Alternative Payment Models Research Articles

Differences in Utilization of Preventive Services for Primary Care Clinicians Participating in MIPS and ACOs.

Value-based payment programs link payments to the performance of providers on cost and quality of care to incentivize high-value care. To improve quality and lower costs, the Centers for Medicare and Medicaid Services (CMS) implemented the Quality Payment Program (QPP) for clinicians in 2017. Under the Medicare QPP, most eligible clinicians participate in one of the payment models: (a) Advanced Alternative Payment Models (A-APMs) through eligible APMs like Accountable Care Organizations (ACOs) or (b) the Merit-based Incentive Payment System (MIPS). ACO and MIPS clinicians participating in QPP differ in quality reporting requirements, and these differences are likely to affect the utilization of different quality measures, including preventive services. This study evaluated the differences in the utilization of preventive services by primary care clinicians participating in MIPS and ACOs. We use difference-in-difference regressions to compare preventive services in MIPS versus ACOs. Since preventive services like immunization and certain cancer screening are mandatory reporting measures for ACOs and voluntary measures for MIPS, the treatment group for this study is ACO clinicians and the comparison group is non-ACO MIPS clinicians. We obtained the rates of influenza immunization, pneumonia vaccination, tobacco use cessation intervention, depression screening, colorectal cancer screening, breast cancer screening, and wellness visits per 10000 Medicare beneficiaries from Medicare Provider Utilization and Payment Public Use File (2012-2018). We had 508144 total observations (ACO=25.78% and MIPS=74.22%) from 72592 unique primary care clinicians. Compared to MIPS clinicians, ACO clinicians had significantly higher rates of pneumonia vaccination (incidence rate ratio [IRR] 1.25; 95% confidence interval [CI], 1.10-1.43) but lower rates of colorectal cancer screening (IRR 0.69; 95% CI, 0.50-0.96). Similarly, clinicians in ACO shared savings-only models had significantly higher rates of pneumonia vaccination (IRR 1.28; 95% CI, 1.11-1.48), depression screening (IRR 1.72; 95% CI, 1.09-2.71), and wellness visits (IRR 1.27; 95% CI, 1.09-1.47) compared to MIPS clinicians. There were no differences between ACO and MIPS clinicians on the utilization of breast cancer screening procedures and tobacco use cessation interventions. ACO clinicians may have prioritized relatively low-cost services such as pneumonia vaccination, depression screening, and wellness visits to improve their performance under QPP. Policymakers may need to alter incentives in performance-based payment programs to ensure that clinicians are improving all types of quality measures, including cancer screening.

Non-Home Discharge is an Independent Risk Factor for Readmission Following Primary Total Shoulder Arthroplasty

Utilization of total shoulder arthroplasty (TSA) in the United States has increased substantially within the last two decades and this trend is expected to continue. As TSA volume has continued to increase, healthcare policy has shifted towards an emphasis on value-based care. Therefore, it is important to understand variables that may increase TSA costs, including readmission rates. Patients discharged to home healthcare (HHC) or post-acute care (PAC) facilities have demonstrated increased readmission rates following TSA. However, few studies have directly compared HHC to PAC facilities and routine home discharge while accounting for pertinent demographics. The purpose of this study was to compare 180-day readmission rates between routine home discharge, HHC, and PAC facility groups following primary TSA. The Nationwide Readmissions Database was queried from 2010 to 2020 to identify all patients that underwent primary TSA. Readmission rates were compared between routine home discharge, HHC, and PAC facility groups. Binary logistic regression identified independent risk factors for readmission within 180 days. From 2010 to 2020 a total of 171,898 patients underwent TSA. 71% were routinely discharged home, 21% were discharged to HHC, and 8% were discharged to a PAC facility. After adjusting for income, insurance, obesity status, age, Charlson Comorbidity index, and gender, discharge to a PAC facility was independently predictive of readmission within 180 days following TSA (OR: 1.69, 95% CI 1.59-1.79, p<0.001). Patients discharged to a PAC facility after TSA had higher readmission rates compared to HHC and routine home discharge that persisted even after controlling for relevant demographics. Clinicians should be cognizant of the risks and benefits of different discharge methods and consider home discharges for suitable candidates. Understanding risk factors that increase healthcare expenditures has significant utility for institutions in the era of bundled care. However, it is important that alternative payment models do not disincentivize orthopedic surgeons from providing care to medically complex patients.

