Asian woman in a mask paying a medicial bill

No one supporting the recently announced strategy for the Centers for Medicare and Medicaid Services (CMS) focused on accelerating the transition to value-based care and embedding equity into payment models should miss the research presented as part of the Payment and Delivery System Innovations theme at the Academy Health Research (ARM) meeting this year. Four research and abstract panels and numerous poster presentations promise to deliver a substantial body of meaningful, relevant, – and sometimes surprising research results. Researchers across the academic, government and non-profit spectrum make considerable contributions to our understanding of important aspects of payment models, regulations, and emerging market forces spurred by the Affordable Care Act. Highlights from the findings of the panels to be presented at ARM are described below.

Impacts of Vertical Integration

Unpacking the financial, quality, and patient-experience impacts of growing trends in vertical integration is a hot research topic with substantial policy implications. Three new studies at this year’s Payment and Delivery System Innovations Research panel highlight the heterogeneity of impact that these arrangements may have on cost, referral patterns and drug expenditures. Interestingly, two of these studies relied on the creation of novel data sets to identify provider linkages for study, including one that explored the impact on cancer drug use and expenditures by Oncology practices with integrated pharmacies, an arrangement that has increased by 20 percent over 10 years. Focusing on cancers for which intravenous (IV) and oral therapies are available, the authors found a significant increase in adoption of and expenditures for branded oral anti-cancer therapies, but minimal changes to overall anti-cancer drug expenditures, perhaps indicating greater shifts from IV to novel oral anti-cancer treatments in Oncology practices with integrated pharmacies.

Impact of CMS-led Payment Models

Each Academy Health Research Meeting brings new results of payment models from CMS, states, private payers and provider systems. This year Justin Timbie from RAND will moderate a panel discussion on findings from CMS-led payment models, one of which has surprising results. Using a difference-in-difference approach to compare changes in the use of home and in-center dialysis modalities and kidney transplantation for ESRD patients served by nephrologists participating in the Comprehensive ESRD Care (CEC) model relative to patients of non-participating nephrologists, this study found that patients served by CEC participants were significantly less likely to receive a kidney transplant or in-home peritoneal dialysis within the first five months of initiating ESRD treatment. Other studies explore early behavior change within Skilled Nursing Facilities following implementation of the new Patient-Driven Payment Model, organizational, market and provider-driven factors to explain variation in spending reductions across Next-Generation ACOs that could inform future ACO models of care and a qualitative evaluation of participant experience, practice transformation efforts and lessons learned in the Oncology Care Model. Findings from each study can inform future iterations of payment policy and incentive structures for primary care and specialty models.

Impact of Value-Based Payments on Equity and Vulnerable Populations

CMS has articulated a bold strategy to ensure policies and payment models strengthen equity for underserved populations. Four research teams offer relevant insights from their work on a panel moderated by Robert Saunders from Duke. To inform the impact of participation requirements on health care disparities for historically marginalized groups, one team explored the impact of mandatory participation in the Comprehensive Joint Replacement (CJR) model on cost and quality outcomes for Black and dual-eligible patients. The authors examined disparities in outcomes for hospitals that participated in CJR only because of the mandate versus hospitals that previously participated in the voluntary Bundled Payment for Care Initiative (BPCI) and were in a CJR MSA. They found that while both mandatory and voluntary hospitals achieved savings for dual eligible patients, only the mandatory hospitals achieved savings for Black patients. Reassuringly, there were no disparities in outcomes such as readmissions and mortality across the two groups of hospitals. Other abstracts on this panel investigate selection bias and disparities in cost and quality outcomes in the BPCI-Advanced program, the relationship between increasing Medicare Advantage penetration in rural areas and rural hospital financial distress and how an employer-sponsored Value-based Insurance Design program for low-income people with Type 2 Diabetes impacts medication adherence. Dora Hughes from CMMI (CMS Innovation Center) will round out this panel with reflections on the results of each of these studies, and the ways in which CMS is embedding equity-focused strategies into new payment and care delivery models.

Impact of State-Led Regulations and Models

This year saw a host of studies focused on state-led payment models and regulatory changes. Facilitated by Anna Sommers of RTI International, researchers on this panel will discuss the value of states as laboratories for innovative payment models. The topics vary in their areas of focus, from CMMI-funded state models, to innovation in employer-based health plans, to decades-old state regulations and their implications in a value-based world. On this last topic, researchers explored implications of Certificate of Need (CON) laws around major medical equipment prices within states. While these laws have been on the books for years, understanding their true spending impact has been limited due to the lack of commercial price information. Leveraging a new price transparency database, the authors find that facilities in states with more restrictive CON laws related to major medical equipment had lower prices on outpatient radiology imaging services than states with more lax CON regulations. The authors will share their perspective on the impact of these regulations in a world of increasing value-based payment designs and provider accountability for total cost of care.

Many more insights and methodologic approaches to policy evaluation are on the agenda at ARM this year. To get the details and understand the policy implications of all of this great work, be sure to join these Payment and Delivery System Innovation panel sessions this June! Register here.

Kate Goodrich Headshot

Kate Goodrich, M.D., M.H.S.

Senior Vice President for Trend and Analytics - Humana, Inc.

Kate Goodrich, MD, MHS, is SVP for Trend and Analytics within the Clinical and Pharmacy Solutions segment of H... Read Bio

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