Combining Patient Survey Data With Diagnosis Codes Improved Medicare Advantage Risk-Adjustment Accuracy.

Under the current Medicare Advantage (MA) risk-adjustment system, plans are incentivized to report diagnosis codes on enrollees' medical claims reflecting additional and more severe health conditions to increase enrollees' risk scores and corresponding plan payments. To improve the integrity of risk adjustment, researchers have proposed four alternative methods to construct risk scores: calculate Hierarchical Condition Categories (HCC) scores excluding diagnosis codes from health risk assessments and chart reviews, calculate HCC scores excluding diagnosis codes most subject to score inflation, use pharmaceutical claims alone, and use self-reported survey responses alone or in combination with diagnosis codes. Using 2016-19 medical and pharmaceutical claims linked to Consumer Assessment of Healthcare Providers and Systems survey responses from 151,432 MA enrollees, we compared the predictive accuracy of each alternative strategy with the standard HCC approach.

Hospital Payment Caps Could Save State Employee Health Plans Millions While Keeping Hospital Operating Margins Healthy.

State employee health plans are consuming an ever-larger portion of state budgets because of rising health insurance premiums. Often the largest purchaser of commercial health insurance in their state, state employee health plans possess a unique opportunity to implement cost containment strategies. This study estimated potential savings from hospital payment caps among state employee health plans and the impact on commercial hospital operating margins.

Commercial Prices and Care for Medicare Beneficiaries With Prostate Cancer.

Objective: To examine the relationship between market dynamics, in the form of commercial prices paid to urologists, and utilization of services, as measured by Medicare spending, in men with newly diagnosed prostate cancer.

Methods: We performed a retrospective national cohort study of Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2019, with follow-up through 2020. The primary exposure was the commercial price index (ie, the ratio of commercial prices to Medicare prices for a common set of services performed by urologists).

Commercial prices and their influence on urology practices: Prostate cancer care among men with Medicare.

Background: For men with prostate cancer, there is substantial variation in the use of conservative management, such as active surveillance. Commercial prices, which vary across urology practices, may afford incentives that foster physician behaviors associated with utilization. Such behaviors may "spillover" to the Medicare population and affect quality.

Oregon's Hospital Payment Cap and Enrollee Out-of-Pocket Spending and Service Use.

Importance: Enrollee cost-sharing and health insurance premiums have grown alongside rising hospital prices. To control prices and price growth, the Oregon State Employee plan instituted a cap on hospital facility payments in October 2019 that was found to reduce hospital prices. Yet the program's association with out-of-pocket spending and use among enrollees is unknown.

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

Objective: To determine whether hospital system affiliation was associated with changes in surgical episode spending or postoperative outcomes.

Background: Over 70% of US hospitals are now part of a hospital system. The presumed benefits of hospital consolidation include concentrating volume and expertise, care integration, and investment in quality improvement.

Bundled payments lead to quality improvements in hospitals' skilled nursing facility referral networks.

Objectives: To assess whether hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program for joint replacement changed their referral patterns to favor higher-quality skilled nursing facilities (SNFs).

Study Design: Retrospective observational study using 2009-2015 inpatient and outpatient claims from a 20% sample of Medicare beneficiaries undergoing joint replacement in US hospitals (N = 146,074) linked with data from Medicare's BPCI program and Nursing Home Compare.

Methods: We ran fixed effect regression models regressing BPCI participation on hospital-SNF referral patterns (number of SNF discharges, number of SNF partners, and SNF referral concentration) and SNF quality (facility inspection survey rating, patient outcome rating, staffing rating, and registered nurse staffing rating).

Physician Group Practices Accrued Large Bonuses Under Medicare's Bundled Payment Model, 2018-20.

The Bundled Payments for Care Improvement Advanced Model (BPCI-A), a voluntary Alternative Payment Model for Medicare, incentivizes hospitals and physician group practices to reduce spending for patient care episodes below preset target prices. The experience of physician groups in BPCI-A is not well understood. We found that physician groups earned $421 million in incentive payments during BPCI-A's first four performance periods (2018-20).

