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Purpose:Implementing episode based payment models requires a detailed understanding of health care utilization throughout the 90-day postoperative episode. This includes nonindex hospital readmissi...

This case-control study examines the association between counties that adopted state mask mandates in Kansas with COVID-19 cases, hospitalizations, and deaths.

Importance Medicare’s Comprehensive Care for Joint Replacement (CJR) model, initiated in 2016, is a national episode-based payment model for lower-extremity joint replacement (LEJR). Metropolitan statistical areas (MSAs) were randomly assigned to participation. In the third year of the program, Medicare made hospital participation voluntary in half of the MSAs and enabled LEJRs for knees to be performed in the outpatient setting without being subject to episode-based payment. How these changes affected program savings is unclear. Objective To estimate savings from the CJR program over time and assess how responses by hospitals to changing incentives were associated with those savings. Design, Participants, and Setting This controlled population-based study used Medicare claims data from January 1, 2014, to December 31, 2019, to analyze the spending for beneficiaries who received LEJR in 171 MSAs randomized to CJR vs typical payment. One-quarter of beneficiaries before and after the April 1, 2016, start date were excluded as a 6-month washout period (January 1 to June 30, 2016) to allow time in the evaluation period for hospitals to respond to the program rules. Main Outcomes and Measures The main outcomes were episode spending and, starting in year 3 of the program, the hospitals’ decision to no longer participate in CJR and perform LEJRs in the outpatient setting. Results Data from 1 087 177 patients (mean [SD] age, 74.4 [8.4] years; 692 604 women [63.7%]; 980 635 non-Hispanic White patients [90.2%]) were analyzed. Over the first 4 years of CJR, 321 038 LEJR episodes were performed at 702 CJR hospitals, and 456 792 episodes were performed at 826 control hospitals. From the second to the fourth year of the program, savings in CJR vs control MSAs diminished from −$976 per LEJR episode (95% CI, −$1340 to −$612) to −$331 (95% CI, −$792 to $130). In MSAs where hospital participation was made voluntary in the third year, more hospitals in the highest quartile of baseline spending dropped out compared with the lowest quartile (56 of 60 [93.3%] vs 29 of 56 [51.8%]). In MSAs where participation remained mandatory, CJR hospitals shifted fewer knee replacements to the outpatient setting in years 3 to 4 than controls (12 571 of 59 182 [21.2%] vs 21 650 of 68 722 [31.5%] of knee LEJRs). In these mandatory MSAs, 75% of the reduction in savings per episode from years 1 to 2 to years 3 to 4 of the program ($455; 95% CI, $137-$722) was attributable to CJR hospitals’ decision on which patients would undergo surgery or whether the surgical procedure would occur in the outpatient setting. Conclusions and Relevance This controlled population-based study found that savings observed in the second year of CJR largely dissipated by the fourth year owing to a combination of responses among hospitals to changes in the program. These results suggest a need for caution regarding the design of new alternative payment models.

Breast imaging radiologists are considered by many to be leaders among diagnostic radiologists in the transition to value-based care. Many strategies for success in the changing healthcare landscape are exemplified by the day-to-day practice of breast imaging, including well-developed quality measures, standardized accepted best practices and terminology, and a prominent role in communicating with patients and coordinating care. Further development of these strategies will be important for continued success in both the Merit-Based Incentive Payment System and in alternative payment models.

This cohort study examines whether communities in Medicare’s Comprehensive Care for Joint Replacement (CJR) Model are representative of others nationwide with respect to residents’ socioeconomic status.

Among 84,447 radiotherapy (RT) courses for Medicare beneficiaries age≥65 with prostate cancer treated with external beam RT (EBRT), brachytherapy, or both, 42,608 (51%) were delivered in hospital-affiliated and 41,695 (49%) in freestanding facilities. Freestanding centers were less likely to use EBRT+brachytherapy than EBRT (OR 0.84 [95%CI 0.84–0.84];p

Background The coincidence of Black Lives Matter (BLM) protests with the COVID-19 pandemic in the USA has raised concerns about the safety of mass gatherings for political causes. This study examines two databases to probe any correlation between protests and increases of COVID-19 case rates afterward. Methods A BLM protest aggregator and a county-level COVID-19 database were crosswalked, matching the city that the protest occurred in with the county and its case rates at 0, 1, 2 and 3 weeks after the index protest, and was compared with a control county in the same state with the nearest match of population size and case rate at Week 0. Results In the 22 days after the killing of George Floyd, there were 326 counties participating in 868 protests, attended by an estimated 757 077 protestors. The median case rate at Week 3 was 0.0049 in protest counties versus 0.0041 in control counties, which was found to be statistically significant. Regression analysis found that each individual protestor contributed to the case rate by 7.65 × 10−9, which was not statistically significant. Conclusion Although the increase was statistically significant, it was very small in magnitude and likely due to limitations of significantly different population sizes in comparators.