91EMF Interventions to Reduce Emergency Department Admissions for High-Variation Conditions Under an Alternative Payment Model

91EMF Interventions to Reduce Emergency Department Admissions for High-Variation Conditions Under an Alternative Payment Model

Navigating financial risk: Unlocking the power of modeling and risk quantification in episode-based payment models.

28 Background: The Centers for Medicare and Medicaid Innovation’s (CMMI) Enhancing Oncology Model (EOM) is a voluntary value-based care (VBC) model that requires physician group practices (PGPs) to assume financial risk and performance accountability for episodes of care related to seven common cancers. However, PGPs often lack the means to assess the financial impact and risks associated with these alternative payment models. To address this, we employed Monte Carlo Simulations (MCS) to calculate the likelihood of outcomes and associated risks. This information can assist PGPs in making informed decisions about assuming risk and participating in the EOM. Methods: Using historical episode files from 2019 to 2022 for 23 PGPs in The US Oncology Network, along with the EOM Price Prediction Model provided by CMMI, we calculated the predicted baseline price and savings per episode. We then determined the average savings for each PGP per time-period and utilized the MCS technique to simulate savings and risk, under each EOM risk arrangement. We shared the simulation results with the PGPs to support their decision-making process and participation. Results: Despite having enough episodes per time-period (ranging from 105 to 6100) for the 23 PGPs, the limited number of time-based populations (only 6) based on case mix and patient volume made traditional probability assessments inadequate. To overcome this, we utilized MCS with 5000 simulations per PGP, assuming a normal distribution based on population characteristics. By assessing the savings outcomes of each simulation, we developed probability distributions and confidence intervals to determine the likelihood of generating shared savings, recoupment, or landing in the neutral zone within the EOM. Factors such as episode counts, baseline price, and risk arrangement had the greatest impact on the range of outcomes. We shared the MCS results with all 23 PGPs, highlighting the limitations of the original data and facilitating their decision-making process. Ultimately, 12 PGPs chose to assume risk based on the probability of financial outcomes with the model, and to select the appropriate risk arrangement in the EOM. Conclusions: Compared to the status quo measures of central dispersion, MCS yields a wide range of expected financial outcomes per PGP. MCS is a robust technique for quantifying outcome probabilities in VBC models despite low data volumes but relies on the representativeness and quality of the original data. Conducting sensitivity analysis with MCS to assess the impact of individual assumptions or data inputs on outcome probabilities is an area for further exploration.

Outcomes by Race and Ethnicity Following a Medicare Bundled Payment Program for Joint Replacement

