995 PMCID: PMC6394223 DOI: 10.1377/hlthaff.2018.05407] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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] [Indexed: 01/26/2023]
Abstract
The Medicare Shared Savings Program (MSSP) adjusts savings benchmarks by beneficiaries' baseline risk scores. To discourage increased coding intensity, the benchmark is not adjusted upward if beneficiaries' risk scores rise while in the MSSP. As a result, accountable care organizations (ACOs) have an incentive to avoid increasingly sick or expensive beneficiaries. We examined whether beneficiaries' exposure to the MSSP was associated with within-beneficiary changes in risk scores and whether risk scores were associated with entry to or exit from the MSSP. We found that the MSSP was not associated with consistent changes in within-beneficiary risk scores. Conversely, beneficiaries at the ninety-fifth percentile of risk score had a 21.6 percent chance of exiting the MSSP, compared to a 16.0 percent chance among beneficiaries at the fiftieth percentile. The decision not to upwardly adjust risk scores in the MSSP has successfully deterred coding increases but might discourage ACOs to care for high-risk beneficiaries in the MSSP .
Collapse
Affiliation(s)
- Adam A Markovitz
- Adam A. Markovitz is an MD-PhD candidate in the Department of Health Management and Policy, University of Michigan School of Public Health, and the University of Michigan Medical School, in Ann Arbor
| | - John M Hollingsworth
- John M. Hollingsworth is an associate professor in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, in Ann Arbor
| | - John Z Ayanian
- John Z. Ayanian is the Alice Hamilton Collegiate Professor of Medicine in the Department of Internal Medicine, University of Michigan Medical School
| | - Edward C Norton
- Edward C. Norton is a professor in the Department of Health Management and Policy in the University of Michigan School of Public Health, in Ann Arbor
| | - Nicholas M Moloci
- Nicholas M. Moloci is a senior statistician in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School
| | - Phyllis L Yan
- Phyllis L. Yan is a statistician in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School
| | - Andrew M Ryan
- Andrew M. Ryan ( ) is the UnitedHealthcare Professor of Health Care Management in the Department of Health Management and Policy, University of Michigan School of Public Health
| |
Collapse
|
14
|
Markovitz AA, Ellimoottil C, Sukul D, Mullangi S, Chen LM, Nallamothu BK, Ryan AM. Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments. Health Aff (Millwood) 2018; 36:2165-2174. [PMID: 29200351 DOI: 10.1377/hlthaff.2017.0940] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 11/05/2022]
Abstract
To reduce variation in spending, Medicare has considered implementing a cardiac bundled payment program for acute myocardial infarction and coronary artery bypass graft. Because the proposed program does not account for patient risk factors when calculating hospital penalties or rewards ("reconciliation payments"), it might unfairly penalize certain hospitals. We estimated the impact of adjusting for patients' medical complexity and social risk on reconciliation payments for Medicare beneficiaries hospitalized for the two conditions in the period 2011-13. Average spending per episode was $29,394. Accounting for medical complexity substantially narrowed the gap in reconciliation payments between hospitals with high medical severity (from a penalty of $1,809 to one of $820, or a net reduction of $989), safety-net hospitals (from a penalty of $217 to one of $87, a reduction of $130), and minority-serving hospitals (from a penalty of $70 to a reward of $56, an improvement of $126) and their counterparts. Accounting for social risk alone narrowed these gaps but had minimal incremental effects after medical complexity was accounted for. Risk adjustment may preserve incentives to care for patients with complex conditions under Medicare bundled payment programs.
