Expenditures around episodes of hospitalization vary widely across hospitals. In our recent national study. Medicare payments for inpatient surgery differed 10% to 39% between the least and most expensive hospital quintiles, after adjusting for price differences and case mix.
Aimi ng to reduce such variation, CMS is moving steadily toward bundled payments, which would provide a single lump sum to hospitals, physicians, and other caregivers involved in care around hospitalizations. The hope is that bundled payments will give hospital and physicians stronger incentives to coordinate care and reduce the use of unnecessary services. Extending our previous P01-funded research, this project will explore determinants of variation in hospital payments, incorporating both claims data from the under-65 population and clinically rich outcomes and safety culture information from 50 hospitals in Michigan. We will also evaluate the direct and indirect consequences of the Center for Medicare and Medicaid Innovation's (CMMI) recent bundled payment initiative. This subproject has three goals. First, we plan to examine the association between hospital quality and Medicare episode payments. Taking advantage of Michigan's unique clinical outcomes data infrastructure, we will examine surgical cohorts to understand relationships among patient-level outcomes such as risk adjusted morbidity and mortality, measures of technical quality such as hospital safety culture and teamwork, and price-adjusted episode costs. Second, we propose to evaluate the direct impact of the CMMI bundled payment initiative on costs and quality. For the subset of Michigan hospitals participating in the CMMI bundled payment program, we will evaluate the direct effects of this intervention on episode payments and quality of care with targeted conditions and procedures. And finally, we plan to assess spillover and substitution effects of episode payments for the under-65 population, and for Medicare patients with unbundled conditions. Using the CMMI bundled payment program as a shift in relative prices for post discharge services, we will also assess the program's spillover effects on procedures for the under-65 population, and for unrelated and untargeted conditions in the over-65 population.

Public Health Relevance

Results from this study will have immediate impact in informing CMS decision-makers about the efficiency of its bundled payment program. Moreover, a deeper understanding of the determinants of hospital payments - and heterogeneity in terms of which hospitals are successful under bundled payments - will help guide the development of broader interventions to improve efficiency.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Program Projects (P01)
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Special Emphasis Panel (ZAG1-ZIJ-1)
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Dartmouth College
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Goodney, Philip P; Tarulli, Massimo; Faerber, Adrienne E et al. (2015) Fifteen-year trends in lower limb amputation, revascularization, and preventive measures among medicare patients. JAMA Surg 150:84-6
Colla, Carrie H; Sequist, Thomas D; Rosenthal, Meredith B et al. (2015) Use of non-indicated cardiac testing in low-risk patients: Choosing Wisely. BMJ Qual Saf 24:149-53
Morden, N E; Schpero, W L; Zaha, R et al. (2014) Overuse of short-interval bone densitometry: assessing rates of low-value care. Osteoporos Int 25:2307-11
Mangalmurti, Sandeep; Seabury, Seth A; Chandra, Amitabh et al. (2014) Medical professional liability risk among US cardiologists. Am Heart J 167:690-6
Chen, Christopher; Scheffler, Gabriel; Chandra, Amitabh (2014) Readmission penalties and health insurance expansions: a dispatch from Massachusetts. J Hosp Med 9:681-7
Schoenfeld, Andrew J; Harris, Mitchel B; Liu, Haiyin et al. (2014) Variations in Medicare payments for episodes of spine surgery. Spine J 14:2793-8
Reames, Bradley N; Shubeck, Sarah P; Birkmeyer, John D (2014) Strategies for reducing regional variation in the use of surgery: a systematic review. Ann Surg 259:616-27
Sirovich, Brenda E; Lipner, Rebecca S; Johnston, Mary et al. (2014) The association between residency training and internists' ability to practice conservatively. JAMA Intern Med 174:1640-8
Lewis, Valerie A; Colla, Carrie H; Schoenherr, Karen E et al. (2014) Innovation in the safety net: integrating community health centers through accountable care. J Gen Intern Med 29:1484-90
Liu, Stephen K; Munson, Jeffrey C; Bell, John-Erik et al. (2014) Response letter to Herbert L. Muncie, Jr. J Am Geriatr Soc 62:998-9

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