PURPOSE: An episode-based payment model, the Radiation Oncology Alternative Payment Model (RO-APM), has been proposed for Medicare reimbursement of radiation services provided to oncology patients. RO-APM may have significant impact on reimbursement for specific patient populations. METHODS: This investigation compares historical fee-for-service technical reimbursement estimates at a large hospital-based system to the RO-APM for advanced radiotherapy treatment of specific cancer types. These advanced techniques, stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), online-adaptive SBRT, and proton therapy, were specifically chosen because they are resource intensive and are correspondingly among the most expensive radiation oncology procedures. A total of 203 Medicare patients were analyzed. RESULTS: RO-APM base-rate reimbursements were similar for SRS and were 38%-47% higher for SBRT. The proposed rates were 1%-31% lower for online-adaptive SBRT, and 48%-71% lower for proton therapy. CONCLUSION: These data suggest that the RO-APM may have the desired effect of encouraging shorter courses of radiotherapy, such as SBRT. However, emerging technologies that require large capital and operating investments may see an overall significant reduction in proposed reimbursement.

This study describes monthly test, test positivity, and case rates for coronavirus disease 2019 (COVID-19) among individuals detained by US Immigration and Customs Enforcement (ICE) between April and August 2020.

Background and Aims Malnutrition Inflammation score (MIS) is a risk score published in 2001 (Kalantar-Zadeh, 2001) and validated in 2008 (Rambod, 2009). It is associated with a high mortality and morbidity risk in hemodialysis (HD) patients (pts). Currently, HD pts population is composed of much older individuals, submitted to a high efficient treatment with access to pharmacological and nutritional therapy, assured by a bundled payment, when comparing with the validation study population. The objective of this study is to evaluate if MIS maintain its predictive risk assessment. Method Cross sectional analysis of HD pts from 25 outpatient clinics. MIS was evaluated at the study baseline. Univariable and multivariable Cox additive regression models were used to analyze the data. C-index was estimated to assess the performance of the final model. A level of significance of α= 0.05 was considered. Results A total of 2444 pts were analyzed (59.0% males; 32.0% diabetic) during a median period of 48 months (P25=31; P75=48), 875 patients registered MIS In univariable analysis using Cox additive model, the main results were: In multivariable analysis, adjusting for age, nPNA, IDWG, Kt/V and diabetes, a MIS ≥ 5 and ≥ 7 showed, respectively, a HR of 1.761 (IC 95%, p Conclusion The findings of this analysis confirms that MIS maintains a discriminative power to identify higher risk of mortality. In this model, age and diabetes also correlate with mortality risk increase, while nPNA, IDWG and Kt/V have the opposite effect.

Uses a contemporary bundled payment reform and a difference-in-differences research design to estimate spillovers from Medicare payment reforms to non-Medicare populations

Medicare's Bundled Payments for Care Improvement (BPCI) program, which ran from 2013 to 2018, was an important experiment in physician-focused alternative payment models. However, little is known about whether the program was associated with better quality or outcomes or lower costs.To determine whether participation in BPCI among physician group practices was associated with advantageous or deleterious changes in costs or patient outcomes.This cross-sectional study used 2013 to 2017 Medicare files and difference-in-differences (DID) models to compare the change over time in Medicare payments, patient selection, and clinical outcomes between 91 orthopedic groups in BPCI Model 2 and 169 propensity-matched controls for patients undergoing joint replacement. Analyses were performed between December 2019 and February 2021.Voluntary participation in BPCI.The primary outcome was 90-day Medicare payments; secondary outcomes were patient selection (volume, comorbidities) and clinical outcomes (30-day and 90-day emergency department visits, readmissions, mortality, and healthy days at home).There were 74 343 patient episodes in the baseline period and 102 790 during the intervention in BPCI practices, and 88 147 patient episodes in the baseline period and 120 253 during the intervention in control practices; 291 214 of 461 598 (63.1%) patients were women, and 419 619 (90.9%) were White. At baseline, mean episode payments among BPCI-participating practices were $18 257, which decreased to $15 320 during the intervention, while control practices decreased from $17 927 to $16 170 (DID, -$1180; 95% CI, -$1565 to -$795;Group practice participation in BPCI for joint replacement was associated with reduced Medicare payments and improvements in clinical outcomes.

