Publications
1.
Khullar, Dhruv; Schpero, William L.; Civelek, Yasin; Casalino, Lawrence P.; Zhang, Manyao; Pierre, Reekarl; Bond, Amelia M.
Budgetary Impact of the Medicare Shared Savings Program on Traditional Medicare Journal Article
In: JAMA Health Forum , vol. 7, no. 2, 2026.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{,
title = {Budgetary Impact of the Medicare Shared Savings Program on Traditional Medicare},
author = {Dhruv Khullar and William L. Schpero and Yasin Civelek and Lawrence P. Casalino and Manyao Zhang and Reekarl Pierre and Amelia M. Bond },
doi = {10.1001/jamahealthforum.2025.6915},
year = {2026},
date = {2026-02-20},
urldate = {2026-02-20},
journal = {JAMA Health Forum },
volume = {7},
number = {2},
abstract = {The Medicare Shared Savings Program (MSSP), which began in 2012, makes incentive payments to groups of clinicians and health care organizations known as accountable care organizations (ACOs) that achieve spending reductions for attributed patients while meeting quality targets. A study by Ryan and Markovitz1 found that the program was associated with net losses (after incentive payments) to traditional Medicare of $584 million to $1.42 billion between 2013 and 2021, using estimates of ACO savings in the initial years of MSSP.2,3 In this cross-sectional study, we provide updated estimates of MSSP’s budgetary impact between 2012 and 2023 using a more recent longitudinal evaluation of the program’s effects.4},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
The Medicare Shared Savings Program (MSSP), which began in 2012, makes incentive payments to groups of clinicians and health care organizations known as accountable care organizations (ACOs) that achieve spending reductions for attributed patients while meeting quality targets. A study by Ryan and Markovitz1 found that the program was associated with net losses (after incentive payments) to traditional Medicare of $584 million to $1.42 billion between 2013 and 2021, using estimates of ACO savings in the initial years of MSSP.2,3 In this cross-sectional study, we provide updated estimates of MSSP’s budgetary impact between 2012 and 2023 using a more recent longitudinal evaluation of the program’s effects.4
2.
Bond, Amelia M.; Civelek, Yasin; Schpero, William L.; Casalino, Lawrence P.; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Long-Term Spending of Accountable Care Organizations in the Medicare Shared Savings Program Journal Article
In: JAMA, vol. 333, no. 21, pp. 1897-1905, 2025.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Long-Term Spending of Accountable Care Organizations in the Medicare Shared Savings Program},
author = {Amelia M. Bond and Yasin Civelek and William L. Schpero and Lawrence P. Casalino and Manyao Zhang and Reekarl Pierre and Dhruv Khullar },
doi = {10.1001/jama.2025.3870},
year = {2025},
date = {2025-04-28},
urldate = {2025-04-28},
journal = {JAMA},
volume = {333},
number = {21},
pages = {1897-1905},
abstract = {Importance: Evidence from initial cohorts of accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) found modest reductions in health care spending. Little is known about whether these effects have changed over time.
Objective: To determine long-term changes in spending for MSSP ACO participants.
Design, Setting, and Participants: Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).
Exposure: Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.
Main Outcomes and Measures: Total annual per-patient Medicare spending.
Results: The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, −$171 [95% CI, −$223 to −$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, −$193 to −$92) in annual per-patient spending over 3 years and $294 (95% CI, −$347 to −$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, −$298 to −$171) in year 3 and $584 (95% CI, −$680 to −$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.
Conclusions and Relevance: During the MSSP’s first decade, ACOs generated meaningful reductions in spending, with larger effects over time.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance: Evidence from initial cohorts of accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) found modest reductions in health care spending. Little is known about whether these effects have changed over time.
Objective: To determine long-term changes in spending for MSSP ACO participants.
Design, Setting, and Participants: Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).
Exposure: Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.
Main Outcomes and Measures: Total annual per-patient Medicare spending.
Results: The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, −$171 [95% CI, −$223 to −$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, −$193 to −$92) in annual per-patient spending over 3 years and $294 (95% CI, −$347 to −$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, −$298 to −$171) in year 3 and $584 (95% CI, −$680 to −$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.
Conclusions and Relevance: During the MSSP’s first decade, ACOs generated meaningful reductions in spending, with larger effects over time.
Objective: To determine long-term changes in spending for MSSP ACO participants.
Design, Setting, and Participants: Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).
Exposure: Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.
Main Outcomes and Measures: Total annual per-patient Medicare spending.
Results: The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, −$171 [95% CI, −$223 to −$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, −$193 to −$92) in annual per-patient spending over 3 years and $294 (95% CI, −$347 to −$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, −$298 to −$171) in year 3 and $584 (95% CI, −$680 to −$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.
Conclusions and Relevance: During the MSSP’s first decade, ACOs generated meaningful reductions in spending, with larger effects over time.
3.
Bond, Amelia M.; Schpero, William L.; Civelek, Yasin; Tormohlen, Kayla; Casalino, Lawrence P.; Jones, David J.; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Changes in Primary Care Practice Setting and Practice Type for Medicare Beneficiaries Journal Article
In: JAMA Health Forum , vol. 6, iss. 4, 2025.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Changes in Primary Care Practice Setting and Practice Type for Medicare Beneficiaries},
author = {Amelia M. Bond and William L. Schpero and Yasin Civelek and Kayla Tormohlen and Lawrence P. Casalino and David J. Jones and Manyao Zhang and Reekarl Pierre and Dhruv Khullar },
doi = {10.1001/jamahealthforum.2025.0445},
year = {2025},
date = {2025-04-25},
journal = {JAMA Health Forum },
volume = {6},
issue = {4},
abstract = {This cross-sectional study examined changes in practice setting and practice type in 2012 vs 2022 among patients with traditional Medicare coverage.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
This cross-sectional study examined changes in practice setting and practice type in 2012 vs 2022 among patients with traditional Medicare coverage.