Identifying Sources of Inter-Hospital Variation in Episode Spending for Sepsis Care.

Objective: To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care.

Data Sources/study Setting: Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018.

Research Design: Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending.

Hospital Facility Prices Declined As A Result Of Oregon's Hospital Payment Cap.

Hospital prices for commercially insured people are high and vary widely, prompting states to seek ways to control hospital price growth. In October 2019, the Oregon state employee health insurance plan instituted a cap on hospital payments. Using 2014-21 data from the Oregon All Payer All Claims Reporting Program database, we performed a difference-in-differences analysis to test the impact of the cap on hospital facility prices for Oregon's state employee plan enrollees.

Heterogeneity within the Oregon Health Insurance Experiment: An application of causal forests.

Existing evidence regarding the effects of Medicaid expansion, largely focused on aggregate effects, suggests health insurance impacts some health, healthcare utilization, and financial hardship outcomes. In this study we apply causal forest and instrumental forest methods to data from the Oregon Health Insurance Experiment (OHIE), to explore heterogeneity in the uptake of health insurance, and in the effects of (a) lottery selection and (b) health insurance on a range of health-related outcomes. The findings of this study suggest that the impact of winning the lottery on the health insurance uptake varies among different subgroups based on age and race.

Association Between the Medicare Advantage Quartile Adjustment System and Plan Behavior and Enrollment.

Importance: Medicare Advantage (MA) has grown in popularity, but critics believe that insurers are overpaid, partially due to the quartile adjustment system that determines plan benchmarks. However, elimination of the quartile adjustments may be associated with less generous benefits and fewer plan offerings, which could slow MA enrollment growth.

Objective: To examine whether the quartile adjustment system is associated with differences in county-level benefits, insurer offerings, and MA enrollment.

Estimated Savings From the Medicare Shared Savings Program.

Importance: The Medicare Shared Savings Program (MSSP) is the largest and most important alternative payment model that has been implemented by the Centers for Medicare & Medicaid Services (CMS). Its budgetary impact to CMS is not well understood.

Objective: To evaluate the association between the MSSP and net savings to CMS for performance years 2013 to 2021.

Evaluating Educational Outcomes Using Patient Outcomes of New Surgeons Performing Partial Colectomy Compared to Cholecystectomy.

Purpose: Despite ongoing efforts to improve surgical education, surgical residents face gaps in their training. However, it is unknown if differences in the training of surgeons are reflected in the patient outcomes of those surgeons once they enter practice. This study aimed to compare the patient outcomes among new surgeons performing partial colectomy-a common procedure for which training is limited-and cholecystectomy-a common procedure for which training is robust.

Favorable Selection In Medicare Advantage Is Linked To Inflated Benchmarks And Billions In Overpayments To Plans.

Increases in Medicare Advantage (MA) enrollment, coupled with concerns about overpayment to plans, have prompted calls for change. Benchmark setting in MA, which determines plan payment, has received relatively little attention as an avenue for reform. In this study we used national data from the period 2010-20 to examine the relationships among unobserved favorable selection, benchmark setting, and payments to plans in MA.

Trends in Cumulative Disenrollment in the Medicare Advantage Program, 2011-2020.

Importance: The Medicare Advantage (MA) program is rapidly growing. While previous work has found that beneficiaries with substantial health needs disenroll from plans at higher rates, the long-term frequency of disenrollment is not well understood.

Objective: To compare cumulative disenrollment trends in the MA program by beneficiary and plan characteristics.

Legislative and Regulatory Options for Improving Medicare Advantage.

The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance.

Hospital-physician integration and clinical volume in traditional Medicare.

Objective: To test the effect of hospital-physician integration on primary care physicians' (PCP) clinical volume in traditional Medicare.

Data Sources And Study Setting: Nationwide retrospective longitudinal study using Medicare claims and other data sources from 2010 to 2016.

Study Design: We identified 70,000 PCPs, some of whom remained non-integrated and some who became hospital-integrated during this study period.