Bundled Payment Research Articles

Widely Integrated Services in Home (WISH) for homebound older adults: a study protocol for a randomized encouragement trial.

Home-based primary care (HBPC) is an emerging patient-centered, interprofessional healthcare service model that can address unmet medical needs and care burdens for homebound older adults. In December 2022, the Ministry of Health and Welfare in South Korea launched the Home-Based Medical Center Demonstration project to provide a new bundle payment for physician home visits. In this study, we seek to determine whether the recently introduced HBPC services in South Korea have been associated with a reduction in long-term care (LTC) facility admissions and acute hospitalizations among homebound older adults. The study is a community-based, multicenter, two-arm, randomized encouragement design trial with a 12-month follow-up period (n = 600). Eligible study participants are community-dwelling LTC recipients with multimorbidity and functional deterioration. Study participants are recruited from five HBPC centers located in urban areas (Northeast Seoul, West Seoul, Daejeon, Wonju, and Paju). The study participants are randomly assigned to either the HBPC group or the usual care group with a 1:1 allocation ratio. Those assigned to the HBPC group receive longitudinal home visits at least once a month by an interprofessional HBPC team according to the Widely Integrated Services in Home (WISH) intervention protocol. This protocol adheres to the Integrated Care for Older People principles, which call for a person-centered assessment and broader integration of health and LTC services at the micro-, meso- and macro-levels. Primary outcomes of the trial are 1) between-group community survival days and 2) between-group potentially avoidable hospitalizations. Results of the treatment are estimated by both modified intention-to-treat and complier average causal effect analytic methods. This study aims to investigate the real-world effectiveness of HBPC on the reduction of LTC facility admissions and acute care hospitalizations in the community setting. The findings may inform healthcare policy decisions to expand HBPC services in South Korea and other countries. CRIS KCT0007921.

Fragmentation of international trade: interim results, challenges and policy issues

The article analyzes key issues related to the fragmentation of international trade at the current stage of global economic development. The impact of economic globalization on disruptions in modern international exchange is discussed, including in the chronological context of the formation of the modern structure of international trade. The main channels of trade fragmentation are identified, including the ambiguous dynamics of cross-border direct investment, the aggressiveness of export control measures taken by key countries, as well as stresses observed in the global payment system. A separate aspect of the study was the analysis of national security considerations dictating the use of various subsidies, which is an additional determinant of the fragmentation of international trade. It is proven that fragmentation has led to uncertainty and increased volatility in global raw materials markets, and has strengthened the speculative and "financialized" nature of their development. In general, international trade under the influence of fragmentation should become more adaptive, and it is necessary to continue developing multilateral cooperation, but it should take place in a fundamentally different format and with the help of alternative instruments aimed at developing new trade models.

A Quality Improvement Initiative for Inpatient Advance Care Planning

The Centers for Medicare & Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied. To determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes. This nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024. Billed ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death). The total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P < .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant. This nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members.

The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program. This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending, defined as medical spending during a 6-month episode. Secondary outcomes included hospitalization and emergency department (ED) utilization and quality measures. From the pre-OCM to the OCM period, mean total episode payments increased from $45,504 in US dollars (USD) to $46,239 USD for OCM-participating practices, and increased from $50,519 USD to $58,591 USD for non-OCM practices (adjusted difference-in-differences -$6,287 USD [95% CI, -$10,076 USD to -$2,498 USD], P = .001). The OCM was associated with adjusted spending decreases for both high-risk (-$6,756 USD [95% CI, -$10,731 USD to -$2,781 USD], P = .001) and low-risk (-$4,171 USD [95% CI, -$7,799 USD to -$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (-$5,243 USD [95% CI, -$8,589 USD to -$1,897 USD], P = .002) and infused/injected anticancer drug (-$3,031 USD [95% CI, -$5,193 USD to -$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care. The OCM was associated with reductions in spending for nontargeted members, a spillover effect.

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.

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 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...

