Global Budget Revenue Research Articles

Maryland's Global Budget Revenue Program and Equitable Access to Esophagectomy for Esophageal Cancer

IntroductionWe evaluated equity in access to esophagectomy after Maryland's 2014 “Global Budget Revenue” (GBR) implementation, which equalizes reimbursement rates irrespective of patient insurance and employs an annual hospital revenue ceiling to incentivize reductions in unnecessary resource utilization. We hypothesized that more traditionally underserved patients would undergo surgical treatment for esophageal cancers after GBR. MethodsUsing Maryland's Health Services Cost Review Commission database, we retrospectively analyzed patient demographics, insurance statuses, inflation-adjusted hospital charges, postoperative outcomes, and discharge dispositions for esophagectomies for neoplasms between 2012 and 2018. ResultsFour hundred eighty six patients were included: 22.0% (107) pre-GBR and 78.0% (379) post-GBR. The proportion of African-American patients increased post-GBR (5.6% versus 12.9%, P = 0.035) and subsequently exhibited year-over-year increases. While not statistically significant, the proportion of Medicaid patients increased from 4.7% to 10.0% (P = 0.085). The post-GBR era also saw patients from 10 new counties, six of which were in Maryland's bottom half of counties ranked by median household income, receive operative esophageal cancer treatment without losing representation from pre-GBR counties. Patient age and sex were comparable between the two groups, and there were no significant differences in mortality or 30-day readmissions. Inflation-adjusted hospital charges and length of hospital stay did not appreciably change post-GBR, including after adjusting for age, comorbidities, and surgical approach. ConclusionsGBR increased access to esophagectomy for African-Americans, those insured by Medicaid, and those from lower socioeconomic status counties. Contrary to prior studies of outpatient and emergency room settings, we found the GBR program's goal of reduction of resource utilization and cost were not apparent in this complex surgical population.

Patient experience with hospital care following the Maryland global budget revenue model: A difference-in-difference analysis.

As a result of the success of Maryland's full risk capitated payment model experiment (Global Budget Revenue) in constraining healthcare costs, there is momentum for expanding the reach of such models. However, as these models are implemented, studies analyzing their long-term effects suggest unintended spillover effects that may ultimately influence patient experiences. The aim of this study was to determine whether implementation of the GBR was associated with changes in patient experience. Cross-sectional study using a difference-in-difference analysis to examine changes in patient experiences according to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains before and after implementation of the GBR model. Acute care hospitals from 2010-2016 with completed HCAHPS surveys were included. Hospitals identified for inclusion were then matched, based on county location, to area level characteristics using the Area Health Resource File. A total of 844 hospitals were included. Compared to hospitals in non-GBR states, hospitals in GBR states experienced significant declines in the following HCAHPS domains: "would definitely recommend the hospital to others" [Average treatment effect (ATT) = -1.19, 95% CI = -1.97, -0.41)] and 9-10 rating of the hospital (ATT = -0.93, 95% CI = -1.71, -0.15). Results also showed significant increases in the HCAHPS domains: "if patient's rooms and bathroom were always kept clean" (ATT = 1.10, 95% CI = 0.20, 2.00). There were no significant differences in changes for the other domains, including no improvements in: nursing communication, doctor communication, help from hospital staff, pain control, communication on medicines, discharge information, and quietness of the patient environment. These findings suggest there should be efforts made to ascertain and mitigate potential adverse effects of care transformation initiatives on patient experience. Patients are stakeholders and their inputs should be sought and incorporated in care transformation efforts to ensure that these models align with improved patient experiences.

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.

Transforming Specialty Care Delivery and Payment Under Global Budgets—Insights from the Provision of Surgical Services in Maryland

This Viewpoint discusses Maryland’s global budget revenue model, which centrally regulates reimbursement rates for all payers via a hospital-specific, prospectively set cap on total annual revenue across all care sites.

Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors.

To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy. The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates. A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges. Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.

