National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Ambulatory Care and Surgery (1)
- Children's Health Insurance Program (CHIP) (1)
- Diabetes (1)
- Electronic Health Records (EHRs) (1)
- Healthcare Costs (4)
- Health Information Technology (HIT) (1)
- (-) Health Insurance (7)
- Hospital Readmissions (1)
- Hospitals (1)
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- (-) Payment (7)
- Policy (1)
- Provider Performance (1)
- Surgery (2)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 7 of 7 Research Studies DisplayedRoberts ET, Nimgaonkar A, Aarons J
New evidence of state variation in Medicaid payment policies for dual Medicare-Medicaid enrollees.
The authors developed the first longitudinal database of state Medicaid policies for paying the cost sharing in Medicare Part B for services provided to dual Medicare-Medicaid enrollees (duals), and an index summarizing the impact of these policies on payments for physician office services. Information from 2004-2018 was consolidated from online Medicaid policy documents, state laws, and policy data reported to them by state Medicaid programs. The database showed that in 2018 42 states had policies to limit Medicaid payments of Medicare cost sharing when Medicaid’s fee schedule was lower than Medicare’s. This was an increase from 36 such states in 2004. In most states, combined Medicare and Medicare payments for evaluation and management services provided to duals averaged 78% of the Medicare allowed amount for these services.
AHRQ-funded; HS026727.
Citation: Roberts ET, Nimgaonkar A, Aarons J .
New evidence of state variation in Medicaid payment policies for dual Medicare-Medicaid enrollees.
Health Serv Res 2020 Oct;55(5):701-09. doi: 10.1111/1475-6773.13545..
Keywords: Medicaid, Medicare, Payment, Policy, Healthcare Costs, Health Insurance
Encinosa WE
AHRQ Author: Encinosa WE
Is it time for ACOs to start tackling the high costs of surgery?
This article discusses an article appearing in the same issue revisiting the impact of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) on surgery expenditures. The author suggests that, in order to engage even more surgeons, it is likely that MSSP ACOs will have to work with surgeons in the various Medicare bundled payment programs for surgery. He concludes that the next stage is to examine how these different programs can work together to produce even more savings in surgical care.
AHRQ-authored.
Citation: Encinosa WE .
Is it time for ACOs to start tackling the high costs of surgery?
Am J Accountable Care 2020 Sep 15;8(3):26-27..
Keywords: Surgery, Healthcare Costs, Medicaid, Health Insurance, Payment
Apathy NC, Everson J
High rates of partial participation in the first year of the merit-based incentive payment system.
This article discusses concerns over the implementation of the Merit-based Incentive Payment System (MIPS) for clinicians, which was authorized with the Medicare Access and CHIP Reauthorization Act of 2015. Data was analyzed from 2017, the first implementation year of MIPS. The authors found that although 90% of participating clinicians reported performance equal to or better than the lower performance threshold of 3 out of 100, almost half of clinicians did not participate in at least one of the three program categories. Even with the low participation rate, 74% of clinicians who only partially participated in the program received positive payment adjustments. The findings underline concerns that the design may have been too flexible to effectively incentivize clinicians to make incremental progress across all targeted aspects of the program (quality, advancing care information, and improvement activities).
AHRQ-funded; K12 HS026395.
Citation: Apathy NC, Everson J .
High rates of partial participation in the first year of the merit-based incentive payment system.
Health Aff 2020 Sep;39(9):1513-21. doi: 10.1377/hlthaff.2019.01648..
Keywords: Payment, Medicare, Medicaid, Children's Health Insurance Program (CHIP), Health Insurance
Brown TT, Guo C, Whaley C
Reference-based benefits for colonoscopy and arthroscopy: large differences in patient payments across procedures but similar behavioral responses.
This study examined how reference-based benefits (RBB) affect out-of-pocket payments across outpatient procedures. The California Public Employees’ Retirement System (CalPERS) applied RBB only to outpatient procedures performed in a hospital outpatient department (HOPD) and not to outpatient procedures performed in a lower cost ambulatory surgery center. Claims from 2009-2013 on arthroscopy and colonoscopy services were analyzed. CalPERS patients paid an average of 63.9% more for HOPDs than ambulatory surgery centers in 2012, but for arthroscopy there was no statistically different cost sharing. This led to high-priced HOPDs being less likely to be chosen by CalPERS patients for both procedures.
