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1 to 25 of 95 Research Studies Displayed
Mulcahy JF, Patel SY, Mehrotra A
Quantifying indirect billing within the Medicare physician fee schedule.
This cohort study’s goal was to quantify indirect billing within the Medicare physician fee schedule. Under certain circumstances advance practice clinicians (APCs) such as physician assistants and nurse practitioners can bill Medicare directly or indirectly. Indirect billing means the submitted claim states the care was provided by the physician, and the reimbursement is higher. The authors looked at Medicare fee-for-service and Medicare Advantage claims data to identify indirectly billed APC services. Office-based Medicare Part B claims were linked to Part D claims for prescription drug fills. The number of indirect billings for office encounters provided by an APC in 2022 was 38.9%. For all median physician visits in 2022, indirect billing on behalf of APCs represented 11.1% of all billed encounters. APC billing was most common among surgical specialists (29.7% of all encounters) and least common for primary care physicians (3.9%). The authors found that if all indirectly billed APC-provided care was billed directly by the APC, Medicare would have saved $270 million in 2022.
AHRQ-funded; HS028490.
Citation: Mulcahy JF, Patel SY, Mehrotra A . Quantifying indirect billing within the Medicare physician fee schedule. JAMA Health Forum 2025 Apr 4; 6(4):e250433. doi: 10.1001/jamahealthforum.2025.0433.
Keywords: Medicare, Payment
Ianni K, Chen A, Rodrigues D
Transporting difference-in-differences estimates to assess health equity impacts of payment and delivery models.
This simulation study’s objective was to transport the effects of the Comprehensive Primary Care Plus (CPC+) model to a target population of Black fee-for-service (FFS) Medicare beneficiaries living outside the original 18 CPC+ regions. Main outcome variable was total Medicare spending per beneficiary per year (pbpy). The authors simulated practice-level spending in 18 CPC+ regions and 32 non-CPC+ regions (1200 practices per region). They calibrated the parameters from the literature and then varied four key parameters to create 16 realistic simulation scenarios. Across the 16 simulation scenarios, transporting the treatment effect regions yielded median treatment effects that ranged from $15.5 pbpy smaller to $10 pbpy larger than in the sample. These differences turned out to be roughly the same magnitude as the estimated overall effect of $13 pbpy.
AHRQ-funded; HS028985.
Citation: Ianni K, Chen A, Rodrigues D . Transporting difference-in-differences estimates to assess health equity impacts of payment and delivery models. Health Serv Res 2025 Apr; 60(suppl 2):e14419. doi: 10.1111/1475-6773.14419.
Keywords: Primary Care, Payment, Medicare, Healthcare Costs, Simulation
Kim N, Jacobson M
Outcomes by race and ethnicity following a Medicare bundled payment program for joint replacement.
The objective of this cohort study was to evaluate outcomes associated with the Comprehensive Care for Joint Replacement (CJR) model--a traditional Medicare bundled payment program for lower-extremity joint replacement--among Hispanic patients who were not enrolled in traditional Medicare. Three metropolitan statistical areas (MSAs) were randomly selected in California to participate in CJR. The results indicated that CJR program outcomes differed by race and ethnicity for patients outside traditional Medicare. The authors noted that these findings suggested the importance of considering differential outcomes of Medicare payment policies for racial and ethnic minority patient populations beyond the initially targeted groups.
AHRQ-funded; HS026488.
Citation: Kim N, Jacobson M . Outcomes by race and ethnicity following a Medicare bundled payment program for joint replacement. JAMA Netw Open 2024 Sep 3; 7(9):e2433962. doi: 10.1001/jamanetworkopen.2024.33962..
Keywords: Medicare, Payment, Surgery, Orthopedics, Racial and Ethnic Minorities
Lin SC, Funk RJ, Ryan AM
Bundled payments lead to quality improvements in hospitals' skilled nursing facility referral networks.
This study’s goal was to assess hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program for joint replacement who changed their referral patterns to favor higher-quality skilled nursing facilities (SNFs). This study used 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. Researchers found that BPCI participation was associated with a decrease in the number of SNF referrals and no significant change in the number of SNF partners or concentration of SNF partners. BPCI participation was associated with discharge to SNFs with a higher patient outcome rating by 0.04 stars. BPCI participation was not associated with improvements in discharge to SNFs with a higher facility survey rating, staffing rating, or registered nurse staffing rating.
