Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance.

IMPORTANCE: Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE: The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS: A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES: Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS: BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS: BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.

Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening: A Systematic Review and Meta-analysis.

Importance: Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening. Objective: To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening. Data Sources: PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies. Study Selection: Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded. Data Extraction and Synthesis: The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised. Main Outcomes and Measures: The primary outcome was CRC screening completion within 12 months of receiving the intervention. Results: A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18). Conclusions and Relevance: Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.

Primary care physicians' perceptions of the role of alternative payment models in recruitment and retention in rural Alberta: a qualitative study.

BACKGROUND: Despite well-documented challenges in recruiting physicians to rural practice, few Canadian studies have described the role physician payment models may play in attracting and retaining physicians to rural practice. This study examined the perspectives of rural primary care physicians on the factors that attract and retain physicians in rural locations, including the role that alternative payment models (APMs) might play. METHODS: This was a qualitative study involving in-depth, open-ended interviews with rural primary care physicians practising under fee-for-service (FFS) models and APMs in Alberta, Canada. Participants were recruited from the Rural Health Professions Action Plan member list (consisting of physicians practising in rural or remote locations in Alberta) and the College of Physicians and Surgeons of Alberta online database. Interviews were conducted April to June 2020, and data were analyzed using a thematic framework approach. RESULTS: Fourteen physicians were interviewed. There were 5 themes identified: factors that attract physicians to rural practice, barriers and challenges associated with rural practice, the potential role of APMs in recruitment and retention, factors that physicians consider in deciding to change payment models, and physician perceptions of APMs compared with FFS models. Participants expressed that APMs may have some role to play in retaining rural physicians but identified professional challenges, and family-related and personal factors as key determinants. Most FFS physicians indicated that they were interested in exploring APMs provided specific concerns were addressed (e.g., clear and adequately compensated APM contracts, and physician involvement in the development of APMs). INTERPRETATION: Primary care physicians practising in rural regions in Alberta view payment models as one consideration among many in their decision to pursue rural practice. Alternative payment model contracts designed with the input of physicians may have a role to play in attracting and retaining physicians to rural practice.

Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists.

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.

Payment methods for healthcare providers working in outpatient healthcare settings.

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

Optimal staffing in community health centers to improve quality of care.

OBJECTIVE: To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services. DATA SOURCES: We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs. STUDY DESIGN: We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function. FINDINGS: Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ. CONCLUSION: As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients.

IMPORTANCE: The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE: To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES: Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS: The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS: The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

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.

Trends in Diagnosis Related Groups for Inpatient Admissions and Associated Changes in Payment From 2012 to 2016.

Importance: Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities. Objective: To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment. Design, Setting, and Participants: This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019. Exposures: Quarter year of hospitalization. Main Outcomes and Measures: The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts. Results: Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment. Conclusions and Relevance: In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment.

Association of Billed Advance Care Planning with End-of-Life Care Intensity for 2017 Medicare Decedents.

BACKGROUND/OBJECTIVE: The Centers for Medicare & Medicaid Services (CMS) reimburses clinicians for advance care planning (ACP) discussions with Medicare patients. The objective of the study was to examine the association of CMS-billed ACP visits with end-of-life (EOL) healthcare utilization. DESIGN: Patient-level analyses of claims for the random 20% Medicare fee-for-service (FFS) sample of decedents in 2017. To account for multiple comparisons, Bonferroni adjusted P value <.008 was considered statistically significant. SETTING: Nationally representative sample of Medicare FFS beneficiaries. PARTICIPANTS: A total of 237,989 Medicare FFS beneficiaries who died in 2017 and included those with and without a billed ACP visit during 2016-17. INTERVENTION: The key exposure variable was receipt of first billed ACP (none, >1 month before death). MEASUREMENTS: Six measures of EOL healthcare utilization or intensity (inpatient admission, emergency department [ED] visit, intensive care unit [ICU] stay, and expenditures within 30 days of death, in-hospital death, and first hospice within 3 days of death). Analyses was adjusted for age, race, sex, Charlson Comorbidity Index, expenditure by Dartmouth hospital referral region (high, medium, or low), and dual eligibility. RESULTS: Overall, 6.3% (14,986) of the sample had at least one billed ACP visit. After multivariable adjustment, patients with an ACP visit experienced significantly less intensive EOL care on four of six measures: hospitalization (odds ratio [OR] = .77; 95% confidence interval [CI] = .74-.79), ED visit (OR = .77; 95% CI = .75-.80), or ICU stay (OR = .78; 95% CI = .74-.81) within a month of death; and they were less likely to die in the hospital (OR = .79; 95% CI = .76-.82). There were no differences in the rate of late hospice enrollment (OR = .97; 95% CI = .92-1.01; P = .119) or mean expenditures ($242.50; 95% CI = -$103.63 to $588.61; P = .169). CONCLUSION: Billed ACP visits were relatively uncommon among Medicare FFS decedents, but their occurrence was associated with less intensive EOL utilization. Further research on the variables affecting hospice use and expenditures in the EOL period is recommended to understand the relative role of ACP.

