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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
Results1 to 25 of 34 Research Studies Displayed
Markovitz AA, Ayanian JZ, Warrier A
Medicare Advantage plan double bonuses drive racial disparity in payments, yield no quality or enrollment improvements.
Using national data for 2008-18, investigators found that double bonuses were not associated with either improvements in plan quality or increased Medicare Advantage enrollment. Additionally, double bonuses increased payments to plans to care for Black beneficiaries by $60 per year, compared with $91 for White beneficiaries. These findings suggest that double bonuses not only fail to improve quality and enrollment but also foster a racially inequitable distribution of Medicare funds that disfavors Black beneficiaries. This study supports eliminating double bonuses, thereby saving Medicare an estimated $1.8 billion per year.
Citation: Markovitz AA, Ayanian JZ, Warrier A . Medicare Advantage plan double bonuses drive racial disparity in payments, yield no quality or enrollment improvements. Health Aff 2021 Sep;40(9):1411-19. doi: 10.1377/hlthaff.2021.00349..
Keywords: Medicare, Health Insurance, Payment, Quality Improvement, Quality of Care, Disparities, Racial / Ethnic Minorities
Fung V, McCarthy S, Price M
Payment discrepancies and access to primary care physicians for dual-eligible Medicare-Medicaid beneficiaries.
This study examined whether the Affordable Care Act (ACA) primary care fee bump for dual-eligible Medicare-Medicaid beneficiaries impacted primary care physicians (PCP) acceptance of duals. The authors assessed differences in the likelihood that PCPs had dual caseloads of ≥10% or 20% in states with lower versus full dual reimbursement using linear probability models adjusted for physician and area-level traits. The proportion of PCPs with dual caseloads of ≥10% or 20% decreased significantly between 2012 and 2017. The fee bump was not consistently associated with increases in dual caseloads.
Citation: Fung V, McCarthy S, Price M . Payment discrepancies and access to primary care physicians for dual-eligible Medicare-Medicaid beneficiaries. Med Care 2021 Jun;59(6):487-94. doi: 10.1097/mlr.0000000000001525..
Keywords: Primary Care, Medicaid, Medicare, Health Insurance, Payment, Access to Care
Spivack SB, Murray GF, Rodriguez HP
Avoiding Medicaid: characteristics of primary care practices with no Medicaid revenue.
Primary care access for Medicaid patients is an ongoing area of concern. Most studies of providers' participation in Medicaid have focused on factors associated with the Medicaid program, such as reimbursement rates. Few studies have examined the characteristics of primary care practices associated with Medicaid participation. In this study, the investigators used a nationally representative survey of primary care practices to compare practices with no, low, and high Medicaid revenue.
Citation: Spivack SB, Murray GF, Rodriguez HP . Avoiding Medicaid: characteristics of primary care practices with no Medicaid revenue. Health Aff 2021 Jan;40(1):98-104. doi: 10.1377/hlthaff.2020.00100..
Keywords: Medicaid, Health Insurance, Payment, Primary Care, Provider
Roberts 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.
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
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.
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, Value
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.
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.
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
Sun EC, Mello MM, Moshfegh J
Assessment of out-of-network billing for privately insured patients receiving care in in-network hospitals.
This retrospective analysis used data from the Clinformatics Data Mart database (Optum) to examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals. The investigators found that out-of-network billing appeared to have become common for privately insured patients even when they soughttreatment at in-network hospitals. They indicated that the mean amounts billed appeared to be sufficiently large that they may create financial strain for a substantial proportion of patients.
Citation: Sun EC, Mello MM, Moshfegh J . Assessment of out-of-network billing for privately insured patients receiving care in in-network hospitals. JAMA Intern Med 2019 Nov;179(11):1453-612. doi: 10.1001/jamainternmed.2019.3451..
Keywords: Health Insurance, Healthcare Costs, Payment, Hospitals, Emergency Department
Wood SJ, Albertson EM, Conrad DA
Accountable care program implementation and effects on participating health care systems in Washington state: a conceptual model.
