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)
Project #
Application #
Study Section
Special Emphasis Panel (ZAG1-ZIJ-1)
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Dartmouth College
United States
Zip Code
Bekelis, Kimon; Missios, Symeon; Shu, Joel et al. (2018) Surgical outcomes for patients diagnosed with dementia: A coarsened exact matching study. J Clin Neurosci 53:160-164
Bekelis, Kimon; Missios, Symeon; Coy, Shannon et al. (2018) Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis. World Neurosurg 110:e689-e698
Missios, Symeon; Bekelis, Kimon (2018) Association of Hospitalization for Neurosurgical Operations in Magnet Hospitals With Mortality and Length of Stay. Neurosurgery 82:372-377
Ouayogodé, Mariétou H; Meara, Ellen; Chang, Chiang-Hua et al. (2018) Forgotten patients: ACO attribution omits those with low service use and the dying. Am J Manag Care 24:e207-e215
Rosenthal, Meredith B; Colla, Carrie H; Morden, Nancy E et al. (2018) Overuse and insurance plan type in a privately insured population. Am J Manag Care 24:140-146
Bekelis, Kimon; Missios, Symeon; Coy, Shannon et al. (2018) Emergency medical services for acute ischemic stroke: Hub-and-spoke model versus exclusive care in comprehensive centers. J Clin Neurosci :
Chen, Lena M; Ryan, Andrew M; Shih, Terry et al. (2018) Medicare's Acute Care Episode Demonstration: Effects of Bundled Payments on Costs and Quality of Surgical Care. Health Serv Res 53:632-648
Moen, Erika L; Bynum, Julie P; Austin, Andrea M et al. (2018) Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks. Med Care 56:350-357
Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A (2018) Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work. Neurosurgery 82:329-334
Jeffery, Molly Moore; Hooten, W Michael; Henk, Henry J et al. (2018) Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 362:k2833

Showing the most recent 10 out of 263 publications