The Comprehensive Care for Joint Replacement (CJR) model, a traditional Medicare bundled payment program for lower-extremity joint replacement, is associated with care for patients outside traditional Medicare. Whether CJR model outcomes have differed by patient race or ethnicity outside of traditional Medicare is unclear. To evaluate outcomes associated with the CJR model among Hispanic patients not enrolled in traditional Medicare. This cohort study used hospitalization data from California's Patient Discharge Dataset for all patients who underwent lower-extremity joint replacement in California between January 1, 2014, and December 31, 2017. In California, 3 metropolitan statistical areas (MSAs) were randomly selected to participate in CJR in April 2016. Hospitals not participating in other Medicare Alternative Payment Models were included in the treated group if they were in these 3 MSAs and in the control group if they were in the remaining 23 MSAs. The data analysis was performed between October 1 and December 31, 2023. Comprehensive Care for Joint Replacement program implementation. The main outcomes were hospital length of stay and home discharge rates by race and ethnicity. Home discharge status included self-care, the use of home health services, and hospice care at home. Event study, difference-in-differences, and triple differences models were used to estimate differential changes in health care service use by race and ethnicity for patients in the treated MSAs compared with the control MSAs before vs after CJR implementation. Of 309 834 hospitalizations (patient mean [SD] age, 68.3 [11.3] years; 60.6% women; 14.8% Hispanic; 72.4% non-Hispanic White), 48.0% were in treated MSAs and 52.0% in control MSAs. The CJR program was associated with an increase in home discharge rates for patients without traditional Medicare coverage; however, the increase differed by patient race and ethnicity. The increase was 0.05 (95% CI, 0.02-0.08) percentage points higher for Hispanic patients with Medicare Advantage and 0.03 (95% CI, 0.01-0.04) percentage points higher for Hispanic patients without Medicare compared with their non-Hispanic White counterparts. This cohort study shows that CJR program outcomes differed by race and ethnicity for patients covered outside traditional Medicare, with home discharge rates increasing more for Hispanic compared with non-Hispanic White patients. These findings suggest the importance of considering differential outcomes of Medicare payment policies for racial and ethnic minority patient populations beyond the initially targeted groups.

Alternative payment models in Dutch hospital care: what works, how, why and under what circumstances? Protocol for a realist evaluation study

IntroductionThe predominant provider payment models in healthcare, particularly fee-for-service, hinder the delivery of high-value care and can encourage healthcare providers to prioritise the volume of care over the value of...

Integrating Maternity Care Through Bundled Payments In The Netherlands: Early Results And Policy Lessons.

Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers' behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.

Alternative payment models in the music streaming market: A comparative approach based on stream-level data

Music streaming platforms’ models for sharing revenues with content providers have been the subject of intense debate for nearly a decade. The dominating model involves pooling platform revenues and allocating these funds to songs based on a song's share of the total number of platform streams. Since this model has several controversial consequences, alternative models have been proposed. This paper uses a novel approach to assess the two most discussed models – the “user-centric” and the “artist-centric”. Our approach relies on a unique data set of 154,505 streaming platform users (890 million streams) and simulates how a large-scale implementation of these models may reallocate revenues across different songs and rightsholders. We disentangle the static effects of a transition to a “user-centric” or an “artist-centric” model across each of six different song characteristics. We then compare the results of the two models. We show that contrary to its objective, an artist-centric payment system does not significantly improve remuneration to professional artists while the user-centric payment system would generate more significant changes in revenue reallocation, mainly at the expense of Rap & Hip-hop songs, superstars and new releases. Finally, we analyze the positions of the various stakeholders with regard to each of them.

How adoption of new pharmaceuticals can impact US health system reimbursement under alternative payment models: An economic model measuring the impact of sotagliflozin among patients with heart failure and diabetes.

