Stroke prevalence is highest in adults ≥65years, the majority of whom are Medicare beneficiaries. Fee-for-Service Medicare (FFS) incentivizes utilization by paying for each service. Medicare Advantage (MA) uses capitated payments to reduce overutilization. It is not clear if stroke patients with FFS or MA receive different stroke preventive care and whether those differences are associated with differences in post-acute care utilization, cost and clinical outcomes. We performed an empirical narrative review of published peer-reviewed studies in the PubMed, EMBASE and Web of Science databases comparing stroke preventive care between FFS and MA using the American Heart Association's Life's Essential 8 and American Heart Association/American Stroke Association national guidelines. We added atrial fibrillation (AF), post-acute care utilization and outcomes, including mortality. 7/1356 studies met inclusion criteria. Studies were heterogenous in their design and settings. There was limited availability of clinical data. Within those limitations, published studies suggest that MA appears to allow for guideline-directed stroke preventive care for hyperlipidemia, smoking cessation and AF in specific study populations. Post-acute care utilization was generally lower in MA. Functional outcomes improvements were similar but occurred in fewer days in MA, though the absence of acute stroke treatment data is notable. Mortality data were mixed. Given the importance of stroke in Medicare and the growth in MA enrollment, comparing the effectiveness of MA and FFS warrants further study among appropriately matched MA and FFS beneficiaries with stroke.

As the population ages more quickly, the smart elderly care sector has emerged as a crucial avenue to address the issues surrounding elder care. However, obstacles to its growth include a lack of funding and a misalignment between supply and demand. Through risk management, payment guarantees, diversified financing, and other methods, pension finance is a crucial enabling tool that may support the modernization of the smart aged care sector. This study systematically analyzed the internal mechanism of elderly care finance empowering smart elderly care, including six dimensions: capital formation, payment guarantee, risk management, financial innovation, policy coordination and market cultivation, and proposed a collaborative path of "capital supply - demand activation - ecological coordination - institutional protection". Research suggests that by optimizing the investment in the three pillars of pensions, innovating the application of insurance funds, improving the payment system, building a fin-tech ecosystem and perfecting the regulatory framework, a deep coupling between pension finance and the smart elderly care industry can be achieved. Ultimately, this will promote the industry's development towards intelligence, scale and inclusiveness, and help address the challenges of an aging society.

Background: Respiratory syncytial virus (RSV) is one of the leading causes of acute respiratory infections and severe cases can lead to hospitalization or death. The epidemiology and health resource utilization of RSV infection in Colombia is not well understood. Given the recent availability of new RSV preventatives, this study estimated the economic burden of RSV in Colombia. Methods: This cost-of-illness study employed a retrospective cohort design and bottom-up costing approach to estimate direct healthcare costs associated with RSV-related acute respiratory infections across pediatric and adult populations. Administrative data from sentinel surveillance centers belonging to the National Epidemiological Surveillance System of the Colombian National Institute of Health, the database for the study of the Capitation Payment Unit database, and the Integrated Social Protection Information System were utilized to estimate RSV incidence, mortality, and healthcare costs. Costs were expressed in US dollars. Results: A total of 264 744 RSV-related healthcare consultations were identified in 2019. The highest incidence was among infants under 1 year (61.8 per 1000), while general mortality was highest in adults 75 years and older (46.6 per 100 000), followed by infants (42.4 per 100 000). Total direct healthcare costs were estimated at $682.87 million (95% CI, $281.39 million–$1084.35 million), with the largest share contributed by individuals aged 15 years and older. Among infants under 1 year, intensive care unit (ICU) patients had the highest average cost ($3619), and hospitalization accounted for 49% of total spending, followed by ICU services (29%) and medications (8%). Conclusions: RSV poses a significant economic burden on Colombia’s healthcare system. These findings support the need for targeted prevention strategies and efficient resource allocation. Future research should incorporate indirect costs and long-term impacts.

