Background
The Medicare Bundled Payments for Care Improvement (BPCI) program reimburses 90-day care episodes post-hospitalization. COPD is a leading cause of early readmissions making it a target for ...value-based payment reform.
Objective
Evaluate the financial impact of a COPD BPCI program.
Design, Participants, Interventions
A single-site retrospective observational study evaluated the impact of an evidence-based transitions of care program on episode costs and readmission rates, comparing patients hospitalized for COPD exacerbations who received versus those who did not receive the intervention.
Main Measures
Mean episode costs and readmissions.
Key Results
Between October 2015 and September 2018, 132 received and 161 did not receive the program, respectively. Mean episode costs were below target for six out of eleven quarters for the intervention group, as opposed to only one out of twelve quarters for the control group. Overall, there were non-significant mean savings of $2551 (95% CI: − $811 to $5795) in episode costs relative to target costs for the intervention group, though results varied by index admission diagnosis-related group (DRG); there were additional costs of $4184 per episode for the least-complicated cohort (DRG 192), but savings of $1897 and $1753 for the most complicated index admissions (DRGs 191 and 190, respectively). A significant mean decrease of 0.24 readmissions per episode was observed in 90-day readmission rates for intervention relative to control. Readmissions and hospital discharges to skilled nursing facilities were factors of higher costs (mean increases of $9098 and $17,095 per episode respectively).
Conclusions
Our COPD BPCI program had a non-significant cost-saving effect, although sample size limited study power. The differential impact of the intervention by DRG suggests that targeting interventions to more clinically complex patients could increase the financial impact of the program. Further evaluations are needed to determine if our BPCI program decreased care variation and improved quality of care.
Primary Source of Funding
This research was supported by NIH NIA grant #5T35AG029795-12.
•In East-Central Europe 9% of patients make informal payments to healthcare professionals.•Formal institutional imperfections result in higher levels of informal payments by patients.•The greater the ...institutional asymmetry, the more prevalent are informal payments.•Tackling informal payments requires changes in both the formal and informal institutions.
The aim of this paper is to explain informal payments by patients to healthcare professionals for the first time through the lens of institutional theory as arising when there are formal institutional imperfections and asymmetry between norms, values and practices and the codified formal laws and regulations. Reporting a 2013 Eurobarometer survey of the prevalence of informal payments by patients in 28 European countries, a strong association is revealed between the degree to which formal and informal institutions are unaligned and the propensity to make informal payments. The association between informal payments and formal institutional imperfections is then explored to evaluate which structural conditions might reduce this institutional asymmetry, and thus the propensity to make informal payments. The paper concludes by exploring the implications for tackling such informal practices.
Strongly increasing costs of congestion management have provoked a discussion in Europe about new approaches to solve grid congestions in a more efficient way. One approach is to design flexibility ...markets. In this paper we focus on the effects of subsidies for renewable energy on the market outcome of a flexibility market. We show that subsidies can cause market distortions and lead to an inefficient selection of flexibility options to solve grid congestions. We propose the implementation of side payments together with price caps and uniform pricing to achieve an efficient market design. Ultimately choosing between flexibility markets with and without side payments involves a tradeoff between minimizing system costs and maximizing renewable infeed. Our analysis provides the framework for a conscious political choice on that subject.
•Flexibility markets decrease congestion management costs by acquiring DSM options•RES can also offer flexibility by voluntarily curtailing power infeed•RES consider guaranteed subsidies as opportunity costs•RES bidding at opportunity costs can lead to inefficient and costly market outcomes•Side payments, price caps and uniform pricing lead to an efficient market design
Many countries serving in multilateral military coalitions are “paid” to do so, either in cash or in concessions relating to other international issues. An examination of hundreds of declassified ...archival sources as well as elite interviews relating to the Korean War, the Vietnam War, the Gulf War, the Iraq War, the North Atlantic Treaty Organization operation in Afghanistan, the United Nations–African Union operation in Darfur, and the African Union operation in Somalia reveals that these payment practices follow a systematic pattern: pivotal states provide the means to cover such payments. These states reason that rewarding third parties to serve in multilateral coalitions holds important political benefits. Moreover, two distinct types of payment schemes exist: deployment subsidies and political side deals. Three types of states are most likely to receive such payments: (1) states that are inadequately resourced to deploy; (2) states that are perceived by the pivotal
states as critical contributors to the coalition endeavor; and (3) opportunistic states that perceive a coalition deployment as an opportunity to negotiate a quid pro quo. These findings provide a novel perspective on what international burden sharing looks like in practice. Moreover, they raise important questions about the efficiency and effectiveness of such payment practices in multilateral military deployments.