Implementation of the Maryland Global Budget Revenue Model and Variation in the Expenditures and Outcomes of Surgical Care: A Systematic Review and Meta-analysis.

To assess the effect of the Global Budget Revenue (GBR) program on outcomes after surgery. There is limited data summarizing the effect of the GBR program on surgical outcomes as compared with traditional fee-for-service systems. The Medline, Embase, Scopus, and Web of Science databases were used to conduct a systematic literature search on April 5, 2022. We identified full-length reports of comparative studies involving patients who underwent surgery in Maryland after implementation of the GBR program. A random effects model calculated the overall pooled estimate for each outcome which included complications, rates of readmission and mortality, length of stay, and costs. Fourteen studies were included in the qualitative synthesis, with 8 unique studies included in the meta-analysis. Our analytical sample was comprised of 170,011 Maryland patients, 78,171 patients in the pre-GBR group, and 91,840 patients in the post-GBR group. The pooled analysis identified modest reductions in costs [standardized mean difference (SMD) -0.34; 95% CI, -0.42, -0.25; P <0.001], complications [odds ratio (OR): 0.57; 95% CI, 0.36-0.92, P =0.02], readmission (OR: 0.78; 95% CI, 0.72-0.85, P <0.001), mortality (OR: 0.58; 95% CI, 0.47-0.72, P <0.001), and length of stay (standardized mean difference: -0.26; 95% CI, -0.32, -0.2, P <0.001) after surgery. Implementation of the GBR program is associated with improved outcomes and reductions in costs among Maryland patients who underwent surgical procedures. This is particularly salient given the increasing need to disseminate and scale population-based payment models that improve patient care while controlling health care costs.

Is the Centralization of Complex Surgical Procedures an Unintended Spillover Effect of Global Capitation? - Insights from the Maryland Global Budget Revenue Program.

To determine if global budget revenue (GBR) models incent the centralization of complex surgical care. In 2014, Maryland initiated a statewide GBR model. While prior research has shown improvements in cost and outcomes for surgical care post-GBR implementation, the mechanism remains unclear. Utilizing state inpatient databases, we compared the proportion of adults undergoing elective complex surgeries (gastrectomy, pneumonectomy/lobectomy, proctectomies, and hip/knee revision) at high-concentration hospitals (HCHs) in Maryland and control states. Annual concentration, per procedure, was defined as hospital volume divided by state volume. HCHs were defined as hospitals with a concentration at least at the 75 th percentile in 2010. We estimated the difference-in-differences (DiD) of the probability of patients undergoing surgery at HCHs before and after GBR implementation. Our sample included 122,882 surgeries. Following GBR implementation, all procedures were increasingly performed at HCHs in Maryland. States satisfied the parallel trends assumption for the centralization of gastrectomy and pneumonectomy/lobectomy. Post-GBR, patients were more likely to undergo gastrectomy (DiD: 5.5 p.p., 95% CI [2.2, 8.8]) and pneumonectomy/lobectomy (DiD: 12.4 p.p., 95% CI [10.0, 14.8]) at an HCH in Maryland compared with control states. For our hip/knee revision analyses, we assumed persistent counterfactuals and noted a positive DiD post-GBR implementation (DiD: 4.8 p.p., 95% CI [1.3, 8.2]). No conclusion could be drawn for proctectomy due to different pre-GBR trends. GBR implementation is associated with increased centralization for certain complex surgeries. Future research is needed to explore the impact of centralization on patient experience and access.