BackgroundRespiratory syncytial virus (RSV) is one of the leading causes of acute respiratory infections and severe cases can lead to hospitalization or death. The epidemiology and health resource utilization of RSV infection in Colombia is not well understood. Given the recent availability of new RSV preventatives, this study estimated the economic burden of RSV in Colombia.MethodsThis cost-of-illness study employed a retrospective cohort design and bottom-up costing approach to estimate direct healthcare costs associated with RSV-related acute respiratory infections across pediatric and adult populations. Administrative data from sentinel surveillance centers belonging to the National Epidemiological Surveillance System of the Colombian National Institute of Health, the database for the study of the Capitation Payment Unit database, and the Integrated Social Protection Information System were utilized to estimate RSV incidence, mortality, and healthcare costs. Costs were expressed in US dollars.ResultsA total of 264 744 RSV-related healthcare consultations were identified in 2019. The highest incidence was among infants under 1 year (61.8 per 1000), while general mortality was highest in adults 75 years and older (46.6 per 100,000), followed by infants (42.4 per 100 000). Total direct healthcare costs were estimated at 682.87million(95281.39 million–1084.35million),withthelargestsharecontributedbyindividualsaged15yearsandolder.Amonginfantsunder1year,intensivecareunit(ICU)patientshadthehighestaveragecost(3619), and hospitalization accounted for 49% of total spending, followed by ICU services (29%) and medications (8%).ConclusionsRSV poses a significant economic burden on Colombia’s healthcare system. These findings support the need for targeted prevention strategies and efficient resource allocation. Future research should incorporate indirect costs and long-term impacts.

Background: Performance-based capitation payments are an innovative approach in the health financing system implemented by Social Security Agency on Health (BPJS Health). Purpose: To analyze of the implementation of capitation policy based on service commitment. Method: A descriptive qualitative approach with a case study approach, which aims to analyzing the implementation of the Performance-Based Capitation policy, by taking four variables that are considered most crucial in determining the success of the implementation of the Performance-Based Capitation policy in the city of Semarang, with the policy implementation model approach from Donald Van Meter and Carl Van Horn, namely communication factors, resources, implementer disposition, and implementer characteristics. Results: This approach aims to stimulate the provision of higher quality and more efficient health services, by providing incentives to health service providers based on optimal performance and service outcomes. The implementation of performance-based capitation payments provides several benefits, including increased accountability of health service providers, more effective cost management, and stimulation of innovation in service provision. Conclusion: Performance-based capitation payments by BPJS Health are a step forward in creating a health insurance system that focuses on service quality. Performance-based capitation payments by BPJS Health are a step forward in creating a health insurance system that focuses on service quality.

Accounting for morbidity in capitation payments: A person-based workload formula for primary medical care in England.

Recent federal and state policies have been facilitating the participation of federally qualified health centers (FQHCs) in value-based payment programs to transform care delivery for underserved populations. However, evidence regarding FQHCs' value-based payment revenue and its relationship with the quality of care is limited. Using administrative data from all FQHCs in the US, we assessed trends in the centers' value-based payment and capitation revenue penetration during the period 2014-23 and examined the associations of quality outcomes with the receipt of these revenues. Although value-based payment and capitation revenue penetration increased over time, only 51.2percent of FQHCs received value-based payment and 34.1percent received capitation payment in 2023, accounting for an average of 2.4percent and 9.4percent of patient revenue, respectively. Receiving value-based payment was associated with increased levels in seven of nine quality measures relevant to preventive and primary care. Our findings suggested potential quality improvement effects of value-based payment, although barriers for FQHCs to participating in these programs may still exist.

