Bundled Payment Research Articles

Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America.

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care

Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.

Healthcare payment mechanism: Execution results of bundled payment program for bariatric surgery diagnosis in its first year of implementation in Chile.

More than 600 thousand people in Chile live with morbid obesity. Effective, safe, cost-effective therapeutic interventions are critical for healthcare systems and insurance schemes. In 2022, two bundled payment codes for bariatric surgery (gastric bypass and gastric sleeve) were incorporated into the National Health Fund's free-choice modality fee scheme. The objective was to characterize the execution of this payment mechanism program associated with bariatric surgery diagnosis in its first year of implementation.More than six hundred thousand people in Chile are estimated to live with morbid obesity. Effective, safe, cost-effective therapeutic interventions are critical for health systems and insurance schemes. In 2022, FONASA incorporated two Bariatric Surgery codes into the Free Choice Modality: Gastric Bypass and Sleeve Gastrectomy. Our objective was to characterize the execution of the Bariatric Surgery Bundled Payment Program in its first year of implementation. Descriptive and observational study of the pragmatic approach of the national execution of the payment associated with diagnosis in bariatric surgery. We examined sociodemographic variables (sex, age brackets, and National Health Fund tranches) and characterization of surgeries by code broken down by public or private provider, period of issue, unit cost, co-payment, and medical loans between March and December 2022. We recorded n = 13 118 surgeries (45.81% bypass versus 54.19% sleeve), of which n = 2424 (18.48%) used medical loans. A total of 85.01% (p = 0.01) of the procedures were in women, in people between 35 and 39 years of age (20.15%), and 45.12% in beneficiaries of tranche B. Private providers performed a total of 99.21% of the surgeries. Ten accounted for 50% of the activity (range n = 1200 to 426 surgeries per year; n = 4.8 to 1.7 surgeries per working day). Total program expenditure was $71 626 948 350 CLP, accounting for 5.04% of the total activity of the national Diagnosis Associated Payment Program. The implementation of this bariatric surgery voucher benefited more than 13 thousand people living with obesity, mostly women of productive ages and with purchasing capacity. As an equity strategy, regardless of the access route through the voucher, it will be important to safeguard the activity in the public network.

Global Payment Systems Index - a measure of development of payment systems across countries

Global Payment Systems Index - a measure of development of payment systems across countries

КЛАСИФІКАЦІЯ ПЛАТІЖНИХ СИСТЕМ В ЕЛЕКТРОННІЙ КОМЕРЦІЇ

The article examines the payment systems used in the world and in Ukraine, their features and components, existing varieties. It has been proven that payment systems based on electronic money include: payment systems based on smart cards; softwarebased payment systems operating on the Internet; payment systems based on mobile communication networks. The existing classifications of payment systems are given according to various characteristics: by the method of execution, by the type of operation, by the form of ownership, by the territory of operation, by the degree of residency of the participants, by the volume of payments made, etc. The article, based on its own long-term experience of working with various electronic payment systems, offers its own classification of payment systems by the scope of coverage: a) global payment systems; b) local (national) payment systems. The main global payment systems of the world and local payment systems of the United States, Canada, Great Britain, the countries of the European Union and Ukraine are indicated. A general scheme of the entire system of electronic payments has been built. The mechanism of making payments through LiqPay, WISE and PAYONEER payment services and the features of the functioning of these payment systems are described. The nuances of the acquiring payment transaction processing process, as well as the procedure for introducing an international bank account number (IBAN) in Ukraine, were traced and indicated. Facilitation of greater integration of the Ukrainian payment space with the European one due to savings on bank commissions and speed of operations was revealed. The dependence of the development of electronic commerce on the perfection, volume and convenience of payment systems is singled out.