4.
Yu, Jiani; Casalino, Lawrence P; Jung, Hye-Young; Lake, Derek; Zhang, Manyao; Pierre, Reekarl; Khullar, Dhruv
Utilization and Quality Among Medicare Advantage Beneficiaries with High Vs Low Access to Telehealth Journal Article
In: Health Affairs Scholar , 2025.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Utilization and Quality Among Medicare Advantage Beneficiaries with High Vs Low Access to Telehealth },
author = {Jiani Yu and Lawrence P Casalino and Hye-Young Jung and Derek Lake and Manyao Zhang and Reekarl Pierre and Dhruv Khullar},
doi = {10.1093/haschl/qxaf064},
year = {2025},
date = {2025-03-26},
urldate = {2025-03-26},
journal = {Health Affairs Scholar },
abstract = {Introduction
Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions.
Methods
We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019-2021.
Results
We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total ED visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions.
Conclusions
Increases in telehealth-delivered E&M visits among MA beneficiaries with high telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Introduction
Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions.
Methods
We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019-2021.
Results
We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total ED visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions.
Conclusions
Increases in telehealth-delivered E&M visits among MA beneficiaries with high telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.
Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions.
Methods
We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019-2021.
Results
We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total ED visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions.
Conclusions
Increases in telehealth-delivered E&M visits among MA beneficiaries with high telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.
5.
Casalino, Lawrence P.; Bond, Amelia M.; Khullar, Dhruv
Steering, Switching, and the Medicare Advantage “Trap” Journal Article
In: JAMA, iss. JAMA, 2025.
Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Steering, Switching, and the Medicare Advantage “Trap”},
author = { Lawrence P. Casalino and Amelia M. Bond and Dhruv Khullar },
doi = {10.1001/jama.2025.1759},
year = {2025},
date = {2025-03-17},
urldate = {2025-03-17},
journal = {JAMA},
issue = {JAMA},
publisher = {JAMA},
howpublished = {Online},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
6.
Khullar, Dhruv; Schpero, William L.; Casalino, Lawrence P.; Pierre, Reekarl; Carter, Samuel; Civelek, Yasin; Zhang, Manyao; Bond, Amelia M.
Meeting The Needs Of Socially Vulnerable Patients: Views Of ACO Leaders On Moving From Intent To Action Journal Article
In: Health Affairs , vol. 43, no. 8, 2024.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Meeting The Needs Of Socially Vulnerable Patients: Views Of ACO Leaders On Moving From Intent To Action},
author = {Dhruv Khullar and William L. Schpero and Lawrence P. Casalino and Reekarl Pierre and Samuel Carter and Yasin Civelek and Manyao Zhang and Amelia M. Bond},
doi = {10.1377/hlthaff.2023.00673},
year = {2024},
date = {2024-08-05},
urldate = {2024-08-05},
journal = {Health Affairs },
volume = {43},
number = {8},
abstract = {The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how accountable care organizations (ACOs) aim to meet the needs of vulnerable patients. During September–December 2022, we interviewed leaders of forty-nine ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non–health care sectors, to help socially vulnerable patients.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how accountable care organizations (ACOs) aim to meet the needs of vulnerable patients. During September–December 2022, we interviewed leaders of forty-nine ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non–health care sectors, to help socially vulnerable patients.
7.
Khullar, Dhruv; Schpero, William L.; Casalino, Lawrence P.; Pierre, Reekarl; Carter, Samuel; Civelek, Yasin; Zhang, Manyao; Bond, Amelia M.
Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program Journal Article
In: JAMA Health Forum, 2024.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program},
author = {Dhruv Khullar and William L. Schpero and Lawrence P. Casalino and Reekarl Pierre and Samuel Carter and Yasin Civelek and Manyao Zhang and Amelia M. Bond},
doi = {10.1001/jamahealthforum.2024.0126},
year = {2024},
date = {2024-03-15},
journal = {JAMA Health Forum},
abstract = {Importance
The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.
Objective
To understand the priorities, strategies, and challenges of ACO leaders in MSSP.
Design, Setting, and Participants
In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.
Main Outcomes and Measures
Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.
Results
Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.
Conclusions and Relevance
In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.
},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance
The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.
Objective
To understand the priorities, strategies, and challenges of ACO leaders in MSSP.
Design, Setting, and Participants
In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.
Main Outcomes and Measures
Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.
Results
Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.
Conclusions and Relevance
In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.
The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.
Objective
To understand the priorities, strategies, and challenges of ACO leaders in MSSP.
Design, Setting, and Participants
In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.
Main Outcomes and Measures
Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.
Results
Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.
Conclusions and Relevance
In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.
8.
Schpero, William L.; Brahmbhatt, Diksha; Liu, Michael X.; Ndumele, Chima D.; Chatterjee, Paula
Variation in Procedural Denials of Medicaid Eligibility Across States Before the COVID-19 Pandemic Journal Article
In: JAMA Health Forum , vol. 4, no. 11, 2023.
Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Variation in Procedural Denials of Medicaid Eligibility Across States Before the COVID-19 Pandemic},
author = {William L. Schpero and Diksha Brahmbhatt and Michael X. Liu and Chima D. Ndumele and Paula Chatterjee},
doi = {10.1001/jamahealthforum.2023.3892},
year = {2023},
date = {2023-11-11},
urldate = {2023-11-11},
journal = {JAMA Health Forum },
volume = {4},
number = {11},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
9.
Bond, Amelia M.; Dean, Emma B.; Desai, Sunita M.
The Role Of Financial Incentives In Biosimilar Uptake In Medicare: Evidence From The 340B Program Journal Article
In: Health Affairs, vol. 42, no. 5, 2023.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {The Role Of Financial Incentives In Biosimilar Uptake In Medicare: Evidence From The 340B Program},
author = {Amelia M. Bond and Emma B. Dean and Sunita M. Desai},
doi = {https://doi.org/10.1377/hlthaff.2022.00812},
year = {2023},
date = {2023-05-01},
urldate = {2023-05-01},
journal = {Health Affairs},
volume = {42},
number = {5},
abstract = {Biosimilar drugs—lower-cost alternatives to expensive biologic drugs—have the potential to slow the growth of US drug spending. However, rates of biosimilar uptake have varied across hospital outpatient providers. We investigated whether the 340B Drug Pricing Program, which offers eligible hospitals substantial discounts on drug purchases, inhibits biosimilar uptake. Almost one-third of US hospitals participate in the 340B program. Using a regression discontinuity design and two high-volume biologics with biosimilar competitors, filgrastim and infliximab, we estimated that 340B program eligibility was associated with a 22.9-percentage-point reduction in biosimilar adoption. In addition, 340B program eligibility was associated with 13.3 more biologic administrations annually per hospital and $17,919 more biologic revenue per hospital. Our findings suggest that the program inhibited biosimilar uptake, possibly as a result of financial incentives making reference drugs more profitable than biosimilar medications.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Biosimilar drugs—lower-cost alternatives to expensive biologic drugs—have the potential to slow the growth of US drug spending. However, rates of biosimilar uptake have varied across hospital outpatient providers. We investigated whether the 340B Drug Pricing Program, which offers eligible hospitals substantial discounts on drug purchases, inhibits biosimilar uptake. Almost one-third of US hospitals participate in the 340B program. Using a regression discontinuity design and two high-volume biologics with biosimilar competitors, filgrastim and infliximab, we estimated that 340B program eligibility was associated with a 22.9-percentage-point reduction in biosimilar adoption. In addition, 340B program eligibility was associated with 13.3 more biologic administrations annually per hospital and $17,919 more biologic revenue per hospital. Our findings suggest that the program inhibited biosimilar uptake, possibly as a result of financial incentives making reference drugs more profitable than biosimilar medications.
10.
Khullar, Dhruv
Payment, Priorities, and Primary Care - Can Cognitive Work Be Properly Valued? Journal Article
In: JAMA, vol. 329, iss. 8, pp. 635-636, 2023.
Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Payment, Priorities, and Primary Care - Can Cognitive Work Be Properly Valued?},
author = {Dhruv Khullar},
doi = {10.1001/jama.2023.0880},
year = {2023},
date = {2023-02-28},
journal = {JAMA},
volume = {329},
issue = {8},
pages = {635-636},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
11.
Bond, Amelia M.; Schpero, William L.; Casalino, Lawrence P.; Zhang, Manyao; Khullar, Dhruv
Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes Journal Article
In: JAMA, vol. 328, iss. 21, pp. 2136–2146, 2022.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes},
author = {Amelia M. Bond and William L. Schpero and Lawrence P. Casalino and Manyao Zhang and Dhruv Khullar},
doi = {10.1001/jama.2022.20619},
year = {2022},
date = {2022-12-06},
urldate = {2022-12-06},
journal = {JAMA},
volume = {328},
issue = {21},
pages = {2136–2146},
abstract = {Importance: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide.
Objective: To examine whether primary care physicians’ MIPS scores are associated with performance on process and outcome measures.
Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019.
Exposures: MIPS score.
Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure.
Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, −7.1 percentage points [95% CI, −8.0 to −6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, −4.8 percentage points [95% CI, −5.4 to −4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, −12.2 percentage points [95% CI, −13.1 to −11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, −8.9 [95% CI, −13.7 to −4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care–sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes.
Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide.
Objective: To examine whether primary care physicians’ MIPS scores are associated with performance on process and outcome measures.
Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019.
Exposures: MIPS score.
Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure.
Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, −7.1 percentage points [95% CI, −8.0 to −6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, −4.8 percentage points [95% CI, −5.4 to −4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, −12.2 percentage points [95% CI, −13.1 to −11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, −8.9 [95% CI, −13.7 to −4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care–sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes.
Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.
Objective: To examine whether primary care physicians’ MIPS scores are associated with performance on process and outcome measures.
Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019.
Exposures: MIPS score.
Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure.
Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, −7.1 percentage points [95% CI, −8.0 to −6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, −4.8 percentage points [95% CI, −5.4 to −4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, −12.2 percentage points [95% CI, −13.1 to −11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, −8.9 [95% CI, −13.7 to −4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care–sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes.
Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.
12.
Bond, Amelia M.; Zhang, Yongkang; Toscano, Fabrizio; Zhang, Manyao; Johnson, Phyllis; Qian, Yuting; Unruh, Mark Aaron; Casalino, Lawrence P.
