| Field | Before | After |
|---|---|---|
| Field Study Withdrawn | Before | After No |
| Field Intervention Completion Date | Before | After December 31, 2017 |
| Field Data Collection Complete | Before | After Yes |
| Field Final Sample Size: Number of Clusters (Unit of Randomization) | Before | After 196 metropolitan statistical areas |
| Field Was attrition correlated with treatment status? | Before | After No |
| Field Final Sample Size: Total Number of Observations | Before | After Among the 196 MSAs, there were 1633 hospitals, with 131 285 eligible LEJR procedures performed during the study period (mean volume, 110 LEJR episodes per hospital) among 130 343 patients. |
| Field Final Sample Size (or Number of Clusters) by Treatment Arms | Before | After Treatment: 67 MSAs (8 of the original 75 were subsequently excluded due to revised eligibility criteria). Control: 121 MSAs. |
| Field Is there a restricted access data set available on request? | Before | After No |
| Field Program Files | Before | After Yes |
| Field Program Files URL | Before | After https://doi.org/10.7910/DVN/DEULAR |
| Field Data Collection Completion Date | Before | After December 31, 2017 |
| Field Is data available for public use? | Before | After No |
| Field | Before | After |
|---|---|---|
| Field Paper Abstract | Before | After Importance: Bundled payments are an increasingly common alternative payment model for Medicare, yet there is limited evidence regarding their effectiveness. Objective: To report interim outcomes from the first year of implementation of a bundled payment model for lower extremity joint replacement (LEJR). Design, Setting, and Participants: As part of a 5-year, mandatory-participation randomized trial by the Centers for Medicare & Medicaid Services, eligible metropolitan statistical areas (MSAs) were randomized to the Comprehensive Care for Joint Replacement (CJR) bundled payment model for LEJR episodes or to a control group. In the first performance year, hospitals received bonus payments if Medicare spending for LEJR episodes was below the target price and hospitals met quality standards. This interim analysis reports first-year data on LEJR episodes starting April 1, 2016, with data collection through December 31, 2016. Exposure: Randomization of MSAs into the CJR bundled payment model group (75 assigned; 67 included) or to the control group without the CJR model (121 assigned; 121 included). Instrumental variable analysis was used to evaluate the relationship between inclusion of MSAs in the CJR model and outcomes. Main Outcomes and Measures: The primary outcome was share of LEJR admissions discharged to institutional postacute care. Secondary outcomes included the number of days in institutional postacute care, discharges to other locations, Medicare spending during the episode (overall and for institutional postacute care), net Medicare spending during the episode, LEJR patient volume and patient case mix, and quality-of-care measures. Results: Among the 196 MSAs and 1633 hospitals, 131 285 eligible LEJR procedures were performed during the study period (mean volume, 110 LEJR episodes per hospital) among 130 343 patients (mean age, 72.5 [SD, 0.91] years; 65% women; 90% white). The mean percentage of LEJR admissions discharged to institutional postacute care was 33.7% (SD, 11.2%) in the control group and was 2.9 percentage points lower (95% CI, −4.95 to −0.90 percentage points) in the CJR group. Mean Medicare spending for institutional postacute care per LEJR episode was $3871 (SD, $1394) in the control group and was $307 lower (95% CI, −$587 to −$27) in the CJR group. Mean overall Medicare spending per LEJR episode was $22 872 (SD, $3619) in the control group and was $453 lower (95% CI, −$909 to $3) in the CJR group, a statistically nonsignificant difference. None of the other secondary outcomes differed significantly between groups. Conclusions and Relevance: In this interim analysis of the first year of the CJR bundled payment model for LEJR among Medicare beneficiaries, MSAs covered by CJR, compared with those that were not, had a significantly lower percentage of discharges to institutional postacute care but no significant difference in total Medicare spending per LEJR episode. Further evaluation is needed as the program is more fully implemented. Trial Registration: ClinicalTrials.gov Identifier: NCT03407885; American Economic Association Registry Identifier: AEARCTR-0002521 |
| Field Paper Citation | Before | After Finkelstein A, Ji Y, Mahoney N, Skinner J. Mandatory Medicare Bundled Payment Program for Lower Extremity Joint Replacement and Discharge to Institutional Postacute Care: Interim Analysis of the First Year of a 5-Year Randomized Trial. JAMA. 2018;320(9):892–900. doi:10.1001/jama.2018.12346 |
| Field Paper URL | Before | After https://jamanetwork.com/journals/jama/fullarticle/2698927 |
| Field | Before | After |
|---|---|---|
| Field Paper Abstract | Before | After Changes in the way health insurers pay healthcare providers may not only directly affect the insurer’s patients but may also affect patients covered by other insurers. We provide evidence of such spillovers in the context of a nationwide Medicare bundled payment reform that was implemented in some areas of the country but not in others, via random assignment. We estimate that the payment reform—which targeted traditional Medicare patients—had effects of similar magnitude on the healthcare experience of nontargeted, privately insured Medicare Advantage patients. We discuss the implications of these findings for estimates of the impact of healthcare payment reforms and more generally for the design of healthcare policy. |
| Field Paper Citation | Before | After Einav L, Finkelstein A, Ji Y, Mahoney N. Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform. Proc Natl Acad Sci U S A. 2020 Aug 11;117(32):18939-18947. doi: 10.1073/pnas.2004759117. Epub 2020 Jul 27 |
| Field Paper URL | Before | After https://www.pnas.org/doi/abs/10.1073/pnas.2004759117 |
| Field | Before | After |
|---|---|---|
| Field Paper Abstract | Before | After Government programs are often offered on an optional basis to market participants. We explore the economics of such voluntary regulation in the context of a Medicare payment reform, in which one medical provider receives a single, predetermined payment for a sequence of related healthcare services, instead of separate service-specific payments. This “bundled payment” program was originally implemented as a 5-year randomized trial, with mandatory participation by hospitals assigned to the new payment model; however, after two years, participation was made voluntary for half of these hospitals. Using detailed claim-level data, we document that voluntary participation is more likely for hospitals that can increase revenue without changing behavior (“selection on levels”) and for hospitals that had large changes in behavior when participation was mandatory (“selection on slopes”). To assess outcomes under counterfactual regimes, we estimate a stylized model of responsiveness to and selection into the program. We find that the current voluntary regime generates inefficient transfers to hospitals, and that alternative (feasible) designs could reduce these inefficient transfers and raise welfare. Our analysis highlights key design elements to consider under voluntary regulation. |
| Field Paper Citation | Before | After Einav L, Finkelstein A, Ji Y, Mahoney N. VOLUNTARY REGULATION: EVIDENCE FROM MEDICARE PAYMENT REFORM. Q J Econ. 2022 Feb;137(1):565-618. doi: 10.1093/qje/qjab035. Epub 2021 Sep 20. PMID: 35233120; PMCID: PMC8884469. |
| Field Paper URL | Before | After https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8884469/ |