Collapse
Affiliation(s)
- Adam A Markovitz
- Adam A. Markovitz ( ) is an MD/PhD candidate in health management and policy and a graduate student research assistant in the Center for Evaluating Health Reform at the University of Michigan, in Ann Arbor, and the Center for Clinical Management Research at the Veterans Affairs (VA) Ann Arbor Healthcare System
| | - Chandy Ellimoottil
- Chandy Ellimoottil is an assistant professor in the Department of Urology and the Institute for Healthcare Policy and Innovation, both at the University of Michigan. He is also director of analytics for the Michigan Value Collaborative, in Ann Arbor
| | - Devraj Sukul
- Devraj Sukul is a fellow in cardiovascular medicine at the University of Michigan Medical School
| | - Samyukta Mullangi
- Samyukta Mullangi is a healthcare administration scholar in internal medicine at the University of Michigan
| | - Lena M Chen
- Lena M. Chen is an assistant professor in the Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, both at the University of Michigan, and a physician in the VA Ann Arbor Healthcare System
| | - Brahmajee K Nallamothu
- Brahmajee K. Nallamothu is a professor in the Department of Internal Medicine, Division of Cardiovascular Medicine, and the Institute for Healthcare Policy and Innovation and director of the Michigan Integrated Center for Health Analytics and Medical Prediction, all at the University of Michigan. He is also an investigator in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor in the Department of Health Management and Policy and the Institute for Healthcare Policy and Innovation, and director of the Center for Evaluating Health Reform, all at the University of Michigan
| |
Collapse
|
15
|
Markovitz AA, Hofer TP, Froehlich W, Lohman SE, Caverly TJ, Sussman JB, Kerr EA. An Examination of Deintensification Recommendations in Clinical Practice Guidelines: Stepping Up or Scaling Back? JAMA Intern Med 2018; 178:414-416. [PMID: 29255902 PMCID: PMC5885915 DOI: 10.1001/jamainternmed.2017.7198] [Citation(s) in RCA: 12] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
In light of initiatives to decrease use of unnecessary services, this article examines whether current guidelines for diabetes and cardiovascular disease preferentially recommend intensification rather than deintensification of care.
Collapse
Affiliation(s)
- Adam A Markovitz
- VA Center for Clinical Management and Research, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Timothy P Hofer
- VA Center for Clinical Management and Research, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Whit Froehlich
- VA Center for Clinical Management and Research, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Shannon E Lohman
- VA Center for Clinical Management and Research, Ann Arbor, Michigan
| | - Tanner J Caverly
- VA Center for Clinical Management and Research, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jeremy B Sussman
- VA Center for Clinical Management and Research, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Eve A Kerr
- VA Center for Clinical Management and Research, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| |
Collapse
|
16
|
Abstract
OBJECTIVES To assess the incremental effects of adding extra antihypertensive drugs from a new class to a patient's regimen. DESIGN Instrumental variable analysis of data from SPRINT (Systolic Blood Pressure Intervention Trial). To account for confounding by indication-when treatments seem less effective if they are administered to sicker patients-randomization status was used as the instrumental variable. Patients' randomization status was either intensive (systolic blood pressure target <120 mm Hg) or standard (systolic blood pressure target <140 mm Hg) treatment. Results from instrumental variable models were compared with those from standard multivariable models. SETTING Secondary data analysis of a randomized clinical trial conducted at 102 sites in 2010-15. PARTICIPANTS 9092 SPRINT participants with hypertension and increased cardiovascular risk but no history of diabetes or stroke. MAIN OUTCOMES MEASURES Systolic blood pressure, major cardiovascular events, and serious adverse events. RESULTS In standard multivariable models not adjusted for confounding by indication, addition of an antihypertensive drug from a new class was associated with modestly lower systolic blood pressure (-1.3 mm Hg, 95% confidence interval -1.6 to -1.0) and no change in major cardiovascular events (absolute risk of events per 1000 patient years, 0.5, 95% confidence interval -1.5 to 2.3). In instrumental variable models, the addition of an antihypertensive drug from a new class led to clinically important reductions in systolic blood pressure (-14.4 mm Hg, -15.6 to -13.3) and fewer major cardiovascular events (absolute risk -6.2, -10.9 to -1.3). Incremental reductions in systolic blood pressure remained large and similar in magnitude for patients already taking drugs from zero, one, two, or three or more drug classes. This finding was consistent across all subgroups of patients. The addition of another antihypertensive drug class was not associated with adverse events in either standard or instrumental variable models. CONCLUSIONS After adjustment for confounding by indication, the addition of a new antihypertensive drug class led to large reductions in systolic blood pressure and major cardiovascular events among patients at high risk for cardiovascular events but without diabetes. Effects on systolic blood pressure persisted across all levels of baseline drug use and all subgroups of patients.