Heart failure (HF) is among the leading causes of death in the United States. Further, patients hospitalized because of HF with comorbid diabetes mellitus (DM) are at a significantly increased risk of death and rehospitalization. Results from the SOLOIST-WHF trial show that sotagliflozin lowered rates of readmission among hospitalized patients with HF and comorbid DM. However, it is unclear what the economic impact of the use of sotagliflozin would be on hospitals and health systems, particularly in an age where provider reimbursement is increasingly tied to value. To quantify the 1-year financial impact on US provider health systems of adopting sotagliflozin relative to standard of care (SoC) across different alternative payment models. This study created a 3-part decision tree model to quantify the financial impact of using sotagliflozin to treat patients hospitalized with HF in a US hospital setting. The model first estimated the clinical and economic outcomes of health systems with current SoC (no sotagliflozin) to treat US patients hospitalized for HF with comorbid DM. Then, using the results from the SOLOIST trial, the changes in clinical and economic outcomes with sotagliflozin adoption were modeled. Finally, the differences in health care utilization between sotagliflozin and SoC arms were translated to differences in health system reimbursement in the context of 3 common alternative payment models (APMs) in addition to the baseline fee-for-service (FFS) model: FFS with the Hospital Readmissions Reduction Program, the Bundled Payments for Care Improvement-Advanced program, and Accountable Care Organizations. A typical community hospital would have 83.4 patients per year on average with an index HF hospitalization with comorbid DM. The model predicted that sotagliflozin would reduce the probability of hospitalization, emergency department visits, and deaths by 29.3%, 38.5%, and 17.8%, respectively, compared with SoC. For hospitals not participating in APM programs, sotagliflozin resulted in a net loss of $92.94 per person ($7,754 per health system). Conversely, when accounting for provider health system participation in APMs, sotagliflozin adoption increased financial returns by $4,720 per person ($305,604 per health system) under the Hospital Readmissions Reduction Program, $1,200 per person ($100,106 per health system) for the Bundled Payments for Care Improvement-Advanced program, and $1,078 per person ($31,029 per health system) for Accountable Care Organizations. Based on the national average composition of APM reimbursement, sotagliflozin adoption resulted in a $1,576 increase in margin per patient with HF ($105,454 per health system). Although sotagliflozin adoption reduced health system revenue in an FFS payment model, it led to a net positive financial impact after accounting for APM bonus payments.

Evolving oncology care management trends in the United States: A survey among health care decision makers.

There is limited knowledge of how US managed care professionals view and prioritize quality metrics/performance measures, care models, alternative payment models, and clinical pathways in oncology settings. To characterize payor perspectives on, and the use of, oncology clinical pathways and performance measures in their reimbursement/access decision-making process. A survey was implemented via SurveyMonkey software and distributed electronically to a national sample of the Academy of Managed Care Pharmacy (AMCP) Market Insights Panel members from July 11 through August 5, 2022. The survey was created by a steering committee based on literature reviews of the current and future oncology care landscapes. The survey consisted of 47 questions, including those to establish respondents' position, responsibilities, and demographics. The results are presented as descriptive statistics for 7 key questions that covered the perceptions and use of quality metrics/performance measures, alternative payment models, and oncology care pathways as prioritized by the steering committee. Among the 695 AMCP panel members who were sent the survey, 73 responded (response rate 10.5%), 54 were eligible to continue, and 31 completed the entire questionnaire; the low response rate may limit generalizability of the survey results. Specific oncology clinical and economic measures of performance were currently used (70%-88%) but generally received less endorsement for future use (39%-49%) except for chemotherapy during end of life, which was considered for future use by 80% of respondents but was only currently used by 31%. Benchmarking was the primary reason for the use of performance measures; only 27% used these to inform value-based agreements. Real-world data tracked by respondents' institutions primarily focused on managed care and pharmacy utilization (39%-85%), with patient-reported and clinical outcomes tracked by only 17%-34%. Almost one-third (31%) did not use clinical oncology pathways, and among those who did, fewer than half (48%) reported that their organization tracks whether treatment decisions agree with the oncology care pathways, and only 26% reported feedback to oncology providers on how often their treatment decisions agree with the pathways. When considering alternative payment models, patient-related components received lower rankings in importance than clinical relevance, actionability, and costs. Variation among payors regarding current trends in oncology care management, including on the importance of patient-centric outcomes and the use of oncology clinical pathways, suggests the need to focus on value-based health care and greater uptake of oncology clinical pathways.