The power of data: Transforming compliance with anti-money laundering measures in domestic and cross-border payments

Financial crime is on the rise. The interconnectedness of global payments is making illicit cross-border transactions increasingly frictionless, while digitisation has not only increased the attack surface but also enabled criminals to employ increasingly sophisticated methods to evade detection, such as social engineering. Compounding the threat is the ever-growing mountain of data being generated, which is threatening to drown detection and prevention efforts. It is clear that a new level of defence is required in the fight against financial crime. This paper argues that the implementation of data-driven technologies, with a focus on artificial intelligence (AI), is a near-term imperative for effective risk-based anti-money laundering (AML) compliance programmes in the payments industry, where legacy AML programmes over-rely on a rule-based approach with a checklist of predetermined rules and indicators to flag potentially suspicious activity. To support the development and implementation of such data-driven enhancements, this paper hones in on the current hurdles, and explains the benefits and technical aspects of AI integration, emphasising the foundational importance of ISO/IEC AI-related standards. Finally, the paper discusses future opportunities for broader collaboration to build stronger collective defences.

Association of Hospital System Affiliation with Spending and Postoperative Outcomes: A Longitudinal Study of Hospital Mergers And Acquisitions From 2010 To 2018.

To determine whether hospital system affiliation was associated with changes in surgical episode spending or postoperative outcomes. Over 70% of US hospitals are now part of a hospital system. The presumed benefits of hospital consolidation include concentrating volume and expertise, care integration, and investment in quality improvement. However, there is conflicting evidence as to whether expanding hospital systems are actually reducing health spending or improving quality. These observations call into question whether systems are leveraging their collective volume and experience to standardize care and maximize efficiencies. The American Hospital Association Annual Survey was used to identify whether a hospital was part of a system and in which year a hospital joined the respective system. Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective inpatient coronary artery bypass graft colon resection, lung resection, hip replacement, or knee replacement from 2010 to 2018. We used a difference-in-differences framework to evaluate hospital spending and outcomes before and after joining a system. The primary outcome was Medicare 30-day episode spending, with specific attention to the total episode payment, index hospitalization, and post-acute care components. Secondary outcomes included serious complications, 30-day mortality, and 30-day readmission. The cohort included 3,395,565 Medicare beneficiaries who underwent surgery between 2010 and 2018. Patients were treated at 3961 hospitals, of which 1097 (27.7%) were never in a system, 2262 (57.1%) were always in a system, and 602 (15.2%) joined a system during the study period. By 1 year after system affiliation, 30-day episode spending had decreased by $303 (95% CI: 63, 454, P=0.01), and after 5 years, 30-day episode spending decreased by $429 (95% CI: 5, 853, P=0.04). One year after system association, index hospitalization spending was not statistically different from before system affiliation ($-30, 95% CI: -160, 100, P=0.65). Conversely, 1 year after system association, postacute care spending decreased by $268 (95% CI: 107, 429, P<0.01) and remained lower for ≥5 years. There was no significant change in hospitals serious complications (-0.14, 95% CI: -0.40, 0.11, P=0.27), 30-day readmission (-0.14, 95% CI:-0.52, 0.25, P=0.48), or 30-day mortality (-0.08, 95% CI: -0.18, 0.03, P=0.17), 1 year after joining a system; similar patterns were observed at three and ≥5 years. system affiliation was associated with a small decrease in 30-day episode spending, driven by decreased spending in postacute care services. Notably, there was no difference in postoperative outcomes after system affiliation.

De-Dollarization

De-dollarization is a “significant reduction in the use of dollars in world trade and financial transactions, [as well as] decreasing national, institutional and corporate demand” for United States dollars. (Goldman Sachs 2023; Li Yuefen 2024) De-dollarization has been a persistent theme since the collapse of the Bretton Woods Gold System in 1971 and the rising US national debt. (Cohen 2015) Efforts to minimise reliance upon the US dollar, such as the 1976 introduction of the IMF Special Drawing Right and the 2002 introduction of the Euro, failed to displace dollar dominance. (Eichengreen 2011) The Euro is a currency without a Nation State and the IMF SDR is not a currency used to invoice and settle international trade and financial transactions. However, the decision of the United States to “weaponize” the use of the dollar and to impose restrictions on global payment systems have impelled countries to construct an alternative to the dollar system. (Sen 2019) This article first examines the adverse effects of using the US dollar as a global reserve currency. Second, the article examines the application of economic sanctions, specifically against the Russian Federation, to illustrate the probable development of an alternative reserve and invoice currency to co-exist with the dollar. Third, the article posits the conditions necessary to establish a viable alternative to the dollar and then examines efforts to promote alternatives to global payment systems such as SWIFT, and to build a new reserve currency. The article concludes: [1] the imposition of economic sanctions compels target countries to create alternative financial systems and settle international trade in national currencies; [2] establishing a new reserve currency out of whole cloth is a formidable task and lacks a recent historical counterpart, [3] the renminbi is the likely currency to rival, not displace, the US dollar.