Analysis of health outcomes in acute myocardial infarction: A value-based healthcare approach

Introduction: Understanding the impact of value-based healthcare and various healthcare payment models on the health outcomes of patients with acute myocardial infarction (AMI) is pivotal for guiding clinical strategies and decisions. Objective: To compare health outcomes and costs associated with healthcare for AMI patients under insurance prospective global payment (PGP) and fee-for-service models. Materials and Methods: A retrospective cohort study encompassing AMI patients was conducted from 2021-2023. Convenience sampling of participants over 18 years of age diagnosed with type 2 myocardial infarction was conducted. Analysis was based on Colombian healthcare system payment models: PGP and fee-for-service. Results: The study involved 2134 patients, 657 (31%) under PGP and 1477 (69%) under fee-for-service. Length of hospital stay was associated with the payment model (coefficient -0.68, CI 95%: 0.40 to 0.98, p=0.037). Payment models also correlated with costs (845 USD, CI 95%: 87.92 to 1601; p=0.02 ). In-hospital mortality is not associated with either of the two contracting models. Quality-adjusted life years (QALYs) totaled 1.6 over a 2-year follow-up. Discussion: It is evident that throughout the care cycle at the Center of Excellence for Acute Myocardial Infarction, there is added value for patients with the PGP model, as the costs are lower and health outcomes comparable to the fee-for-service model. Conclusions: The findings of this study underscore the importance of understanding the relationship between value-based healthcare, different healthcare payment models, and health outcomes in AMI patients.

Global Payment Systems Index - a measure of development of payment systems across countries

Global Payment Systems Index - a measure of development of payment systems across countries

Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits

Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of TCPs at reducing healthcare costs, hospital readmissions, and ED visits. Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) program adjudicated claims files and electronic health records from Greenville Memorial Hospital, Greenville, SC, were accessed. Data on post-discharge 30- and 90-day ED visits and readmissions, total costs, and episodes with costs over BPCI target prices were extracted from November 2017 to July 2020 and compared between the “TCP-Graduates” (N = 85) and “Did Not Graduate” (DNG) (N = 1310) groups. As compared to the DNG group, the TCP-Graduates group had significantly fewer 30-day (7.1% vs. 14.9%, p = 0.046) and 90-day (15.5% vs. 26.3%, p = 0.025) readmissions, episodes with total costs over target prices (25.9% vs. 36.6%, p = 0.031), and lower total cost/episode (USD 22,439 vs. USD 28,633, p = 0.018), but differences in 30-day (9.4% vs. 11.2%, p = 0.607) and 90-day (20.0% vs. 21.9%, p = 0.680) ED visits were not significant. TCP was associated with reduced post-discharge hospital readmissions, total care costs, and episodes exceeding target prices. Further studies with rigorous designs and individual-level data should test these findings.

The Challenges of Digital Transformation Faced by Bank Employees in Malaysia

This study focuses on the challenges and best practices for digital transformation within AAA Bank Malaysia Berhad, specifically examining the experiences of employees in the Commercial Banking and Global Payments Solutions departments. The objective is to identify the challenges faced by bank employees in Malaysia regarding digitalization and digital transformation and propose best practices to overcome these challenges while ensuring a smooth transition that benefits both the organization and its staff. The study begins with a comprehensive literature review on digital transformation in the banking industry, the challenges encountered by bank employees during this process, and the best practices for successful digital transformation. It also highlights the regulatory environment that banks and financial institutions must navigate. A qualitative research approach is employed, involving interviews with selected employees ranging from managers to executives. The interview questions are designed to gather information on the factors impacting digital transformation, the effectiveness of current practices, and the challenges faced by employees in embracing digitalization. The collected data are analyzed using an inductive approach to identify themes and patterns, forming the basis for recommendations. The study provides insights into the challenges faced by bank employees during digital transformation and proposes best practices to facilitate a smooth transition. It also emphasizes the importance of security and compliance considerations in this process. The findings contribute to supporting bank workers in navigating the hurdles of digital transformation and helping the organization achieve successful implementation.

