IMPORTANCE Bundled Payments for Care Improvement (BPCI) is a voluntary initiative of the Centers for Medicare & Medicaid Services to test the effect of holding an entity accountable for all services provided during an episode of care on episode payments and quality of care. OBJECTIVE To evaluate whether BPCI was associated with a greater reduction in Medicare payments without loss of quality of care for lower extremity joint (primarily hip and knee) replacement episodes initiated in BPCI-participating hospitals that are accountable for total episode payments (for the hospitalization and Medicare-covered services during the 90 days after discharge). DESIGN, SETTING, AND PARTICIPANTS A difference-indifferences approach estimated the differential change in outcomes for Medicare fee-for-service beneficiaries who had a lower extremity joint replacement at a BPCI-participating hospital between the baseline (October 2011 through September 2012) and intervention (October 2013 through June 2015) periods and beneficiaries with the same surgical procedure at matched comparison hospitals. EXPOSURE Lower extremity joint replacement at a BPCI-participating hospital. MAIN OUTCOMES AND MEASURES Standardized Medicare-allowed payments (Medicare payments), utilization, and quality (unplanned readmissions, emergency department visits, and mortality) during hospitalization and the 90-day postdischarge period. RESULTS There were 29 441 lower extremity joint replacement episodes in the baseline period and 31 700 in the intervention period (mean [SD] age, 74.1 [8.89] years; 65.2% women) at 176 BPCI-participating hospitals, compared with 29 440 episodes in the baseline period (768 hospitals) and 31 696 episodes in the intervention period (841 hospitals

he Centers for Disease Control and Prevention 1 estimates that a quarter of adults in the United States report having a mental illness at any given time and about half will experience mental illness during their lifetime. In the wake of the Connecticut school shooting and other recent mass shootings, policy makers and the public have called for increased access to mental health services. 2 For example, President Obama's "Now Is the Time" proposal, released in January 2013, called for better mental health services, including programs to identify diagnosable mental health problems early so that patients can be referred for treatment, and increased training of mental health professionals. 2 Psychiatrists play an important role in the diagnosis and treatment of patients with mental illnesses particularly because of their training and ability to prescribe medications. 3 One issue that advocates for increased mental health access have neglected to explore is limited access owing to psychiatrists' refusal to accept insurance. 4 In previous studies, we and others have shown that overall physician acceptance rates for private noncapitated insurance was high but declining modestly in recent years. [5][6][7] Little is known about specialty differences in insurance acceptance rates, but prior reports suggest that nonacceptance of insurance may be particularly high for psychiatrists.IMPORTANCE There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance.OBJECTIVE To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties. DESIGN, SETTING, AND PARTICIPANTSWe used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not. MAIN OUTCOMES AND MEASURESOur main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings

Principles of patient-centered care imply that physicians should use electronic communication with patients more extensively, including as a substitute for office visits when clinically appropriate. We interviewed leaders of 21 medical groups that use electronic communication with patients extensively and also interviewed staff in six of these groups. Electronic communication was widely perceived to be a safe, effective and efficient means of communication that improves patient satisfaction and saves patients time, but increases the volume of physician work unless office visits are reduced. Practice redesign and new payment methods are likely necessary for electronic communication to be used more extensively.

Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

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