Maryland’s Global Budget Revenue Payment Model and Shifts in the Surgical Site of Care Among Medicare Beneficiaries

Objective: To assess the association between the Global Budget Revenue (GBR) payment model and shifts to the outpatient setting for surgical procedures among Medicare fee-for-service beneficiaries in Maryland versus control states. Summary Background Data: The GBR model provides fixed global payments to hospitals to reduce spending growth and incentivize hospitals to reduce the costs of care while improving care quality. Since surgical care is a major contributor to hospital spending, the GBR model might accelerate the ongoing shift from the inpatient to the outpatient setting to generate additional savings. Methods: A difference-in-differences (DiD) design was used to compare changes in surgical care settings over time from pre-GBR (2011-2013) to post-GBR (2014-2018) for Maryland versus control states for common surgeries that could be performed in the outpatient setting. A cross-sectional approach was used to compare the difference in care settings in 2018 for total knee arthroplasty which was on Medicare’s Inpatient-Only List before then. Results: We studied 47,542 surgical procedures from 44,410 beneficiaries in Maryland and control states. GBR’s 2014 implementation was associated with an acceleration in the shift from inpatient to outpatient settings for surgical procedures in Maryland (DiD: 3.9 percentage points, 95% CI: 2.3, 5.4). Among patients undergoing total knee arthroplasty in 2018, the proportion of outpatient surgeries in Maryland was substantially higher than that in control states (difference: 27.6 percentage points, 95% CI: 25.6, 29.6). Conclusions: Implementing Maryland’s GBR payment model was associated with an acceleration in the shift from inpatient to outpatient hospital settings for surgical procedures.

Hospital strategies in commercial episode-based reimbursement.

To understand hospitals' approaches to spending reduction in commercial episode-based payment programs and inform incentive design. Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state's largest commercial payer. We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference-based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains. Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment. The findings highlighted hospitals' most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians.

The oncology care model and initiation of systemic therapy for cancer.

11031 Background: The CMS Oncology Care Model (OCM) was an episode payment model for patients with cancer receiving systemic therapy (chemotherapy, targeted therapy, immunotherapy, or hormonal therapy) that began in July 2016. Voluntarily participating practices received monthly care coordination payments of $160 per patient per month and were required to deliver enhanced services; they were eligible to share in savings if they achieved quality and spending targets (based on historic spending trended forward; all practices were in one-sided risk arrangements before 2019). Prior research identified savings of $499 per episode (excluding monthly payments) through OCM’s first 5 years, but no overall savings after including incentive payments. One concern about an episode payment model triggered by initiation of systemic therapy is that the financial incentives may prompt an increase in the total number of episodes. We assessed if OCM led to an increase in the likelihood of initiating systemic therapy. Methods: Using Medicare data, we studied care for beneficiaries enrolled in Parts A, B, and D of fee-for-service Medicare with index cancer diagnoses in 2010 through 2019. We assessed initiation of systemic therapy in the one year after the index diagnosis date. We studied two populations: (1) all patients with an index cancer diagnosis and no cancer diagnosis in the preceding two years, suggesting newly diagnosed or newly progressive cancers (incident cohort) and (2) patients with poor prognosis cancers. We used a difference-in-differences (DiD) analysis to assess systemic therapy initiation among patients with index cancer diagnoses who had office visits to medical oncology practices that were participating in OCM, compared with matched comparison practices (on number of patients attributed, number of physicians, number of medical oncologists, and academic affiliation, favoring matches within Hospital Referral Region), before and after OCM’s start in July 2016. Analyses adjusted for patient demographic and clinical variables. Results: Among 742,699 beneficiaries in the incident cancer cohort, 61.9% initiated systemic therapy within 1 year of their index diagnosis. Among 777,951 beneficiaries in the poor prognosis cohort, 58.2% initiated systemic therapy within 1 year of their index diagnosis date. OCM was not associated with the likelihood of initiating systemic therapy in the incident cohort (DID:-0.7 percentage point change, 95% CI:-1.9,0.4, P=0.19) or the poor prognosis cohort (DID:-1.0 percentage point change, 95% CI:-2.1,0.1, P=0.07). Conclusions: Despite financial incentives of episode payment models that may favor greater use of systemic therapy for patients with cancer, OCM did not increase the likelihood of initiating systemic therapy episodes among patients with newly diagnosed/newly progressive cancers or poor prognosis cancers who visited a medical oncology practice.

