Payment & Delivery

How insurers and providers are organized and paid to deliver care. Research by LDI Senior Fellows examines the shift from fee-for-service payments to newer models of paying for and delivering value, such as Accountable Care Organizations and Patient-Centered Medical Homes.

National Shifts in Outpatient Care for Patients With Cirrhosis

Nov. 24, 2020

As the U.S. enters the tenth month of the COVID-19 pandemic, it is hard to imagine a time when telemedicine was not a mainstay of health care delivery, particularly in the care of vulnerable patients. However, few studies have examined the scale of how outpatient care has changed at the national level, and whether the changes have been sustained beyond the early months of the pandemic.

Understanding Racial and Ethnic Disparities in Autism-Related Service Use Among Medicaid-Enrolled Children

Nov. 21, 2020

Lucy A. Bilaver, Sarah A. Sobotka, David S. Mandell

Abstract [from journal]

Racial and ethnic disparities in the use of nine common autism-related services among Medicaid-enrolled children with autism spectrum disorder (ASD) were examined, distinguishing between school and other community-based outpatient settings. Using 2012 Medicaid Analytic Extract data, we identified 117,848 continuously enrolled children with ASD. Several racial and ethnic disparities were found, varying by geography. Black, Asian, and Native American/Pacific Islanders received fewer outpatient services compared with white children, but


Using Nationally Representative Percentiles to Interpret PROMIS Pediatric Measures

Christopher B. Forrest, MD, PhD
Nov. 17, 2020

Adam C. Carle, Katherine B. Bevans, Carole A. Tucker, Christopher B. Forrest 

Abstract [from journal]

Purpose: This study's aim was to use a representative sample of the US pediatric population to estimate percentiles for several PROMIS pediatric measures: Anger, Anxiety, Depressive Symptoms, Family Relationships, Fatigue, Global Health, Life Satisfaction, Meaning and Purpose, Pain Behavior, Pain Interference, Physical Activity, Physical Function Mobility, Physical Function Upper Extremity, Physical Stress Experiences, Positive Affect, Psychological Stress Experiences, Sleep Disturbance, Sleep Impairment, and Peer


Costs and Outcomes for Patients with Dementia in Medicare Advantage Plans

Nov. 12, 2020

How do patients with Alzheimer's disease and related dementias (ADRD) fare in capitated Medicare Advantage (MA) managed care plans, compared to their peers in traditional Medicare (TM)? This question is increasingly important, as nearly one-third of beneficiaries now choose MA, and the human and financial cost of living with ADRD is substantial.

CMS’ Inpatient Psychiatric Facility Quality Reporting Program

Nov. 9, 2020

Patients in inpatient psychiatric care are especially vulnerable to physical and psychological harm, but they have largely been excluded from efforts to monitor, understand, and improve quality of care. In 2012, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program to ease inpatient psychiatry into the norms and scrutiny that general hospital care has received for a long time.

Disruptions in Preventive Care: Mammograms During the COVID-19 Pandemic

Nov. 4, 2020

Hummy Song, Alon Bergman, Angela T. Chen, Dan Ellis, Guy David, Ari B. Friedman, Amelia M. Bond, Julie M. Bailey, Ronald Brooks, Aaron Smith‐McLallen

Abstract [from journal]

Objective: To measure the extent to which the provision of mammograms was impacted by the COVID‐19 pandemic and surrounding guidelines.

Data Sources: De‐identified summary data derived from medical claims and eligibility files were provided by Independence Blue Cross for women receiving mammograms.

Study Design:


Improving Emergency Care for Children with Complex Conditions

Oct. 29, 2020

Only about 1% of children in the U.S. are considered medically complex, but when you work in a busy Children’s Hospital Emergency Department (ED) in a large urban area, the prevalence seems much higher. We see a range of children with complex conditions, such as severe asthma coupled with significant eczema, metabolic disorders, and illnesses requiring a ventilator or other life-sustaining equipment.