BACKGROUND: Bundled payment programs broaden hospitals’ responsibility for spending to entire episodes of care. After demonstration programs in cardiac surgery and joint replacement, these payment reforms could soon extend to major operations like colectomy under Medicare’s Bundled Payments for Care Improvement-Advanced Program. OBJECTIVE: To evaluate how specific policies and surgical practice patterns would influence hospital reimbursement in a bundled payment program for colectomy. DESIGN: This was a population-based study. SETTINGS: We used national data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014. PATIENTS: We identified patients undergoing colon resections using Diagnosis Related Group codes and International Classification of Disease, Ninth Revision, Clinical Modification codes. MAIN OUTCOME MEASURES: We simulated per case reconciliation payments as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks among fee-for-service Medicare beneficiaries undergoing colectomy (2010-2014).We projected per-patient and overall hospital-level reconciliation payments and the proportion of hospitals that would achieve shared shavings under bundled payment conditions. We also assessed how variation in the use of laparoscopy could influence shared savings, using instrumental variable methods to account for selection bias between laparoscopic and open procedures. RESULTS: Under simulated bundled payment conditions, 51.8% of hospitals would achieve shared savings, but the average case would incur a reconciliation penalty of −$234 (95% CI −$245 to −$223). Risk-adjustment would increase the proportion of hospitals with shared savings to 54.3% (per case payment +$237, 95% CI $96 to $379). Hospitals performing a greater proportion of cases laparoscopically would achieve higher per case reconciliation payments. For example, per case reconciliation penalties would be −$472 (95% CI −$506 to −$438) for hospitals that performed 10% of their procedures laparoscopically, whereas those that performed 70% laparoscopically would receive payments of +$294 (95% CI $262 to $326). LIMITATIONS: Alternative payment models for colectomy have not yet been introduced. CONCLUSIONS: Surgical leaders must be prepared with strategies for optimizing episode efficiency. Inclusion of risk-adjustment in bundled payment calculations and expanding utilization of laparoscopic surgery may represent approaches to achieve shared-savings and improve surgeon engagement in alternative payment models for surgical care. See Video Abstract at http://links.lww.com/DCR/A928.

US policy makers are making efforts to simultaneously improve the quality of and reduce spending on health care through alternative payment models such as bundled payment. Bundled payment models are predicated on the theory that aligning financial incentives for all providers across an episode of care will lower health care spending while improving quality. Whether this is true remains unknown. Using national Medicare fee-for-service claims for the period 2011-12 and data on hospital quality, we evaluated how thirty- and ninety-day episode-based spending were related to two validated measures of surgical quality-patient satisfaction and surgical mortality. We found that patients who had major surgery at high-quality hospitals cost Medicare less than those who had surgery at low-quality institutions, for both thirty- and ninety-day periods. The difference in Medicare spending between low- and high-quality hospitals was driven primarily by postacute care, which accounted for 59.5 percent of the difference in thirty-day episode spending, and readmissions, which accounted for 19.9 percent. These findings suggest that efforts to achieve value through bundled payment should focus on improving care at low-quality hospitals and reducing unnecessary use of postacute care.

Date Presented 03/28/20 As the population ages, bundled payment initiatives are being used to optimize quality and cost outcomes. Currently, research on these new models does not describe OT’s value. In response, this presentation will describe current evidence on the total joint arthroplasty bundled-payment initiative, articulate OT’s value throughout the care continuum, and generate recommendations for practice and research. Primary Author and Speaker: Ryan Walsh Additional Authors and Speakers: Asari Yahata Contributing Authors: Gail Fisher, Natalie Leland

This study examines how the reduced use of institutional post–acute care in Medicare’s Comprehensive Care for Joint Replacement program affected patients who underwent lower extremity joint replacement.