Evaluation of the impact of prospective payment systems on cholecystectomy: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to evaluate the impact of prospective payment systems (PPSs) on cholecystectomy. A comprehensive literature review was conducted, examining studies published until December 2023. The review process focused on identifying research across major databases that reported critical outcomes such as length of stay (LOS), mortality, complications, admissions, readmissions, and costs following PPS for cholecystectomy. The studies were specifically selected for their relevance to the impact of PPS or the transition from fee-for-service (FFS) to PPS. The study analyzed six papers, with three eligible for meta-analysis, to assess the impact of the shift from FFS to PPS in laparoscopic and open cholecystectomy procedures. Our findings indicated no significant changes in LOS and mortality rates following the transition from FFS to PPS. Complication rates varied and were influenced by the diagnosis-related group categorization and surgeon cost profiles under episode-based payment. There was a slight increase in admissions and readmissions, and mixed effects on hospital costs and financial margins, suggesting varied responses to PPS for cholecystectomy procedures. The impact of PPS on cholecystectomy is nuanced and varies across different aspects of healthcare delivery. Our findings indicate a need for adaptable, patient-centered PPS models that balance economic efficiency with high-quality patient care. The study emphasizes the importance of considering specific surgical procedures and patient demographics in healthcare payment reforms.

Cost Difference in Performing Total Knee Arthroplasty at Ambulatory Surgical Centers Compared With Hospital-Based Outpatient Departments: Observational Study.

As total knee arthroplasty (TKA) further transitions toward an outpatient procedure, it becomes important to identify the resource utilization after TKAs at different outpatient facilities. The objective of this study was to determine the 90-day cost of patients who underwent TKAs at an ambulatory surgical center (ASC) or a hospital outpatient department (HOPD). An observational cohort study was conducted using the Marketscan database with patients who had a TKA at an ASC or HOPD between January 1st, 2019, and October 2nd, 2021. The primary outcome was cost in a 90-day period (including the day of surgery), with inpatient admissions and ED visits as secondary outcomes. Multivariable regression analyses were conducted, adjusting for patient characteristics. The study population consisted of 47,261 patients with 7,874 ASC patients and 39,387 HOPD patients. 90-day costs for ASC patients were lower compared with HOPD patients ($35,634 ± 19,030 vs. $38,096 ± 24,389, P < 0.001). 90-day inpatient admission rates were lower for ASC than HOPD patients (2.5% vs. 4.8%, P < 0.001). 90-day ED visits for ASC patients were lesser compared with HOPD patients (8.9% vs. 12.7%, P < 0.001). Patients with TKAs at an ASC had an overall lower cost, inpatient admissions, and ED visits over a 90-day period compared with HOPD patients. Future consideration for which outpatient facilities patients have their TKA at is necessary as TKAs shift toward bundle payments and outpatient procedures.

Early Experiences With Bundled Payments for Care Improvement for Major Bowel Surgery.

Bundled Payment (BP) models are becoming more common in surgery. We share our early experiences with Bundled Payments for Care Improvement for major bowel surgery. Patients undergoing major bowel surgery between January and October 2021 were identified using Medicare Severity-Diagnosis Related Group (MS-DRG) codes. Major drivers of cost in a BP model are reported and compared to the Fee-For-Service (FFS) payment model. A total of 202 cases (173 FFS vs 29 BP) were analyzed. The mean BP cost per Clinical Episode was $28,340. Eleven patients (38%) in the BP model had costs greater than the Target Price. The drivers of cost in the BP model were 59% acute care facility, 17% physician services, 9% post-acute care facilities, 8% other, and 7% readmissions. Clinical Episode of care costs varied considerably by MS-DRG case complexity. Robotic surgery increased costs by 35% (mean increase $3724, P < .01). The 90-day readmission rate was 17% for a mean cost of $11,332 per readmission. Three patients (10%) were discharged to a skilled nursing facility at an average cost of $11,009, while fifteen patients (52%) received home health services at a mean cost of $2947. Acute care facility costs were similar in the BP vs FFS groups (mean difference $1333, P = .22). Patients undergoing major bowel surgery are a heterogeneous population. Physicians are ideally positioned to deliver high-value, patient-centered care and are crucial to the success of a BP model. The post-acute care setting is a key component of improving efficiency and quality of care.

