Maryland's Global Budget Revenue Model: How Do Costs and Readmission Rates Fare for Patients Undergoing Total Knee Arthroplasty?

Abstract

In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011–2013) and post-GBR (2014–2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges (p < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets.

Keywords

total knee arthroplasty - global budget revenue - health care economics

Publication History

Received: 02 January 2020

Accepted: 01 March 2020

Article published online:
05 May 2020

• References

• 1 CMS. National healthcare expenditures 2017 highlights; 2018. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf
• 2 Lovald ST, Ong KL, Lau EC, Schmier JK, Bozic KJ, Kurtz SM. Mortality, cost, and health outcomes of total knee arthroplasty in medicare patients. J Arthroplasty 2013; 28 (03) 449-454
• 3 Krause A, Sayeed Z, El-Othmani M, Pallekonda V, Mihalko W, Saleh KJ. Outpatient total knee arthroplasty: are we there yet? (part 1). Orthop Clin North Am 2018; 49 (01) 1-6
• 4 Courtney PM, Bohl DD, Lau EC, Ong KL, Jacobs JJ, Della Valle CJ. Risk adjustment is necessary in medicare bundled payment models for total hip and knee arthroplasty. J Arthroplasty 2018; 33 (08) 2368-2375
• 5 Background of Vermont's all-payer ACO model. Accessed November 12, 2019 at: www.onecarevt.org
• 6 OneCare Vermont seeks approval of $1.36 billion budget - VTDigger. Accessed November 12, 2019 at: https://vtdigger.org/2019/10/20/onecare-vermont-seeks-approval-of-1-36-billion-budget/
• 7 State announces hospitals, payers selected for Pennsylvania's rural health payment model | PAMED. Accessed November 12, 2019 at: https://www.pamedsoc.org/detail/article/pennsylvania-rural-health-model
• 8 Pennsylvania Rural Health Model | Center for Medicare & Medicaid Innovation. Accessed November 15, 2019 at: https://innovation.cms.gov/initiatives/pa-rural-health-model/
• 9 Beil H, Haber SG, Giuriceo K. et al. Maryland's global hospital budgets: impacts on medicare cost and utilization for the first 3 years. Med Care 2019; 57 (06) 417-424
• 10 Roberts ET, McWilliams JM, Hatfield LA. et al. Changes in health care use associated with the introduction of hospital global budgets in Maryland. JAMA Intern Med 2018; 178 (02) 260-268
• 11 Sharfstein JM, Stuart EA, Antos J. Global budgets in Maryland: assessing results to date. JAMA 2018; 319 (24) 2475-2476
• 12 Healthcare Cost and Utilization Project (HCUP). HCUP Databases. Rockville, MD. March 17, 2020 at: www.hcup-us.ahrq.gov/sidoverview.jsp
• 13 Fraccaro P, Kontopantelis E, Sperrin M. et al. Predicting mortality from change-over-time in the Charlson Comorbidity Index: a retrospective cohort study in a data-intensive UK health system. Medicine (Baltimore) 2016; 95 (43) e4973
• 14 Ahern TP, Bosco JL, Silliman RA. et al. Potential misinterpretations caused by collapsing upper categories of comorbidity indices: an illustration from a cohort of older breast cancer survivors. Clin Epidemiol 2009; 1: 93-100
• 15 Yang C-C, Fong Y, Lin L-C. et al. The age-adjusted Charlson comorbidity index is a better predictor of survival in operated lung cancer patients than the Charlson and Elixhauser comorbidity indices. Eur J Cardiothorac Surg 2018; 53 (01) 235-240
• 16 Cost-to-charge ratio files. Rockville, MD. Accessed March 17, 2020 at: https://www.hcup-us.ahrq.gov/db/state/costtocharge.jsp
• 17 Inflation Calculator CPI. . Bureau of labor statistics. Accessed March 17, 2020 at: https://data.bls.gov/cgi-bin/cpicalc.pl
• 18 Maryland's all-payer hospital model results performance year three; 2018. Accessed July 5, 2019 at: https://hscrc.maryland.gov/Documents/Modernization/MarylandAPMPerformanceReport-CY2016_3_9_18.pdf
• 19 Buchmueller TC, Levinson ZM, Levy HG, Wolfe BL. Effect of the affordable care act on racial and ethnic disparities in health insurance coverage. Am J Public Health 2016; 106 (08) 1416-1421
• 20 Gwam CU, Mohamed NS, Etcheson JI. et al. Changes in total knee arthroplasty utilization since the implementation of ACA: an analysis of patient-hospital demographics, costs, and charges. J Knee Surg 2019. Doi: 10.1055/s-0039-1683926
• 21 Ponnusamy KE, Vasarhelyi EM, Somerville L, McCalden RW, Marsh JD. Cost-effectiveness of total knee arthroplasty vs nonoperative management in normal, overweight, obese, severely obese, morbidly obese, and super-obese patients: a markov model. J Arthroplasty 2018; 33 (7S): S32-S38
• 22 Delanois RE, Gwam CU, Cherian JJ. et al. Global budget revenue on a single institution's costs, outcomes, and patient quality metrics in patients undergoing total knee arthroplasty. J Arthroplasty 2019; 34 (01) 15-19
• 23 An Analysis of Centers for Medicare & Medicaid Service Payment in Maryland: Can a Global Budget Revenue Model Save Money in Lower Extremity Arthroplasty?- Clinical Key. Accessed November 15, 2019 at: https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0883540318308763?returnurl=null&referrer=null
• 24 Meyer H. Pa taps hospitals, payers for rural global budget experiment. Modern Health. Available at: https://www.modernhealthcare.com/payment/pa-taps-hospitals-payers-rural-global-budget-experiment
• 25 Giuriceo K, Haber S, Beil SH. et al. Evaluation of the Maryland all-payer model third annual report. Accessed March, 2018 at: https://downloads.cms.gov/files/cmmi/md-all-payer-thirdannrpt.pdf