Physician prices and low-value services: evidence from general internal medicine Journal Article
In: American Journal of Managed Care, vol. 28, iss. 5, pp. e178-e184, 2022.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Physician prices and low-value services: evidence from general internal medicine},
author = {Amelia M. Bond and Yongkang Zhang and Fabrizio Toscano and Manyao Zhang and Phyllis Johnson and Yuting Qian and Mark Aaron Unruh and Lawrence P. Casalino},
doi = {https://doi.org/10.37765/ajmc.2022.89149},
year = {2022},
date = {2022-05-01},
urldate = {2022-05-01},
journal = {American Journal of Managed Care},
volume = {28},
issue = {5},
pages = {e178-e184},
abstract = {Objectives: To assess the cross-sectional relationship between prices paid to physicians by commercial insurers and the provision of low-value services.
Study Design: Observational study design using Health Care Cost Institute claims representing 3 large national commercial insurers.
Methods: The main outcome was count of 19 potential low-value services in 2014. The secondary outcome was total spending on the low-value services. Independent variables of interest were price quintiles based on each physician’s mean geographically adjusted price of a mid-level office visit, the most commonly billed service by general internal medicine (GIM) physicians. We estimated the association between physician price quintile and provision of low-value services via negative binomial or generalized linear models with adjustments for measure, region, and patient and physician characteristics.
Results: This study included 750,452 commercially insured patients attributed to 28,951 GIM physicians. In 2014, the mean geographically adjusted price for physicians in the highest price quintile was $122.6 vs $54.7 for physicians in the lowest quintile ($67.9 difference; 95% CI, $67.5-$68.3). Relative to patients attributed to the lowest-priced physicians, those attributed to the highest-priced physicians received 3.6, or 22.9%, fewer low-value services per 100 patients (95% CI, 2.7-4.7 services per 100 patients). Spending on low-value services attributed to the highest-priced physicians was 10.9% higher ($520 difference per 100 patients; 95% CI, $167-$872).
Conclusions: Commercially insured patients of high-priced physicians received fewer low-value services, although spending on low-value services was higher. More research is needed to understand why high-priced providers deliver fewer low-value services and whether physician prices are correlated with other measures of quality.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Objectives: To assess the cross-sectional relationship between prices paid to physicians by commercial insurers and the provision of low-value services.
Study Design: Observational study design using Health Care Cost Institute claims representing 3 large national commercial insurers.
Methods: The main outcome was count of 19 potential low-value services in 2014. The secondary outcome was total spending on the low-value services. Independent variables of interest were price quintiles based on each physician’s mean geographically adjusted price of a mid-level office visit, the most commonly billed service by general internal medicine (GIM) physicians. We estimated the association between physician price quintile and provision of low-value services via negative binomial or generalized linear models with adjustments for measure, region, and patient and physician characteristics.
Results: This study included 750,452 commercially insured patients attributed to 28,951 GIM physicians. In 2014, the mean geographically adjusted price for physicians in the highest price quintile was $122.6 vs $54.7 for physicians in the lowest quintile ($67.9 difference; 95% CI, $67.5-$68.3). Relative to patients attributed to the lowest-priced physicians, those attributed to the highest-priced physicians received 3.6, or 22.9%, fewer low-value services per 100 patients (95% CI, 2.7-4.7 services per 100 patients). Spending on low-value services attributed to the highest-priced physicians was 10.9% higher ($520 difference per 100 patients; 95% CI, $167-$872).
Conclusions: Commercially insured patients of high-priced physicians received fewer low-value services, although spending on low-value services was higher. More research is needed to understand why high-priced providers deliver fewer low-value services and whether physician prices are correlated with other measures of quality.
Study Design: Observational study design using Health Care Cost Institute claims representing 3 large national commercial insurers.
Methods: The main outcome was count of 19 potential low-value services in 2014. The secondary outcome was total spending on the low-value services. Independent variables of interest were price quintiles based on each physician’s mean geographically adjusted price of a mid-level office visit, the most commonly billed service by general internal medicine (GIM) physicians. We estimated the association between physician price quintile and provision of low-value services via negative binomial or generalized linear models with adjustments for measure, region, and patient and physician characteristics.
Results: This study included 750,452 commercially insured patients attributed to 28,951 GIM physicians. In 2014, the mean geographically adjusted price for physicians in the highest price quintile was $122.6 vs $54.7 for physicians in the lowest quintile ($67.9 difference; 95% CI, $67.5-$68.3). Relative to patients attributed to the lowest-priced physicians, those attributed to the highest-priced physicians received 3.6, or 22.9%, fewer low-value services per 100 patients (95% CI, 2.7-4.7 services per 100 patients). Spending on low-value services attributed to the highest-priced physicians was 10.9% higher ($520 difference per 100 patients; 95% CI, $167-$872).
Conclusions: Commercially insured patients of high-priced physicians received fewer low-value services, although spending on low-value services was higher. More research is needed to understand why high-priced providers deliver fewer low-value services and whether physician prices are correlated with other measures of quality.
13.
Forgia, Ambar M. La; Bond, Amelia M.; Braun, Robert Tyler; Kjaer, Klaus; Zhang, Manyao; Casalino, Lawrence P.
In: JAMA Internal Medicine, vol. 181, iss. 10, pp. 1324-1331, 2021.