Spillover Effects Of Mandatory Hip And Knee Replacement Surgery Bundles In Medicare

Amole Navathe, MD, PhD
Oct. 28, 2020

Joshua M. Liao, Robin Wang, Akriti Mishra, Ezekiel J. Emanuel, Jingsan Zhu, Deborah S. Cousins, Amol S. Navathe

Abstract [from journal]

Background: Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking.

Objective: To evaluate the association between CJR


Impact Of Dependent Coverage Provision Of The Affordable Care Act On Insurance Continuity For Adolescents And Young Adults With Cancer

Jeffrey H. Silber, MD, PhD
Oct. 22, 2020

Lena E. Winestone, Lauren L. Hochman, James E. Sharpe, Elysia Alvarez, Laura Becker, Eric J. Chow, Joseph G. Reiter, Jill P. Ginsberg, Jeffrey H. Silber

Abstract [from journal]

Purpose: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed enrollees to remain on their parents' health insurance until 26 years of age. We compared rates of insurance disenrollment among patients with cancer who were DCP-eligible at age 19 to those who were not eligible at age 10.

Methods: Using OptumLabs Data Warehouse, which contains longitudinal, real-world, de-identified administrative claims for commercial enrollees, we examined


Who Joins The Franchise, Affiliation Model Of Hospital Networks? An Analysis Of Hospital And Market Characteristics Of Members

Ingrid Nembhard, PhD
Oct. 19, 2020

Bonnie Jin & Ingrid M. Nembhard

Abstract [rfom journal]

Joining nonownership based, organization-driven networks and alliances is a common strategy for hospitals to pursue yet little is known about what types of hospitals join these collaborations, due in part to challenges in identifying members. One novel network form that has recently emerged, and made identification feasible, is franchise-like "affiliation networks" in which affiliate hospitals pay an annual membership fee that allows access to the clinical expertise and resources of high-status, nationally ranked sponsor hospitals.


Burden Of Parkinson's Disease By Severity: Health Care Costs In The U.S. Medicare Population

Nabila Dahodwala, MD, MS
Oct. 8, 2020

Nabila DahodwalaPengxiang Li, Jordan Jahnke, Vrushabh P. Ladage, Amy R. Pettit, Prasanna L. Kandukuri, Yanjun Bao, Jorge Zamudio, Yash J. Jalundhwala, Jalpa A. Doshi 

Abstract [from journal]

Background: Current understanding of the health care costs of Parkinson's disease (PD) and the incremental burden of advanced disease is incomplete.

Objectives: The aim of this study was to assess the direct economic burden associated with advanced versus mild/moderate PD in a prevalent national sample of elderly U.S. Medicare beneficiaries with a PD diagnosis.

Methods: Analyzing 100% fee-for-service Medicare claims from 2013, we defined advanced PD with a medication-


The Design Of A Randomized Controlled Trial To Evaluate Multi-dimensional Effects Of A Section 1115 Medicaid Demonstration Waiver With Community Engagement Requirements

Oct. 7, 2020

Kristin A. Linn, Kristen Underhill, Erica L. Dixon, Elizabeth F. Bair, William J. Ferrell, Margrethe E. Montgomery, Kevin G. VolppAtheendar S. Venkataramani

Abstract [from journal]

Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization - the gold standard for assessing causality - has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of


Drug Reimbursement Regulation In 6 Peer Countries

Sep. 28, 2020

Ezekiel J. Emanuel, Cathy Zhang, Aaron Glickman, Emily Gudbranson, Sarah S. P. DiMagno, John W. Urwin

Abstract [from journal]

The US has nearly 4.5% of the world's population but accounts for more than 40% of global drug spending. With the upcoming 2020 election, a top priority of many voters is to better control drug prices and reform the pharmaceutical market. In this Special Communication, the drug price mechanisms and government regulations used in 6 representative peer countries are evaluated: Australia, France, Germany, Norway, Switzerland, and the United Kingdom. Drug price regulation is compared with that currently used in the US