Impact of the Maryland Global Budget Revenue Program on Lobectomies for Lung Cancer

INTRODUCTION: In 2014, Maryland introduced a “Global Budget Revenue” (GBR) program in an effort to reduce hospital costs by prospectively capping annual hospital revenue at a predetermined amount, thereby incentivizing hospitals to reduce expenditures while maintaining quality. Our objective was to investigate the impact of the GBR model on thoracic surgery outcomes. METHODS: We used the Maryland Health Services Cost Review Commission (HSCRC) database to retrospectively review adult patients who underwent lobectomy for primary lung cancer between 2012 and 2018. Patients were dichotomized as “pre-GBR” if they underwent lobectomy prior to 2014, and “post-GBR” if they underwent lobectomy in 2014 or later. RESULTS: Baseline demographics between the two groups were comparable, although patients in the post-GBR group were less likely to be uninsured (0.2% vs 1.1%, p < 0.01). In-hospital mortality was similar between the two groups (1.0% vs 1.5%, p = 0.20), as was 30-day readmission rate (8.2% vs 7.9%, p = 0.80). On average, patients in the post-GBR era had a shorter length of stay (5.7 days vs 6.1 days, p = 0.02), but were more likely to be discharged with home health services (23.4% vs 19.5%, p = 0.01). CONCLUSION: These results suggest successful incentivization to reduce hospital length of stay with implementation of the GBR model, without evidence of inadvertent negative consequences such as increased mortality or need for readmission. The increased use of home health services suggest a multi-disciplinary approach will be integral to reducing overall health expenditures under this model, and demonstrates promise for use of the GBR model in thoracic surgery.

Association of Maryland Global Budget Revenue With Spending and Outcomes Related to Surgical Care for Medicare Beneficiaries With Cancer

In 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care. To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states. Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011-2013) to after (2015-2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection). Thirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. Relative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, -4.3 to -0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures. Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.

Access to Total Knee Arthroplasty Among Patients With Low Incomes Has Not Increased Under Global Budget Revenue.

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained (P<.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained (P<.001). Mean cost decreased for both cohorts of patients (both P<.001). Discharges to home increased for both cohorts (P<.001), while length of stay decreased (both P<.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [Orthopedics. 2022;45(1):e11-e16.].

Potential Financial Effects on Hospitals of the Removal of Common Orthopaedic and Spinal Procedures From Medicare's "Inpatient-Only" List: A Comparison of the Medicare Fee-for-service Payment Model Versus Maryland's Global Budget Revenue Model.

When treating Medicare beneficiaries, orthopaedic surgeons must follow Centers for Medicare & Medicaid Services (CMS) policies regarding whether to perform surgical treatments under inpatient or outpatient status. Recently, most orthopaedic and spinal procedures were removed from the CMS's "inpatient-only" list (IPOL). We investigated differences in hospital payments under the Diagnosis Related Group (DRG)/Ambulatory Payment Classification (APC) system when common orthopaedic/spinal procedures are done under outpatient rather than inpatient status. We compared these differences under the DRG/APC model with differences in payments to Maryland hospitals, which are paid under the alternative Global Budget Revenue model. We used the CMS Inpatient Pricer and CMS Addendum B to retrieve the mean duration-of-stay data, estimated DRG (inpatient) payment, and APC (outpatient) payment for eight common orthopaedic/spinal procedures for four non-Maryland hospitals (2 urban academic hospitals and 2 neighboring community hospitals). We retrieved Maryland's Health Services Cost Review Commission hospital rates for the same eight procedures done under inpatient or outpatient status to estimate hospital charges for a Maryland urban academic hospital and a neighboring community hospital. Among the four non-Maryland hospitals, estimated differences in payment for hospitalizations under inpatient versus outpatient status for common orthopaedic/spinal procedures with a mean duration of stay of <2 days, whose status would be most subject to change from inpatient to outpatient by its removal from the IPOL, ranged from $19 to $13,042. For the two Maryland hospitals, differences in outpatient versus inpatient payment for these same procedures ranged from $182 to $1,273. Non-Maryland hospitals receive widely different CMS payments for common orthopaedic/spinal procedures based on a change in hospitalization status (inpatient to outpatient) prompted by the procedure being removed from the IPOL. The Maryland global budget revenue mitigates most of the effect of hospitalization status on hospital payment and may serve as a guide toward DRG/APC payment reassessment. N/A.