AHRQ-funded; HS024525; HS024728; HS025875.
Citation: Lin SC, Funk RJ, Ryan AM . Bundled payments lead to quality improvements in hospitals' skilled nursing facility referral networks. Am J Manag Care 2024 Jun; 30(6):e184-e90. doi: 10.37765/ajmc.2024.89566.
Keywords: Medicare, Payment, Quality Improvement, Quality of Care
Crowley AP, Neville S, Sun C
Differential hospital participation in bundled payments in communities with higher shares of marginalized populations.
This study’s objective was to examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). Communities with higher shares of dual-eligible Medicare and Medicaid individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced, however communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1).
AHRQ-funded; HS027595.
Citation: Crowley AP, Neville S, Sun C . Differential hospital participation in bundled payments in communities with higher shares of marginalized populations. J Gen Intern Med 2024 May; 39(7):1180-87. doi: 10.1007/s11606-024-08655-4..
Keywords: Payment, Hospitals, Medicare
Anderson KE, DiStefano MJ, Liu A
Incorporating added therapeutic benefit and domestic reference pricing into Medicare payment for expensive part B drugs.
The objective of this retrospective analysis was to identify expensive Part B drugs and to consider the evidence for each drug's added benefit in order to model a reimbursement policy for Medicare that integrates added benefit assessment and domestic reference pricing. Data were taken from a nationally representative sample of traditional Medicare Part B claims. The analysis showed that more than one-third of the expensive Part B drugs prescribed in 2019 offered low added benefit. The authors concluded that reference pricing based on added benefit assessment could be used to address the launch prices for expensive Part B drugs with low added benefit.
AHRQ-funded; HS000029.
Citation: Anderson KE, DiStefano MJ, Liu A . Incorporating added therapeutic benefit and domestic reference pricing into Medicare payment for expensive part B drugs. Value Health 2023 Sep; 26(9):1381-88. doi: 10.1016/j.jval.2023.05.018..
Keywords: Medicare, Payment, Medication, Healthcare Costs
Landon BE, Lam MB, Landrum MB
Opportunities for savings in risk arrangements for oncologic care.
High spending for cancer care is a target for savings as the United States hastens adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA). The purpose of this study was to quantify the level at which Accountable Care Organizations ACOs and other risk-bearing organizations operating in a specific geographic area could realize savings by directing patients to efficient medical oncology practices. The incident cohort included 1,309,825 patients Options for directing differed across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57,314 in 2009 to 2010 to $66,028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% greater than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods followed by Part B (infused) chemotherapy. Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high.
Citation: Landon BE, Lam MB, Landrum MB . Opportunities for savings in risk arrangements for oncologic care. JAMA Health Forum 2023 Sep; 4(9):e233124. doi: 10.1001/jamahealthforum.2023.3124..
Keywords: Cancer, Medicare, Healthcare Costs, Payment
Tummalapalli SL, Struthers SA, White D
Optimal care for kidney health: development of a Merit-based Incentive Payment System (MIPS) value pathway.
This article detailed the iterative consensus-building process used by the American Society of Nephrology Quality Committee to develop the Optimal Care for Kidney Health Merit-based Incentive Payment System (MIPS) Value Pathway (MVP). The Optimal Care for Kidney Health MVP, published in the 2023 Medicare Physician Fee Schedule Final Rule, included measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The MVP nephrology’s goal was to streamline measure selection in MIPS and served as a case study of collaborative policymaking between one professional organization and national regulatory agencies.
AHRQ-funded; HS028684.
Citation: Tummalapalli SL, Struthers SA, White D . Optimal care for kidney health: development of a Merit-based Incentive Payment System (MIPS) value pathway. J Am Soc Nephrol 2023 Aug; 34(8):1315-28. doi: 10.1681/asn.0000000000000163..
Keywords: Kidney Disease and Health, Payment, Healthcare Costs, Medicare
Ko H, Martin BI, Nelson RE
How does the effect of the comprehensive Care for Joint Replacement model vary based on surgical volume and costs of care?