Hospital–Skilled Nursing Facility Integration and Participation in a Bundled Payment Initiative

Reduced institutional postacute care has been associated with savings in alternative payment models. However, organizations may avoid voluntary participation if participation could threaten their own revenues. To characterize the association between hospital-skilled nursing facility (SNF) integration and participation in Medicare's Bundled Payments for Care Improvement Advanced (BPCI-A) program. This is a cross-sectional analysis of hospital participation in BPCI-A beginning with its launch in 2018. Each SNF-integrated hospital was matched with 2 nonintegrated hospitals for each of 4 episode-specific analyses. Fifteen hospital-level variables were used for matching: beds, case mix index, days, area SNF beds, metropolitan location, ownership, region, system membership, and teaching status. Hospitals were also matched on episode-specific volume, target price, and the interaction of target price and case mix. Episode-specific logistic models were estimated regressing hospital participation on integration and the previously listed variables. The marginal effect of integration on participation was then calculated. Analysis took place from August 2022 to May 2024. Hospital-SNF integration, as defined by common ownership and referral patterns and identified using cost reports, Medicare claims, and Provider Enrollment, Chain, and Ownership System records. Additional sources included records of target prices and participation, the Area Health Resources File, and the Compendium of US Health Systems. Participation in BPCI-A. In total, 1524 hospitals met criteria for inclusion in the hip and femur (HFP) analysis, 1825 were included in the major joint replacement of the lower extremity (MJRLE) analysis, 2018 were included in the sepsis analysis, and 1564, were included in the stroke-specific analysis. Across episodes, 191 HFP-eligible hospitals (12.5% of HFP-eligible hospitals), 302 MJRLE-eligible hospitals (16.5%), 327 sepsis-eligible hospitals (16.2%), and 185 sepsis-eligible hospitals (11.8%) were SNF integrated. In total, 79 hospitals (5.2%) participated in the HFP episode, 128 (7.0%) participated in the MJRLE episode, 204 (10.1%) participated in the sepsis episode, and 141 (9.0%) participated in the stroke episode. Integration was associated with a 4.7-percentage point decrease (95% CI, 2.4 to 6.9 percentage points) in participation in the MJRLE episode. There was no association between integration and participation for HFP (0.5-percentage point increase in participation moving from nonintegrated to integrated; 95% CI, -2.9 to 3.8 percentage points), sepsis (1.0-percentage point increase; 95% CI, -2.2 to 4.2 percentage points), and stroke (0.3-percentage point decrease; 95% CI, -3.1 to 3.8 percentage points). In this cross-sectional study, there was an uneven association between hospital-SNF integration and participation in Medicare's BPCI-A program. Other factors may be more consistent determinants of selection into voluntary payment reform.

Bridging the Gap Between Oncologists and Payers: Impact of an EHR-Embedded CDS Tool in Oncology Clinical Pathway (OCP) Adherence

As value-based oncology care gains traction, health practices and providers on the frontlines of care delivery increasingly rely on technological so­lutions that enable and support favorable performance across a dynamic array of alternative payment models. Successful participation requires a values-based transformation, a key component of which includes practice alignment with ev­idence-based pathways, which prioritizes the highest-quality treatment options over lower-value, clinically equivalent regimens. In this retrospective, observa­tional, real-world study of treatment selection patterns across American On­cology Network medical oncologists, we analyze pathway adherence rates be­fore and after a pilot project where Evolent level 1 pathways were integrated into Flatiron Assist, an electronic health record-embedded clinical decision sup­port tool in OncoEMR. Results suggest that integrating evidence-based path­ways into ordering workflows may improve adherence by providing clinicians with just-in-time clinical and financial insights for optimal treatment decisions.

The Case for Alternative Payment Models for Nursing Care.

A policy solution to improve staffing and patient care.

Alternative Payment Models and Performance in Federally Qualified Health Centers

ImportanceSeveral state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance.ObjectiveTo assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs.Design, Setting, and ParticipantsThis retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023.ExposureInitial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021.Main Outcomes and MeasuresThe main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs.ResultsA total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (–0.01 pp; 95% CI, –0.21 to 0.19 pp) or stinting on care (–0.02 visits; 95% CI, –0.08 to 0.04 visits).Conclusions and RelevanceIn this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.

