Publications by authors named "Arnold M Epstein"
Importance: Hospital participation in the Bundled Payments for Care Improvement-Advanced (BPCI-A) initiative has been associated with modest savings and stable clinical outcomes overall, but it is unknown whether the program performs differently for medical and surgical or procedural (henceforth, surgical) episodes.
Objective: To assess the association of BPCI-A participation with Medicare spending and clinical outcomes for medical and surgical episodes.
Design, Setting, And Participants: This retrospective difference-in-differences cohort study utilized 100% Medicare fee-for-service inpatient claims for episodes initiated between January 1, 2017, and September 30, 2019, and included 90 days of follow-up.
Purpose: As US hospital markets become increasingly consolidated, empirical evidence is needed on the clinical and financial impacts of mergers on care provided by rural hospitals. We identified characteristics of rural hospitals that underwent mergers or acquisitions and examined changes in profitability, clinical outcomes, and patient experience at acquired versus non-acquired rural hospitals.
Methods: We identified 145 rural US hospitals that underwent merger or acquisition between 2009 and 2014 and 906 rural non-acquired control hospitals.
Objectives: Hospitals in the US operate under various value-based payment programs, but little is known regarding the strategies they use in this context to improve quality and reduce costs, overall or in voluntary programs including Bundled Payments for Care Improvement Advanced (BPCI-A).
Study Design: A survey was administered to hospital leaders at 588 randomly selected acute care hospitals, with oversampling of BPCI-A participants, from November 2020 to June 2021. Twenty strategies and 20 barriers were queried in 4 domains: inpatient, postacute, outpatient, and community resources for vulnerable patients.
Importance: States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care.
Objective: To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states.
Background: Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients.
Methods: We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy.
Background: Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model.
View Article and Find Full Text PDFImportance: In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits.
Objective: To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries.
Design, Setting, And Participants: This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs.
Background: Nursing home quality of care is a persistent challenge, with recent reports calling for increased reforms to improve quality and safety. Less is known about the clinical approaches currently used and the barriers perceived by skilled nursing facilities (SNFs) to provide care for their short-stay residents.
Methods: We conducted a nationally representative survey of SNFs from October 2020 to May 2021 to understand their care delivery approaches and perceived barriers.
Background: The COVID-19 pandemic caused massive disruption in usual care delivery patterns in hospitals across the USA, and highlighted long-standing inequities in health care delivery and outcomes. Its effect on hospital operations, and whether the magnitude of the effect differed for hospitals serving historically marginalized populations, is unknown.
Objective: To investigate the perspectives of hospital leaders on the effects of COVID-19 on their facilities' operations and patient outcomes.
Importance: The Medicare alternative payment models are designed to incentivize cost reduction and quality improvement, but there are no requirements established for evaluating the outcomes of the Medicare populations.
Objective: To examine whether participation in the Medicare Bundled Payments for Care Improvement Advanced (BPCI-A) program was associated with narrowing or widening of Black and White racial inequities in outcomes and access.
Design, Setting, And Participants: Retrospective cohort alternative payment models on equity and quality for disadvantaged populations were studied between April 6, 2021, and August 28, 2022, in US hospitals.
Medicare's Bundled Payments For Care Improvement Advanced Model: Impact On High-Risk Beneficiaries.
Health Aff (Millwood)
November 2022
Medicare's Bundled Payments for Care Improvement Advanced Model (BPCI-A) is a voluntary Alternative Payment Model in which participating hospitals are held accountable for ninety-day episodes of care. To meet spending targets, hospitals must either decrease utilization or attract a less sick patient population; this could lead to the elimination of necessary care or avoidance of patients with medical or social vulnerability. We used publicly available data on BPCI-A participation, along with Medicare claims from the period 2017-19, to examine patient selection, changes in Medicare payment, and key clinical outcomes among three groups: patients with frailty, patients with multimorbidity, and patients with dual enrollment (both Medicare and Medicaid).
View Article and Find Full Text PDFImportance: During the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects.
Objective: To assess health outcomes among SNFs with and without known COVID-19 cases.
Importance: It is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid.
Objective: To determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status.
Design Setting And Participants: This random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020.
Background: While the impact of the COVID-19 recession on the economy is clear, there is limited evidence on how the COVID-19 pandemic-related job losses among low-income people may have affected their access to health care.
Objective: To determine the association of job loss during the pandemic with insurance coverage and access to and affordability of health care among low-income adults.
Design: Using a random digit dialing telephone survey from October 2020 to December 2020 of low-income adults in 4 states-Arkansas, Kentucky, Louisiana, and Texas-we conducted a series of multivariable logistic regression analyses, adjusting for demographics, chronic conditions, and state of residence.
The Affordable Care Act (ACA) Marketplace plays a critical role in providing affordable health insurance for the nongroup market, yet the accessibility of plans from insurers with high quality ratings has not been investigated. Our analysis of recently released insurer quality star ratings for plan year 2020 found substantial variation in access to high rated plans in the federally facilitated ACA Marketplace. In most participating counties (1,390 of 2,265, or 61.
View Article and Find Full Text PDFThis study assesses how a limited supply of monoclonal antibody therapy was allocated to patients at highest risk of severe disease among a population of fee-for-service Medicare beneficiaries with a new COVID-19 diagnosis or confirmed exposure between November 2020 and August 2021.
View Article and Find Full Text PDFBackground: The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments.
Methods: We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals).
Background: Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs) accountable for 90-day costs of care. Its overall impact on Medicare spending and clinical outcomes is unknown.
Methods: Retrospective cohort study using Medicare claims from 2012 to 2017.
Importance: Medicare's Bundled Payments for Care Improvement (BPCI) program, which ran from 2013 to 2018, was an important experiment in physician-focused alternative payment models. However, little is known about whether the program was associated with better quality or outcomes or lower costs.
Objective: To determine whether participation in BPCI among physician group practices was associated with advantageous or deleterious changes in costs or patient outcomes.
Background: Hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program were incented to reduce Medicare payments for episodes of care.
Objective: To identify factors that influenced whether or not hospitals were able to save in the BPCI program, how the cost of different services changed to produce those savings, and if "savers" had lower or decreased quality of care.
Design: Retrospective cohort study.
Importance: Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model.
Objective: To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR).
In June 2018 Arkansas became the first US state to implement work requirements in Medicaid, requiring adults ages 30-49 to work twenty hours a week, participate in "community engagement" activities, or qualify for an exemption to maintain coverage. By April 2019, when a federal judge put the policy on hold, 18,000 adults had already lost coverage. We analyze the policy's effects before and after these events, using a telephone survey performed in late 2019 of 2,706 low-income adults in Arkansas and three control states compared with data from 2016 and 2018.
View Article and Find Full Text PDFBackground: Studies of medical conditions in the Bundled Payments for Care Improvement (BPCI) initiative did not show reductions in Medicare payments for the majority of conditions, but this could mask heterogeneity.
Objective: To determine whether earlier enrollment and/or longer participation in BPCI were associated with performance.
Design: We divided BPCI hospitals into wave 1 (joined 10/1/13, 1/1/14, or 4/1/14), wave 2 (joined 7/1/14, 10/1/14, 1/1/15, or 4/1/15), and wave 3 (joined 7/1/15, 10/1/15, or 1/1/16) and compared changes in Medicare payments for acute myocardial infarction, heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease between BPCI and matched controls in 6-month increments.
This survey study investigates perceptions of the Trump administration’s new public charge rule among low-income Texan adults.
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