Cooperation among humans is highly dependent on social and institutional conditions, with individual incentives playing a key role in determining the level of cooperation achieved. Understanding the ...conditions under which cooperation can emerge has important implications for the design of resource management and wildlife conservation interventions. Incentive-based conservation approaches are being widely implemented, yet very few studies test the role of incentives in promoting cooperation in relevant developing country contexts. Using a common pool resource game, in four villages in Cambodia, we investigated how the level of within-group cooperation varies under different institutional arrangements, including opportunities for social approval, external enforcement of rules and individual and collective incentive payments. Our results demonstrate the significance of self-organisation, the ability to devise, monitor and enforce a set of rules, among resource users. Treatments which promoted self-organisation had the greatest effect in reducing individual extraction, achieved the greatest efficiencies and had the strongest interaction with group decision-making in reducing extraction. The effects of these treatments carried over to reduce extraction in subsequent treatments, irrespective of their institutional arrangements. These results suggest that policies designed to incentivise certain behaviour in local stakeholder groups may be more successful if they create opportunities for local decision-making.
► We use a common pool resource game to investigate resource appropriation behaviour. ► Promotion of self-organisation reduces individual extraction from a CPR. ► Incentive-based conservation policies should encourage local decision-making.
Diabetes process and outcome measures are common quality measures in payment reform models, including Alternative Payment Models (APMs) and value-based insurance design (VBID). In this commentary we ...review evidence from selected research to examine whether these payment models can improve the value of diabetes care. We found that higher-risk APMs yielded greater improvements in diabetes process measures than lower-risk APMs, and that VBID models appeared to improve medication adherence but not other quality measures. We argue that these models are promising first steps in redesigning the payment system to improve diabetes care. However, greater coordination and alignment across models is needed to enhance their impact on providers' behavior, diabetes care processes, and patient health outcomes.
Personal payments from the pharmaceutical industry to US physicians are common and are associated with changes in physicians' clinical practice and interpretation of clinical trial results. We ...assessed temporal trends in industry payments to oncologists, with particular emphasis on payments to authors of oncology clinical practice guideline and on payments related to immunotherapy drugs.
We included US physicians with active National Plan and Provider Enumeration System records and demographic data available in the Centers for Medicare & Medicaid Services Physician Compare system who had a specialty type of medical oncology or general internal medicine. Medical oncologists serving on NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Panels were identified manually. Industry payments, and the subset associated with PD-1/PD-L1 drugs, were identified in Open Payments, the federal repository of all transactions of financial value from industry to physicians and teaching hospitals, from 2014 to 2017.
There were 13,087 medical oncologists and 85,640 internists who received payments. The mean, annual, per-physician value of payments to oncologists increased from $3,811 in 2014 to $5,854 in 2017, and from $444 to $450 for internists; the median payment increased from $152 to $199 for oncologists and remained at $0 for internists. Oncologists who served on NCCN Guidelines Panels received a greater value in payments and experienced a greater relative increase: mean payments increased from $10,820 in 2014 to $18,977 in 2017, and median payments increased from $500 to $1,366. Among companies marketing PD-1/PD-L1 drugs, mean annual per-oncologist payments associated with PD-1/PD-L1 drugs increased from $28 to $773. Total per-oncologist payments from companies marketing PD-1/PD-L1 drugs experienced a 165% increase from 2014 to 2017, compared with a 31% increase among similar companies not marketing PD-1/PD-L1 drugs.
Pharmaceutical industry payments increased for US oncologists from 2014 to 2017 more than for general internists. The increase was greater among oncologists contributing to clinical practice guidelines and among pharmaceutical companies marketing PD-1/PD-L1 drugs. The increasing flow of money from industry to US oncologists supports ongoing concern regarding commercial interests in guideline development and clinical decision-making.
Abstract
Prebisch is responsible for three significant but often ignored contributions to international macroeconomics. First, Prebisch characterised the Gold Standard as an unstable and asymmetric ...system, which worked for peripheral countries only when there was a balance of payments surplus. Second, Prebisch considered that the increasing importance of the US economy was the main reason for the collapse of the Gold Standard and the Great Depression, and rejected explanations based on the inflexibility of wages and prices. Third, and as response to the abovementioned issues, Prebisch implemented several policies in Argentina during the 1930s, lifting the country out of the crisis. These theoretical insights and the policy prescriptions predated significant contributions by eminent scholars and proved to be successful during the last decades.
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