Background Blended payment models have been hypothesized as one approach to incentivizing service delivery that reduces premature termination of healthcare. In 2019, Vermont implemented a blended fee-for-service and capitated Medicaid payment structure for mental health and substance use treatment provided by community mental health centers. This study assesses the blended payment model’s impact on the odds of premature termination and transitions in care for Medicaid recipients in Vermont’s substance use disorder treatment system. Methods This study employs a difference-in-differences design with a generalized two-way fixed effects model using Vermont-specific Treatment Episode Data Set-Discharges data for 2017 through 2019. Treatment episodes of adult Medicaid utilizers were compared to episodes of adult non-Medicaid utilizers pre-and-post implementation of the blended payment model. Results The odds ratio for termination from intensive outpatient and outpatient programs for Medicaid utilizers post-intervention was OR = 0.730 (p < 0.010). Treatment episodes also had higher odds transfer of care for Medicaid utilizers post-blended payment implementation (OR = 1.45; p < 0.001). Conclusions and implications These results provide evidence that incentivizing co-occurring care through blended payment models may increase the availability of co-occurring mental health and substance use disorder treatment within community mental health centers. This increase in availability may also enable transfers of care from the rest of the substance use disorder treatment system while reducing premature termination from care.

Despite recommendations, screening for unhealthy alcohol use occurs infrequently in US ambulatory care. One barrier to screening often cited by physicians is misalignment of incentives, but it is unclear which financial arrangements contribute to or alleviate this misalignment. This analysis investigates how determinants of income-both patient care revenue and physician remuneration-encourage or discourage guideline-concordant alcohol screening. Cross-sectional data from the US National Ambulatory Medical Care Survey 2015, 2016, 2018, and 2019 are pooled. Covariate-adjusted logistic regression is used to estimate associations between alcohol screening during visits and variables capturing methods of patient care revenue generation and of physician remuneration. Methods of revenue generation include receipt of revenue from capitation and Medicaid. Methods of physician remuneration include payment by share of practice billings, consideration of productivity and patient satisfaction in determining compensation, and practice ownership. Of 10,607 visits under study, fewer than 3% included screening. In the adjusted model, visits to physicians who received > 25% of patient revenue from capitated payments had higher odds of including screening (adjusted odds ratio (aOR) = 5.94; 95% confidence interval (CI) = 2.33, 15.13) compared with visits to physicians who received less from capitation, as did visits to physicians for whom patient satisfaction surveys impacted compensation (aOR = 3.56; 95% CI = 1.51, 8.37). Payment methods that reward value (e.g., capitation) and patient-centered outcomes (e.g., patient satisfaction), rather than productivity, may promote alcohol screening in US ambulatory care. However, the low rates of screening observed suggest transitioning towards such methods will not be sufficient to achieve optimal screening rates.

Diabetes imposes a substantial economic burden on patients worldwide, and various national healthcare insurance systems adopt different payment methods to mitigate medical costs. However, the impact of insurance payment methods on patient health remains unclear. This study uses the reform of per capita payment for diabetes in Tianjin, China, as a quasi-experiment to investigate the effects of insurance payment methods on diabetes complications. The results indicate that the experimental group exhibited a significant reduction in vascular complications compared to the control group. The incidence of peripheral neuropathy, peripheral vascular disease, diabetic nephropathy, retinopathy, cardiovascular disease, and diabetic foot decreased significantly, with these effects becoming more pronounced over time. Moreover, compared to the control group, the incidence rates of complications in retired individuals were lower than those in employees within the experimental group.

The Quality Incentive Program and Patient-Centered Dialysis Care: Mastering the Numbers.

