Association of Maryland Global Budget Revenue With Spending and Outcomes Related to Surgical Care for Medicare Beneficiaries With Cancer

Abstract

IMPORTANCEIn 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care. OBJECTIVE To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states.DESIGN, SETTING, AND PARTICIPANTS Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011)(2012)(2013) to after (2015)(2016)(2017)(2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection). MAIN OUTCOMES AND MEASURESThirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. RESULTSRelative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, −4.3 to −0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures.CONCLUSIONS AND RELEVANCE Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.

Implementation of the Maryland Global Budget Revenue Model and Variation in the Expenditures and Outcomes of Surgical Care

“…All studies reported a reduction in either the costs of the index hospitalization or total care episode payments after surgery. One study reported total care episode Medicare payments after surgery as $47,137 and $41,955 in the pre-GBR and post-GBR groups, respectively 12. However, this study was excluded from our pooled analysis because it was the only one to adopt this payer perspective (ie, Medicare) and scope (ie 30-day care episode).…”

“…All studies reported a reduction in readmission rates in the Maryland post-GBR group. After accounting for data overlap, 5 studies including 57,055 patients in the pre-GBR group and 68,911 patients in the post-GBR group were included in the analytic sample 12,14–16,19. Overall, 2217 and 2564 readmissions were reported in the pre-GBR and post-GBR groups, respectively.…”

“…All studies reported a reduction in mortality after surgery in the Maryland post-GBR group. After accounting for data overlap, four studies including 59,688 patients in the pre-GBR group and 71,550 patients in the post-GBR group were included in the analytic sample 12,14,15,21. Mortality was reported in 194 (0.003%) patients in the pre-GBR group and 199 (0.002%) patients in the post-GBR group.…”

“…After accounting for data overlap, 5 studies including 57,055 patients in the pre-GBR group and 68,911 patients in the post-GBR group were included in the analytic sample. 12,[14][15][16]19 Overall, 2217 and 2564 readmissions were reported in the pre-GBR and post-GBR groups, respectively. The pooled estimate rates of the occurrence of a readmission after surgery favored the post-GBR group with an OR of 0.78 (95% CI, 0.72-0.85, P < 0.001) (Fig.…”

“…11 Within the context of surgical care, previous evidence suggests that GBR implementation is associated with varied effects on clinical outcomes, health resource utilization, and costs. 8,[12][13][14][15][16][17][18][19][20][21] Synthesizing this evidence will be of considerable interest to surgeon leaders, hospital administrators, and policy experts, particularly considering the growing interest in disseminating the GBR program beyond Maryland. 22,23 We therefore conducted a systematic review and meta-analysis to appraise the current evidence of the effect of the GBR program on surgical outcomes.…”