Analyze the Impact of the Digital RMB on International Payments and Financial Structure Based on Literature Review

With the development of network technology and digital economy, the demand for convenience, security, inclusiveness and privacy of retail payment is increasing. Central banks or monetary authorities in many countries and regions are actively exploring ways to digitize fiat money to meet this demand. The Chinese government has decided to introduce digital RMB as a digital form of legal tender to enhance the payment experience, strengthen financial supervision, promote economic transformation and financial technology innovation and application. The introduction of digital RMB helps to reduce the cost and risk of traditional cash flow, promote the upgrading of payment methods and the development of digital economy. Based on the comprehensive and systematic collection, collation and analysis of the relevant literature in the field of digital RMB, this paper explores the impact of digital RMB on international payment and financial structure. The study found that digital RMB has international security as a payment tool, which can promote cross-border transactions and change the global payment system. Digital RMB can enhance international financial security and affect the implementation of financial policies in various countries.

Cash to Cashless Economy: Opportunities & Challenges in India

Cash may be defined as the legal common way for all kinds of material transactions in an economy. In a highly unorganized economy, the circulation of currency notes without disclosing of its actual income to appropriate authorities provides enough scope for the accumulation of black money in the hands of people as well as the circulation of duplicate currency notes. So, it is necessary to promote digital transaction & plastic money in order to track all the payments and income sources of people. Cash use doesn't seem to be waning all that much, with around 85% of global payments still made using cash. the main reasons are that there is nothing to truly compete with the flexibility of notes and coins. Indian governments also inclined to transform the Indian banking system from traditional branch-based practices to technology-driven cashless banking. And for this it provides enough opportunities such as increasing mobile & internet penetration, raising disposable income, ensuring various lifestyle, urbanization, increasing foreign investment and latest economic and taxation reforms, etc. to accelerate digital transactions but we have to encounter a number of challenges also like poor internet connectivity in rural areas, digital literacy, cybersecurity issues, highly fragmented unorganized economy, etc. Now we can conclude that we have initiated such measures which will pave the way for such a digital transformation of the Indian economy.

Pneumonia is not just pneumonia: Differences in utilization and costs with common comorbidities.

We sought to explore the heterogeneity among patients hospitalized with pneumonia, a condition targeted in payment reform. In a retrospective cohort study of Medicare beneficiaries hospitalized for pneumonia, we compared postacute care utilization and costs of 90-day episodes of care among patients with and without comorbidities of chronic obstructive pulmonary disease (COPD) and/or heart failure. Of the 1,926,674 discharges, 28.1% had COPD, 14.3% had heart failure, and 14.6% carried both diagnoses. Patients with pneumonia were more likely to be discharged to a facility than those with pneumonia and COPD with or without heart failure, though less likely than those with pneumonia and heart failure only. Compared to patients with pneumonia only, patients with COPD and/or heart failure had higher episode payments. Acute conditions such as pneumonia may hold promise for episode-based care payment reform; however, the heterogeneity within this diagnosis indicates the need to consider other patient characteristics in interventions to improve value-based care.

Impact of a centralized population health pharmacy program on value-based Medicare patients

