The effects of global budget payments on hospital utilization in rural Maryland.
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ABSTRACT: Objective
To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation.Data sources/study setting
Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File.Study design
We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization.Data collection
Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census.Principal findings
We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department.Conclusions
We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.
SUBMITTER: Done N
PROVIDER: S-EPMC6505416 | biostudies-literature | 2019 Jun
REPOSITORIES: biostudies-literature
Publications
The effects of global budget payments on hospital utilization in rural Maryland.
Done Nicolae N Herring Bradley B Xu Tim T
Health services research 20190601 3
<h4>Objective</h4>To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation.<h4>Data sources/study setting</h4>Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File.<h4>Study design</h4>We use ...[more]
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Project description:In a substantial shift in payment policy, the State of Maryland implemented a global budget program for acute care hospitals in 2010. Goals of the program include controlling hospital use and spending. Eight rural hospitals entered the program in 2010, while urban and suburban hospitals joined in 2014. Prior analyses, which focused on urban and suburban hospitals, did not find consistent evidence that Maryland's program had contributed to changes in hospital use after two years. However, these studies were limited by short follow-up periods, may have failed to isolate impacts of Maryland's payment change from other state trends, and had limited generalizability to rural settings. To understand the effects of Maryland's global budget program on rural hospitals, we compared changes in hospital use among Medicare beneficiaries served by affected rural hospitals versus an in-state control population from before to after 2010. By 2013-three years after the rural program began-there were no differential changes in acute hospital use or price-standardized hospital spending among beneficiaries served by the affected hospitals, versus the within-state control group. Our results suggest that among Medicare beneficiaries, global budgets in rural Maryland hospitals did not reduce hospital use or price-standardized spending as policy makers had anticipated.
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Project description:BackgroundMedical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending.ObjectiveTo assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services.MethodsWe conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index.ResultsGlobal budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses.ConclusionsWe did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.
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Project description: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.
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Project description:This study sought to examine whether Supplemental Nutrition Assistance Program (SNAP) participation and benefit levels are associated with reduced subsequent hospital and emergency department utilization in low-income older adults. Study participants were 68,956 Maryland residents aged ≥65 years who were dually enrolled in Medicare and Medicaid (2009-2012). Annual inpatient hospital days and costs and emergency department visits were modeled as a function of either 1-year lagged SNAP participation or lagged SNAP benefit amounts, controlling for sociodemographic characteristics, autoregressive effects, year, health status, and Medicaid participation. SNAP participation (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI]: 0.93, 0.99), and, among participants, each $10 increase in monthly benefits (aOR = 0.99, 95% CI: 0.99-0.99) are associated with a reduced likelihood of hospitalization, but not emergency department use. The authors estimate that enrolling the 47% of the 2012 population who were eligible nonparticipants in SNAP could have been associated with $19 million in hospital cost savings. Accounting for the strong effects of health care access, this study finds that SNAP is associated with reduced hospitalization in dually eligible older adults. Policies to increase SNAP participation and benefit amounts in eligible older adults may reduce hospitalizations and health care costs for older dual eligible adults living in the community.
| S-EPMC5906726 | biostudies-literature
Project description:ImportanceIn 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program included reducing unnecessary hospital utilization and encouraging greater use of primary care.ObjectiveTo compare changes in hospital and primary care use through the first 2 years of Maryland's hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas.Design, setting, and participantsWe matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption).Main outcomes and measuresHospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay).ResultsWe matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean [SD] age, 71.7 [12.5] years). Assuming parallel trends, we estimated a differential change in Maryland of -0.47 annual hospital stays per 100 beneficiaries (95% CI, -1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of -1.24 stays per 100 beneficiaries (95% CI, -2.46 to -0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (-0.8 visits/100 beneficiaries; 95% CI, -10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland's program.Conclusions and relevanceWe did not find consistent evidence that Maryland's hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.
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Project description:ObjectiveTo determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012-2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File).MethodsIndividual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services.ResultsWe identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (-6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially.ConclusionsThe Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.
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Project description:BackgroundGlobal budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease.ObjectiveEvaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes.DesignObservational cohort study.ParticipantsOne hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021.InterventionsTeam-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support).Main measuresPatient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations).Key resultsPatient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months.ConclusionsCCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.
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Project description:ObjectiveTo develop and validate a prediction model of avoidable hospital events among Medicare fee-for-service (FFS) beneficiaries in Maryland.Data sourcesMedicare FFS claims from Maryland from 2017 to 2020 and other publicly available ZIP code-level data sets.Study designMultivariable logistic regression models were used to estimate the relationship between a variety of risk factors and future avoidable hospital events. The predictive power of the resulting risk scores was gauged using a concentration curve.Data collection/extraction methodsOne hundred and ninety-eight individual- and ZIP code-level risk factors were used to create an analytic person-month data set of over 11.6 million person-month observations.Principal findingsWe included 198 risk factors for the model based on the results of a targeted literature review, both at the individual and neighborhood levels. These risk factors span six domains as follows: diagnoses, pharmacy utilization, procedure history, prior utilization, social determinants of health, and demographic information. Feature selection retained 73 highly statistically significant risk factors (p < 0.0012) in the primary model. Risk scores were estimated for each individual in the cohort, and, for scores released in April 2020, the top 10% riskiest individuals in the cohort account for 48.7% of avoidable hospital events in the following month. These scores significantly outperform the Centers for Medicare & Medicaid Services hierarchical condition category risk scores in terms of predictive power.ConclusionsA risk prediction model based on standard administrative claims data can identify individuals at risk of incurring a future avoidable hospital event with good accuracy.
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Project description:ImportanceTelemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services.ObjectiveTo evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions.Design, setting, and participantsThis retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine.ExposuresConsultation modality (telemedicine or in person) in the outpatient neurology clinics.Main outcomes and measuresDemographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples.ResultsThe telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P?<?.001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions.Conclusions and relevancePediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.
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Project description:Global budget (GB) arrangements have become a popular method worldwide to control the rise in healthcare expenditures. By guaranteeing hospital funding, payers hope to eliminate the drive for increased production, and incentivize providers to deliver more efficient care and lower utilization. We evaluated the introduction of GB contracts by certain large insurers in Dutch hospital care in 2012 and compared health care utilization to those insurers who continued with more traditional production-based contracts, i.e., cost ceiling (CC) contracts. We used the share of GB hospital funding per postal code region to study the effect of contract types. Our findings show that having higher share of GB financing was associated with lower growth in treatment intensity, but it was also associated with higher growth in the probability of having at least one hospital visit. While the former finding is in line with our expectation, the latter is not and suggests that hospital visits may take longer to respond to contract incentives. Our study covers the years of 2010-2013 (2 years before and 2 years following the introduction of the new contracts). Therefore, our results capture only short-term effects.
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