ENVIRONMENTAL IMPACT OF CRYPTOCURRENCY MINING: SUSTAINABILITY CHALLENGES AND SOLUTIONS

The rapid growth of cryptocurrencies over the past 14 years has led to increased deep-level mining activities. This research aims to explore the environmental impacts resulting from the surge in crypto mining and proposed solutions to mitigate these impacts. Cryptocurrencies, gaining popularity as alternative investments and global payment tools, have significantly boosted crypto mining activities. However, the increasing number of transactions requiring computer validation has resulted in adverse consequences for the environment, particularly in terms of substantial energy consumption. Literature review and systematic analysis were conducted to comprehend the environmental impact of crypto mining, focusing on major cryptocurrencies such as Bitcoin, Ethereum, and others. The analysis highlights that crypto mining, especially Bitcoin, requires a significant amount of electricity, leading to a substantial carbon footprint and broad environmental repercussions. Proposed solutions to address the environmental impact of crypto mining include the use of renewable energy sources such as solar and wind power, enhancing the efficiency of specialized mining devices (ASICs), and exploring more energy-efficient consensus mechanisms like Proof of Stake (PoS) compared to the currently utilized Proof of Work (PoW). Reducing redundancy in blockchain technology has also been identified as a crucial step in minimizing unnecessary energy consumption. However, this research has limitations concerning data consistency, a comprehensive understanding of overall environmental impacts, and continuous technological changes in the crypto world. Therefore, future research should focus on developing more efficient consensus mechanisms, effective policy frameworks and governance, as well as real-world implementation studies to evaluate the sustainability solutions proposed.

Co-operative Banks - A Helping Hands for Small and Medium Entrepreneurs in Saharanpur District

Co-operative banks are more structured compared to credit associations. While local branches of cooperative banks can pick their own leaders and manage their own tasks, big decisions need to be approved by a main office. Credit associations frequently exercise significant local fundamental leadership, but by joining forces, they can share back-office functions including access to the global payments system. This essay provides background information on cooperative banks and small bank groups. Co-operative banks have more information available than "little establishments" as a whole cooperative banking systems exhibit greater organizational structure compared to credit association systems. Local branches of cooperative banks have autonomy in selecting their executive candidates and managing their operations. Small and medium enterprises (SMEs) encounter unique challenges in their development compared to large enterprises. The competitive market environment demands that SMEs adapt to the survival-of-the-fittest dynamics inherent in a market economy. In essence, this translates to a competition for human resources, making staff training a crucial method for SMEs aiming at long-term, stable development. Staff training serves as a fundamental approach to elevate the quality of human resources within SMEs. The paper provides background information on cooperative banks and small bank groups, highlighting their organizational structure and decision-making processes. It emphasizes the importance of staff training in small and medium enterprises (SMEs) for long-term, stable development, as it enhances the quality of human resources and improves overall productivity and competitiveness. The paper discusses the role of corporate culture in SMEs, stating that cultivating a positive corporate culture can enhance cohesion, employee loyalty, motivation, and job satisfaction, ultimately fostering productivity and innovative outcomes. It also highlights that a strong corporate culture can be a unique selling proposition for SMEs in attracting and retaining top talent. Additionally, the paper mentions the significance of cooperative banks in rural financing and their growing activity in metropolitan areas, contributing to the local economy and employment generation.

Hospital and Physician Group Practice Participation in Prior and Next-Generation Value-Based Payment Programs

This cohort study examines whether prior direct or indirect participation in the Centers for Medicare &amp;amp;amp; Medicaid Innovation Bundled Payments for Care Improvement (BCPI) Initiative was associated with their participation in the next generation of the program.