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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 66 Research Studies Displayed
Haddad DN, Shipe ME, Absi TS
Preparing for bundled payments: impact of complications post-coronary artery bypass grafting on costs.
This study examined the impact of complications on bundled payments for coronary artery bypass grafting (CABG) for care provided from admission through 90 days post-discharge. The authors linked clinical and internal cost data for patients undergoing CABG from 2014 to 2017 at a single institution. They performed multivariable linear regression to evaluate drivers of high costs, adjusting for preoperative and intraoperative characteristics and postoperative complications. They reviewed records of 1789 patients undergoing CABG with an average of 2.7 vessels. A large proportion of patients were diabetic and obese. Factors associated with increased adjusted costs were preoperative renal failure, diabetes and body mass index, postoperative stroke, prolonged ventilation, rebleeding requiring reoperation, and renal failure with varying magnitude.
Citation: Haddad DN, Shipe ME, Absi TS . Preparing for bundled payments: impact of complications post-coronary artery bypass grafting on costs. Ann Thorac Surg 2021 Apr;111(4):1258-63. doi: 10.1016/j.athoracsur.2020.06.105..
Keywords: Cardiovascular Conditions, Surgery, Adverse Events, Healthcare Costs, Payment
Hambley BC, Anderson KE, Shanbhag SP
Payment incentives and the use of higher-cost drugs: a retrospective cohort analysis of intravenous iron in the Medicare population.
Researchers examined prescribing patterns in the context of intravenous (IV) iron, for which multiple similarly safe and efficacious formulations exist, with wide variations in price. Using Medicare data, they found an increase in the dispensing of a higher-priced IV iron formulation associated with a shortage of a less expensive drug that persisted once the shortage ended. They concluded that their findings in IV iron have broader implications for Part B drug payment policy because the price of the drug determines the physician and health system payment.
Citation: Hambley BC, Anderson KE, Shanbhag SP . Payment incentives and the use of higher-cost drugs: a retrospective cohort analysis of intravenous iron in the Medicare population. Am J Manag Care 2020 Dec;26(12):516-22. doi: 10.37765/ajmc.2020.88539..
Keywords: Elderly, Medication, Medicare, Payment, Healthcare Costs, Practice Patterns
Ganguli I, Lupo C, Mainor AJ
Association between specialist compensation and Accountable Care Organization performance.
This study’s objective was to determine whether Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. National cross-sectional survey data on ACOs from 2013-2015 was linked to public-use data on ACO performance from 2014-2016. Out of 160 ACOs surveys, 26% reported using cost reduction measures to help determine specialist compensation. However, these ACOs did not have savings in the short term.
Citation: Ganguli I, Lupo C, Mainor AJ . Association between specialist compensation and Accountable Care Organization performance. Health Serv Res 2020 Oct;55(5):722-28. doi: 10.1111/1475-6773.13323..
Keywords: Provider Performance, Healthcare Costs, Value, Payment, Medicare
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
Machta RM, Reschovsky J, Jones DJ
AHRQ Author: Furukawa MF
Can vertically integrated health systems provide greater value: the case of hospitals under the comprehensive care for joint replacement model?
The authors sought to assess whether system providers perform better than non-system providers under an alternative payment model that incentivizes high-quality, cost-efficient care. Using CMS data linked to AHRQ’s Compendium of US Health Systems, along with secondary sources, they found that when operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.
AHRQ-authored; AHRQ-funded; 290201600001C.
Citation: Machta RM, Reschovsky J, Jones DJ . Can vertically integrated health systems provide greater value: the case of hospitals under the comprehensive care for joint replacement model? Health Serv Res 2020 Aug;55(4):541-47. doi: 10.1111/1475-6773.13313..
Keywords: Healthcare Systems, Hospitals, Orthopedics, Value, Healthcare Costs, Payment, Quality of Care
Kennedy G, Lewis VA, Kundu S
Kennedy G, Lewis VA, Kundu S, Mousqués J, Colla CH. Accountable care organizations and post-acute care: a focus on preferred SNF networks.
This study examined the relationship between accountable care organizations (ACOs) and skilled nursing facilities (SNFs) for patients who are discharged from a hospital into a SNF. A mixed-method design was used and survey data was examined from 366 respondents to the National Survey of ACOs along with 16 semi-structured interviews with ACOs who performed well on cost and quality measures. Over half of ACOs had no formal relationship with SNFs; however the majority of ACO interviewees had preferred SNF networks. These preferred networks are beginning to transform the ACO post-acute care landscape.
Citation: Kennedy G, Lewis VA, Kundu S . Kennedy G, Lewis VA, Kundu S, Mousqués J, Colla CH. Accountable care organizations and post-acute care: a focus on preferred SNF networks. Med Care Res Rev 2020 Aug;77(4):312-23. doi: 10.1177/1077558718781117..
Keywords: Nursing Homes, Healthcare Costs, Payment, Value
He D, McHenry P, Mellor JM
Do financial incentives matter? Effects of Medicare price shocks on skilled nursing facility care.