Effects of Maryland's global budget revenue model on emergency department utilization and revisits.

In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72h and 9days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

Maryland's Global Budget Revenue Program: Impact on Neonatal Intensive Care Unit Admissions and Infant Mortality.

In 2014, Maryland implemented the Global Budget Revenue (GBR) program to reduce unnecessary hospital utilization and contain spending. Little is known about its impact on pediatric health outcomes and high-cost services that are primarily financed by payers other than Medicare. The aim was to examine the impact of the GBR program on neonatal intensive care unit (NICU) admission and infant mortality. We conducted a difference-in-differences analysis comparing changes of NICU admissions and infant mortality in Maryland with changes in 20 comparison states (including DC), before and after implementation of the GBR program. Effects were estimated for all infants and for risk groups defined by birthweight and gestation. A total of 11,965,997 newborns in Maryland and the comparison states was identified using US birth certificate data from 2011 to 2017. NICU admissions, the infant mortality rate, and the neonatal mortality rate. The GBR program was associated with a 1.26 percentage points (-16.8%, P=0.03) decline in NICU admissions over three full years of implementation. Reductions were driven by fewer admissions among moderately low to normal birthweight (1500-3999 g) and moderately preterm to term (32-41 wk) infants. The effects for very-low birthweight and very preterm infants were small and not statistically precise. There was no significant change in infant or neonatal mortality rates. Maryland's hospitals reacted to the GBR program by reducing NICU services for infants that did not have clear observed clinical need. Our results suggest that GBR constrained high-cost services, without adversely affecting infant mortality.

Comparing Outcomes for Female Total Knee Arthroplasty Patients Under Global Budget Revenue

Maryland implemented the all-payer, rater-setting Global Budget Revenue (GBR) payment model in 2014 to reduce cost and improve quality. This study assessed the effect of GBR on total knee arthroplasty (TKA) outcomes by sex. Specifically, the authors assessed (1) demographics and (2) outcomes of males and females undergoing TKA before and after GBR implementation. The Maryland State Inpatient Database was queried from 2011 to 2016. There were 71,066 TKAs (male, n=25,413; female, n=45,634). For continuous and categorical variables, t testing and chi-square analyses were used, respectively. Difference-in-difference analyses using multiple regression compared changes in sex from the pre-GBR period (2011-2013) with the post-GBR period (2014-2016). The female proportion decreased (-1.9%; P=.040). Proportionally more TKA patients were Hispanic and Asian, from high-income areas, using Medicare and Medicaid, and morbidly obese (all P<.001). The mean length of stay (LOS), charges, and costs were decreased after GBR implementation (all P<.001). More patients were discharged routine and had fewer readmissions (both P<.001). There were fewer complications, including deep venous thromboses/pulmonary emboli, urinary tract infections, and blood transfusions (all P<.001). The difference-in-difference analyses suggested more females were discharged with home health care and had longer LOS than did males (both P<.001). The GBR appears to meet its main objective of cost reduction and improvements in quality of care. However, the proportion of females receiving TKA decreased, and their LOS did not improve as much as that of males. As other states consider global budgets, more research is needed to ensure this all-payer, rate-setting, capitated system does not cause decreased access to care. [Orthopedics. 2021;44(2):e266-e273.].

The Affordable Care Act and Global Budget Revenue: The Impact on Total Hip Arthroplasties

BackgroundMaryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.). MethodsWe identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods. ResultsAfter GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (−4.2% vs −1.8%) (all P < .001). There were proportionally less home health care patients in Maryland, but more in the U.S. (−3.5% vs +1.6%; both P < .001). The mean costs decreased for both cohorts (−$1780.80 vs −$209.40; both P < .001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected (P = .001). The DID also found decreased costs for patients under GBR (P < .001 for both). ConclusionMaryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets.

