Is it ethical to incentivize mammography screening in medicaid populations?- A policy review and conceptual analysis.

Mammography screening is controversial, as screening decisions are preference-sensitive: equally well-informed women do not universally get mammograms. Offering financial incentives for screening risks unduly influencing the decision-making process and may undermine voluntariness-yet incentives are being used in 4 US states (Arizona, Indiana, Kentucky, Michigan) under Section 1115 waivers. These initiatives are especially problematic in Medicaid populations who typically have lower health literacy and face the potential threat of disenrollment if they opt out. From June 2018 to January 2019, we analyzed publicly-available information on mammography incentives from the Centers for Medicare and Medicaid Services (CMS) and identified criteria (i.e. starting age and frequency of mammography) for incentive eligibility; income brackets of the affected beneficiaries; whether incentives were financial rewards or penalties; and evaluation arrangements. Several ethically relevant differences emerged: all states except Michigan incentivize screening at starting ages and frequencies that conflict with the US Preventive Services Task Force guidelines. Some incentives are rewards (e.g. reduced cost-sharing), and some penalties (e.g. disenrollment). Across states, rewards range from the equivalent of <1 min of work at state minimum wage to 9 days, and penalties range from 2 to 8 h. Political objectives, rather than evidence and ethics, appear to drive mammography incentive design. Programs risk harming vulnerable low-income populations. CMS and US states should therefore review variations and prevent unjustifiable practices, such as incentivizing 35-year-old women. Large incentives should be offered only if accompanied by robust studies. Incentives for using evidence-based mammography decision-aids, instead of mammography completion, better realize the intended goals.

Spillover Effects of Medicare's Voluntary Bundled Payments for Joint Replacement Surgery to Patients Insured by Commercial Health Plans.

BACKGROUND: Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries. OBJECTIVE: To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA). DESIGN: Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016. SETTING: LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals. PATIENTS: 184 922 patients with MA or commercial insurance. MEASUREMENTS: Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers. RESULTS: Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; P = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; P = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status. LIMITATION: Nonrandomized studies are subject to residual confounding and selection. CONCLUSION: Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage. PRIMARY FUNDING SOURCE: Leonard Davis Institute of Health Economics at the University of Pennsylvania.

Public Opinion on Cognitive Enhancement Varies across Different Situations.

People vary widely in their acceptance of the use of pharmacological cognitive enhancement (CE). We tested the hypothesis that the acceptability of CE is malleable, by varying the context in which CE use takes place, by framing the use of CE with positive and negative metaphors, and by distinguishing between self and other CE use. 2,519 US-based participants completed 2 surveys using Amazon's Mechanical Turk. First, participants responded to vignettes describing a fictional character, which varied by framing metaphor (Pandora's box that releases brain performance vs. key that unlocks brain potential), role/setting (student/educational vs. employee/professional), and activity type (blue vs. white collar). Second, participants viewed personalized vignettes describing their own situations. Across both surveys, participants generally found CE use more acceptable for employees than students, while the effects of framing metaphors were unreliable and smaller than previously reported. People were more accepting of CE use by others than by themselves. Participants also found CE use more acceptable if more peers used CE, the environment was less competitive, and authority figures encouraged CE use. Our findings suggest that opinions about CE are indeed malleable, and concerns that peer pressure, the influence of authority figures, and competition might affect CE use are not unfounded.

Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study.

OBJECTIVE: To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. DESIGN: Quasi-experimental difference-in-differences analysis. SETTING: US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. PARTICIPANTS: 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. MAIN OUTCOME MEASURES: Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. RESULTS: In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points). CONCLUSIONS: In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

Changes in Outpatient Imaging Utilization and Spending Under a New Population-Based Primary Care Payment Model.

