Impact of an Episode-Based Payment Initiative by Commercial Payers in Arkansas on Procedure Volume: an Observational Study

go back to reference Dummit LA, Kahvecioglu D, Marrufo G, et al. Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes. JAMA. 2016;316(12):1267–1278.CrossRef Dummit LA, Kahvecioglu D, Marrufo G, et al. Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes. JAMA. 2016;316(12):1267–1278.CrossRef

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go back to reference Dummit LA, Marrufo G, Marshall J, et al; The Lewin Group. CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report. 2017. Available at: https://downloads.cms.gov/files/cmmi/bpci-models2-4yr3evalrpt.pdf. Accessed June 28, 2019. Dummit LA, Marrufo G, Marshall J, et al; The Lewin Group. CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 3 Evaluation & Monitoring Annual Report. 2017. Available at: https://​downloads.​cms.​gov/​files/​cmmi/​bpci-models2-4yr3evalrpt.​pdf. Accessed June 28, 2019.

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go back to reference Currently, the Arkansas EBP initiative features 20 clinical episodes, which have either been implemented, will be implemented, or are under development. Compared to the Medicare BPCI and BPCI Advanced models, the Arkansas model features a smaller number of episodes. However, the Arkansas initiative is novel in that it covers a broad scope of conditions and tests bundled payment for several conditions that are not included in the Medicare models. For example, the Arkansas model features various outpatient episodes, and it uniquely includes episodes for women’s health (e.g., perinatal care, hysterectomy), behavioral health (e.g., attention deficit hyperactivity disorder, oppositional defiant disorder), and children’s health (e.g., neonatal care, pediatric pneumonia). A list of episodes is provided on page 43 of the AHCPII statewide tracking report, which is available at: https://achi.net/library/ahcpii-tracking-report/. Accessed 28 June 2019. Currently, the Arkansas EBP initiative features 20 clinical episodes, which have either been implemented, will be implemented, or are under development. Compared to the Medicare BPCI and BPCI Advanced models, the Arkansas model features a smaller number of episodes. However, the Arkansas initiative is novel in that it covers a broad scope of conditions and tests bundled payment for several conditions that are not included in the Medicare models. For example, the Arkansas model features various outpatient episodes, and it uniquely includes episodes for women’s health (e.g., perinatal care, hysterectomy), behavioral health (e.g., attention deficit hyperactivity disorder, oppositional defiant disorder), and children’s health (e.g., neonatal care, pediatric pneumonia). A list of episodes is provided on page 43 of the AHCPII statewide tracking report, which is available at: https://​achi.​net/​library/​ahcpii-tracking-report/​. Accessed 28 June 2019.

go back to reference The use of risk adjustment is common to all episode types, but the actual algorithm and which specific risk factors are included may vary slightly across payers and across episode types. In general, the risk adjustment algorithm considers diagnoses, comorbidities, procedures, and demographic characteristics drawn from a patient’s historical claims data. The use of risk adjustment is common to all episode types, but the actual algorithm and which specific risk factors are included may vary slightly across payers and across episode types. In general, the risk adjustment algorithm considers diagnoses, comorbidities, procedures, and demographic characteristics drawn from a patient’s historical claims data.

go back to reference To the extent that the analyzed episodes are sometimes performed on an emergent basis, it could dampen the impact of EBP on provider behavior. Nonetheless, we believe that emergent cases constitute a small minority of the procedures analyzed. To the extent that the analyzed episodes are sometimes performed on an emergent basis, it could dampen the impact of EBP on provider behavior. Nonetheless, we believe that emergent cases constitute a small minority of the procedures analyzed.

go back to reference The perinatal and asthma episodes were also implemented by commercial payers and have adequate sample size. However, we chose not to study the perinatal episode because we do not expect to find a volume expansion effect, as providers cannot plausibly induce additional births. We chose not to study the asthma episode due to two reasons. First, the asthma episode is not procedure-based, and our focus is on how procedure volume responds to EBP. Second, identifying asthma episode triggers in the claims data requires accurate and detailed coding of diagnoses; however, diagnoses are not coded consistently in the MarketScan data. The perinatal and asthma episodes were also implemented by commercial payers and have adequate sample size. However, we chose not to study the perinatal episode because we do not expect to find a volume expansion effect, as providers cannot plausibly induce additional births. We chose not to study the asthma episode due to two reasons. First, the asthma episode is not procedure-based, and our focus is on how procedure volume responds to EBP. Second, identifying asthma episode triggers in the claims data requires accurate and detailed coding of diagnoses; however, diagnoses are not coded consistently in the MarketScan data.

go back to reference Market Share and Enrollment of Largest Three Insurers - Large Group Market. Kaiser Family Foundation. Available at: https://www.kff.org/other/state-indicator/market-share-and-enrollment-of-largest-three-insurers-large-group-market/. Accessed June 28, 2019. Market Share and Enrollment of Largest Three Insurers - Large Group Market. Kaiser Family Foundation. Available at: https://​www.​kff.​org/​other/​state-indicator/​market-share-and-enrollment-of-largest-three-insurers-large-group-market/​. Accessed June 28, 2019.