BACKGROUND: Episode-based payment (EBP) is gaining traction among payers as an alternative to fee-for-service reimbursement. However, there is concern that EBP could influence the number of episodes. OBJECTIVE: To examine how procedure volume changed after the introduction of EBP in 2013 and 2014 under the Arkansas Health Care Payment Improvement Initiative. DESIGN: Using 2011–2016 commercial claims data, we estimate a difference-in-differences model to assess the impact of EBP on the probability of a beneficiary having an episode for four procedures that were reimbursed under EBP in Arkansas: total joint replacement, cholecystectomy, colonoscopy, and tonsillectomy. PARTICIPANTS: Commercially insured beneficiaries in Arkansas serve as our treatment group, while commercially insured beneficiaries in neighboring states serve as our comparison group. INTERVENTIONS: Statewide implementation of EBP for various clinical conditions by two of Arkansas’ largest commercial insurers. MAIN MEASURES: For a given procedure type, the primary outcomes are the annual rate of procedures (number of procedures per 1000 beneficiaries) and the probability of a beneficiary undergoing that procedure in a given quarter. KEY RESULTS: The relationship between EBP and procedure volume varies across procedures. After EBP was implemented, the probability of undergoing colonoscopy increased by 17.2% (point estimate, 2.63; 95% CI, 1.18 to 4.08; p

This study characterizes participation of skilled nursing facilities in Medicare’s Model 3 Bundled Payments for Care Improvement (BPCI) initiative and the factors associated with that participation.

Episode-based payment bundles a single lumped payment around a health care event, such as ischemic stroke. Hospitals are already experienced with a type of episode-based payment for stroke, the diagnosis-related group payment system. Ischemic stroke fits well into an episode-based system because (1) ischemic stroke is common, (2) an ischemic stroke care episode lasts for a definable period of time, and (3) ischemic stroke care costs are high and episode-based payment could provide savings. In an episode-based ischemic stroke care payment system built around cost savings, it is unclear whether neurologists would provide savings. Neurologists need to prove, and define, the value they bring to ischemic stroke care.

Purpose of review Use of budget-based payment methodologies (capitation and episode-based bundled payment) has been demonstrated to drive value in healthcare delivery. With a focus on high-volume, high-cost surgical procedures, inclusion of anaesthesiology services in these methodologies is likely. This review provides a summary of budget-based payment methodologies and practical information necessary for anaesthesiologists to prepare for participation in these programmes. Recent findings Although few examples of anaesthesiologists' participation in these models exist, an understanding of the structure of these programmes and opportunities for participation are available. Prospective preparation in developing anaesthesiology-specific bundled payment profiles and early participation in pathway development associated with selected episodes of care are essential for successful participation as a gainsharing partner. Summary With significant opportunity to contribute to care coordination and cost management, anaesthesiology can play an important role in budget-based payment programmes and should expect to participate as full gainsharing partners. Precise costing methodologies and accurate economic modelling, along with identification of quality management and cost control opportunities, will help identify participation opportunities and appropriate payment and gainsharing agreements. Anaesthesiology-specific examples with budget-based payment models are needed to help guide increased participation in these programmes.

We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment Improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.

Objective To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures. Methods Using 2008-2011 Surveillance, Epidemiology, and End Results-Medicare linked data, we identified all beneficiaries aged greater than 65 years who underwent cystectomy, prostatectomy, or nephrectomy for cancer. Total episode payments were determined by aggregating hospital, professional, and post-acute care claims from the index surgical hospitalization through 90 days post discharge. Total episode payments were then compared to examine hospital level-variation within each procedure type and the specific payment components (ie, index hospitalization, professional, readmission, and post-acute care) driving spending variation. Results Ninety-day episodes of care were identified for 1849 cystectomies, 8770 prostatectomies, and 4304 nephrectomies. We observed wide variation in mean episode payments for all 3 conditions (cystectomy mean $35,102: range $24,112-$57,238, prostatectomy mean $10,803: range $8,816-$17,877, nephrectomy mean $17,475: range $11,681-$26,711). Majority of payment variation was attributable to index hospitalization and post-acute care for cystectomy and nephrectomy and professional payments for prostatectomy. The most expensive hospitals by procedure each demonstrated a unique opportunity for spending reduction due to individual differences in component payment patterns between hospitals. Conclusion Ninety-day episode payments for urologic cancer surgery vary widely across hospitals in the United States. The key drivers of this payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urologic cancer care.

