Hospital performance in a statewide commercial insurer episode-based incentive program.

OBJECTIVES: To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN: Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS: Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS: Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS: There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.

Cardiac Rehabilitation Reduces 2-Year Mortality After Coronary Artery Bypass Grafting.

BACKGROUND: Cardiac rehabilitation (CR) is a supervised outpatient exercise and risk reduction program offered to patients who have undergone coronary revascularization procedures. Multiple professional societal guidelines support the use of CR after coronary artery bypass grafting (CABG) based on studies in combined percutaneous coronary intervention and CABG populations with surrogate outcomes. This statewide analysis of patients undergoing CABG evaluated the relationship between CR use and long-term mortality. METHODS: Medicare fee-for-service claims were linked to surgical data for patients discharged alive after isolated CABG from January 1, 2015, through September 30, 2019. Outpatient facility claims were used to identify any CR use within 1 year of discharge. Death within 2 years of discharge was the primary outcome. Mixed-effects logistic regression was used to predict CR use, adjusting for a variety of comorbidities. Unadjusted and inverse probability treatment weighting (IPTW) were used to compare 2-year mortality among CR users vs nonusers. RESULTS: A total of 3848 of 6412 patients (60.0%) were enrolled in CR for an average of 23.2 (SD, 12.0) sessions, with 770 of 6412 (12.0%) completing all recommended 36 sessions. Logistic regression identified increasing age, discharge to home (vs extended care facility), and shorter length of stay as predictors of postdischarge CR use (P < .05). Unadjusted and IPTW analyses showed significant reduction in 2-year mortality in CR users compared with CR nonusers (unadjusted: 9.4% reduction; 95% CI, 10.8%-7.9%; P < .001; IPTW: -4.8% reduction; 95% CI, 6.0%-3.5%; P < .001). CONCLUSIONS: These data suggest that CR use is associated with lower 2-year mortality. Future quality initiatives should consider identifying and addressing root causes of poor CR enrollment and completion.

Assessment of Patterns of Atherectomy Use.

Background Atherectomy has become the fastest growing catheter-based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized. Methods and Results We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee-for-service professional claims data from the Michigan Value Collaborative for patients undergoing office-based laboratory atherectomy in 2019 to calculate provider-specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office-based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office-based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09-$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80-$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90-day conversion rate was 5.0% (IQR, 2.5%-10.0%), whereas the median provider-level average number of vessels treated per patient was 1.20 (IQR, 1.13-1.31) and the median provider-level average number of treatments per patient was 1.38 (IQR, 1.26-1.63). Total annual reimbursement for each provider was directly correlated with new patient-procedure conversion rate (R2=0.47; P<0.001), mean number of vessels treated per patient (R2=0.31; P<0.001), and mean number of treatments per patient (R2=0.33; P<0.001). Conclusions A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.

Area Deprivation and Medicare Spending for Coronary Artery Bypass Grafting: Insights From Michigan.

BACKGROUND: Prior work has established that high socioeconomic deprivation is associated with worse short- and long-term outcomes for patients undergoing coronary artery bypass grafting (CABG). The relationship between socioeconomic status and 90-day episode spending is poorly understood. In this observational cohort analysis, we evaluated whether socioeconomically disadvantaged patients were associated with higher expenditures during 90-day episodes of care after isolated CABG. METHODS: We linked clinical registry data from 8728 isolated CABG procedures from January 1, 2012, to December 31, 2018, to Medicare fee-for-service claims data. Our primary exposure variable was patients in the top decile of the Area Deprivation Index. Linear regression was used to compare risk-adjusted, price-standardized 90-day episode spending for deprived against nondeprived patients as well as component spending categories: index hospitalization, professional services, post acute care, and readmissions. RESULTS: A total of 872 patients were categorized as being in the top decile. Mean 90-day episode spending for the 8728 patients in the sample was $55 258 (SD, $26 252). Socioeconomically deprived patients had higher overall 90-day spending compared with nondeprived patients ($61 579 vs $54 557; difference, $3003; P = .001). Spending was higher in socioeconomically deprived patients for index hospitalizations (difference, $1284; P = .005), professional services (difference, $379; P = .002), and readmissions (difference, $1188; P = .008). Inpatient rehabilitation was the only significant difference in post-acute care spending (difference, $469; P = .011). CONCLUSIONS: Medicare spending was higher for socioeconomically deprived CABG in Michigan, indicating systemic disparities over and above patient demographic factors.

High Socioeconomic Deprivation and Coronary Artery Bypass Grafting Outcomes: Insights From Michigan.

BACKGROUND: Cardiovascular outcomes are worse among individuals from areas with limited socioeconomic resources. This study evaluated the relationship between high socioeconomic deprivation and isolated coronary artery bypass grafting (CABG) outcomes. METHODS: We linked statewide Society of Thoracic Surgeons Adult Cardiac Surgery Database data to Medicare Fee-for-Service records for 10 423 Michigan residents undergoing isolated CABG between January 2012 and December 2018. High socioeconomic deprivation was defined as residing in the highest decile of the ZIP Code-level area deprivation index (ADI). Multivariable logistic regression estimated the relationship between top ADI decile and major morbidity, in-hospital mortality, and operative mortality. Survival analyses evaluated long-term survival comparing patients in the top vs not in the top ADI decile. RESULTS: A total of 1036 patients were in the top decile of ADI (ADI >82.4), and they were more likely to be female, Black, and have a higher predicted risk of mortality. Patients in the top ADI decile had significantly higher rates of major morbidity (17.4% vs 11.4%; adjusted odds ratio, 1.26; 95% CI, 1.04-1.54; P = .021) and in-hospital mortality (3.2% vs 1.3%, adjusted odds ratio, 1.84; 95% CI, 1.18-2.86, P = .007) but not operative mortality. The adjusted hazard of mortality was 16% higher for patients residing in the top ADI decile (95% CI, 1.01-1.33; P = .032). CONCLUSIONS: Isolated CABG patients residing in the highest areas of socioeconomic deprivation differed with respect to demographic and clinical characteristics and experienced worse short- and long-term outcomes compared with those not in the top ADI decile.