go back to reference To construct our analytical dataset, we take repeated cross sections of continuously enrolled beneficiaries (one cross section for each year of 2011–2016). It is possible for a given beneficiary to appear in multiple cross sections over time, though this is not necessarily the case. Certain procedures that we analyze, like cholecystectomy and tonsillectomy, can only be performed on a patient once over time. Due to concern over serial correlation in the outcomes after a beneficiary undergoes these procedures, we drop that beneficiary from all cross sections following the date of the procedure. To construct our analytical dataset, we take repeated cross sections of continuously enrolled beneficiaries (one cross section for each year of 2011–2016). It is possible for a given beneficiary to appear in multiple cross sections over time, though this is not necessarily the case. Certain procedures that we analyze, like cholecystectomy and tonsillectomy, can only be performed on a patient once over time. Due to concern over serial correlation in the outcomes after a beneficiary undergoes these procedures, we drop that beneficiary from all cross sections following the date of the procedure.

go back to reference We exclude the following plan types due to inadequate sample size: basic/major medical, comprehensive, exclusive provider organization, and point-of-service with capitation. We exclude the following plan types due to inadequate sample size: basic/major medical, comprehensive, exclusive provider organization, and point-of-service with capitation.

go back to reference States that geographically border Arkansas are Missouri, Tennessee, Mississippi, Louisiana, Texas, and Oklahoma. The West South Central Census Division consists of Oklahoma, Texas, Arkansas, and Louisiana. The East South Central Census Division consists of Kentucky, Tennessee, Mississippi, and Alabama. States that geographically border Arkansas are Missouri, Tennessee, Mississippi, Louisiana, Texas, and Oklahoma. The West South Central Census Division consists of Oklahoma, Texas, Arkansas, and Louisiana. The East South Central Census Division consists of Kentucky, Tennessee, Mississippi, and Alabama.

go back to reference Our baseline control group differs slightly from that used in Carroll et al. (2018). We additionally include Missouri because it geographically borders Arkansas. We also include Texas. Carroll et al. include Kentucky and Oklahoma in their control group, whereas we exclude both states in our baseline specification. In a sensitivity analysis, we include Kentucky and Oklahoma in the control group, and we obtain similar results. Our baseline control group differs slightly from that used in Carroll et al. (2018). We additionally include Missouri because it geographically borders Arkansas. We also include Texas. Carroll et al. include Kentucky and Oklahoma in their control group, whereas we exclude both states in our baseline specification. In a sensitivity analysis, we include Kentucky and Oklahoma in the control group, and we obtain similar results.

go back to reference Westfall PH, Young SS. Resampling-Based Multiple Testing: Examples and Methods for p-Value Adjustment. New York, NY: John Wiley & Sons; 1993. Westfall PH, Young SS. Resampling-Based Multiple Testing: Examples and Methods for p-Value Adjustment. New York, NY: John Wiley & Sons; 1993.

go back to reference Jones D, Molitor D, Reif J. What Do Workplace Wellness Programs Do? Evidence from the Illinois Workplace Wellness Study. National Bureau of Economic Research working paper 24229. Published January 2018. Revised June 2018. Available at: http://www.nber.org/papers/w24229. Accessed 28 June 2019. Jones D, Molitor D, Reif J. What Do Workplace Wellness Programs Do? Evidence from the Illinois Workplace Wellness Study. National Bureau of Economic Research working paper 24229. Published January 2018. Revised June 2018. Available at: http://​www.​nber.​org/​papers/​w24229. Accessed 28 June 2019.

go back to reference We consider diagnostic and screening colonoscopies together. We include ages 40 to 49 in case EBP induces volume expansion among patients under age 50, which is the US Preventive Services Task Force’s recommended threshold for colorectal cancer screening. We consider diagnostic and screening colonoscopies together. We include ages 40 to 49 in case EBP induces volume expansion among patients under age 50, which is the US Preventive Services Task Force’s recommended threshold for colorectal cancer screening.

go back to reference Maratt JK, Saini SD. Colorectal Cancer Screening in the 21st Century: Where Do We Go From Here? Am J Manag Care. 2015;21(7):e447-e449.PubMed Maratt JK, Saini SD. Colorectal Cancer Screening in the 21^st Century: Where Do We Go From Here? Am J Manag Care. 2015;21(7):e447-e449.PubMed

go back to reference To increase colonoscopy volume, physicians may be modifying their labor supply, readjusting effort, or changing the mix of services that they provide (e.g., displacing certain procedures with colonoscopies). While these behavioral responses are important to understand, studying them is beyond the scope of our work. To increase colonoscopy volume, physicians may be modifying their labor supply, readjusting effort, or changing the mix of services that they provide (e.g., displacing certain procedures with colonoscopies). While these behavioral responses are important to understand, studying them is beyond the scope of our work.

go back to reference Arkansas Medicaid implemented EBP for total joint replacement in October 2012 and for cholecystectomy, colonoscopy, and tonsillectomy in July 2013. Arkansas Medicaid implemented EBP for total joint replacement in October 2012 and for cholecystectomy, colonoscopy, and tonsillectomy in July 2013.