Background The hepatitis C virus (HCV) epidemic in the United States disproportionately impacts people who inject drugs (PWID) who account for 80% of new infections and have a high prevalence of chronic infection. Baltimore City has the highest case rate of HCV in the state of Maryland with over 25% of new cases statewide occurring in the city. Only 10% of PWID have access to directly acting antiviral (DAA) therapy and are cured of HCV. Medication-assisted treatment (MAT) is currently offered in isolated facilities with limited access to other specialty care. In this study, we collocated HCV care continuum in a MAT facility offering opioid agonist therapy and psychosocial interventions Methods Collocation of HCV care was initiated in an MAT (methadone and buprenorphine) clinic, the University of Maryland Drug Treatment Center (UMDTC) serving over 700 patients, for Opioid Use Disorder (OUD) in Baltimore City (Figure 1). Screening for HCV was expanded through health education of patients and staff and expanded testing. HCV antibody-positive patients were linked to care with an experienced HCV provider or referred to hepatologists (decompensated cirrhosis). Results Most of the attendees were African-American with an average age of 52 years. 354 out of 701 clients attending clinic for methadone/suboxone (50.5%) were screened for HCV. Of the 251 patients who were hepatitis C antibody positive (70% of tested), 54 had undetectable HCV RNA. 46 had no HCV RNA labs available. 151 of the remaining HCV Ab positive patients who had a detectable HCV RNA result were evaluated for treatment (Figure 2). At initial assessment, 45 (48%) with liver fibrosis staged greater than F3, including 25 (27%) with cirrhosis. Sixty-four patients initiated DAA therapy. Fifty-four patients completed treatment (84%). Forty patients achieved sustained virologic response (100%) and 14 patients who completed treatment await SVR labs. Conclusion Collocation of HCV care continuum in MAT setting is an effective way to achieve micro elimination of HCV. The follow-up of this marginalized population still remains challenging given the high rates of homelessness and incarceration. In this regard, coordinated care between MAT settings and prisons are likely to demonstrate successful elimination of hepatitis C. Disclosures All authors: No reported disclosures.

Background Hepatitis C virus (HCV) infection has received significant attention in recent years due to the ability for near universal cure, the price of therapy, and increasing incidence due to injection drug use. While the discussion largely focuses on HCV infection in adults, children with HCV are a consistent minority of patients with long-term adverse outcomes of HCV. Few studies have defined the healthcare utilization of HCV-infected children. Objective To define trends in pediatric HCV cases and healthcare utilization using a national administrative database. Methods The Pediatric Health Information Systems (PHIS) database contains inpatient encounter-level data from tertiary care pediatric hospitals in the United States. We identified pediatric HCV cases using validated ICD-9/ICD-10 diagnosis codes (070.41, 070.44, 070.51, 070.54, 070.70, 070.71, V0262, B18.2). We evaluated total cases identified, year of presentation, patient age, geographic location by state, aggregate cost of providing care and HIV-coinfection (ICD-9 code 042/ICD-10 code B20). Results Since 1992, there were 2,175 unique pediatric patients identified with HCV infection. Case rates were highest in patients 15–17 years with a peak of 24 cases/10,000 admissions that fell to 10 cases /10,000 in 2,000 and a low of 1 case/10,000 in 2015. Alarmingly, the rate in this group was back over two cases/10,000 in 2016 and 2017. HCV case rates in children 11–14 were the second highest with more sustained peak from 1992 to 2006 and no precipitous decline. There were 49 patients with HIV co-infection, with rates highest prior to 1998 (range of 6.5–18%), but since 2002 have been

Background Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals.