In 2021, the Centers for Medicare & Medicaid Services implemented a Value-Based Insurance Design (VBID) model to test the impact of including hospice services in the Medicare Advantage (MA) benefits package. In December 2024, the VBID was ended following widespread dissatisfaction, signaling a return to the hospice carve-out model. Under the carve-out model, after an MA enrollee elects hospice, health care related to their terminal illness is paid for by fee-for-service (FFS) Medicare. MA plans stop receiving the inpatient and outpatient portions of that enrollee's capitated payment but continue to receive premium and rebate payments. To estimate MA plan spending relative to premium and rebate payments for hospice enrollees under the carve-out model. This cross-sectional study estimated MA plan spending, premiums, and rebate payments for MA enrollees who elected hospice from 2017 through 2019 using 2016 to 2020 FFS claims, MA encounter records, and publicly available plan-level data. MA plan spending and net payments for MA enrollees who elected hospice. Excess payments to MA plans following hospice election were estimated as the difference between MA plan spending and payments. Analyses were conducted between May 2024 and June 2025. We included 314 087 MA enrollees (180 914 females [57.6%]; mean [SD] age, 80.7 [10.0] years); 125 321 (39.9%) were aged 85 years or older. The mean (SD) length of hospice stay was 1.76 (2.49) months. In the year after hospice election, mean MA spending fell to $57 per enrollee per month, with 81% of enrollees having no inpatient, outpatient, physician, skilled nursing facility, home health care, or prescription drug expenses that MA plans were liable for. MA plans continued to receive $120 per enrollee per month in premiums and rebates, equating to $23 million to $58 million in excess payments to MA plans annually under scenarios in which either 50% of rebate payments or 0% of rebate payments were allocated toward supplemental benefits, respectively. In this cross-sectional study, MA plans received high premium and rebate payments for beneficiaries enrolled in hospice despite low health care spending after enrollees elected hospice. To reduce excess payments, the Centers for Medicare & Medicaid Services could require MA plans to submit information on enrollees' use of supplemental benefits and adjust payments made after election of hospice to align with spending.

The 2021 Royal Commission into Aged Care Quality and Safety proposed a new primary care model to address the growing healthcare needs of Australia's aging population.This study explored the views of general practitioners (GPs) working in residential aged care homes on the proposed model and identified potential implementation challenges. A cross-sectional survey was conducted between December 2023 and April 2024, recruiting GPs through professional networks and social media. The survey used a 5-point Likert scale to gauge agreement with the proposed model and an open-ended question to explore potential implementation barriers. One hundred and fifteen GPs (48.7% male; 59.2% aged 30-49) with an average of 12.2 ± 10.4 years' experience in aged care participated. Respondants indicated broad support for extending practice accreditation to aged care-focused practices, with strong endorsement for criteria such as formal accreditation and telehealth integration. Yet, GPs expressed substantial concerns about the practical implementation of capitation payments and other systemic changes, citing underfunding and increased administrative burdens as major obstacles. Reservations were also raised about the adequacy of support for managing increasingly complex aged care needs. Notably, 46% doubted the feasibility of implementing the recommendations, highlighting challenges in funding, after-hours care, and collaboration. This study highlights key factors influencing the feasibility of implementing the proposed primary care model in aged care, offering valuable insights applicable globally. Addressing GP concerns and fostering collaboration appear crucial, while further stakeholder consultation involving GPs, practice nurses, patients, and their families should guide the implementation of proposed reforms.

