Joshua M. Liao

Association of Hospital Participation in a Medicare Bundled Payment Program With Volume and Case Mix of Lower Extremity Joint Replacement Episodes

Importance Medicare’s Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacement (LEJR) surgery has been associated with a reduction in episode spending and stable-to-improved quality. However, BPCI may create unintended effects by prompting participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings or prompt them to shift case mix to lower-risk patients. Objective To evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix. Design, Setting, and Participants Observational study using Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (nu2009=u2009322) and 175 markets with no participating hospitals (nu2009=u20091340), accounting for 580 043 Medicare beneficiaries treated before (January 2011-September 2013) and 462 161 after (October 2013-December 2015) establishing the BPCI initiative. Hospital-level case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets. Exposures Hospital BPCI participation. Main Outcomes and Measures Changes in market-level LEJR volume in the before vs after BPCI periods and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors. Results Among the 1 717 243 Medicare beneficiaries who underwent LEJR (mean age, 75 years; 64% women; and 95% nonblack race/ethnicity), BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8% from 3.8 episodes per 1000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4% from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32% (95% CI, −0.06% to 0.69%; Pu2009=u2009.10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated with differential changes in hospital-level case mix for only 1 factor, prior skilled nursing facility use (adjusted difference-in-differences estimate, −0.53%; 95% CI, −0.96% to −0.10%; Pu2009=u2009.01) in BPCI vs non-BPCI markets. Conclusions and Relevance In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR.

Trends in hospital-SNF relationships in the care of Medicare beneficiaries

Improving the value of post-acute care at skilled nursing facilities (SNFs) has become a Medicare policy priority. Anecdotally, hospitals have responded by formally acquiring or pursuing tighter informal connections with SNFs. We evaluated the trend in connections between US acute care hospitals and Medicare-certified SNFs between 2000 and 2013 using vertical integration and two novel network-based measures (number of SNF partners, and discharge concentration). Among 4441 hospitals and 17,215 SNFs, hospitals with weaker connections with SNFs were more often non-profit, major teaching hospitals with a larger number of discharges and beds. We found an apparent weakening of hospital-SNF connections over time for all three measures. Over one-third (39%) of hospitals were vertically integrated in 2000 compared to 8.2% in 2013. The number of SNF partners increased between 2000 and 2013, while hospitals discharge concentration declined steadily. Additional work is needed to understand the implications of these trends.

Reframing the Value Proposition of Coronary Artery Bypass Graft Bundles

The Coronary Artery Bypass Graft (CABG) Model— designed to take effect in 98 urban health care markets across the United States—exemplifies Medicare’s commitment to promote value-based care through CABG bundles. The mandatory program would have held over 1100 hospitals accountable for the quality and costs of CABG episodes: hospitals that maintain quality and keep spending below a predefined benchmark are eligible for financial savings, while those whose spending exceeds the benchmark are liable for financial losses. Bundles would be triggered by hospitalization for CABG Medicare severity diagnosis-related groups and encompass 90 days of postacute care. Although the CABG Model aims to improve care delivery and coordination, its initial ruling was met with criticism from lawmakers and stakeholders.1 A recent proposal by Medicare to cancel mandatory bundles for CABG and other conditions in favor of voluntary programs2 highlights major ongoing questions about how best to implement bundled payment going forward. InthisViewpoint,weidentifymandatoryparticipation and potential increases in CABG volume as major areas of contention about CABG bundles as proposed to date. We argue that alternative perspectives on each area can help to reframe the value proposition and provide insight regardless of the future direction of CABG bundles.

The Association Between Mentor-Mentee Network Features and Publication Productivity Among Early Career Academic Generalists

Division of General Internal Medicine at the Perelman School of Medicine , University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, Philadelphia, PA, USA; Division ofGeneral InternalMedicine, University ofWashington, Seattle,Washington, USA; UW Medicine Value and Systems Science Lab, Seattle, Washington, USA; Division of Pulmonary, Allergy and Critical CareMedicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of General Internal Medicine, Harbor-UCLA Medical Center, California, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Physician Perspectives In Year 1 Of MACRA And Its Merit-Based Payment System: A National Survey

We surveyed a national sample of internal medicine physicians in March-Mayxa02017 to explore their beliefs about the newly implemented Merit-based Incentive Payment System (MIPS). Respondents believed that their efforts in the four focus areas identified in the survey would ultimately improve the value of care. When informed that those areas represented the four MIPS domains, the majority remained positive about the likely impact on value. However, expectations varied by physicians characteristics and sense of control over the desired outcomes, and many respondents believed that unintended consequences could occur. Moreover, respondents generally reported low familiarity with the policy and disagreed with program guidelines for weighting domains in the composite score. These findings indicate the need to educate physicians about MIPS and suggest potentially fruitful approaches. Moving forward, policy makers should monitor for unintended consequences and explore ways to better align program guidelines with physicians perspectives.

Comparison Of Hospitals Participating In Medicare’s Voluntary And Mandatory Orthopedic Bundle Programs

We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicares voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost. These findings suggest that while both voluntary and mandatory approaches can play a role in engaging hospitals in bundled payment, mandatory programs can produce more robust, generalizable evidence. Either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payment programs.

The State of Health Information Exchange

Since 1998, when the US government committed approximately 30 billion dollars over 10 years [1] to promoting the use of electronic health records (EHRs) through the Health Information Technology for Economic and Clinical Health Act, a great deal of effort has been made to address how EHRs could be adopted by US care providers and used to improve quality of care through the sharing of important health information. Along with funding, specific meaningful use objectives have been developed for staged implementations [1].