Abstract | Links | BibTeX | Tags: Corporatization and Consolidation, Payment Reform and Health Care Incentives
@article{nokey,
title = {Association of Surprise-Billing Legislation with Prices Paid to In-Network and Out-of-Network Anesthesiologists in California, Florida, and New York: An Economic Analysis},
author = {Ambar M. La Forgia and Amelia M. Bond and Robert Tyler Braun and Klaus Kjaer and Manyao Zhang and Lawrence P. Casalino},
doi = {https://doi.org/10.1001/jamainternmed.2021.4564},
year = {2021},
date = {2021-10-01},
urldate = {2021-10-01},
journal = {JAMA Internal Medicine},
volume = {181},
issue = {10},
pages = {1324-1331},
abstract = {Importance: Several states have passed surprise-billing legislation to protect patients from unanticipated out-of-network medical bills, yet little is known about how state laws influence out-of-network prices and whether spillovers exist to in-network prices.
Objective: To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation.
Design, setting, and participants: This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states.
Exposures: Temporal and state-level variation in exposure to surprise-billing legislation.
Main outcomes and measures: The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists.
Results: This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, -$12.71 (95% CI, -$25.70 to -$0.27; P = .05) and Florida, -$35.67 (95% CI, -$46.27 to -$25.07; P < .001). In New York, a decline in the overall out-of-network price was not statistically significant (-$7.91; 95% CI, -$17.48 to -$1.68; P = .10); however, by the fourth quarter of 2017, the decline was -$41.28 (95% CI, -$70.24 to -$12.33; P = .01). In-network prices decreased in California by -$10.68 (95% CI, -$12.70 to -$8.66; P < .001); in Florida, -$3.18 (95% CI, -$5.17 to -$1.19; P = .002); and in New York, -$8.05 (95% CI, -$11.46 to -$4.64; P < .001).
Conclusions and relevance: This retrospective study found that prices paid to in-network and out-of-network anesthesiologists in hospital outpatient departments and ambulatory surgery centers decreased after the introduction of surprise-billing legislation, providing early insights into how prices may change under the federal No Surprises Act and in states that have recently passed their own legislation.},
keywords = {Corporatization and Consolidation, Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance: Several states have passed surprise-billing legislation to protect patients from unanticipated out-of-network medical bills, yet little is known about how state laws influence out-of-network prices and whether spillovers exist to in-network prices.
Objective: To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation.
Design, setting, and participants: This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states.
Exposures: Temporal and state-level variation in exposure to surprise-billing legislation.
Main outcomes and measures: The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists.
Results: This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, -$12.71 (95% CI, -$25.70 to -$0.27; P = .05) and Florida, -$35.67 (95% CI, -$46.27 to -$25.07; P < .001). In New York, a decline in the overall out-of-network price was not statistically significant (-$7.91; 95% CI, -$17.48 to -$1.68; P = .10); however, by the fourth quarter of 2017, the decline was -$41.28 (95% CI, -$70.24 to -$12.33; P = .01). In-network prices decreased in California by -$10.68 (95% CI, -$12.70 to -$8.66; P < .001); in Florida, -$3.18 (95% CI, -$5.17 to -$1.19; P = .002); and in New York, -$8.05 (95% CI, -$11.46 to -$4.64; P < .001).
Conclusions and relevance: This retrospective study found that prices paid to in-network and out-of-network anesthesiologists in hospital outpatient departments and ambulatory surgery centers decreased after the introduction of surprise-billing legislation, providing early insights into how prices may change under the federal No Surprises Act and in states that have recently passed their own legislation.
Objective: To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation.
Design, setting, and participants: This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states.
Exposures: Temporal and state-level variation in exposure to surprise-billing legislation.
Main outcomes and measures: The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists.
Results: This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, -$12.71 (95% CI, -$25.70 to -$0.27; P = .05) and Florida, -$35.67 (95% CI, -$46.27 to -$25.07; P < .001). In New York, a decline in the overall out-of-network price was not statistically significant (-$7.91; 95% CI, -$17.48 to -$1.68; P = .10); however, by the fourth quarter of 2017, the decline was -$41.28 (95% CI, -$70.24 to -$12.33; P = .01). In-network prices decreased in California by -$10.68 (95% CI, -$12.70 to -$8.66; P < .001); in Florida, -$3.18 (95% CI, -$5.17 to -$1.19; P = .002); and in New York, -$8.05 (95% CI, -$11.46 to -$4.64; P < .001).
Conclusions and relevance: This retrospective study found that prices paid to in-network and out-of-network anesthesiologists in hospital outpatient departments and ambulatory surgery centers decreased after the introduction of surprise-billing legislation, providing early insights into how prices may change under the federal No Surprises Act and in states that have recently passed their own legislation.
14.
Khullar, Dhruv; Bond, Amelia M.; O'Donnell, Eloise; Qian, Yuting; Gans, David N.; Casalino, Lawrence P.
Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study Journal Article
In: JAMA Health Forum , vol. 2, iss. 5, 2021.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study},
author = {Dhruv Khullar and Amelia M. Bond and Eloise O'Donnell and Yuting Qian and David N. Gans and Lawrence P. Casalino},
doi = {https://doi.org/10.1001/jamahealthforum.2021.0527},
year = {2021},
date = {2021-05-14},
urldate = {2021-05-14},
journal = {JAMA Health Forum },
volume = {2},
issue = {5},
abstract = {Importance: The Merit-based Incentive Payment System (MIPS) is a major Medicare value-based purchasing program, influencing payment for more than 1 million clinicians annually. There is a growing concern that MIPS increases administrative burden, and little is known about what it costs physician practices to participate in the program.