11075 Background: Medicare Advantage (MA) has steadily grown during the past decade, covering over half of Medicare beneficiaries in 2024. Because MA plans receive capitated payments for Medicare beneficiaries, they have the financial incentives to reduce service utilization and costs. MA plans may discourage enrollees from using low-value services, such as medically unnecessary care and expensive treatments for which low-cost alternatives are available. No prior study examining the use of low-value services between MA and TM has evaluated the use of low-value cancer treatments specifically. We compared use of low-value cancer treatments between MA and TM. Methods: Using national Medicare data, we performed retrospective analyses of beneficiaries who had a new cancer diagnosis between 2016 and 2021, and who were at risk of receiving one of the following low-value treatments: growth factors (GCSF) for patients receiving low-risk chemotherapy; denosumab for castration sensitive prostate cancer (CSPC); nab-paclitaxel instead of paclitaxel for breast or lung cancers; adding bevacizumab to carboplatin + paclitaxel for ovarian cancer; and branded drugs or biologics for which generic or biosimilar versions existed. We estimated linear regression models for each cohort/outcome separately. The key explanatory variable was MA enrollment (vs. TM). We used inverse probability of treatment weights to balance characteristics between MA and TM: patient age, sex, race, Medicare and Medicaid dual-eligibility status, cancer metastasis, a frailty index, and summary health-risk scores, area-level socio-economic and health care environment variables. We included year indicators to adjust for temporal trends and oncology practice indicators to control for practice-specific prescribing patterns. Results: Receipt of any low-value cancer treatment was 1.7 percentage points lower in MA than in TM (34.2% versus 35.9%; p&lt;0.001). MA enrollees had lower utilization than TM for GCSF (7.3% versus 8.9%; p&lt;0.001), denosumab (26.4% versus 33.1%; p&lt;0.001), nab-paclitaxel (7.9% versus 8.7%; p&lt;0.05), addition of bevacizumab for ovarian cancer (8.3% versus 10.5%, p=0.001), and biologics with biosimilar alternatives (66.8% vs. 68.5%; p&lt;0.001). Receipt of branded drugs did not significantly differ between MA and TM. Conclusions: For Medicare beneficiaries at risk of receiving a low-value cancer treatment, MA enrollees were less likely to receive low-value cancer treatments than TM beneficiaries. These reductions in low value services may prevent avoidable toxicity and lower treatment cost to the patient and health care system. Increased efforts are needed to identify approaches that MA plans use to reduce low-value cancer treatments, and explore ways to promote those approaches in both MA and TM.

ObjectiveAmid efforts to develop primary healthcare, China has been working to establish an integrated care system through the county medical community model, incorporating capitation payment to improve chronic disease management. This study investigates the impact of capitation payment reform on diabetes-related healthcare service behaviors across different levels of healthcare facilities within the county medical community.MethodsWe conducted interrupted time series analysis to evaluate the changes in healthcare service behavior before and after the implementation of the capitation model. Using F County, as the sample area, we collected outpatient reimbursement records of type 2 diabetes mellitus (T2DM) patients from six townships that initiated reform in April 2015. The dataset, covering January 2014 to December 2019, includes 49,326 records from primary healthcare facilities and 1,628 from county hospitals, with information on medical costs, service items, and other details.ResultsFollowing the implementation of capitation, both the average medical costs per visit and proportion of examination and testing costs showed a deceleration in growth in primary healthcare facilities (-0.615, p < 0.05; -1.554, p < 0.01). The proportion of medication costs, the proportion of insulin or combination therapy and the average number of medications exhibited a significant downward trend prior to the reform, while all reversed to upward trends after reform. In county hospitals, the proportion of medication costs increased by 19.115% immediately post-reform, and both the level and slope of average number of medications significantly rose (2.041, p < 0.01; 0.244, p < 0.01). Although the proportion of examination and testing costs increased before the reform, both the instantaneous level and the trend declined afterward (-19.684, p < 0.05; -1.833, p < 0.05).ConclusionsIn the sample area, the average medical costs for T2DM outpatients were effectively controlled after the capitation reform. Township health centers showed improved standardization in prescribing practices, while county hospitals focused more on comprehensive examinations and testing services. Medication prescription intensity increased across all facilities, contributing to enhanced chronic disease management.

The capital payment process for construction investment plays a crucial role in ensuring project progress, reducing losses and waste, especially for projects funded by the state budget. The legal regulations governing this process generally meet management requirements, simplify administrative procedures, strengthen decentralization, and increase transparency in the responsibilities between project owners and payment agencies within the control and payment process. However, there are still several limitations in this process that affect disbursement progress and investment efficiency. This paper will analyze the current situation of capital payments for construction projects funded by the state budget, identify existing issues and their causes, and propose several solutions to improve this process.