This article described differences in costs, quality, and patient selection between hospitals that continued to participate in the comprehensive Care for Joint Replacement (CJR) program after the CMS policy revision and those that withdrew from CJR before and after the implementation of CJR. Study subjects were Medicare beneficiaries who had undergone elective lower extremity joint replacement from 2013 to 2017. The results indicated that hospitals that continued to participate in CJR achieved a greater cost reduction. The authors noted that these the cost reductions were partly attributable to the avoidance of potential higher-cost patients.
AHRQ-funded; HS024714.
Citation: Ko H, Martin BI, Nelson RE . How does the effect of the comprehensive Care for Joint Replacement model vary based on surgical volume and costs of care? Med Care 2023 Jan;61(1):20-26. doi: 10.1097/mlr.0000000000001785..
Keywords: Orthopedics, Surgery, Healthcare Costs, Medicare, Payment
Collins CR, Abel MK, Shui A
Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery.
This study aimed to assess where the largest opportunities for care improvement lay with the bundled payment reimbursement model and how best to identify patients at high risk of suffering costly complications, including hospital readmission. The authors used a cohort of patients from 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Using the results, they identified readmissions as a target for improvement and then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within the bundled payment population who were at high risk of readmission using a logistic regression model. Patients who were readmitted within 90-days post-surgery were 2.53 times more likely to be high-cost (>$60,000) then non-readmitted patients. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days post-surgery.
AHRQ-funded; HS024532.
Citation: Collins CR, Abel MK, Shui A . Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery. Perioper Med 2022 Dec 9;11(1):54. doi: 10.1186/s13741-022-00286-9..
Keywords: Provider Performance, Payment, Hospital Readmissions, Quality Improvement, Quality of Care, Surgery, Medicare, Medicaid
Liao JM, Huang Q, Wang E
Performance of physician groups and hospitals participating in bundled payments among Medicare beneficiaries.
This cohort study compared how physician group practices (PGPs) performed in bundled payments compared with hospitals. The authors used 2011 to 2018 Medicare claims data to compare the association of participants in the Bundled Payments for Care Improvement (BCPI) initiative with episode outcomes. Primary outcome was 90-day total episode spending. The total sampled comprised data from 1,288,781 Medicare beneficiaries, of whom mean age was 76.2 years, 59.7% women, and 85.5% White, with 592,071 individuals receiving care from 6405 physicians in in BPCI-participating PGPs and 24,758 propensity-matched physicians in non-BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical (difference, -$1648 to -$1088) but not for medical episodes (difference, -$410 to $206). Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical ($1345 to -$675) and medical -$1139 to -$386) episodes.
AHRQ-funded; HS027595.
Citation: Liao JM, Huang Q, Wang E . Performance of physician groups and hospitals participating in bundled payments among Medicare beneficiaries. JAMA Health Forum 2022 Dec 2; 3(12):e224889. doi: 10.1001/jamahealthforum.2022.4889..
Keywords: Provider Performance, Payment, Hospitals, Medicare, Quality of Care
Likosky DS, Yang G, Zhang M
Interhospital variability in health care-associated infections and payments after durable ventricular assist device implant among Medicare beneficiaries.
The purpose of this study was to examine differences in durable ventricular assist device implantation infection rates and associated costs across hospitals. The researchers utilized clinical data for 8,688 patients who received primary durable ventricular assist devices from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) hospitals (n = 120) and merged that data with post-implantation 90-day Medicare claims. The primary outcome included infections within 90 days of implantation and Medicare payments. The study found that 27.8% of patients developed 3982 identified infections. The median adjusted incidence of infections (per 100 patient-months) across hospitals was 14.3 and differed according to hospital. Total Medicare payments from implantation to 90 days were 9.0% more in high versus low infection tercile hospitals. The researchers concluded that health-care-associated infection rates post durable ventricular assist device implantation varied according to hospital and were associated with increased 90-day Medicare expenditures.
AHRQ-funded; HS026003.