BackgroundMemorial Healthcare System (MHS) participated in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement Advanced value-based program aimed to improve patient care and reduce health care costs. Challenges with medication therapy problems (MTPs) led to the development of a centralized tele-health population health pharmacy program. This innovative approach aimed to provide comprehensive postdischarge medication support and resolve MTPs during the 90-day risk period. ObjectivesThe program aimed to provide longitudinal medication support, resolve MTPs, and affect 90-day readmission rates. Practice descriptionMHS established uniform workflows, a pharmacy task force, and a dual pharmacy team approach with population health registered nurses (PHRNs). The population health pharmacists (PHPs) conducted postdischarge telephonic encounters to resolve MTPs longitudinally throughout the risk period. Practice innovationThe program used a centralized tele-health model with electronic health record–integrated tools. It targeted readmission rates up to 90 days, beyond the conventional 30-day period. PHPs collaborated with onsite transitions of care pharmacists, PHRNs, and health care professionals for coordinated patient care and MTP resolution. Evaluation methodsA retrospective analysis using descriptive statistics, a Kruskal-Wallis test, and multivariate regression models after stratifying patients into 4 groups were used to assess MTP resolution rates and differences in readmission rates. ResultsOver 7 months, PHPs completed 801 telephonic visits, identifying 433 MTPs with a 94% resolution rate. The program led to a statistically significant reduction in 90-day readmission rates from 35% to a range of 10%-17% (P < 0.01). ConclusionThe centralized tele-health population health pharmacy program improved patient outcomes, resolved MTPs, and reduced readmission rates. The program serves as a model for integrating pharmacists into value-based care initiatives.

Opportunities for Savings in Risk Arrangements for Oncologic Care

As the US accelerates adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA), high spending for cancer care is a potential target for savings. To quantify the extent to which ACOs and other risk-bearing organizations operating in a specific geographic area (hospital referral region [HRR]) could achieve savings by steering patients to efficient medical oncology practices. This observational study included serial cross-sections of Medicare beneficiaries with cancer from 2010 to 2018. Data were analyzed from August 2021 to March 2023. Total spending and spending by category in the 1-year period following an index visit for a patient with newly diagnosed (incident) or poor-prognosis cancer. The incident cohort included 1 309 825 patients with a mean age of 74.0 years; the most common cancer types were breast (21.4%), lung (16.7%), and colorectal cancer (10.0%). The poor prognosis cohort included 1 429 973 (mean age, 72.7 years); the most common cancer types were lung (26.6%), lymphoma (11.7%), and leukemia (7.3%). Options for steering varied across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57 314 in 2009 to 2010 to $66 028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% higher than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods ($20 390 and $19 718, respectively) followed by Part B (infused) chemotherapy ($8022 and $11 699). Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high (>0.90 in all categories with most >0.98), but these attenuated over time. These results suggest there may be opportunities for ACOs and other risk-bearing organizations to select or drive referrals to lower-spending oncology practices in many local markets.

Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study.

The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry. In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods. We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results. Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.

Multi-stage Proof-of-Works: Properties and vulnerabilities

Since its appearance in 2008, Bitcoin has attracted considerable attention. So far, it has been the most successful cryptocurrency, with the highest market capitalization. Nevertheless, due to the method it uses to append new transactions and blocks to the blockchain, based on a Proof-of-Work, Bitcoin suffers from poor scalability, which strongly limits the number of transactions per second and, hence, its adoption as a global payment layer for everyday uses. In this paper we analyze some recent proposals to address this issue. In particular, we focus our attention on permissionless blockchain protocols, whose distributed consensus algorithm lies on a Proof-of-Work composed of k>1 sequential hash-puzzles, instead of a single one. Such protocols are referred to as multi-stage Proof-of-Works. We consider a simplified scenario, commonly used in the blockchain literature, in which the number of miners, their hashing powers, and the difficulty values of the hash-puzzles are constant over time. Our contribution is threefold. Firstly, we derive a closed-form expression for the mining probability of a miner, that is, the probability that the miner completes the Proof-of-Work of the next block to be added to the blockchain, before any other miner does. Secondly, we show that in multi-stage Proof-of-Works the mining probability might not be strictly related to the miner hashing power. This feature could be exploited by a smart miner, and could open up potential fairness and decentralization issues in mining. Finally, we focus on a more restricted scenario and present two attacks, which can be applied successfully against multi-stage Proof-of-Works: a Selfish Mining attack and a Selfish Stage-Withholding attack. We show that both are effective, and we point out that Selfish Stage-Withholding can be seen as a complementary strategy to Selfish Mining, which in some cases increases the selfish miner profitability in the Selfish Mining attack.