Collapse
Affiliation(s)
- Adam A Markovitz
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
- University of Michigan Center for Evaluating Health Reform, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jacob A Mack
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brahmajee K Nallamothu
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John Z Ayanian
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Gerald R Ford School of Public Policy, Ann Arbor, MI, USA
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
- University of Michigan Center for Evaluating Health Reform, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| |
Collapse
|
17
|
Markovitz AA, Holleman RG, Hofer TP, Kerr EA, Klamerus ML, Sussman JB. Effects of Guideline and Formulary Changes on Statin Prescribing in the Veterans Affairs. Health Serv Res 2017; 52:1996-2017. [PMID: 29130272 DOI: 10.1111/1475-6773.12788] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 01/16/2023] Open
Abstract
OBJECTIVE To compare the effects of two sequential policy changes-the addition of a high-potency statin to the Department of Veterans Affairs (VA) formulary and the release of the American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines-on VA provider prescribing. DATA SOURCES/STUDY SETTING Retrospective analysis of 1,100,682 VA patients, 2011-2016. STUDY DESIGN Interrupted time-series analysis of changes in prescribing of moderate-to-high-intensity statins among high-risk patients and across high-risk subgroups. We also assessed changes in prescribing of atorvastatin and other statin drugs. We estimated marginal effects (ME) of formulary and guideline changes by comparing predicted and observed statin use. DATA COLLECTION/EXTRACTION METHODS Data from VA Corporate Data Warehouse. PRINCIPAL FINDINGS The use of moderate-to-high-intensity statins increased by 2 percentage points following the formulary change (ME, 2.4, 95% confidence interval [CI], 2.2 to 2.6) and less than 1 percentage point following the guideline change (ME, 0.8, 95% CI, 0.6 to 0.9). The formulary change led to approximately a 12 percentage-point increase in the use of moderate-to-high-intensity atorvastatin (ME, 11.5, 95% CI, 11.3 to 11.6). The relatively greater provider response to the formulary change occurred across all patient subgroups. CONCLUSIONS Addition of a high-potency statin to formulary affected provider prescribing more than the ACC/AHA guidelines.
Collapse
Affiliation(s)
- Adam A Markovitz
- VA Center for Clinical Management and Research, Ann Arbor, MI.,University of Michigan Medical School, Ann Arbor, MI.,University of Michigan School of Public Health, Ann Arbor, MI
| | - Rob G Holleman
- VA Center for Clinical Management and Research, Ann Arbor, MI
| | - Timothy P Hofer
- VA Center for Clinical Management and Research, Ann Arbor, MI.,University of Michigan Medical School, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Eve A Kerr
- VA Center for Clinical Management and Research, Ann Arbor, MI.,University of Michigan Medical School, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Jeremy B Sussman
- VA Center for Clinical Management and Research, Ann Arbor, MI.,University of Michigan Medical School, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| |
Collapse
|
18
|
Markovitz AA, Ramsay PP, Shortell SM, Ryan AM. Financial Incentives and Physician Practice Participation in Medicare's Value-Based Reforms. Health Serv Res 2017; 53 Suppl 1:3052-3069. [PMID: 28748535 DOI: 10.1111/1475-6773.12743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms. DATA SOURCES/STUDY SETTING Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013). STUDY DESIGN We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures. DATA COLLECTION/EXTRACTION METHODS We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey. PRINCIPAL FINDINGS There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001). CONCLUSIONS Physicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.