Cross-border mergers and acquisitions (CBMA), as an internationalization strategy, have been used by firms from emerging economies to attain competitive advantage at a global level. However, little attention has been paid to capital structure decisions in CBMA, carried out by firms in these economies. The study disentangles this relationship between the acquirer’s capital structure and the financing method used during the course of mergers and acquisitions (M&amp;A) in an international setting. It is a novel attempt to examine the moderating effect of acquirer size on the relationship between leverage and financing method in the acquisition offer. The study utilizes 1817 cross-border deals undertaken by 20 emerging economies from 2009 to 2021. The key findings suggest that highly leveraged acquirers are more likely to have stock in their offer as compared to the cash component. Contrary to expectations, size and liquidity have a negative effect on the choice of financing. Further, a disaggregated analysis examines the impact of the financial system of the acquirer country and the development status of the target country on the method of payment. The implications of the capital structure and payment choices are abundant for various stakeholders -policymakers, managers, and the board of directors involved in CBMA.

One of the critical challenges with capitation payment to primary care providers is ensuring that the fixed payments are equitable and adjusted for expected care needs. Patients of lower socioeconomic status (SES) generally have higher health care need. Sweden developed a Care Needs Index, which is used in the capitation payments to primary care providers to account for patient SES. We aim to examine the potential value of collecting individual-level rather than geographic-level socioeconomic data to support an equitable payment to primary care providers. We used data from 3 regional administrative care registers, which cover all consultations in publicly funded health care, and Statistics Sweden's registers covering individual background characteristics. We estimated linear regression models and evaluated the model fit using the adjusted R2 with the Care Needs Index at the individual and at the district level. The population consisted of the 3,490,943 individuals residing in the 3 study regions for whom we had complete data. The main outcome variable was the number of face-to-face consultations with a GP or a nurse at a primary care practice. We use the R2 to compare the predictive power of the models. The share of the variation explained did not depend on whether the Care Needs Index was measured at the individual level or the small area level. SES explains very little variation in primary care visits, and there is no gain from having individual-level information about the individual's SES compared with having district-level information only.

Expanding explicit Health Benefit Plans (HBP) is a key strategy for achieving universal health coverage while maintaining financial sustainability. However, little is known about the broader effects of periodic updates to these plans on healthcare utilization, expenditures, and market dynamics. This study examines the impact of including new health technologies in Colombia's HBP covered by the Capitation Payment Unit(CPU) between 2012 and 2019, using administrative data and a difference-in-differences approach with multiple periods. Our results indicate that inclusion in the HBP-CPU led to a substantial increase in utilization and access, particularly in remote areas, but had mixed effects on expenditures. While the number of unique users and prescription frequency rose significantly, thecost per user remained stable for procedures but increased for medications, likely due to higher demand and market structures. These findings suggest that although periodic HBP updates enhance access and effective coverage, they do not necessarily generate cost savings. Strengthening health technology assessment processes, integrating price regulation policies, and implementing cost-containment mechanisms are essential for ensuring the financial sustainability of health systems that regularly update benefit plans.

To assess the association between the organizational structure of accountable care organizations (ACOs) and provider workforce composition. Quantifying these relationships may improve understanding of factors contributing to changes in the health care workforce in ACOs and improve clinician recruitment and retention across ACOs to help them succeed in the program. Cross-sectional study of 409 ACOs from the National Survey of Accountable Care Organizations Wave 4 (2017-2018; response rate, 48%). We evaluated ACO provider workforce composition. In multivariable linear regression models, we examined the relationship among ACO provider workforce composition, contract type, structure, and financial risk level. For Medicare Shared Savings Program participants, we also assessed the role of the market environment. We found that provider workforce composition varied across organizations by ACO contract payer. The percentage of primary care providers-physicians and nonphysician providers-was higher in smaller organizations with ACO contracts from a single public payer (77.7% for those with Medicaid-only contracts; 59.5% with Medicare-only contracts) relative to larger organizations with contracts from a single commercial payer (52.4% primary care providers) or multiple payers (54.8%-55.7%). A higher percentage of primary care providers in the ACO was associated with physician leadership, upside financial risk, and financial compensation of physicians being tied to performance measures. With payers' recent interest in more capitated payment models, larger ACOs should consider extending more population-based payments, provider engagement, and compensation strategies to engage aligned providers toward high quality and low costs, mitigate overall provider turnover, and make participation in ACOssustainable.