Objective: To examine the costs for independent physician practices to participate in MIPS in 2019.
Design setting and participants: This qualitative study identified and interviewed leaders of physician practices participating in the US Centers for Medicare & Medicaid Services (CMS) MIPS program, including those in MIPS alternative payment models. Time required and financial costs were calculated from responses to in-depth, semistructured interviews conducted from December 12, 2019, to June 23, 2020. Physician practices were categorized by size (small, 1-9 physicians; medium, 10-25; and large, ≥50), specialty (primary care, general surgery, or multispecialty), and US census region. Participants were asked about 2019 costs related to clinician and staff time, information technology, and external vendors. Time was converted to financial costs using the Medical Group Management Association's Provider Compensation and the Management and Staff Compensation databases.
Main outcomes and measures: Annual time spent by staff on MIPS-related activities and mean per-physician costs to physician practices in 2019.
Results: Leaders of 30 physician practices (9 [30.0%] small primary care, 6 [20.0%] small general surgery, 4 [13.3%] medium primary care, 4 [13.3%] medium general surgery, and 7 [23.3%] large multispecialty) represented all US census regions, and 14 of the 30 (46.7%) practices participated in a MIPS alternative payment model in 2019. The mean per-physician cost to practices of participating in MIPS was $12 811 (interquartile range [IQR], $2861-$17 715). Physicians, clinical staff, and administrative staff together spent 201.7 (IQR, 50.9-295.2) hours annually per physician on MIPS-related activities. Medical assistants and nursing staff together spent a mean of 99.2 (IQR, 0-163.3) hours per physician each year; frontline physicians spent 53.6 (IQR, 0.6-55.8) hours; executive administrators spent 28.6 (IQR, 3.1-26.7) hours; other clinicians and staff spent a combined 20.3 (IQR, 0-36.8) hours. Physician time accounted for the greatest proportion of overall MIPS-related costs (54%; $6909; IQR, $94-$9905).
Conclusions and relevance: In this qualitative study, physician practice leaders reported significant time and financial costs of participating in the MIPS program. Attention to reducing the burden of MIPS may be warranted.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance: The Merit-based Incentive Payment System (MIPS) is a major Medicare value-based purchasing program, influencing payment for more than 1 million clinicians annually. There is a growing concern that MIPS increases administrative burden, and little is known about what it costs physician practices to participate in the program.
Objective: To examine the costs for independent physician practices to participate in MIPS in 2019.
Design setting and participants: This qualitative study identified and interviewed leaders of physician practices participating in the US Centers for Medicare & Medicaid Services (CMS) MIPS program, including those in MIPS alternative payment models. Time required and financial costs were calculated from responses to in-depth, semistructured interviews conducted from December 12, 2019, to June 23, 2020. Physician practices were categorized by size (small, 1-9 physicians; medium, 10-25; and large, ≥50), specialty (primary care, general surgery, or multispecialty), and US census region. Participants were asked about 2019 costs related to clinician and staff time, information technology, and external vendors. Time was converted to financial costs using the Medical Group Management Association's Provider Compensation and the Management and Staff Compensation databases.
Main outcomes and measures: Annual time spent by staff on MIPS-related activities and mean per-physician costs to physician practices in 2019.
Results: Leaders of 30 physician practices (9 [30.0%] small primary care, 6 [20.0%] small general surgery, 4 [13.3%] medium primary care, 4 [13.3%] medium general surgery, and 7 [23.3%] large multispecialty) represented all US census regions, and 14 of the 30 (46.7%) practices participated in a MIPS alternative payment model in 2019. The mean per-physician cost to practices of participating in MIPS was $12 811 (interquartile range [IQR], $2861-$17 715). Physicians, clinical staff, and administrative staff together spent 201.7 (IQR, 50.9-295.2) hours annually per physician on MIPS-related activities. Medical assistants and nursing staff together spent a mean of 99.2 (IQR, 0-163.3) hours per physician each year; frontline physicians spent 53.6 (IQR, 0.6-55.8) hours; executive administrators spent 28.6 (IQR, 3.1-26.7) hours; other clinicians and staff spent a combined 20.3 (IQR, 0-36.8) hours. Physician time accounted for the greatest proportion of overall MIPS-related costs (54%; $6909; IQR, $94-$9905).
Conclusions and relevance: In this qualitative study, physician practice leaders reported significant time and financial costs of participating in the MIPS program. Attention to reducing the burden of MIPS may be warranted.
Objective: To examine the costs for independent physician practices to participate in MIPS in 2019.
Design setting and participants: This qualitative study identified and interviewed leaders of physician practices participating in the US Centers for Medicare & Medicaid Services (CMS) MIPS program, including those in MIPS alternative payment models. Time required and financial costs were calculated from responses to in-depth, semistructured interviews conducted from December 12, 2019, to June 23, 2020. Physician practices were categorized by size (small, 1-9 physicians; medium, 10-25; and large, ≥50), specialty (primary care, general surgery, or multispecialty), and US census region. Participants were asked about 2019 costs related to clinician and staff time, information technology, and external vendors. Time was converted to financial costs using the Medical Group Management Association's Provider Compensation and the Management and Staff Compensation databases.
Main outcomes and measures: Annual time spent by staff on MIPS-related activities and mean per-physician costs to physician practices in 2019.