Maryland's Global Budget Revenue Model: How Do Costs and Readmission Rates Fare for Patients Undergoing Total Knee Arthroplasty?

In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011-2013) and post-GBR (2014-2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges (p < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets.

Maryland's Global Budget Revenue model associated with lower inpatient costs and 30-day readmissions in patients undergoing total hip arthroplasty.

BackgroundMaryland implemented the Global Budget Revenue (GBR) to reduce hospital costs, improve quality, and decrease readmissions. Studies assessing its impact on inpatient total hip arthroplasty (THA) procedures are lacking. This study compared before and after GBR changes in 1) patient characteristics; 2) discharge dispositions and lengths of stay (LOS); 3) costs and charges of inpatient stays; and 4) 30-day readmission rates (RR) for THA recipients.MethodsThe Maryland State Inpatient Database was queried for patients who underwent THA between 2010 and 2016 utilizing the ICD-9 and ICD-10 procedure codes (n = 43,251). Pre- and post-GBR periods were grouped as 2010 to 2013 and 2014 to 2016, respectively. Chi-square analyses were used to analyze patient characteristics. Student’s t-tests were utilized to compare ages, LOS, costs, charges, and RR.ResultsThere were no differences in the proportion of minorities undergoing THA between the pre- and post-GBR periods (18.3% vs 19.4% African American, 1.2% vs 1.3% Hispanic; P = .056). The number of THA patients with Medicaid insurances increased during post-GBR (4.0% vs 6.7%; P < .001). There was an increased rate of home discharges during post-GBR (33.1% vs 40.9%; P < .001). We found lower LOS (−0.50 days; 95% CI: −0.458 to −0.533; P < .001), mean inpatient costs (−$1417.44; 95% CI −$1143.76 to −$1150.32; P < .001), and mean inpatient charges (−$2196.50; 95% CI: −$1980.10 to −$2412.90; P < .001) during the post-GBR period. There were lower 30-day RR during the post-GBR period (−0.9%; P < .001).ConclusionsOur findings suggest favorable preliminary results for patients undergoing THA under the GBR model.

Maryland’s Global Budget Revenue Program and Coronary Artery Bypass Surgery

In 2014 Maryland began a global budget revenue (GBR) program where hospitals were assigned a global budget for each year. We hypothesized that this program would be associated with changes in coronary artery bypass grafting (CABG) patient risk profile, reductions in potentially preventable complications (PPCs) and 30-day hospital readmissions, and low annual per patient charge growth. Patients having isolated CABG surgery in Maryland between fiscal years 2013 and 2017 were included. Patient characteristics, admission all-payer refined severity of illness, PPCs, 30-day hospital readmissions, and per patient hospital charges were compared between years. The impact of Maryland's GBR program on PPCs and 30-day hospital readmissions was evaluated using interrupted time series analysis. During the study period 11,070 patients had CABG surgery. The percentage of patients with major or extreme severity of illness at admission differed significantly between years (34.6% in 2013 vs 46.1% in 2017, P<.001). There was a significant reduction in mean PPCincidence of -22.8% (95% confidence interval, -29.8% to -15.8%) after GBR implementation but no significant reduction in 30-day hospital readmissions (-2.7%; 95% confidence interval, -6.0% to 0.6%). Without adjusting for inflation the annual per patient charge growth remained between -1.4% and 2.6% from 2013 to2017. Maryland's GBR program was associated with significant PPC reductions, minimal charge growth, and no significant change in 30-day hospital readmissions during its first 14 fiscal quarters. These findings suggest that Maryland's GBR program achieved some but not all of its predefined goals in CABG patients.

Impact of Global Budget Revenue Policy on Emergency Department Efficiency in the State of Maryland.