Administrative Burden and Costs of Prior Authorizations in a Dermatology Department.

Importance: Insurance companies use prior authorizations (PAs) to address inappropriate prescribing or unnecessary variations in care, most often for expensive medications. Prior authorizations negatively affect patient care and add costs and administrative burden to dermatology offices. Objective: To quantify the administrative burden and costs of dermatology PAs. Design, Setting, and Participants: The University of Utah Department of Dermatology employs 2 full-time and 8 part-time PA staff. In this cross-sectional study at a large academic department spanning 11 clinical locations, these staff itemized all PA-related encounters over a 30-day period in September 2016. Staff salary and benefits were publicly available. Data were analyzed between December 2018 and August 2019. Main Outcomes and Measures: Proportion of visits requiring PAs, median administrative time to finalize a PA (either approval or denial after appeal), and median cost per PA type. Results: In September 2016, 626 PAs were generated from 9512 patient encounters. Staff spent 169.7 hours directly handling PAs, costing a median of $6.72 per PA. Biologic PAs cost a median of $15.80 each and took as long as 31 business days to complete. The costliest PA equaled 106% of the associated visit's Medicare reimbursement rate. Approval rates were 99.6% for procedures, 78.9% for biologics, and 58.2% for other medications. After appeal, 5 of 23 (21.7%) previously denied PAs were subsequently approved. Conclusions and Relevance: Prior authorizations are costly to dermatology practices and their value appears limited for some requests. Fewer unnecessary PAs and appeals might increase practice efficiency and improve patient outcomes.

Medicare's Bundled Payment Initiatives for Hospital-Initiated Episodes: Evidence and Evolution.

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment. CONTEXT: Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality. METHODS: We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs. FINDINGS: Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change. CONCLUSIONS: Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model. DATA SOURCES: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas. STUDY DESIGN: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR. PRINCIPAL FINDINGS: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant. CONCLUSIONS: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Are Recently Evaluated Drugs More Likely to Receive Positive Reimbursement Recommendations in South Korea? 11-year Experience of the South Korean Positive List System.

PURPOSE: The South Korean government in 2014 introduced various policies to enhance accessibility of pharmaceuticals. This study sought to examine whether positive reimbursement recommendations of pharmaceuticals have increased since 2014. METHODS: Industry submissions evaluated from January 2007 to December 2018 were identified, and characteristics relevant to reimbursement recommendations were extracted. Logistic regression analyses with robust SEs were used to quantify the likelihood of positive recommendations for pharmaceuticals, after controlling for relevant factors influencing the recommendations. FINDINGS: During the study period, 355 (72.9%) of 487 submissions were positively recommended; the drugs evaluated after 2014 (77.8%) were significantly more likely to receive positive reimbursement recommendations than the drugs evaluated before 2014 (69.5%). In the multivariable logistic regression analysis, several factors (labeled a noncancer drug, priced less than alternatives, considered clinically superior, and having budget impact >10 billion South Korean won) were significantly associated with positive recommendations (P < 0.05). When considering interaction effects between evaluation year and other variables, only the interaction between comparative clinical benefit and evaluation year was significant. Specifically, clinically noninferior drugs evaluated after 2014 had 2.85 times the odds of receiving positive recommendations compared with the clinically noninferior drugs evaluated earlier. IMPLICATIONS: Recently evaluated drugs are more likely to receive positive reimbursement recommendations, especially those drugs whose comparative clinical benefits are noninferior.

Reimbursement patterns and user experiences in pediatric allergy home telehealth.

BACKGROUND: Telehealth use has been increasing during the last decade. Studies have found that patients have a positive attitude toward incorporating telehealth into their health care. Substantial uncertainty remains regarding reimbursement policies that vary widely between states and by payer. OBJECTIVE: To explore the clinical, operational, and financial feasibility of a home telehealth (HTH) program in a pediatric allergy and immunology clinic. METHODS: Allergy and immunology physicians defined use cases they deemed appropriate for HTH appointments. Established patients in the allergy and immunology clinic were approached to complete an attitudes and perception survey. Patients who met the use case definitions were asked to participate in the pilot program. After their HTH appointment took place, they completed a validated satisfaction survey. Our institution's revenue cycle management team provided reimbursement data. RESULTS: Patient attitudes toward HTH were generally favorable. A total of 51 HTH appointments were offered, and 46 appointments were made. Notably, 37 appointments were completed successfully among 32 unique patients. Patients were satisfied with the HTH experience. A total of 36 of 37 encounters were reimbursed by 19 different public and private payers. Payers on average reimbursed ±6% of the expected allowable for an equivalent in-person visit. CONCLUSION: Patients had reservations about HTH initially but were satisfied with their experience. Private and public payers reimbursed HTH the same as in-person appointments. Here, we report that HTH is well accepted by patients and is financially viable.

The Impact of Medicare's Alternative Payment Models on the Value of Care.

Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.