Medicare Competitive Bidding Program Realized Price Savings For Durable Medical Equipment Purchases.

From the inception of the Medicare program there have been questions regarding whether and how to pay for durable medical equipment, prosthetics, orthotics, and supplies. In 2011 the Centers for Medicare and Medicaid Services (CMS) implemented a competitive bidding program to reduce spending on durable medical equipment and similar items. Previously, CMS had used prices in an administrative fee schedule to reimburse for these items. We compared prices from Round 1 of the Medicare competitive bidding program, which were established for the periods 2011-13 and 2014-16, to prices paid by national commercial insurers for the same types of items in 2011-14. Our results suggest that the initial years of the program produced prices comparable to those obtained, on average, by large commercial insurers-sophisticated purchasers that presumably were able to negotiate prices with suppliers of durable medical equipment and similar items.

Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief.

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

Vermont's Community-Oriented All-Payer Medical Home Model Reduces Expenditures and Utilization While Delivering High-Quality Care.

Patient-centered medical home programs using different design and implementation strategies are being tested across the United States, and the impact of these programs on outcomes for a general population remains unclear. Vermont has pursued a statewide all-payer program wherein medical home practices are supported with additional staffing from a locally organized shared resource, the community health team. Using a 6-year, sequential, cross-sectional methodology, this study reviewed annual cost, utilization, and quality outcomes for patients attributed to 123 practices participating in the program as of December 2013 versus a comparison population from each year attributed to nonparticipating practices. Populations are grouped based on their practices' stage of participation in a calendar year (Pre-Year, Implementation Year, Scoring Year, Post-Year 1, Post-Year 2). Annual risk-adjusted total expenditures per capita at Pre-Year for the participant group and comparison group were not significantly different. The difference-in-differences change from Pre-Year to Post-Year 2 indicated that the participant group's expenditures were reduced by -$482 relative to the comparison (95% CI, -$573 to -$391; P < .001). The lower costs were driven primarily by inpatient (-$218; P < .001) and outpatient hospital expenditures (-$154; P < .001), with associated changes in inpatient and outpatient hospital utilization. Medicaid participants also had a relative increase in expenditures for dental, social, and community-based support services ($57; P < .001). Participants maintained higher rates on 9 of 11 effective and preventive care measures. These results suggest that Vermont's community-oriented medical home model is associated with improved outcomes for a general population at lower expenditures and utilization. (Population Health Management 2016;19:196-205).

Evaluating health care delivery reform initiatives in the face of "cost disease".

The authors analyzed historical claims data from 2007 to 2011 from the Vermont All-Payer Claims database for all individuals covered by commercial insurance and Medicaid to determine per capita inpatient expenditures, cost per discharge, and cost per inpatient day. The authors further evaluated the proportion of all health care expenditure allocated to mental health, maternity care, surgical services, and medical services. Although utilization of inpatient services declined during the study period, cost per discharge and cost per inpatient day increased in a compensatory manner. Although the utilization of inpatient services by the Medicaid population decreased by 8%, cost per discharge increased by 84%. Among the commercially insured, discharges per 1000 members were essentially unchanged during the study period and inpatient cost per discharge increased by a relatively modest 32%. The relative utilization of mental health, maternity care, surgical services, and medical services was unchanged during the study period. The significant increase in the cost of inpatient services increased the proportion of total expenditure on surgical services from 21% in 2007 to 33% in 2011. The authors conclude that although health care providers are increasingly being assessed on their ability to control health care costs while achieving better outcomes, there are many cost drivers that are outside of their control. Efforts to assess initiatives, such as patient-centered medical homes, should be focused on utilization trends and outcomes rather than cost or, at a minimum, reflect cost drivers that physicians and other providers cannot influence.