Citation: Likosky DS, Yang G, Zhang M . Interhospital variability in health care-associated infections and payments after durable ventricular assist device implant among Medicare beneficiaries. J Thorac Cardiovasc Surg 2022 Nov;164(5):1561-68. doi: 10.1016/j.jtcvs.2021.04.074..
Keywords: Healthcare-Associated Infections (HAIs), Medical Devices, Medicare, Heart Disease and Health, Cardiovascular Conditions, Hospitals, Payment, Healthcare Costs
Li J, Wu B, Flory J
Impact of the Affordable Care Act's Physician Payments Sunshine Act on branded statin prescribing.
The purpose of this study was to assess the impact of the Affordable Care Act's Physician Payments Sunshine Act (PPSA) and its mandate of disclosing pharmaceutical and medical industry payments to physicians for prescribing branded statins. The study found that the PPSA contributed to a 7% decrease in monthly new prescriptions of brand-name statins over the study period. There was no significant change in generic prescribing. The reduction was concentrated among physicians with the highest tercile of drug spending prior to the enactment of the PPSA, with a decrease of 15% in new branded statin prescriptions. The researchers concluded that the PPSA mandate reduced the prescribing of branded statin prescriptions in the time period following its announcement, especially in physicians who were taking part in excessive prescribing of the branded statins.
AHRQ-funded; HS027001.
Citation: Li J, Wu B, Flory J . Impact of the Affordable Care Act's Physician Payments Sunshine Act on branded statin prescribing. Health Serv Res 2022 Oct;57(5):1145-53. doi: 10.1111/1475-6773.14024..
Keywords: Payment, Policy, Medicare, Health Insurance
Waters TM, Burns N, Kaplan CM
Combined impact of medicare's hospital pay for performance programs on quality and safety outcomes is mixed.
The authors examined the combined impact of Medicare's pay for performance (P4P) programs on clinical areas and populations targeted by the programs, as well as those outside their focus. Using HCUP data, and consistent with previous studies for individual programs, they detected minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. They recommended a redesigning of the P4P programs before continuing to expand them.
AHRQ-funded; HS025148.
Citation: Waters TM, Burns N, Kaplan CM . Combined impact of medicare's hospital pay for performance programs on quality and safety outcomes is mixed. BMC Health Serv Res 2022 Jul 28;22(1):958. doi: 10.1186/s12913-022-08348-w..
Keywords: Healthcare Cost and Utilization Project (HCUP), Medicare, Payment, Provider Performance, Hospitals, Quality Indicators (QIs), Quality Measures, Quality Improvement, Quality of Care, Patient Safety
Wilcock AD, Joshi S, Escarce J
Luck of the draw: role of chance in the assignment of Medicare readmissions penalties.
Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. The purpose of this study was to investigate the impact luck can have on the assessment of performance, the researchers investigated its role in assigning penalties under Medicare's Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions.
AHRQ-funded; HS024284.
Citation: Wilcock AD, Joshi S, Escarce J . Luck of the draw: role of chance in the assignment of Medicare readmissions penalties. PLoS One 2021 Dec 21;16(12):e0261363. doi: 10.1371/journal.pone.0261363..
Keywords: Medicare, Payment, Hospital Readmissions, Provider Performance, Quality of Care
Sood N, Yang Z, Huckfeldt P
Geographic variation in Medicare fee-for-service health care expenditures before and after the passage of the Affordable Care Act.
This cross-section study examined geographic variation in Medicare fee-for-service health care expenditures before and after the passage of the Affordable Care Act. The study included all fee-for-service Medicare enrollees aged 65 and older from 2007 to 2018 using data from the Medicare Geographic Variation Public Use File. Hospital referral regions (HRRs) were grouped in each year into deciles (10 equal groups) based on per-beneficiary total spending. Geographic variation was stable from 2007 to 2011 and declined steadily from 2012 through 2018. In specific spending categories, only home health had statistically significant reductions in geographic variation. The ratio of home health spending among HRRs in the top to bottom deciles of total Medicare spending fell from 5.14 in 2007 to 3.45 in 2018.
AHRQ-funded; HS025394.