IMPORTANCE: Medicare’s Bundled Payments for Care Improvement (BPCI) is a voluntary pilot program evaluating bundled payments for several common cardiovascular conditions. Evaluating the external validity of this program is important for understanding the effects of bundled payments on cardiovascular care. OBJECTIVE: To determine whether participants in BPCI cardiovascular bundles are representative of US acute care hospitals and identify factors associated with participation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study of hospitals participating in BPCI model 2 bundles for acute myocardial infarction (AMI), congestive heart failure (CHF), coronary artery bypass graft, and percutaneous coronary intervention and nonparticipating control hospitals (October 2013 to January 2017). The BPCI participants were identified using data from the Centers for Medicare and Medicaid Services, and controls were identified using the 2013 American Hospital Association’s Survey of US Hospitals. Hospital structural characteristics and clinical performance data were obtained from the American Heart Association survey and Centers for Medicare and Medicaid Services. One hundred fifty-nine hospitals participating in BPCI model 2 cardiac bundles and 1240 nonparticipating control hospitals were compared, and a multivariable logistic regression was estimated to identify predictors of BPCI participation. EXPOSURES: Bundled payments. MAIN OUTCOMES AND MEASURES: Hospital-level structural characteristics and 30-day risk-adjusted readmission and mortality rates for AMI and CHF. RESULTS: Compared with nonparticipants, BPCI participants were larger, more likely to be privately owned or teaching hospitals, had lower Medicaid bed day ratios (ratio of Medicaid inpatient days to total inpatient days: 17.0 vs 19.3; P

This study uses Medicare data to compare the characteristics of hospitals that did vs did not realize episodes savings under the Centers for Medicare & Medicaid Services’ Comprehensive Care for Joint Replacement program, which bundled payments for hip and knee surgery and paid bonuses to hospitals that exceeded quality and cost benchmarks.

Background The Medicare program has initiated Comprehensive Care for Joint Replacement (CJR), a bundled payment mandate for lower extremity joint replacements. We sought to determine the degree to which hospitals will invest in care redesign in response to CJR, and to project its economic impacts. Methods We defined 4 potential hospital management strategies to address CJR: no action, light care management, heavy care management, and heavy care management with contracting. For each of 798 hospitals included in CJR, we used hospital-specific volume, cost, and quality data to determine the hospital's economically dominant strategy. We aggregated data to assess the percentage of hospitals pursuing each strategy; savings to the health care system; and costs and percentages of CJR-derived revenues gained or lost for Medicare, hospitals, and postacute care facilities. Results In the model, 83.1% of hospitals (range 55.0%-100.0%) were expected to take no action in response to CJR, and 16.1% of hospitals (range 0.0%-45.0%) were expected to pursue heavy care management with contracting. Overall, CJR is projected to reduce health care expenditures by 0.5% (range 0.0%-4.1%) or $14 million (range $0-$119 million). Medicare is expected to save 2.2% (range 2.2%-2.2%), hospitals are projected to lose 3.7% (range 4.7% loss to 3.8% gain), and postacute care facilities are expected to lose 6.5% (range 0.0%-12.8%). Hospital administrative costs are projected to increase by $63 million (range $0-$148 million). Conclusion CJR is projected to have a negligible impact on total health care expenditures for lower extremity joint replacements. Further research will be required to assess the actual care management strategies adopted by CJR hospitals.

Cancer is a medically complex and expensive disease with costs projected to rise further as new treatment options increase and the United States population ages. Studies showing significant regional variation in oncology quality and costs and model tests demonstrating cost savings without adverse outcomes suggest there are opportunities to create a system of oncology care in the US that delivers higher quality care at lower cost.The Centers for Medicare and Medicaid Services (CMS) have designed an episode-based payment model centered around 6 month periods of chemotherapy treatment. Monthly per-patient care management payments will be made to practices to support practice transformation, including additional patient services and specific infrastructure enhancements. Quarterly reporting of quality metrics will drive continuous quality improvement and the adoption of best practices among participants. Practices achieving cost savings will also be eligible for performance-based payments. Savings are expected through improved care coordination and appropriately aligned payment incentives, resulting in decreased avoidable emergency department visits and hospitalizations and more efficient and evidence-based use of imaging, laboratory tests, and therapeutic agents, as well as improved end of life care.New therapies and better supportive care have significantly improved cancer survival in recent decades. This has come at a high cost, with cancer therapy consuming $124 billion in 2010. CMS has designed an episode-based model of oncology care that incorporates elements from several successful model tests. By providing care management and performance based payments in conjunction with quality metrics and a rapid learning environment, it is hoped that this model will demonstrate how oncology care in the US can transform into a high value, high quality system.