Impacts of Maryland’s Global Budgets on Medicare and Commercial Spending and Utilization

Morrison, Marisa; Haber, Susan; Beil, Heather; Giuriceo, Katherine; Sapra, Katherine J.

doi:10.1177/1077558720954693

Cited by 7 publications

(15 citation statements)

References 11 publications

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“…Our results are consistent with findings from CMS’s final report for the MD model, which examined outcomes among commercial plan beneficiaries and identified a decline in commercial payer ED utilization 11,36 …”

Section: Discussionsupporting

confidence: 89%

Effects of Maryland’s global budget revenue model on emergency department utilization and revisits

Galarraga

DeLia

Huang

et al. 2021

Academic Emergency Medicine

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Background In 2014, Maryland (MD) implemented a “global budget revenue” (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR’s effects on emergency department (ED) visits, admissions, and returns. Methods We performed an interrupted time‐series analysis with difference‐in‐differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR’s effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in‐hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. Results ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post‐GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in‐hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non‐Hispanic Whites and non‐Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. Conclusions GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

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Section: Discussionsupporting

confidence: 89%

Effects of Maryland’s global budget revenue model on emergency department utilization and revisits

Galarraga

DeLia

Huang

et al. 2021

Academic Emergency Medicine

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“…A common criticism of the MDAPM is that it is not generalizable beyond Maryland owing to the historical all-payer rate-setting system. 7,23 The findings of this study suggest that this rate-setting system was important in that it provided technical infrastructure to implement the model and a shared commitment to payer-agnostic hospital reimbursement. However, the study participants noted that one reason for successful MDAPM implementation was that it was designed for the unique circumstances in the state in collaboration with stakeholders from its inception.…”

Section: Discussionmentioning

confidence: 93%

Health Care Leaders’ Perspectives on the Maryland All-Payer Model

et al. 2022

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IMPORTANCESince 2014, all hospitals in Maryland have operated under an all-payer global budget system. Hospital global budgets have gained renewed attention as a strategy for constraining cost growth, improving patient outcomes, and preserving health care access in rural and underserved communities. Lessons from the implementation of the Maryland All-Payer Model (MDAPM) may have implications for policy makers, payers, and hospitals in other settings seeking to adopt global budgets or other value-based payment models. OBJECTIVE To examine perspectives on the implementation of the MDAPM among health care leaders who participated in its design and execution. DESIGN, SETTING, AND PARTICIPANTS This qualitative study with semistructured telephone interviews was conducted from November 1, 2019, to February 11, 2020. The purposive sample of Maryland health care leaders represents diverse stakeholder groups, including hospitals, state government and regulatory agencies, the federal government, and payers. MAIN OUTCOMES AND MEASURES Key high-level themes were extracted from interviews using qualitative content analysis, with barriers and facilitators to implementation specified within each theme.RESULTS A total of 20 interviews were conducted with hospital leaders (n = 6), state regulators (n = 4), federal regulators (n = 4), payer representatives (n = 3), and state leaders (n = 3). Key themes were labeled as (1) expectations (setting bold yet achievable goals), ( 2) autonomy (allowing hospitals to follow individual strategies within MDAPM parameters), (3) communication (encouraging early and ongoing communication between stakeholders), (4) actionable data (sharing useful hospital and patient-level data between stakeholders), (5) global budget calibration (anticipating technical challenges when negotiating budgets for individual hospitals), and (6) shared commitment to change (harnessing collective motivation for system change). Together, these themes suggest that implementing the payment model followed an evolving and collaborative process that requires stakeholder communication, data to guide decisions, and commitment to operating within the new payment system. CONCLUSIONS AND RELEVANCE The implementation of hospital global budgets in the state ofMaryland offers generalizable lessons that can inform the evolution and expansion of this approach to value-based payment in other states and settings.

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“…Previously published findings on MDAPM impacts for the overall Medicare population found expenditure savings in total and for hospital services, reductions in hospital admissions, but no significant effects on ED visits, unplanned readmissions, or follow-up visits within 14 days after hospital discharge (Haber et al, 2019; Morrison et al, 2020). However, MDAPM impacts might not be uniform for all Medicare beneficiaries, and the present analyses found MDAPM impacts often differed among the subpopulations studied.…”

Section: Discussionmentioning

confidence: 98%

“…Despite the increased interest in this payment strategy, global budgets are relatively new in the United States, and the research base on them is still developing. Previous studies have examined the impact of MDAPM on Medicare beneficiaries and found hospital expenditures declined under MDAPM primarily due to reductions for outpatient services (Beil et al, 2019; Haber & Beil, 2018; Morrison et al, 2020). Similarly, inpatient admissions declined, although emergency department (ED) visits increased slightly.…”

Section: Introductionmentioning

confidence: 99%

Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland

et al. 2021

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There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White.

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Impacts of Maryland’s Global Budgets on Medicare and Commercial Spending and Utilization

Cited by 7 publications

References 11 publications

Effects of Maryland’s global budget revenue model on emergency department utilization and revisits

Effects of Maryland’s global budget revenue model on emergency department utilization and revisits

Health Care Leaders’ Perspectives on the Maryland All-Payer Model

Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland

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