OBJECTIVE: To evaluate whether the implementation of a new population-based primary care payment system, Population-Based Payments for Primary Care (3PC), initiated by Hawaii Medical Service Association (HMSA; the Blue Cross Blue Shield of Hawaii), was associated with changes in spending and utilization for outpatient imaging in its first year. METHODS: In this observational study, we used claims data from January 1, 2012, to December 31, 2016. We used a propensity-weighted difference-in-differences design to compare 70,284 HMSA patients in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in 3PC in its first year of implementation (2016) and 195,902 patients attributed to 312 PCPs and 14 physician organizations that used a fee-for-service model during the study period. The primary outcome was total spending on outpatient imaging tests, and secondary outcomes included spending and utilization by modality. RESULTS: The study included 266,186 HMSA patients (mean age of 43.3 years; 51.7% women) and 419 PCPs (mean age of 54.9 years; 34.8% women). The 3PC system was not significantly associated with changes in total spending for outpatient imaging. Of 12 secondary outcomes, only 3 were statistically significant, including changes in nuclear medicine spending (adjusted differential change = -20.1% [95% confidence interval = -27.5% to -12.1%]; P < .001) and utilization (adjusted differential change = -18.1% [95% confidence interval = -23.8 to -11.9%]; P < .001). DISCUSSION: The HMSA 3PC system was not associated with significant changes in total spending for outpatient imaging, though spending and utilization on nuclear medicine tests decreased.

Spending And Quality After Three Years Of Medicare's Voluntary Bundled Payment For Joint Replacement Surgery.

Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highest-volume episode in both BPCI and BPCI Advanced, there is a paucity of independent evidence about its long-term impact on outcomes and about whether improvements vary by timing of participation or arise from patient selection rather than changes in clinical practice. We found that over three years, compared to no participation, participation in BPCI was associated with a 1.6 percent differential decrease in average LEJR episode spending with no differential changes in quality, driven by early participants. Patient selection accounted for 27 percent of episode savings. Our findings have important policy implications in view of BPCI Advanced and its two participation waves.

Overlap between Medicare's Voluntary Bundled Payment and Accountable Care Organization Programs.

Accountable care organizations (ACOs) and bundled payments represent prominent value-based payment models, but the magnitude of overlap between the two models has not yet been described. Using Medicare data, we defined overlap based on attribution to Medicare Shared Savings Program (MSSP) ACOs and hospitalization for Bundled Payments for Care Improvement (BPCI) episodes at BPCI participant hospitals. Between 2013 and 2016, overlap as a share of ACO patients increased from 2.7% to 10% across BPCI episodes, while overlap as a share of all bundled payment patients increased from 19% to 27%. Overlap from the perspectives of both ACO and bundled payments varied by specific episode. In the first description of overlap between ACOs and bundled payments, one in every ten MSSP patients received care under BPCI by the end of our study period, whereas more than one in every four patients receiving care under BPCI were also attributed to MSSP. Policymakers should consider strategies to address the clinical and policy implications of increasing payment model overlap.

Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations.

Importance: An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models. Objective: To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. Design, Setting, and Participants: This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States. Exposures: Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants). Main Outcomes and Measures: Changes in clinical outcomes and mean LEJR episode spending. Results: A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants. Conclusions and Relevance: Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.

National Representativeness Of Hospitals And Markets In Medicare's Mandatory Bundled Payment Program.

In 2016 Medicare implemented its first mandatory alternative payment model, the Comprehensive Care for Joint Replacement (CJR) program, in which the agency pays clinicians and hospitals a fixed amount for services provided in hip and knee replacement surgery episodes. Medicare made CJR mandatory, rather than voluntary, to produce generalizable evidence on what results Medicare might expect if it scaled bundled payment up nationally. However, it is unknown how markets and hospitals in CJR compare to others nationwide, particularly with respect to baseline quality and spending performance and the structural hospital characteristics associated with early savings in CJR. Using data from Medicare, the American Hospital Association, and the Health Resources and Services Administration, we found differences in structural market and hospital characteristics but largely similar baseline hospital episode quality and spending. Our findings suggest that despite heterogeneity in hospital characteristics associated with early savings in CJR, Medicare might nonetheless reasonably expect similar results by scaling CJR up to additional urban markets and increasing total program coverage to areas in which 71 percent of its beneficiaries reside. In contrast, different policy designs may be needed to extend market-level programs to other regions or enable different hospital types to achieve savings from bundled payment reimbursement.

The Current State of Evidence on Bundled Payments.

A review of the evidence shows that bundled payments for surgical procedures can generate savings without adversely affecting patient outcomes. Less is known about the effect of bundled payments for chronic medical conditions, but early evidence suggests that cost and quality improvements may be small or non-existent. There is little evidence that bundles reduce access and equity, but continued monitoring is required.

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 (n = 322) and 175 markets with no participating hospitals (n = 1340), 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%; P = .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%; P = .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.