This study used key informant interviews with health care executives representing 5 large health systems contracted with the Washington State Health Care Authority to provide accountable care network services under the State Innovation Model initiative. Two rounds of semistructured interviews were conducted, and results indicated the need to present a modified conceptual model aligned better with accountable care program (ACP) implementation.
Citation: Wood SJ, Albertson EM, Conrad DA . Accountable care program implementation and effects on participating health care systems in Washington state: a conceptual model. J Ambul Care Manage 2019 Oct/Dec;42(4):321-36. doi: 10.1097/jac.0000000000000302..
Keywords: Healthcare Systems, Provider Performance, Organizational Change, Health Services Research (HSR), Payment, Health Insurance, Implementation
Childrers CP, Dworsky JQ, Kominski G
A comparison of payments to a for-profit dialysis firm from government and commercial insurers.
The authors assessed differences in payments from government and commercial insurers to dialysis clinics through analysis of DaVita’s financial records. They found that, in 2017, commercial insurers paid one of the largest dialysis suppliers 4 times the rate of their government peers. They recommended that reducing payments from commercial insurers, perhaps through increased competition or fixing charges at a percent of Medicare reimbursement, may help alleviate excess spending on dialysis.
Citation: Childrers CP, Dworsky JQ, Kominski G . A comparison of payments to a for-profit dialysis firm from government and commercial insurers. JAMA Intern Med 2019 Aug;179(8):1136-38. doi: 10.1001/jamainternmed.2019.0431..
Keywords: Dialysis, Payment, Health Insurance, Medicare, Medicaid
Sankaran R, Sukul D, Nuliyalu U
Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study.
This study evaluated the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and changes in clinical outcomes. Out of the total of 724 hospitals were penalized in fiscal year 2015, 708 were included in the study. The majority of the penalized hospitals were large teaching institutions and have a greater share of low-income patients than non-penalized hospitals. After penalization, there was a non-significant change in hospital acquired conditions, 30-day readmission rates, and 30-day mortality. This might mean that disparities in care could be exacerbated.
Citation: Sankaran R, Sukul D, Nuliyalu U . Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. BMJ 2019 Jul 3;366:l4109. doi: 10.1136/bmj.l4109..
Keywords: Health Insurance, Healthcare-Associated Infections (HAIs), Hospitals, Medicare, Patient Safety, Provider Performance, Payment, Quality of Care, Quality Indicators (QIs)
Heintzman J, Cottrell E, Angier H
Impact of alternative payment methodology on primary care visits and scheduling.
The authors used electronic health record data to evaluate the impact of Oregon’s Alternative Payment Methodology (APM) on visit and scheduling metrics in the first wave of experiment clinics. They found that APM clinics experienced a greater increase in same-day visits but did not significantly differ from comparators in other visit metrics.
Citation: Heintzman J, Cottrell E, Angier H . Impact of alternative payment methodology on primary care visits and scheduling. J Am Board Fam Med 2019 Jul-Aug;32(4):539-49. doi: 10.3122/jabfm.2019.04.180368..
Keywords: Payment, Medicaid, Health Insurance, Policy
Kelsall AC, Cassidy R, Ghaferi AA
Variation in bariatric surgery episode costs in the commercially insured: implications for bundled payments in the private sector.
The authors described hospital-level variation in roux-en-Y gastric bypass and sleeve gastrectomy in Michigan. Their findings suggested that there are previously underappreciated differences in episode payment variation between bariatric surgery procedures. The authors also suggested that sleeve gastrectomy may be more amenable to cost containment under bundled payment initiatives by virtue of the greater share of variation explained by readmission and post-discharge payments.
AHRQ-funded; HS023621; HS024403.
Citation: Kelsall AC, Cassidy R, Ghaferi AA . Variation in bariatric surgery episode costs in the commercially insured: implications for bundled payments in the private sector. Ann Surg 2018 Dec;268(6):1014-18. doi: 10.1097/sla.0000000000002462..