Patient versus Provider Incentives in Long-Term Care

How do patient and provider incentives affect the provision of long-term care? Our analysis of 551,000 nursing home stays yields three main insights. First, due to limited cost-sharing, Medicaid-covered residents prolong their nursing home stays instead of transitioning to community-based care. Second, when facility capacity binds, nursing homes shorten Medicaid stays to admit more profitable out-of-pocket private payers. Third, providers react more elastically to financial incentives than patients. Thus, targeting provider incentives through alternative payment models, such as episode-based reimbursement, is more effective than increasing patient cost sharing in facilitating transitions to community-based care and generating long-term care savings. (JEL H51, H75, I11, I13, I18, I38, L84)

The Road To Value Can't Be Paved With A Broken Medicare Physician Fee Schedule.

Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of Alternative Payment Models. In this article, we show how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. We trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. We also show how the fee schedule can accommodate bundled payments and population-based payments that are central to Alternative Payment Models. We draw two conclusions. First, the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.

Quality of care for dual eligible beneficiaries in the oncology care model.

Dual eligible beneficiaries are a vulnerable population who often experience inferior access to care and outcomes compared to non-dual eligible beneficiaries. The Oncology Care Model (OCM) is an alternative payment model that aims to improve coordination and quality of care in beneficiaries receiving chemotherapy and thus may improve care for dual eligible beneficiaries with cancer. We used 100% Medicare claims data from 2014 through 2019 and included beneficiaries with bladder, breast, esophageal, colorectal, kidney, lung, pancreatic, or prostate cancer receiving chemotherapy. We constructed multivariable difference-in-differences regression models to evaluate the effect of OCM participation on healthcare utilization and quality of care at the end-of-life among dual eligible beneficiaries. We also compared healthcare utilization and quality of care outcomes to non-dual eligible beneficiaries. We identified 3,043,944 episodes of care among 1,260,892 unique Medicare beneficiaries. Ten percent of all beneficiaries (n = 126,758) were dual eligible and 64,087 (22%) of episodes among dual eligible patients were in an OCM participating practice. We noted no effect of OCM participation on healthcare utilization or end-of-life quality of care for dual eligible beneficiaries. However, we observed higher rates of hospitalization, emergency department visits, intensive care unit stays, and a lower number of office visits among dual eligible beneficiaries compared to non-dual eligible beneficiaries. Participation in OCM was not associated with improvements in quality of care or healthcare utilization for dual eligible beneficiaries. Dual eligible beneficiaries experience lower quality of care across several measures compared to non-dual eligible beneficiaries. Focused policies and incentives may be necessary to address disparities within emerging health reforms.

An analysis of the impact on total cost of care within a pharmacist‐led comprehensive medication management program

AbstractIntroductionThe rise in health care expenditures continues to pose a significant concern regarding the longevity of the current health care system design. The literature has demonstrated a positive return on investment (ROI) when pharmacists perform medication management services. Building upon positive ROI literature, a clinically integrated network (CIN) in Michigan developed an approach to patient targeting for comprehensive medication management (CMM) services in existing alternative payment model (APM) Medicare Advantage, Medicaid, and Commercial contracts.ObjectivesThe primary objective of this study was to examine the real‐world impact of an advanced ambulatory care pharmacy model, inclusive of embedded clinic‐based ambulatory pharmacists, centralized ambulatory pharmacists, centralized population health pharmacists, and specially trained pharmacy technicians, on the total cost of care (TCOC) within a large integrated health system.MethodsFor CMM dates of service occurring in calendar year 2022, pharmacy and medical claims were evaluated during the 6‐month period prior to and following the initial CMM patient encounter. Upon completion of the study period, data were evaluated to assess TCOC and utilization trends for the study population.ResultsStatistically significant differences in median TCOC ($1427.84, p &lt; 0.001), prescription drug costs ($222.82, p &lt; 0.001), and medical costs ($462.26, p &lt; 0.001) were observed between the pre‐CMM and post‐CMM timeframes for the study population. A 16% reduction in hospital admissions was observed between the pre‐CMM and post‐CMM timeframes.DiscussionThis study further supports that pharmacist intervention as part of a CMM program can favorably affect health care costs. Criteria such as a population's benchmark costs and utilization, insurance product types, and core conditions present can help determine whether expanding or initiating CMM services could be beneficial in improving care and health care costs.