Results: Leaders of 30 physician practices (9 [30.0%] small primary care, 6 [20.0%] small general surgery, 4 [13.3%] medium primary care, 4 [13.3%] medium general surgery, and 7 [23.3%] large multispecialty) represented all US census regions, and 14 of the 30 (46.7%) practices participated in a MIPS alternative payment model in 2019. The mean per-physician cost to practices of participating in MIPS was $12 811 (interquartile range [IQR], $2861-$17 715). Physicians, clinical staff, and administrative staff together spent 201.7 (IQR, 50.9-295.2) hours annually per physician on MIPS-related activities. Medical assistants and nursing staff together spent a mean of 99.2 (IQR, 0-163.3) hours per physician each year; frontline physicians spent 53.6 (IQR, 0.6-55.8) hours; executive administrators spent 28.6 (IQR, 3.1-26.7) hours; other clinicians and staff spent a combined 20.3 (IQR, 0-36.8) hours. Physician time accounted for the greatest proportion of overall MIPS-related costs (54%; $6909; IQR, $94-$9905).
Conclusions and relevance: In this qualitative study, physician practice leaders reported significant time and financial costs of participating in the MIPS program. Attention to reducing the burden of MIPS may be warranted.
15.
Khullar, Dhruv; Bond, Amelia M.; Qian, Yuting; O'Donnell, Eloise; Gans, David N.; Casalino, Lawrence P.
Physician Practice Leaders' Perceptions of Medicare's Merit-Based Incentive Payment System (MIPS) Journal Article
In: Journal of General Internal Medicine, vol. 6, iss. 12, pp. 3752-3758, 2021.
Abstract | Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Physician Practice Leaders' Perceptions of Medicare's Merit-Based Incentive Payment System (MIPS)},
author = {Dhruv Khullar and Amelia M. Bond and Yuting Qian and Eloise O'Donnell and David N. Gans and Lawrence P. Casalino},
doi = {https://doi.org/10.1007/s11606-021-06758-w},
year = {2021},
date = {2021-04-09},
urldate = {2021-04-09},
journal = {Journal of General Internal Medicine},
volume = {6},
issue = {12},
pages = {3752-3758},
abstract = {Background: Medicare’s Merit-based Incentive Payment System (MIPS) is a major value-based purchasing program. Little is known about how physician practice leaders view the program and its benefits and challenges.
Objective: To understand practice leaders’ perceptions of MIPS.
Design and Participants: Interviews were conducted from December 12, 2019, to June 23, 2020, with leaders of 30 physician practices of various sizes and specialties across the USA. Practices were randomly selected using the Medical Group Management Association’s membership database. Practices included small primary care and general surgery practices (1–9 physicians); medium primary care and general surgery practices (10–25 physicians); and large multispecialty practices (50 or more physicians). Participants were asked about their perceptions of MIPS measures; the program’s effect on patient care; administrative burden; and rationale for participation.
Main Measures: Major themes related to practice participation in MIPS.
Key Results: Interviews were conducted with 30 practices representing all US census regions. Six major themes emerged: (1) MIPS is understood as a continuation of previous value-based payment programs and a precursor to future programs; (2) measures are more relevant to primary care practices than other specialties; (3) leaders are conflicted on whether the program improves patient care; (4) MIPS creates a substantial administrative burden, exacerbated by annual programmatic changes; (5) incentives are small relative to the effort needed to participate; and (6) external support for participation can be helpful. Many participants indicated that their practice only participated in MIPS to avoid financial penalties; some reported that physicians cared for fewer patients due to the program’s administrative burden.
Conclusions: Practice leaders reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. They held mixed views on whether the program improves patient care. These findings may be useful to policymakers hoping to improve MIPS.},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Background: Medicare’s Merit-based Incentive Payment System (MIPS) is a major value-based purchasing program. Little is known about how physician practice leaders view the program and its benefits and challenges.
Objective: To understand practice leaders’ perceptions of MIPS.
Design and Participants: Interviews were conducted from December 12, 2019, to June 23, 2020, with leaders of 30 physician practices of various sizes and specialties across the USA. Practices were randomly selected using the Medical Group Management Association’s membership database. Practices included small primary care and general surgery practices (1–9 physicians); medium primary care and general surgery practices (10–25 physicians); and large multispecialty practices (50 or more physicians). Participants were asked about their perceptions of MIPS measures; the program’s effect on patient care; administrative burden; and rationale for participation.
Main Measures: Major themes related to practice participation in MIPS.
Key Results: Interviews were conducted with 30 practices representing all US census regions. Six major themes emerged: (1) MIPS is understood as a continuation of previous value-based payment programs and a precursor to future programs; (2) measures are more relevant to primary care practices than other specialties; (3) leaders are conflicted on whether the program improves patient care; (4) MIPS creates a substantial administrative burden, exacerbated by annual programmatic changes; (5) incentives are small relative to the effort needed to participate; and (6) external support for participation can be helpful. Many participants indicated that their practice only participated in MIPS to avoid financial penalties; some reported that physicians cared for fewer patients due to the program’s administrative burden.
Conclusions: Practice leaders reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. They held mixed views on whether the program improves patient care. These findings may be useful to policymakers hoping to improve MIPS.
Objective: To understand practice leaders’ perceptions of MIPS.
Design and Participants: Interviews were conducted from December 12, 2019, to June 23, 2020, with leaders of 30 physician practices of various sizes and specialties across the USA. Practices were randomly selected using the Medical Group Management Association’s membership database. Practices included small primary care and general surgery practices (1–9 physicians); medium primary care and general surgery practices (10–25 physicians); and large multispecialty practices (50 or more physicians). Participants were asked about their perceptions of MIPS measures; the program’s effect on patient care; administrative burden; and rationale for participation.