Citation: Sood N, Yang Z, Huckfeldt P . Geographic variation in Medicare fee-for-service health care expenditures before and after the passage of the Affordable Care Act. JAMA Health Forum 2021 Dec;2(12):e214122. doi: 10.1001/jamahealthforum.2021.4122..
Keywords: Medicare, Policy, Healthcare Costs, Payment
Liao JM, Chatterjee P, Wang E
The effect of hospital safety net status on the association between bundled payment participation and changes in medical episode outcomes.
This study evaluated whether hospital safety net status affected the association between bundled payment participation and medical outcomes. The hospitals included were participants in Medicare’s Bundled Payments for Care Improvement (BCPI) program from 2011-2016. Data from Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease were used. Among BCPI hospitals, safety net status was not associated with differential postdischarge spending or quality. However, BPCI safety net hospitals had differentially greater discharge due to institutional post-acute care and lower discharge home with home health than BPCI non-safety net hospitals.
AHRQ-funded; HS027595.
Citation: Liao JM, Chatterjee P, Wang E . The effect of hospital safety net status on the association between bundled payment participation and changes in medical episode outcomes. J Hosp Med 2021 Dec;16(12):716-23. doi: 10.12788/jhm.3722..
Keywords: Medicare, Payment, Hospitals
Arntson E, Dimick JB, Nuliyalu U
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
This study evaluated changes in Hospital-Acquired Conditions (HACs) and 30-day mortality after the announcement of the Centers for Medicare and Medicare Services’ Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The authors evaluated models to test for changes in HACs and 30-day mortality before and after the Affordable Care Act (ACA), and after the HACRP. Fee-for-service Medicare claims from 2009 to 2015 were used. The HAC rate declined after the ACA was passed and declined further after the HACRP announcement. However, 30-day mortality rates were unchanged.
AHRQ-funded; HS026244.
Citation: Arntson E, Dimick JB, Nuliyalu U . Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program. Ann Surg 2021 Oct 1;274(4):e301-e07. doi: 10.1097/sla.0000000000003641..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Mortality, Medicare, Payment, Prevention, Patient Safety
Roberts ET, Song Z, Ding L
Changes in patient experiences and assessment of gaming among large clinician practices in precursors of the merit-based incentive payment system.
Medicare's Merit-Based Incentive Payment System (MIPS), a public reporting and pay-for-performance program, adjusts clinician payments based on publicly reported measures that are chosen primarily by clinicians or their practices. Within precursor programs of the MIPS, this study examined 1) practices' selection of Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience measures for quality scoring under pay-for-performance and 2) the association between mandated public reporting on CAHPS measures and performance on those measures.
AHRQ-funded; HS026727.
Citation: Roberts ET, Song Z, Ding L . Changes in patient experiences and assessment of gaming among large clinician practices in precursors of the merit-based incentive payment system. JAMA Health Forum 2021 Oct;2(10). doi: 10.1001/jamahealthforum.2021.3105..
Keywords: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Patient Experience, Medicare, Provider Performance, Payment, Quality Improvement, Quality of Care
Markovitz AA, Ayanian JZ, Warrier A
Medicare Advantage plan double bonuses drive racial disparity in payments, yield no quality or enrollment improvements.
Using national data for 2008-18, investigators found that double bonuses were not associated with either improvements in plan quality or increased Medicare Advantage enrollment. Additionally, double bonuses increased payments to plans to care for Black beneficiaries by $60 per year, compared with $91 for White beneficiaries. These findings suggest that double bonuses not only fail to improve quality and enrollment but also foster a racially inequitable distribution of Medicare funds that disfavors Black beneficiaries. This study supports eliminating double bonuses, thereby saving Medicare an estimated $1.8 billion per year.
AHRQ-funded; HS000053.
Citation: Markovitz AA, Ayanian JZ, Warrier A . Medicare Advantage plan double bonuses drive racial disparity in payments, yield no quality or enrollment improvements. Health Aff 2021 Sep;40(9):1411-19. doi: 10.1377/hlthaff.2021.00349..
Keywords: Medicare, Health Insurance, Payment, Quality Improvement, Quality of Care, Disparities, Racial and Ethnic Minorities
Liao JM, Gupta A, Zhao Y
Association between hospital voluntary participation, mandatory participation, or nonparticipation in bundled payments and Medicare episodic spending for hip and knee replacements.