The authors provided new evidence on how Medicare payment changes affect the amount of skilled nursing facility (SNF) care provided to Medicare patients. They found that increases in Medicare payment rates to SNFs increased the total number of Medicare resident days at SNFs. Further, the effects were asymmetric; although Medicare payment increases affected Medicare days, payment decreases did not. They conclude that their results have important implications for policies that alter the Medicare base payment rates to SNFs and other health care providers.
Citation: He D, McHenry P, Mellor JM . Do financial incentives matter? Effects of Medicare price shocks on skilled nursing facility care. Health Econ 2020 Jun;29(6):655-70. doi: 10.1002/hec.4009..
Keywords: Medicare, Nursing Homes, Elderly, Payment, Healthcare Costs
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
Chen LM, Samson LW, Zuckerman RB
Challenges of measuring costs of care for US practices.
Investigators sought to describe the feasibility of applying claims-based cost measures included in Merit-based Incentive Payment System (MIPS) to practices nationwide, and to assess whether feasibility varies by practice size or specialty mix. They found that most practices that qualify for MIPS are small, specialist-only practices that are unable to meet minimum case requirements for MIPS’ two required cost measures, due to a combination of size and provider mix, suggesting that clinicians in small, specialist-only practices are less likely to be evaluated on cost. They stressed the importance of identifying alternative approaches to ensure that value - both quality and cost - is rewarded.
Citation: Chen LM, Samson LW, Zuckerman RB . Challenges of measuring costs of care for US practices. J Gen Intern Med 2020 Apr;35(4):1320-22. doi: 10.1007/s11606-019-05233-x..
Keywords: Healthcare Costs, Payment
Rathi VK, McWilliams JM, Roberts ET
Rathi VK, McWilliams JM, Roberts ET. Getting incentives right in payment reform: thinking beyond financial risk.
In this paper the authors discuss payment reform, global budget models and why incentives differ for health system versus physician group ACO’s. They indicate that incentives in new payment models are closely connected to the structure of the health care delivery system and that policies that ignore this relationship and focus only on the risk terms of payment contracts may miss opportunities for progress.
Citation: Rathi VK, McWilliams JM, Roberts ET . Rathi VK, McWilliams JM, Roberts ET. Getting incentives right in payment reform: thinking beyond financial risk. Ann Intern Med 2020 Mar 17;172(6):423-24. doi: 10.7326/m19-3178..
Keywords: Healthcare Costs, Policy, Payment
AHRQ Author: Selden TM
Differences between public and private hospital payment rates narrowed, 2012-16.
In 2000-12 payments for inpatient hospital stays, emergency department visits, and outpatient hospital care for privately insured patients grew much faster than payments for Medicare and Medicaid patients. This widening of private-public payment gaps slowed or even reversed itself in 2012-16. In this paper, the author discusses the differences between public and private hospital payment rates, 2012-2016.
Citation: Selden TM . Differences between public and private hospital payment rates narrowed, 2012-16. Health Aff 2020 Jan;39(1):94-99. doi: 10.1377/hlthaff.2019.00415..
Keywords: Medical Expenditure Panel Survey (MEPS), Hospitals, Payment, Healthcare Costs, Medicaid, Medicare
Werner RM, Konetzka RT, Qi M
The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs.
The objective of this study was to investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. The investigators concluded that Medicare's SNF copayment policy was associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy had unintended and negative effects on patient outcomes.
Citation: Werner RM, Konetzka RT, Qi M . The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs. Health Serv Res 2019 Dec;54(6):1184-92. doi: 10.1111/1475-6773.13227..
Keywords: Medicare, Nursing Homes, Payment, Long-Term Care, Healthcare Costs, Elderly, Hospitalization, Hospital Discharge
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
Song LD, Newhouse JP, Garcia-De-Albeniz X
Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes.
This study examined changes in screening colonoscopy rates after Medicare reimbursement and cost-sharing changed when the Affordable Care Act (ACA) was implemented. A 20% random sample of fee-for-service (FFS) Medicare claims from 2002-2012 was used in this study. Screening colonoscopy rates did increase after 2001 when cost-sharing was eliminated but the amount varied depending on the algorithm used to classify the indication.
Citation: Song LD, Newhouse JP, Garcia-De-Albeniz X . Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes. Health Serv Res 2019 Aug;54(4):839-50. doi: 10.1111/1475-6773.13150..
Keywords: Colonoscopy, Healthcare Costs, Healthcare Utilization, Medicare, Payment, Prevention, Screening
Markovitz AA, Mullangi S, Hollingsworth JM
ACOs and the 1%: changes in spending among high-cost patients following the Medicare shared savings program.