IntroductionOn January 1, 2014, the State of Maryland implemented the Global Budget Revenue (GBR) program. We investigate the impact of GBR on length of stay (LOS) for inpatients in emergency departments (ED) in Maryland.MethodsWe used the Hospital Compare data reports from the Centers for Medicare and Medicaid Services (CMS) and CMS Cost Reports Hospital Form 2552-10 from January 1, 2012–March 31, 2016, with GBR hospitals from Maryland and hospitals from West Virginia (WV), Delaware (DE), and Rhode Island (RI). We implemented difference-in-differences analysis and investigated the impact of GBR implementation on the LOS or ED1b scores of Maryland hospitals using a mixed-effects model with a state-level fixed effect, a hospital-level random effect, and state-level heterogeneity.ResultsThe GBR impact estimator was 9.47 (95% confidence interval [CI], 7.06 to 11.87, p-value<0.001) for Maryland GBR hospitals, which implies, on average, that GBR implementation added 9.47 minutes per year to the time that hospital inpatients spent in the ED in the first two years after GBR implementation. The effect of the total number of hospital beds was 0.21 (95% CI, 0.089 to 0.330, p-value = 0 .001), which suggests that the bigger the hospital, the longer the ED1b score. The state-level fixed effects for WV were −106.96 (95% CI, −175.06 to −38.86, p-value = 0.002), for DE it was 6.51 (95% CI, −8.80 to 21.82, p-value=0.405), and for RI it was −54.48 (95% CI, −82.85 to −26.10, p-value<0.001).ConclusionOur results indicate that GBR implementation has had a statistically significant negative impact on the efficiency measure ED1b of Maryland hospital EDs from January 2014 to April 2016. We also found that the significant state-level fixed effect implies that the same inpatient might experience different ED processing times in each of the four states that we studied.

219EMF Emergency Department Care Coordination Strategies and Perceived Impact Across Maryland

Seamless care transitions is a major priority for health systems. Population-based payment reforms implemented in Maryland (MD), termed the global budget revenue (GBR) program, has incentivized a shift towards non-hospital care and lower admissions. ED-based care coordination can have an important role in meeting these goals. We examine ED care coordination processes across MD and identify specific interventions. We also examine perceptions on the effectiveness of care coordination and the influence of GBR. We conducted a qualitative study using semi-structured interviews to examine ED care coordination processes, initiatives, and perceptions among emergency physician leadership and care coordination staff (CCS). Participants were purposively recruited across MD EDs to ensure diverse representation of EDs in annual volume (range: 12,000-90,000), system affiliation, trauma level, and metropolitan status. A total of 21 semi-structured interviews encompassing 15 different sites were conducted, with an interdisciplinary group representative of the ED care coordination process: physician leadership (n=14) and CCS (n=7). Interview questions covered domains pertaining to different facets of the care coordination process as well as perceptions of the influence of GBR. Participants’ answers were coded independently using thematic analysis by two members of the research team, with coding disagreements assessed and resolved by the full research team. Across all sites, there was an average of 4.3 full time equivalents (FTEs) of CCS coverage with significant variation (range: 1 - 12 FTEs). The most common care coordination services provided were implementing care plans for high utilizers and arranging outpatient substance abuse services, home health services, and home medical equipment. The number of initiatives implemented to improve ED care coordination ranged from 0 to 7 initiatives per site. The most common initiative was a process to link substance abuse patients with peer counselors and rehabilitation resources (9 sites). Participants perceived ED care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient providers was a significant barrier. (Table 1) The majority of emergency physician leaders (9/14) perceived GBR as having a mixed impact, both positive and negative, on care transitions. The majority noted that ED “care coordination is a beneficial offshoot of GBR...now hospitals are motivated to put money into [care coordination] resources.” However, participants also noted that with GBR “we are working extra hard for extra long to not admit patients” and “GBR has negatively impacted ED length of stay.” Across MD, there is a broad range of ED care coordination services provided and significant variation in the organizational processes to implement them. However, a prevailing theme is that GBR has led to investments to improve ED care coordination. Further research is needed to examine the association of the various approaches to ED care coordination with patient outcomes.