Assessment of a Private Payer Bundled Payment Model for Lumbar Decompression Surgery.

Although bundled payment models are well-established in Medicare-aged individuals, private insurers are now developing bundled payment plans. The role of these plans in spine surgery has not been evaluated. Our objective was to analyze the performance of a private insurance bundled payment program for lumbar decompression and microdiskectomy. A retrospective review was conducted of all lumbar decompressions in a private payer bundled payment model at a single institution from October 2018 to December 2020. 120-day episode of care cost data were collected and reported as net profit or loss regarding set target prices. A stepwise multivariable linear regression model was developed to measure the effect of patient and surgical factors on net surplus or deficit. Overall, 151 of 468 (32.2%) resulted in a deficit. Older patients (58.6 vs. 50.9 years, P < 0.001) with diabetes (25.2% vs. 13.9%, P = 0.004), hypertension (38.4% vs. 28.4%, P = 0.038), heart disease (13.9% vs. 7.57%, P = 0.030), and hyperlipidemia (51.7% vs. 35.6%, P = 0.001) were more likely to experience a loss. Surgically, decompression of more levels (1.91 vs. 1.19, P < 0.001), posterior lumbar decompression (86.8% vs. 56.5%, P < 0.001), and performing surgery at a tertiary hospital (84.8% vs. 70.3%, P < 0.001) were more likely to result in loss. All readmissions resulted in a loss (4.64% vs. 0.0%, P < 0.001). On multivariable regression, microdiskectomy (β: $2,398, P = 0.012) and surgery in a specialty hospital (β: $1,729, P = 0.096) or ambulatory surgery center (β: $3,534, P = 0.055) were associated with cost savings. Increasing number of levels, longer length of stay, active smoking, and history of cancer, dementia, or congestive heart failure were all associated with degree of deficit. Preoperatively optimizing comorbidities and using risk stratification to identify those patients who may safely undergo surgery at a facility other than an inpatient hospital may help increase cost savings in a bundled payment model of working-age and Medicare-age individuals.

Global Payments Inc.

Corporate Philanthropy ReportVolume 38, Issue 7 p. 10-11 Corporate Profiles Global Payments Inc. First published: 12 June 2023 https://doi.org/10.1002/cprt.31656Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume38, Issue7July 2023Pages 10-11 RelatedInformation

Procedures employing interbody devices and multi-level fusion require target price adjustment to build a sustainable lumbar fusion bundled payment model

BACKGROUND CONTEXTBundled payment models require risk adjustment to ensure appropriate targets are set. While this may be standardized for many services, spine fusions demonstrate significant variability in approach, invasiveness, and use of implants, that may require further risk adjustment. PURPOSETo evaluate variability in costs of spinal fusion episodes in a private insurer bundle payment program and identify whether current procedural terminology (CPT) code modifications are necessary for sustainable implementation. STUDY DESIGN/SETTINGRetrospective single-institution cohort study. PATIENT SAMPLEA total of 542 lumbar fusion episodes in a private insurer bundled payment program from October 2018 to December 2020. OUTCOME MEASURESA total of 120-day episode of care net surplus/deficit, 90-day readmissions, discharge disposition, and length of hospital stay. METHODSA review was conducted of all lumbar fusions in a single institution's payer database. Surgical characteristics (approach [posterior lumbar decompression and fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), and circumferential fusion], levels fused, and primary vs revision) were collected from manual chart review. Episode of care cost data were collected as net surplus or deficit with respect to target prices. A multivariate linear regression model was constructed to measure the independent effects of primary versus revision, levels fused, and approach on the net cost savings. RESULTSMost procedures were PLDFs (N=312, 57.6%), single-level (N=416, 76.8%) and primary fusions (N=477, 88.0%). Overall, 197 (36.3%) resulted in a deficit, and were more likely to be three levels (7.11% vs 2.03%, p=.005), revisions (18.8% vs 8.12%, p<.001), and TLIF (47.7% vs 35.1%, p<.001) or circumferential fusions (p<.001). One-level PLDFs resulted in the greatest cost savings per episode ($6,883). Across both PLDFs and TLIFs, 3-level procedures resulted in significant deficit of −$23,040 and −$18,887, respectively. For circumferential fusions, 1-level fusions resulted in deficit of −$17,169 per case which rose to −$64,485 and −$49,222 for 2- and 3-level fusions. All 2- and 3-level circumferential spinal fusions resulted in a deficit. On multivariable regression, TLIF and circumferential fusions were independently associated with a deficit of −$7,378 (p=.004) and −$42,185 (p<.001), respectively. Three-level fusions were independently associated with an additional −$26,003 deficit compared to single-level fusions (p<.001). CONCLUSIONSInterbody fusions, especially circumferential fusions, and multi-level procedures are not adequately risk adjusted by current bundled payment models. Health systems may not be able to financially support these alternative payment models with improved procedure-specific risk adjustment.