Keywords: Surgery, Obesity: Weight Management, Obesity, Payment, Health Insurance, Healthcare Costs
Yu J, Mink PJ, Huckfeldt PJ
Population-level estimates of telemedicine service provision using an all-payer claims database.
Researchers used information from the Minnesota All Payer Claims Database to conduct a population-level analysis of telemedicine service provision from 2010 to 2015. Variations in provision by coverage type, provider type, and rurality of patient residence were documented. During the 2010-15 period, the number of telemedicine visits increased enormously; rates of use varied by coverage type and location. Telemedicine visits in metropolitan areas were usually direct-to-consumer services covered by commercial insurance and provided by nurse practitioners or physician assistants, while telemedicine use in nonmetropolitan areas was more often real-time provider-initiated, publicly insured services. The researchers conclude that expanded coverage and increased provider reimbursement for telemedicine services could lead to expanded use of telemedicine and new approaches to reach new patient populations.
Citation: Yu J, Mink PJ, Huckfeldt PJ . Population-level estimates of telemedicine service provision using an all-payer claims database. Health Aff 2018 Dec;37(12):1931-39. doi: 10.1377/hlthaff.2018.05116..
Keywords: Health Information Technology (HIT), Health Insurance, Payment, Telehealth
Thompson MP, Cabrera L, Strobel RJ
Association between postoperative pneumonia and 90-day episode payments and outcomes among Medicare beneficiaries undergoing cardiac surgery.
Postoperative pneumonia is the most common healthcare-associated infection in cardiac surgical patients, yet their impact across a 90-day episode of care remains unknown. The objective of this study was to examine the relationship between pneumonia and 90-day episode payments and outcomes among Medicare beneficiaries undergoing cardiac surgery. The investigators concluded that postoperative pneumonia was associated with significantly higher 90-day episode payments and inferior outcomes at the patient and hospital level.
Citation: Thompson MP, Cabrera L, Strobel RJ . Association between postoperative pneumonia and 90-day episode payments and outcomes among Medicare beneficiaries undergoing cardiac surgery. Circ Cardiovasc Qual Outcomes 2018 Sep;11(9):e004818. doi: 10.1161/circoutcomes.118.004818..
Keywords: Elderly, Surgery, Medicare, Cardiovascular Conditions, Heart Disease and Health, Pneumonia, Payment, Healthcare Costs, Outcomes, Healthcare-Associated Infections (HAIs), Health Insurance
Whaley CM, Brown TT
Firm responses to targeted consumer incentives: evidence from reference pricing for surgical services.
This study examined how health care providers respond to a reference pricing insurance program that increases consumer cost sharing when they chose high-priced surgical providers. Geographic variation was used to estimate supply-side responses. Limited evidence of market segmentation and price reductions for providers with baseline prices above the reference price was found. However, 75% of the reduction in provider prices benefited a population that was not subject to the program.
Citation: Whaley CM, Brown TT . Firm responses to targeted consumer incentives: evidence from reference pricing for surgical services. J Health Econ 2018 Sep;61:111-33. doi: 10.1016/j.jhealeco.2018.06.012..
Keywords: Health Insurance, Surgery, Value, Payment, Healthcare Costs
Does capitated managed care affect budget predictability? Evidence from Medicaid programs.
This study is the first to test whether managed care enrollment reduces the variance of Medicaid spending, in contrast to the focus of the existing literature on spending levels. Although the majority of Medicaid enrollees are in managed care, the study shows that managed care use has been concentrated among the enrollees with the most stable spending, resulting in only small gains to budget predictability. Perez concludes that this finding is robust to the exclusion of the claims expenditures that exhibit the most variance.
Citation: Perez V . Does capitated managed care affect budget predictability? Evidence from Medicaid programs. Int J Health Econ Manag 2018 Jun;18(2):123-52. doi: 10.1007/s10754-017-9227-7.
Keywords: Healthcare Costs, Payment, Medicaid, Health Insurance
Nyman JA, Koc C, Dowd BE
Decomposition of moral hazard.
This study sought to simulate the portion of moral hazard that is due to the income transfer contained in the coinsurance price reduction. The investigators found that the efficient proportion of moral hazard varied from disease to disease, but was the highest for those with diabetes and cancer.