Collapse
Affiliation(s)
- Adam A Markovitz
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor, MI.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Patricia P Ramsay
- Center for Healthcare Organizational and Innovation Research, University of California Berkeley School of Public Health, Berkeley, CA
| | - Stephen M Shortell
- Center for Healthcare Organizational and Innovation Research, University of California Berkeley School of Public Health, Berkeley, CA
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| |
Collapse
|
19
|
Abstract
Research on the effects of pay-for-performance (P4P) in health care indicates largely disappointing results. This central finding, however, may mask important heterogeneity in the effects of P4P. We conducted a literature review to assess whether hospital and physician performance in P4P vary by patient and catchment area factors, organizational and structural capabilities, and P4P program characteristics. Several findings emerged: organizational size, practice type, teaching status, and physician age and gender modify performance in P4P. For physician practices and hospitals, a higher proportion of poor and minority patients is consistently associated with worse performance. Other theoretically influential characteristics-including information technology and staffing levels-yield mixed results. Inconsistent and contradictory effects of bonus likelihood, bonus size, and marginal costs on performance in P4P suggest organizations have not responded strategically to financial incentives. We conclude that extant heterogeneity in the effects of P4P does not fundamentally alter current assessments about its effectiveness.
Collapse
|
20
|
Ryan AM, Tompkins CP, Markovitz AA, Burstin HR. Linking Spending and Quality Indicators to Measure Value and Efficiency in Health Care. Med Care Res Rev 2016; 74:452-485. [DOI: 10.1177/1077558716650089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Policy makers and stakeholders have reached a consensus that both quality and spending or resource use indicators should be jointly measured and prioritized to meet the objectives of our health system. However, the relative merits of alternative approaches that combine quality and spending indicators are not well understood. We conducted a literature review to identify different approaches that combine indicators of quality and spending measures to profile provider efficiency in the context of specific applications in health care. Our investigation identified seven alternative models that are either in use or have been proposed to evaluate provider efficiency. We then used publicly available data to profile hospitals using these approaches. Profiles of hospital efficiency using alternative models yielded wide variation in performance, underscoring the importance of model selection. By identifying the current efficiency models and evaluating their trade-offs within specific programmatic contexts, our analysis informs stakeholder and policy maker decisions about how to link quality and spending indicators when measuring efficiency in health care.
Collapse
Affiliation(s)
- Andrew M. Ryan
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | | | | |
Collapse
|
21
|
Markovitz AA, Simanek AM, Yolken RH, Galea S, Koenen KC, Chen S, Aiello AE. Toxoplasma gondii and anxiety disorders in a community-based sample. Brain Behav Immun 2015; 43:192-7. [PMID: 25124709 DOI: 10.1016/j.bbi.2014.08.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/28/2014] [Accepted: 08/04/2014] [Indexed: 01/13/2023] Open
Abstract
A growing body of literature suggests that exposure to the neurotropic parasite Toxoplasma gondii (T. gondii) is associated with increased risk of mental disorders, particularly schizophrenia. However, a potential association between T. gondii exposure and anxiety disorders has not been rigorously explored. Here, we examine the association of T. gondii infection with both anxiety and mood disorders. Participants (n=484) were drawn from the Detroit Neighborhood Health Study, a population-representative sample of Detroit residents. Logistic regression was used to examine the associations between T. gondii exposure (defined by seropositivity and IgG antibody levels) and three mental disorders: generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD) and depression. We found that T. gondii seropositivity was associated with a 2 times greater odds of GAD (odds ratio (OR), 2.25; 95% confidence interval (CI), 1.11-4.53) after adjusting for age, gender, race, income, marital status, and medication. Individuals in the highest antibody level category had more than 3 times higher odds of GAD (OR, 3.35; 95% CI, 1.41-7.97). Neither T. gondii seropositivity nor IgG antibody levels was significantly associated with PTSD or depression. Our findings indicate that T. gondii infection is strongly and significantly associated with GAD. While prospective confirmation is needed, T. gondii infection may play a role in the development of GAD.
Collapse
Affiliation(s)
- Adam A Markovitz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI 48109, United States
| | - Amanda M Simanek
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI 53201, United States
| | - Robert H Yolken
- Department of Pediatrics, Stanley Division of Developmental Neurovirology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Sandro Galea
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, United States
| | - Karestan C Koenen
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, United States
| | - Shu Chen
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, United States
| | - Allison E Aiello
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC 27599, United States.
| |
Collapse
|