Impact of the oncology care model (OCM) on Medicare payments, utilization, and care delivery: Update through year 5.

1512 Background: OCM was a voluntary episode-based alternative payment model designed to improve the value of care for fee-for-service Medicare beneficiaries receiving systemic therapy for cancer. Participating practices received monthly enhanced oncology services (MEOS) care coordination payments and could receive additional payments (or penalties) if they met quality and total episode spending goals during 6-month episodes. Methods: We used a difference-in-differences approach to evaluate OCM impacts on Medicare payments, utilization, and quality measures during 6-month episodes before (July ‘14-January ’16) and after (July ‘16-June ‘21) OCM’s start. Patient-episodes were attributed to OCM-participating practices (n = 202) or propensity-matched comparison practices (n = 534). Statistical significance was defined as p≤0.10 to avoid missing program impacts. Results: Total episode payments (TEP) for 6-month OCM episodes increased from 29,120 in the baseline period to 35,467 in the OCM period (+21.8%). In reference to comparison episodes, OCM led to a 499 relative reduction in TEP (90%CI -771, -227, -1.7% relative to baseline.) OCM had no significant impact on TEP for low-risk breast, prostate, and bladder cancers, and OCM led to a relative decrease of 755 (CI -1140, -371) for all other higher risk cancers. Reductions in TEP were largest for high-risk breast cancer, lymphoma, lung cancer and colorectal cancer. The overall OCM impact on TEP was attributable to relative reductions in both Part A payments (-152, [CI -257, -47]) and Part B payments (-276, [CI -459, -92]). There was no OCM impact on Part D payments. While OCM had no impact on Part B chemotherapy payments, OCM reduced Part B non-chemotherapy drug payments by 251 (CI -330, -173; -9.3%). Utilization analyses showed no impact of OCM on ED visits or hospitalizations, but OCM reduced the likelihood of ICU admission by 0.6 percentage points (PP; CI -1.0, -0.1, -5.4%). OCM had no impact on initial chemotherapy regimen selection, but OCM led to greater use of biosimilar cancer therapies and value sensitive changes in the use of antiemetics, bone supportive medications, and WBC growth factors (including greater use of biosimilar WBC growth factors; all p &lt; 0.10). OCM reduced hospitalizations in the last 30 days of life by 0.8 PP (CI -1.6, -0.1; -1.5%) with no impact on use of chemotherapy or hospice at the end of life. Despite OCM-related TEP reductions, OCM resulted in net losses to Medicare after accounting for MEOS and performance-based payments. Conclusions: OCM led to reductions in TEP with similar or improved quality. Reductions in TEP were greatest for common, high-cost cancer types and were driven primarily by changes in use of supportive care medications. The Medicare Enhancing Oncology Model will build on the experience of OCM to further the goal of improving the quality and value of cancer care for Medicare beneficiaries.