Research Objective The Home Health Value‐Based Purchasing (HHVBP) Model provides financial incentives for quality improvement to home health agencies in nine states with the goal of improving quality and efficiency of care for Medicare beneficiaries. The maximum Medicare payment adjustment increases during each of the five years of the model, ranging from ±3% in 2018 to ±8% in 2022. Our goal is to understand the early impact of the HHVBP Model on quality, utilization, and Medicare spending during its first three years (2016–2018), which includes the first year in which payment adjustments to agencies took effect. Study Design CMS randomly selected nine states to participate in the HHVBP Model starting January 2016, with mandatory participation from all agencies. Agencies in these states received performance scores for 20 measures of quality of care used to determine their payment adjustment relative to other agencies within their state. To evaluate the effects of HHVBP, we used a difference‐in‐differences design and multivariate linear regression to compare differences in the changes in outcomes of the nine HHVBP states with those in the 41 comparison states for three years pre‐intervention (2013–2015) through the first three years of the model (2016–2018). We evaluated agency performance using Outcome and Assessment Information Set (OASIS)‐based quality measures and measures of claims‐based Medicare fee‐for‐service (FFS) health care utilization and spending. Population Studied Medicare and Medicaid patients receiving home health care in the nine HHVBP states and forty‐one comparison states. Principal Findings We found evidence of slightly greater improvements in most measures of improved functional status used to determine payment adjustments in HHVBP states relative to non‐HHVBP states. Compared to non‐HHVBP states, Medicare FFS beneficiaries who received home health care in the nine HHVBP states had a relative decrease in unplanned hospitalization rate (−1.8%) and in skilled nursing facility (SNF) stays (−4.9%) from pre‐HHVBP implementation average levels. Conversely, we observed a 2.4% increase in emergency department (ED) visits relative to the average pre‐implementation rates for HHVBP states. Overall, we found evidence of a 1.2% reduction in Medicare spending due to HHVBP, corresponding to an average $141 million reduction in annual Medicare spending in HHVBP states over the first three years of the model. The reduction in spending among home health Medicare FFS patients was driven primarily by reductions in inpatient hospital spending (−2%) and SNF spending (−4%). We did not find an appreciable difference in savings between the third year—in which payment adjustments were applied—and the first two years of the model prior to HHVBP agencies receiving payment adjustments. Conclusions Through the HHVBP Model's first three years—which includes the first year of payment adjustments to agencies—we found modest impacts of HHVBP: lower growth in Medicare spending, declines in unplanned hospitalizations and use of...

Dialysis chains appear to employ a mix of turn-around and cream-skimming strategies. Poor financial health is a predictor of chain acquisition as in other health care sectors, but the increased likelihood of chain acquisition among higher quality facilities is unique to the dialysis industry. Significant differences among predictors of acquisition by small and large chains reinforce the importance of using a richer classification for chain status.

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Background: Previous research suggests that most people with multiple sclerosis (MS) in the United States have health insurance. However, little is known about their coverage or how it differs between public and private insurance. We examined whether the perceived change in health insurance coverage from the previous year differs between individuals with MS who are privately insured compared with those who are publicly insured.

Medicare is considering an expansion of the bundle of dialysis-related services to be paid on a prospective basis. Exploratory models were developed to assess the potential limitations of case-mix adjustment for such an expansion. A broad set of patient characteristics explained 11.8% of the variation in Medicare allowable charges per dialysis session. Although adding recent hematocrit values or prior health care utilization to the model did increase explanatory power, it could also create adverse incentives. Projected gains or losses relative to prevailing fee-for-service payments, assuming no change in practice patterns, were significant for some individual providers. However, systematic gains or losses for different classes of providers were modest. Medicare's current payment methodology for outpatient, dialysis-related care is a blend of prospective and fee-for-service approaches. Medicare pays a predetermined composite rate for a specified set of services comprising the basic dialysis treatment. The composite rate is an example of a prospective payment system (PPS) under which providers receive a flat rate for a bundle of services. Generally in a PPS, payments vary across providers and patients as a result of only predetermined adjustments that account for factors such as local wage rates and patient characteristics related to the cost of care but beyond the provider's control. However, the composite rate bundle is far from all-inclusive. Therefore, the dialysis payment system retains a significant element of fee-for-service payment, as dialysis facilities and other providers bill separately for services not covered by the composite rate, primarily injectable medications and laboratory tests.The Medicare Modernization Act of 2003 mandates that the Centers for Medicare and Medicaid Services (CMS) study the possibility of expanding the scope of prospective renal care payment to include many or all of the dialysis-related services now billed on a fee-for-service basis. This legislation requires CMS to conduct a demonstration project and to submit a report to Congress regarding policy options for such an expanded bundle.Of separately billable services, erythropoietin (EPO), iron, and vitamin D comprise 95% of Medicare Allowable Charges (MAC) submitted by dialysis facilities. MAC represent the sum of the Medicare payment for a service and the amount for which the patient or the patient's secondary insurer is responsible. As is the case in any PPS, variation in patients' needs for care may create financial risk for providers and compromise access to care for more costly patients. To mitigate these concerns, casemix adjustment increases payments to facilities treating more costly patients. If unacceptable risk remains after the implementation of a feasible casemix adjustment system, policy makers may seek to supplement case-mix adjustment with additional