Specialty Payment Model Opportunities and Assessment

Specialty Payment Model Opportunities and Assessment: Gastroenterology and Cardiology Model Design Report

Andrew W. Mulcahy
Chris Chan
Samuel Hirshman
Peter J. Huckfeldt
Aaron Kofner
Jodi L. Liu
Susan L. Lovejoy
Ioana Popescu
Justin W. Timbie
Peter S. Hussey
Copyright Date: 2015
Published by: RAND Corporation
Pages: 174
https://www.jstor.org/stable/10.7249/j.ctt14bs4ph
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  • Book Info
    Specialty Payment Model Opportunities and Assessment
    Book Description:

    Gastroenterology and cardiology services are common and costly among Medicare beneficiaries. Episode-based payment models may offer a way to create incentives for high-quality, low-cost care. This report describes research related to the design of episode-based payment models for ambulatory gastroenterology and cardiology services for possible testing by the Centers for Medicare and Medicaid Services’ Center for Medicare and Medicaid Innovation.

    eISBN: 978-0-8330-9021-8
    Subjects: Health Sciences, History

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Preface
    (pp. iii-iii)
  3. Table of Contents
    (pp. iv-vi)
  4. Figures
    (pp. vii-ix)
  5. Tables
    (pp. ix-xi)
  6. Summary
    (pp. xii-xviii)
  7. Acknowledgments
    (pp. xix-xix)
  8. Abbreviations
    (pp. xx-xx)
  9. 1. Background
    (pp. 1-3)

    This report describes research related to the design of payment models for outpatient gastroenterology and cardiology services for possible testing by the Center for Medicare and Medicaid Innovation (CMMI) at the Centers for Medicare and Medicaid Services (CMS). Gastroenterology and cardiology services are common and costly among Medicare beneficiaries. It is estimated that 60– 70 million people are affected by digestive diseases in the United States, resulting in $141.8 billion in health care costs per year (National Digestive Diseases Information Clearinghouse, 2013). Despite technological advances that have decreased gastrointestinal (GI) procedure costs and increased quality of care (Dulai, Fisher, and...

  10. 2. Methods
    (pp. 4-17)

    The study population included Medicare FFS beneficiaries receiving at least one of the gastroenterology and cardiology study procedures listed in Table 2.1 between January 2 and December 24, 2012, allowing for a nine-day episode of analysis occurring entirely in calendar year 2012. We selected the Healthcare Common Procedure Coding System (HCPCS) procedure codes listed in Table 2.1 in consultation with CMS based on general procedure categories initially suggested by CMS (colonoscopy, upper GI endoscopy, cardiac catheterization, and PCI). We selected a nine-day maximum episode duration in consultation with CMS and members of technical expert panels convened by the Brookings Institution....

  11. 3. Results: Gastroenterology Analyses
    (pp. 18-69)

    This chapter describes the results from our analyses in five topic areas: (1) summary of index procedures, (2) considerations regarding setting of service/care delivery, (3) utilization of other services during episodes of care, (4) practice characteristics, and (5) patient characteristics. Analyses of utilization of index procedures, differences between service settings, and related services during episodes of care can inform CMS decisions about episode definition, payment adjustments, and the scope of the payment model. Analyses of practice and patient characteristics can inform decisions about eligibility for payment models.

    This section includes descriptive data on the volume of gastroenterology index procedures. Table...

  12. 4. Results: Cardiology Analyses
    (pp. 70-106)

    This chapter describes the results from our analyses related to new payment approaches for episodes anchored on cardiology index procedures. As in Chapter Three, analyses of utilization of index procedures, differences between service settings, and related services during episodes of care can inform CMS decisions about episode definition, payment adjustments, and the scope of the payment model. Analyses of practice and patient characteristics can inform decisions about eligibility for payment models.

    Table 4.1.1 reports the total volume of eligible cardiology HCPCS codes in the Medicare data and the number of index procedures identified for our study. The highest volume procedures...

  13. 5. Discussion
    (pp. 107-110)

    Our analyses in Chapters Three and Four respond to specific questions from CMS that relate to the design and implementation of episode-based payment approaches for select gastroenterology and cardiology procedures. In this chapter, we summarize key results and discuss the implications of our analyses on episode-based payment models. We highlight how our results could factor into CMS’s future deliberations and decision-making related to new payment models. We close with a separate discussion on model monitoring.

    CMS faces a series of decisions as it considers new payment models for gastroenterology and cardiology services. The premise of our analyses—informed by input...

  14. Appendix
    (pp. 111-152)
  15. References
    (pp. 153-154)