AHRQ-funded; HS022098.
Citation: Brown TT, Guo C, Whaley C .
Reference-based benefits for colonoscopy and arthroscopy: large differences in patient payments across procedures but similar behavioral responses.
Med Care Res Rev 2020 Jun;77(3):261-73. doi: 10.1177/1077558718793325..
Keywords: Payment, Healthcare Costs, Health Insurance, Ambulatory Care and Surgery
Dekhne MS, Nuliyalu U, Schoenfeld AJ
"Surprise" out-of-network billing in orthopedic surgery: charges from surprising sources.
This study examined “surprise” out-of-network billing in orthopedic surgery. Data was analyzed from the Clinformatics DataMart on commercial insured patients undergoing 4 different elective orthopedic procedures from 2012 to 2017: arthroscopic meniscal repair, lumbar discectomy, total knee replacement and total hip replacement. They defined surprise bills as out-of-network bills for procedures done at in-network hospitals. The rate of potential surprise bills was 24.8% for total knee replacement, 24.5% lumbar discectomy, 23.5% for total hip replacement, and 12.5% for meniscal repair. The largest number of surprise bills came from anesthesiologists (39% of all episodes), and durable medical equipment (15%). Per episode, the largest bills came from nonphysician surgical assistants, neurologists, and physician assistants.
AHRQ-funded; HS000053; HS023597.
Citation: Dekhne MS, Nuliyalu U, Schoenfeld AJ .
"Surprise" out-of-network billing in orthopedic surgery: charges from surprising sources.
Ann Surg 2020 May;271(5):e116-e18. doi: 10.1097/sla.0000000000003825..
Keywords: Orthopedics, Surgery, Payment, Healthcare Costs, Health Insurance
Hoffman GJ, Yakusheva O
Association between financial incentives in Medicare's hospital readmissions reduction program and hospital readmission performance.
This study compared the outcome of penalties versus rewards to prevent hospital readmission in Medicare’s Hospital Readmissions Reduction Program (HRRP). This retrospective cohort study used Medicare readmissions data from 2823 US short-term acute care hospitals participating in HRRP. Data from pre-HRRP in 2016 was compared with 2016-2019 3-year follow-up readmission performance classified by tertile of hospitals using baseline marginal incentives for 5 HRRP-targeted conditions: acute myocardial infarction (AMI), heart failure, chronic obstructive pulmonary disease (COPD), pneumonia, and hip and/or knee surgery. Of the 2823 hospitals participating in HRRP from baseline to follow-up, 81% had more than 1 excess readmission for 1 or more applicable condition and 19% did not. Financial incentives ranged from a mean range of $8762 to $58,158 per 1 avoided readmission. Hospitals with greater incentives for readmission avoidance had greater decreases than hospitals with smaller incentives. An additional $5000 in the incentive amount was associated with up to a 26% decrease in readmissions. The findings suggest that incentives work better than penalties to reduce hospital readmissions for those 5 conditions.
AHRQ-funded; HS025838.
Citation: Hoffman GJ, Yakusheva O .
Association between financial incentives in Medicare's hospital readmissions reduction program and hospital readmission performance.
JAMA Netw Open 2020 Apr;3(4):e202044. doi: 10.1001/jamanetworkopen.2020.2044..
Keywords: Medicare, Hospital Readmissions, Provider Performance, Payment, Health Insurance, Hospitals
Zhang M, Shubina M, Morrison F
Following the money: copy-paste of lifestyle counseling documentation and provider billing.
To find out whether copied documentation of lifestyle counseling was used to justify higher evaluation and management (E&M) charges, researchers investigated 12,527 patient encounters in which lifestyle counseling was documented. When time spent on counseling was recorded, copied lifestyle counseling was associated with a decrease of 70.5% in the odds of higher E&M charges.
AHRQ-funded; HS017030
Citation: Zhang M, Shubina M, Morrison F .
Following the money: copy-paste of lifestyle counseling documentation and provider billing.
BMC Health Serv Res. 2013 Oct 2;13:377. doi: 10.1186/1472-6963-13-377..
Keywords: Diabetes, Electronic Health Records (EHRs), Health Information Technology (HIT), Health Insurance, Lifestyle Changes, Payment