Payment

Hawaii Medical Services Association (HMSA), is an independent licensee of Blue Cross Blue Shield of Hawaii. Since 2017, the Payment Insights Team has offered guidance to and conducted research for HMSA (Blue Cross Blue Shield, Hawaii) to inform the roll-out of a new provider-payment initiative that has s shifted primary care provider payment from a fee-for-service model to a newer value-based framework. This payment model, which incentivizes providers for both efficiency and effectiveness, has by now been implemented throughout most of the state of Hawaii. In addition, our ongoing partnership with HMSA’s Health Strategy Department works to identify gaps in and improve delivery of care to millions of members who trust BCBS with their health care. Our next phase of work is intended to design health care models and interventions that address current gaps in care that exist in scientific literature, as well as in current practice patterns observed in HMSA’s claims data.

Patients with end-stage renal disease (ESRD) are a vulnerable population with high rates of morbidity, mortality, and acute care use. Medicare Advantage Special Needs Plans (SNPs) are an alternative financing and delivery model designed to improve care and reduce costs for patients with ESRD, but little is known about their impact. In this study, we used detailed clinical, demographic, and claims data to identify fee-for-service Medicare beneficiaries who switched to ESRD SNPs offered by a single health plan (SNP enrollees) and similar beneficiaries who remained enrolled in fee-for-service Medicare plans (fee-for-service controls). We then compared three-year mortality and twelve-month utilization rates. Compared with fee-for-service controls, SNP enrollees had lower mortality and lower rates of utilization across the care continuum. These findings suggest that SNPs may be an effective alternative care financing and delivery model for patients with ESRD.

Ochsner Health Network is a leader in providing high quality clinical and hospital patient care in the Gulf South and is the largest Clinically Integrated Network in the region. The objective of this collaboration is to perform detailed analytics on Ochsner data to understand the significant differences in spending between the two patient groups. These analytics will be used to inform 1) MSSP program/intervention design across Ochsner Health System (OHS) and 2) the national policy audience of key findings through publication and dissemination of results.

Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and largest portion of spending on cancer care. This project evaluated the association between a national commercial insurer’s ongoing pay-for-performance (P4P) program for oncology and changes in prescribing of evidence-based cancer drugs and spending. In all, we found that P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.

This partnership with Blue Cross Blue Shield North Carolina is centered around and evaluating the model (Nova), including use of evidence-based practices, principles from behavioral economics, and econometric measurement techniques, implemented and tested using scientific quasi-experimental and pragmatic randomized trial methods.

Under bundled payments, hospitals have maintained quality and achieved financial savings for medical condition episodes. However, certain patients may be more or less likely to experience these benefits given their high clinical, social, or health care utilization risk. This project is to evaluate the association between bundled payment participation and changes in outcomes for high-risk patients. An observational propensity-matched difference-in-differences analysis was conducted using Medicare fee-for-service beneficiaries hospitalized data between 2011 and 2016.

Under the Medicare fee-for-service Bundled Payments for Care Improvement (BPCI) program, lower extremity joint replacement (LEJR) bundled payments are associated with 2-4% cost savings with stable quality. BPCI may prompt practice changes that benefit all patients, not just Medicare fee-for-service beneficiaries, and magnify the potential benefits of bundled payments. This project is to examine the association between hospital participation in BPCI and outcomes for commercially insured and Medicare Advantage (MA) patients receiving LEJR.

Bundled payment is a promising arrangement for encouraging health care providers to improve the value of care. CMS is rapidly expanding bundled payment nationwide in not only voluntary but also mandatory arrangement. There is a critical need to evaluate its impact on patients, hospitals and payers.

The objective of this project is to examine the effects of bundled payment under the BPCI program on the quality and costs of care. We hope this study can provide much needed empirical evidence on the effects of bundled payment and provide guidance on how to design future bundled payment policy in order to improve health care value.

This study examines how bundled payments implemented via voluntary and mandatory participation impact access and outcomes among vulnerable patients – evidence needed to inform policymakers about the broader policy impact and whether to scale bundled payments through voluntary and/or mandatory participation.

The CJR model was implemented in a group of randomly selected geographic areas to test bundled payment and quality measurement for LEJR. Some hospitals also participate in other payment models, such as MSSP ACOs. The goal of this project is to conduct analysis based on hospital-level outcomes to evaluate whether any benefits derive from the overlap.