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.

The Developmental Check-In: Development and Initial Testing of an Autism Screening Tool Targeting Young Children From Underserved Communities

May. 3, 2018

Yvette M. Janvier, Caroline N. Coffield, Jill F. Harris, David S. Mandell, Zuleyha Cidav

Abstract [from journal]

Children with autism spectrum disorder from low-income, minority families or those with limited English proficiency are diagnosed at a later age, or not at all, compared with their more advantaged peers. The Developmental Check-In is a new tool that could potentially be used to screen for autism that uses pictures to illustrate target behaviors. It was developed to enhance early identification of autism spectrum disorder in low literacy groups. The Developmental Check-In was tested in a sample of 376 children between the ages of 24 and 60 months, from...

Clinical Outcomes After Cardiac Stress Testing Among US Patients Younger Than 65 Years

May. 2, 2018

Vinay Kini, Elias J. Dayoub, Paul L. Hess, Lucas N. Marzec, Frederick A. Masoudi, P. Michael Ho, Peter W. Groeneveld

Abstract [from journal]

Background: Scientific statements have championed the measurement of clinical outcomes after cardiac stress testing to better define their value. Using contemporary national data, we sought to describe the characteristics of patients who experience outcomes after stress testing.

Methods and Results: Using administrative claims from a large national private insurer, we conducted an observational cohort study of


Rates of Hospital Readmission Among Medicare Beneficiaries With Gastrointestinal Bleeding Vary Based on Etiology and Comorbidities

May. 1, 2018

Abstract [from journal]

Background & Aims: Gastrointestinal bleeding results in significant morbidity, mortality, and healthcare costs in the United States. The Center for Medicare and Medicaid Services' payment reform programs assess quality and value based on rates of hospital readmission for patients with gastrointestinal bleeding, but they identify these patients using Medicare Severity Diagnosis Related Groups (MS-DRGs), which include many types of gastrointestinal bleeding and do not account for the clinical heterogeneity among these patients. We aimed...

US National Trends in Mortality From Acute Myocardial Infarction and Heart Failure: Policy Success or Failure?

Apr. 26, 2018

Paula Chatterjee, Karen E. Joynt Maddox

Abstract [from journal]

Importance: Hospitals in the United States have been subject to mandatory public reporting of mortality rates for acute myocardial infarction (AMI) and heart failure (HF) since 2007 and to value-based payment programs for these conditions since 2011. However, whether hospitals with initially poor baseline performance have improved relative to other hospitals under these programs, and whether patterns of improvement differ by condition, is unknown. Understanding trends within...

Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce

Research Brief
Apr. 11, 2018

Surgical patients age 65 and over with Alzheimer’s disease and related dementias (ADRD) were more likely to die within 30 days of admission and to die after a complication than those without ADRD. Having better-educated nurses in the hospital improved the likelihood of good outcomes for all surgical patients, but had a much greater effect in individuals with ADRD. Specifically, a 10% increase in the proportion of nurses with a Bachelor of Science in Nursing (BSN) degree or higher was associated with 10% lower odds of death and 10% lower odds of dying after a complication for surgical patients with ADRD.

Prior Authorization Requirements for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Across US Private and Public Payers

Research Brief
Mar. 28, 2018

A comprehensive review of prior authorization (PA) requirements for a new class of expensive cholesterol-lowering drugs known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has found unusually complex and burdensome demands across public and private insurance plans in the United States. These findings raise concerns that current policies may create undue barriers to care even in medically appropriate patients, particularly since requirements were just as stringent for patients with a genetic condition that creates more clear-cut eligibility for PCSK9 inhibitor treatment.

Do Changes in Post-Acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

Mar. 22, 2018

Amol S. Navathe, Alexander M. Bain, Rachel M. Werner

Abtract [from journal]

While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.

The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare


State Adoption of Incentives to Promote Evidence-Based Practices in Behavioral Health Systems

Mar. 14, 2018

Rebecca E. Stewart, Steven C. Marcus, Trevor R. Hadley, Brian M. Hepburn, ...

Abstract [from journal]

ObjectiveDespite the critical role behavioral health care payers can play in creating an incentive to use evidence-based practices (EBPs), little research has examined which incentives are used in public mental health systems, the largest providers of mental health care in the United States.

MethodsThe authors surveyed state mental health directors from 44 states about whether they used any...

Characteristics of Hospitals Earning Savings in the First Year of Mandatory Bundled Payment for Hip and Knee Surgery

Mar. 8, 2018

Amol S. NavatheJoshua M. Liao, Yash Shah, Zoe Lyon, Paula ...

In JAMA, Amol Navathe and LDI colleagues Joshua Liao, Paula Chatterjee, Dan Polsky, and Ezekiel Emanuel examine hospital savings and quality results for the first year of the Comprehensive Care for Joint Replacement (CJR) bundled payment program. Since April 2016, Medicare has bundled payments for hip and knee replacements at 799 hospitals through CJR. The program incentivizes quality and cost containment by providing retrospective bonus payments that increase as hospitals exceed their cost and quality benchmarks, or imposing penalties if hospitals fall short. While the CJR...

Value Based Payment: Is This Time Actually Different?

Mar. 8, 2018

Practice transformation and payment reform are defining features of contemporary health policy debates. The story goes like this: new provider organizations, such as Accountable Care Organizations (ACOs) are transforming care delivery from fragmented and volume driven to integrated and optimized for quality; meanwhile, innovative payment models, such as bundled payments and risk-based contracting, herald a national transition from fee-for-service (FFS) to value-based payments.

The Effect of Integration of Hospitals and Post-Acute Care Providers on Medicare Payment and Patient Outcomes

Research Brief
Mar. 6, 2018

Vertical integration between hospitals and skilled nursing facilities (SNFs) increases Medicare payments for the first 60 days of care by $2,424 (17%), compared to hospital-SNF pairs that are not vertically integrated. These integrated hospital–SNF pairs also experience a decline in 30-day rates of rehospitalization or death of 5 percentage points on a base rate of 31.3%. Vertical integration between hospitals and home health agencies (HHAs) has little effect on Medicare payments and patient outcomes, nor does informal integration in either setting.

Payment Reform and Health Disparities: Two New Views

Mar. 2, 2018

The concern that value-based payments will worsen health disparities is not new. Much ink has been spilled about the best way to avoid penalizing hospitals that care for disproportionately poor populations, without rewarding poor performance. The big question has been whether and how to adjust value-based payments for socioeconomic factors.

A Qualitative Exploration of Co-location as an Intervention to Strengthen Home Visiting Implementation in Addressing Maternal Child Health

Feb. 28, 2018

Katherine S. Kellom, Meredith Matone, Aderinola Adejare, Frances K. Barg, David M. Rubin, Peter F. Cronholm

Abstract [from journal]

Objectives: The aim of this paper is to explore the process and impact of co-locating evidence-based maternal and child service models to inform future implementation efforts.

Methods: As part of a state-wide evaluation of maternal and child home visiting programs, we conducted semi-structured interviews with administrators and home visitors from home visiting agencies across Pennsylvania. We collected 33 interviews from 4 co-located agencies. We used the Consolidated Framework for...