Main Measures: Major themes related to practice participation in MIPS.
Key Results: Interviews were conducted with 30 practices representing all US census regions. Six major themes emerged: (1) MIPS is understood as a continuation of previous value-based payment programs and a precursor to future programs; (2) measures are more relevant to primary care practices than other specialties; (3) leaders are conflicted on whether the program improves patient care; (4) MIPS creates a substantial administrative burden, exacerbated by annual programmatic changes; (5) incentives are small relative to the effort needed to participate; and (6) external support for participation can be helpful. Many participants indicated that their practice only participated in MIPS to avoid financial penalties; some reported that physicians cared for fewer patients due to the program’s administrative burden.
Conclusions: Practice leaders reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. They held mixed views on whether the program improves patient care. These findings may be useful to policymakers hoping to improve MIPS.
16.
Khullar, Dhruv; Schpero, William L.; Bond, Amelia M.; Qian, Yuting; Casalino, Lawrence P.
Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System Journal Article
In: JAMA, vol. 324, iss. 10, pp. 975-983, 2020.
Abstract | Links | BibTeX | Tags: Drivers of Health, Payment Reform and Health Care Incentives
@article{nokey,
title = {Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System},
author = {Dhruv Khullar and William L. Schpero and Amelia M. Bond and Yuting Qian and Lawrence P. Casalino},
doi = {https://doi.org/10.1001/jama.2020.13129},
year = {2020},
date = {2020-09-08},
urldate = {2020-09-08},
journal = {JAMA},
volume = {324},
issue = {10},
pages = {975-983},
abstract = {Importance: The US Merit-based Incentive Payment System (MIPS) is a major Medicare value-based payment program aimed at improving quality and reducing costs. Little is known about how physicians' performance varies by social risk of their patients.
Objective: To determine the relationship between patient social risk and physicians' scores in the first year of MIPS.
Design, setting, and participants: Cross-sectional study of physicians participating in MIPS in 2017.
Exposures: Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile.
Main outcomes and measures: The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted -4% to 4% based on scores.
Results: The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, -10.7 [95% CI, -11.0 to -10.4]; highest vs lowest, -11.2 [95% CI, -11.6 to -10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, -8.3 percentage points [95% CI, -8.7 to -8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, -13.9 percentage points [95% CI, -14.4 to -13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001).
Conclusions and relevance: In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.},
keywords = {Drivers of Health, Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
Importance: The US Merit-based Incentive Payment System (MIPS) is a major Medicare value-based payment program aimed at improving quality and reducing costs. Little is known about how physicians' performance varies by social risk of their patients.
Objective: To determine the relationship between patient social risk and physicians' scores in the first year of MIPS.
Design, setting, and participants: Cross-sectional study of physicians participating in MIPS in 2017.
Exposures: Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile.
Main outcomes and measures: The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted -4% to 4% based on scores.
Results: The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, -10.7 [95% CI, -11.0 to -10.4]; highest vs lowest, -11.2 [95% CI, -11.6 to -10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, -8.3 percentage points [95% CI, -8.7 to -8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, -13.9 percentage points [95% CI, -14.4 to -13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001).
Conclusions and relevance: In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.
Objective: To determine the relationship between patient social risk and physicians' scores in the first year of MIPS.
Design, setting, and participants: Cross-sectional study of physicians participating in MIPS in 2017.
Exposures: Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile.
Main outcomes and measures: The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted -4% to 4% based on scores.
Results: The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, -10.7 [95% CI, -11.0 to -10.4]; highest vs lowest, -11.2 [95% CI, -11.6 to -10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, -8.3 percentage points [95% CI, -8.7 to -8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, -13.9 percentage points [95% CI, -14.4 to -13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001).
Conclusions and relevance: In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.
17.
Casalino, Lawrence P.
Technical Assistance for Primary Care Practice Transformation: Free Help to Perform Unpaid Labor? Journal Article
In: Annals of Family Medicine, vol. 16 , no. Suppl 1 , pp. S12-S15, 2018.
Links | BibTeX | Tags: Payment Reform and Health Care Incentives
@article{nokey,
title = {Technical Assistance for Primary Care Practice Transformation: Free Help to Perform Unpaid Labor? },
author = {Lawrence P. Casalino},
doi = {https://doi.org/10.1370/afm.2226},
year = {2018},
date = {2018-04-09},
urldate = {2018-04-09},
journal = {Annals of Family Medicine},
volume = {16 },
number = {Suppl 1 },
pages = {S12-S15},
keywords = {Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}
18.
Khullar, Dhruv; Burke, Gregory C.; Casalino, Lawrence P.
Can Small Physician Practices Survive? Sharing Services as a Path to Viability Journal Article
In: JAMA, vol. 319, iss. 13, pp. 1321–1322, 2018.
Links | BibTeX | Tags: Corporatization and Consolidation, Payment Reform and Health Care Incentives
@article{nokey,
title = {Can Small Physician Practices Survive? Sharing Services as a Path to Viability},
author = {Dhruv Khullar and Gregory C. Burke and Lawrence P. Casalino},
doi = {10.1001/jama.2017.21704},
year = {2018},
date = {2018-04-03},
urldate = {2018-04-03},
journal = {JAMA},
volume = {319},
issue = {13},
pages = {1321–1322},
keywords = {Corporatization and Consolidation, Payment Reform and Health Care Incentives},
pubstate = {published},
tppubtype = {article}
}