This paper analyzed changes in spending among high-cost patients following the creation of accountable care organizations (ACOs), specifically for the Medicare Shared Savings Program – which is Centers for Medicare and Medicaid Services (CMS) flagship program. Changes in spending for Medicare fee-for-services were analyzed for different spending percentiles (50th, 90th, and 99th) as well as regionally. While there was a reduction in spending, it was not considered statistically significant and has not affected spending within or across regions. However, the authors note that the study is limited by the program’s voluntary nature and may be not a full reflection of the changes.
AHRQ-funded; HS024525; HS024728; HS025615.
Citation: Markovitz AA, Mullangi S, Hollingsworth JM . ACOs and the 1%: changes in spending among high-cost patients following the Medicare shared savings program. J Gen Intern Med 2019 Jul;34(7):1116-18. doi: 10.1007/s11606-019-04963-2..
Keywords: Medicare, Healthcare Costs, Value, Payment
Sheetz KH, Dimick JB, Regenbogen SE
How patient complexity and surgical approach influence episode-based payment models for colectomy.
This study looked into how the use of bundled payment programs would affect hospital reimbursements for colectomies. National data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014 was used. Patients undergoing colectomies were identified using diagnosis-related group codes and ICD-9, Clinical Modification codes. Reconciliation payments were simulated as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks. The simulated bundled payment conditions showed 51.8% of hospitals would achieve shared savings, but the average case would incur reconciliation penalties. Laparoscopies would achieve the highest savings.
Citation: Sheetz KH, Dimick JB, Regenbogen SE . How patient complexity and surgical approach influence episode-based payment models for colectomy. Dis Colon Rectum 2019 Jun;62(6):739-46. doi: 10.1097/dcr.0000000000001372..
Keywords: Surgery, Payment, Healthcare Costs, Medicare, Hospitals
Diaz-Perez MJ, Hanover R, Sites E
Producing comparable cost and quality results from all-payer claims databases.
This study describes how all-payer claims databases (APCDs) can produce comparable cost and quality results for 4 states using a multistate analysis. Data was used from 2014 commercial claims in Colorado, Massachusetts, Oregon, and Utah. The partners standardized the rules for including payers, data set elements, measure specifications, SAS code and adjustments for population differences in age and gender. A Uniform Data Structure file format was created which can be used across multiple population, measures, and research dimensions.
Citation: Diaz-Perez MJ, Hanover R, Sites E . Producing comparable cost and quality results from all-payer claims databases. Am J Manag Care 2019 May;25(5):e138-e44..
Keywords: Healthcare Costs, Payment, Quality of Care, Value
Damberg CL, Silverman M, Burgette L
Are value-based incentives driving behavior change to improve value?
The purpose of this study, which used semi-structured interviews and surveys, was to understand physician organization (PO) responses to financial incentives for quality and total cost of care among POs that were exposed to a statewide multipayer value-based payment (VBP) program, and to identify challenges that POs face in advancing the goals of VBP.
Citation: Damberg CL, Silverman M, Burgette L . Are value-based incentives driving behavior change to improve value? Am J Manag Care 2019 Feb;25(2):e26-e32..
Keywords: Healthcare Costs, Payment, Value
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
Makam AN, Nguyen OK, Kirby B
Effect of site-neutral payment policy on long-term acute care hospital use.
The purpose of this study was to assess the projected effect of the Centers for Medicare and Medicaid Services new site-neutral payment policy, which aims to decrease unnecessary long-term acute care hospital (LTACH) admissions by reducing reimbursements for less-ill individuals by 2020. The investigators concluded that the site-neutral payment policy may limit LTACH access in existing LTAC-scarce markets, with potential adverse implications for recovery of hospitalized older adults.
Citation: Makam AN, Nguyen OK, Kirby B . Effect of site-neutral payment policy on long-term acute care hospital use. J Am Geriatr Soc 2018 Nov;66(11):2104-11. doi: 10.1111/jgs.15539..
Keywords: Policy, Hospitalization, Payment, Long-Term Care, Healthcare Costs, Medicare, Elderly, Hospitals
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
Sen AP, Chen LM, Wong Samson L
Performance in the Medicare Shared Savings Program by accountable care organizations disproportionately serving dual and disabled populations.
The purpose of this study was to examine performance by accountable care organizations (ACOs) in the top quintile of their proportion of beneficiaries who were dually enrolled in Medicare and Medicaid (high-dual), and the top quintile of disabled beneficiaries (high-disabled). Measures used were quality scores, savings per beneficiary, whether or not the ACO shared savings and the amount of shared savings. The researchers found that high-dual and high-disabled ACOs had similar or higher spending than other ACOs at baseline, but achieved greater savings and were equally or more likely to earn shared savings; alternative payment models can have positive financial outcomes for providers serving vulnerable populations.
Citation: Sen AP, Chen LM, Wong Samson L . Performance in the Medicare Shared Savings Program by accountable care organizations disproportionately serving dual and disabled populations. Med Care 2018 Sep;56(9):805-11. doi: 10.1097/mlr.0000000000000968..
Keywords: Disabilities, Medicare, Healthcare Costs, Provider Performance, Payment, Low-Income, Vulnerable Populations