Citation: Nyman JA, Koc C, Dowd BE . Decomposition of moral hazard. J Health Econ 2018 Jan;57:168-78. doi: 10.1016/j.jhealeco.2017.12.003..
Keywords: Health Insurance, Healthcare Costs, Medical Expenditure Panel Survey (MEPS), Payment
Koroukian SM, Basu J, Schiltz NK
AHRQ Author: Basu J
Changes in case-mix and health outcomes of Medicare fee-for-service beneficiaries and managed care enrollees during the years 1992-2011.
This study examined changes in differentials between managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) both in case-mix and health outcomes over time. It found that the case-mix differential between MCEs and FFSBs persisted over time. Both MCEs and FFSBs were as likely to die within 2 years from the Health and Retirement Study interview.
AHRQ-authored; AHRQ-funded; HS023113.
Citation: Koroukian SM, Basu J, Schiltz NK . Changes in case-mix and health outcomes of Medicare fee-for-service beneficiaries and managed care enrollees during the years 1992-2011. Med Care 2018 Jan;56(1):39-46. doi: 10.1097/mlr.0000000000000847.
Keywords: Elderly, Payment, Medicare, Health Insurance, Outcomes
Biener AI, Selden TM
AHRQ Author: Biener AI, Selden TM
Public and private payments for physician office visits.
Using data for 2014-15 from the Medical Expenditure Panel Survey to estimate standardized payments for nonelderly adults' physician office visits by type of insurance, researchers found that adults with public insurance, especially Medicaid, had substantially lower provider payments, out-of-pocket spending, and third-party payments than their peers with employer-sponsored or Marketplace insurance.
Citation: Biener AI, Selden TM . Public and private payments for physician office visits. Health Aff 2017 Dec;36(12):2160-64. doi: 10.1377/hlthaff.2017.0749.
Keywords: Healthcare Costs, Payment, Health Insurance, Ambulatory Care and Surgery, Medical Expenditure Panel Survey (MEPS)
Whaley CM, Guo C, Brown TT
The moral hazard effects of consumer responses to targeted cost-sharing.
This paper examines the effects of the reference pricing program implemented by the California Public Employees Retirement System (CalPERS) in 2012. The investigators found that the cost savings from the reference pricing program was about two to three times as large as the reduction from implementing a high-deductible health plan, while the accompanying consumer surplus reduction was much smaller under reference pricing.
Citation: Whaley CM, Guo C, Brown TT . The moral hazard effects of consumer responses to targeted cost-sharing. J Health Econ 2017 Dec;56:201-21. doi: 10.1016/j.jhealeco.2017.09.012..
Keywords: Healthcare Costs, Health Insurance, Payment
Jacobs PD, Molloy E
AHRQ Author: Jacobs PD
How do Medicare Advantage beneficiary payments vary with tenure?
This study compared how premiums and expected out-of-pocket medical costs (OOPC) vary with the length of time Medicare Advantage (MA) beneficiaries have been enrolled in their plans. Beneficiaries who remained in their plans for 6 or more years were paying $786 more than they would have spent in the lowest-cost plan compared with $552 for beneficiaries in their first year of enrollment.
Citation: Jacobs PD, Molloy E . How do Medicare Advantage beneficiary payments vary with tenure? Am J Manag Care 2017 Jun;23(6):372-77.
Keywords: Medicare, Payment, Healthcare Costs, Health Insurance
Carey K, Dor A
Price variations and their trends in U.S. hospitals.
This study tracked trends in prices paid to hospitals by commercial insurers over the period 2008 to 2014 using private sector claims data that contain actual payments. It contrasted these with trends in the CMS published charges. Results indicated that variation in actual commercially-transacted prices is substantially lower than variation in published charges.
Citation: Carey K, Dor A . Price variations and their trends in U.S. hospitals. J Health Care Finance 2017 Sum;44(1).
Keywords: Healthcare Costs, Payment, Health Insurance, Hospitals, Value