The purpose of this study was to examine and compare 2011-2017 spending for hip and joint replacements between hospitals with voluntary participation, mandatory participation and nonparticipation in the Medicare Bundled Payments for Care Improvement program.
Citation: Liao JM, Gupta A, Zhao Y . Association between hospital voluntary participation, mandatory participation, or nonparticipation in bundled payments and Medicare episodic spending for hip and knee replacements. JAMA 2021 Aug 3;326(5):438-40. doi: 10.1001/jama.2021.10046..
Keywords: Medicare, Hospitals, Payment, Surgery, Orthopedics, Healthcare Costs
Hoffman GJ, U U, Bynum J
Alzheimer's disease and related dementias and episode spending under Medicare's Bundled Payment for Care Improvements Advanced (BPCI-A).
Investigators evaluated the prevalence of Alzheimer’s disease and related dementias (ADRD) across the episodes included in Medicare's Bundled Payments for Care Improvement Advanced (BPCI-A) program and the association between ADRD and 90-day spending among hospitals participating in the BPCI-A program. They found that ADRD is associated with higher episode spending, highlighting the importance of closely monitoring the experience of these patients under BPCI-A to ensure that they are receiving appropriate care. This is particularly important for episodes like sepsis and pneumonia that are common among patients with ADRD and also highly prevalent under BPCI-A.
AHRQ-funded; HS025838.
Citation: Hoffman GJ, U U, Bynum J . Alzheimer's disease and related dementias and episode spending under Medicare's Bundled Payment for Care Improvements Advanced (BPCI-A). J Gen Intern Med 2021 Aug;36(8):2499-502. doi: 10.1007/s11606-020-06348-2..
Keywords: Elderly, Dementia, Medicare, Payment
Fung V, McCarthy S, Price M
Payment discrepancies and access to primary care physicians for dual-eligible Medicare-Medicaid beneficiaries.
This study examined whether the Affordable Care Act (ACA) primary care fee bump for dual-eligible Medicare-Medicaid beneficiaries impacted primary care physicians (PCP) acceptance of duals. The authors assessed differences in the likelihood that PCPs had dual caseloads of ≥10% or 20% in states with lower versus full dual reimbursement using linear probability models adjusted for physician and area-level traits. The proportion of PCPs with dual caseloads of ≥10% or 20% decreased significantly between 2012 and 2017. The fee bump was not consistently associated with increases in dual caseloads.
AHRQ-funded; HS024725.
Citation: Fung V, McCarthy S, Price M . Payment discrepancies and access to primary care physicians for dual-eligible Medicare-Medicaid beneficiaries. Med Care 2021 Jun;59(6):487-94. doi: 10.1097/mlr.0000000000001525..
Keywords: Primary Care, Medicaid, Medicare, Health Insurance, Payment, Access to Care
Sanghavi P, Jena AB, Newhouse JP
Identifying outlier patterns of inconsistent ambulance billing in Medicare.
The objective of this study was to illustrate a method that accounts for sampling variation in identifying suppliers and counties with outlying rates of a particular pattern of inconsistent billing for ambulance services to Medicare. The investigators concluded that health care fraud and abuse were frequently asserted but could be difficult to detect. They suggested that their data-driven approach may be a useful starting point for further investigation.
AHRQ-funded; 6HS022798; HS025720.
Citation: Sanghavi P, Jena AB, Newhouse JP . Identifying outlier patterns of inconsistent ambulance billing in Medicare. Health Serv Res 2021 Apr;56(2):188-92. doi: 10.1111/1475-6773.13622..
Keywords: Medicare, Payment, Health Services Research (HSR)
Post B, Norton EC, Hollenbeck B
Hospital-physician integration and Medicare's site-based outpatient payments.
AHRQ-funded; HS027044.
Citation: Post B, Norton EC, Hollenbeck B . Hospital-physician integration and Medicare's site-based outpatient payments. Health Serv Res 2021 Feb;56(1):7-15. doi: 10.1111/1475-6773.13613..
Keywords: Hospitals, Payment, Medicare, Ambulatory Care and Surgery, Healthcare Delivery

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