Clinical trial participation and end-of-life care among older adults: A multi-center longitudinal observational cohort analysis of 121,717 patients with cancer.

11181 Background: Patients’ access to clinical trials remains significantly disparate across the US &amp; world. Complex drivers, some rooted in evidence while others in perceptions, impact shared decision making about trial participation esp in older adults (65y+). To that end, we investigated clinical trial participation (CTP) and unplanned healthcare utilization &amp; hospice use in patients w cancer. Methods: We queried the prospective longitudinal observational cohort of all patients with cancer receiving care at any of the 323 practice locations of 14 multi-site community cancer centers across 11 US states, all within the US Oncology Network and participating in the Oncology Care Model (OCM), an alternative payment model pilot from CMS to promote quality cancer care while reducing costs. We extracted data from OCM episode claims, medical records from 7/1/17-6/30/22 and used propensity score matching by time period, age, gender, date of death, cancer type to identify matched episodes for further stratification by CTP, to compare hospice care &amp; unplanned ER utilization by non-trial usual care vs CTP. Results: Overall, 121,717 pts received cancer care across 282,604 OCM care episodes in the community during this 5-yr period. Most (94%) were older adults aged 65y+ with breast, lung, multiple myeloma being the most common cancers. Of 121,717 pts, 4800 (3.9%) participated in a cancer treatment clinical trial in at least one care episode. Analysis of the 13,260 propensity score-matched episodes (6630 usual care vs 6630 CTP) shows: 1. ER/Observation visits: Patients on clinical trials did nothave any more ER/Obs visits vs usual care (ER/Obs episodes: CTP 23.4%, usual care 22.3%, p0.11). 2. Hospitalizations: The proportion of care episodes with hospitalization was higher in CTP vs usual care (25.9% vs 21.9%, p&lt;0.001). 3. Hospice enrollment: Patients on clinical trials were no less likely to enroll in hospice &gt;3 days prior to death, compared to non-trial usual care cohort (CTP 56.8%, usual care 52.6%, OR 1.18, p 0.13). Furthermore, median duration of hospice in patients on trials was not different from usual care (CTP 8 days, usual care 9 days, p 0.16). Conclusions: Our findings show that while more hospitalizations were observed, clinical trials participation is not associated with suboptimal end of life care outcomes pertaining to hospice enrollment &amp; duration as well as unplanned ER/healthcare utilization. Further efforts to integrate access to clinical trials and evidence-based supportive/palliative care in a scalable sustainable model of goal-concordant, patient-center cancer care are ongoing. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

Physician Group Practices Accrued Large Bonuses Under Medicare's Bundled Payment Model, 2018-20.

The Bundled Payments for Care Improvement Advanced Model (BPCI-A), a voluntary Alternative Payment Model for Medicare, incentivizes hospitals and physician group practices to reduce spending for patient care episodes below preset target prices. The experience of physician groups in BPCI-A is not well understood. We found that physician groups earned $421million in incentive payments during BPCI-A's first four performance periods (2018-20). Target prices were positively associated with bonuses, with a mean reconciliation payment of $139 per episode in the lowest decile of target prices and $2,775 in the highest decile. In the first year of the COVID-19 pandemic, mean bonuses increased from $815 per episode to $2,736 per episode. These findings suggest that further policy changes, such as improving target price accuracy and refining participation rules, will be important as the Centers for Medicare and Medicaid Services continues to expand BPCI-A and develop other bundled payment models.