Publications

2020

Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills (Karan R Chhabra, Keegan McGuire, Kyle H Sheetz, John W Scott, Ushapoorna Nuliyalu, Andrew M Ryan)                                         Video: Why Ambulance Rides Are So Expensive In The United States

Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities (Karan R Chhabra, Kyle H Sheetz, Ushapoorna Nuliyalu, Mihir S Dekhne, Andrew M Ryan, Justin B Dimick)

 

2019

Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries (Adam A Markovitz, John M Hollingsworth, John Z Ayanian, Edward C Norton, Nicholas M Moloci, Phyllis L Yan, Andrew M Ryan)

Physician Participation in Medicare Accountable Care Organizations and Spillovers in Commercial Spending (Brady Post, Andrew M Ryan, Nicholas M Moloci, Jun Li, James M Dupree, John M Hollingsworth)

ACOs and the 1%: Changes in Spending Among High-Cost Patients Following the Medicare Shared Savings Program (Adam A Markovitz, Samyukta Mullangi, John M Hollingsworth, Ushapoorna Nuliyalu, Andrew M Ryan)

Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: restrospective cohort study (Roshun Sankaran, Devraj Sukul, Ushapoorna Nuliyalu, Baris Gulseren, Tedi A Engler, Emily Arnston, Hanna Zlotnick, Justin B Dimick, Andrew M Ryan)

Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis (Adam A Markovitz, John M Hollingsworth, John Z Ayanian, Edward C Norton, Phyllis L Yan, Andrew M Ryan)

Changes in coding of pneumonia and impact on the Hospital Readmission Reduction Program (Jason D Buxbaum, Peter K Lindenauer, Colin R Cooke, Ushapoorna Nuliyalu, Andrew M Ryan)

Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement (Kyle H Sheetz, Justin B Dimick, Michael J Englesbe, Andrew M Ryan)

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians (Adam A Markovitz, Michael D Rozier, Andrew M Ryan, Susan D Goold, John Z Ayanian, Edward C Norton, Timothy A Peterson, John M Hollingsworth)

A delicate balance: Accountability for very high-cost patients in new payment models (Samyukta Mullangi, Matthew J Press, Andrew M Ryan)

Accuracy of quality measurement for the Hospital Acquired Conditions Reduction Program (Kyle H Sheetz, Andrew M Ryan)

 

2018

Association of Coded Severity with Readmission Reduction After the Hospital Readmissions Reduction Program (Andrew M Ibrahim, Justin B Dimick, Shashank S Sinha, John M Hollingsworth, Ushapoorna Nuliyalu, Andrew M Ryan)

Sprint to work: A novel model for team science collaboration in academic medicine (Shashank S Sinha, Tedi A Engler, Brahmajee K Nallamothu, Andrew M Ibrahim, Ann Verhey-Henke, Marianna Kerppola, Chad Ellimoottil, Andrew M Ryan)

Well‐Balanced or too Matchy–Matchy? The Controversy over Matching in Difference‐in‐Differences (Andrew M Ryan)

Modeling the Cost-Effectiveness of Pay-for-Performance in Primary Care for the UK (Ankur Pandya, Tim Doran, Jinyi Zhu, Simon Walker, Emily Arntson, Andrew M Ryan)

Now Trending: Coping with Non-Parallel Trends in Difference-in-Differences Analysis (Andrew M Ryan, Evangelos Kontopantelis, Ariel Linden, James F Burgess)

 

2017

Association Between Hospitals' Engagement in Value-Based Reforms and Readmission Reduction in the Hospital Readmission Reduction Program (Andrew M Ryan, Sam Krinsky, Julia Adler-Milstein, Cheryl L Damberg, Kristin A Maurer, John M Hollingsworth)

Changes in Hospital Quality Associated with Hospital Value-Based Purchasing (Andrew M Ryan, Sam Krinsky, Kristin A Maurer, Justin B Dimick)

The incremental effects of antihypertensive drugs: instrumental variable analysis (Adam A Markovitz, Jacob A Mack, Brahmajee K Nallamothu, John Z Ayanian, Andrew M Ryan)

Risk Adjustment May Lessen Financial Burden Imposed on Hospitals That Treat Complex Patients in Medicare's New Cardiac Bundled Payment Program (Adam A Markovitz, Andrew M Ryan, Chad Ellimoottil, Sam Mullangi, Devraj Sukul, Brahmajee K Nallamothu, Lena Chen)

Rising Use of Observation Care Among the Commercially Insured May Lead to Total and Out-of-Pocket Cost Savings (Emily R Adrion, Keith E Kocher, Brahmajee K Nallamothu, Andrew M Ryan)

 

2016

Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study (Andrew M Ryan, Sam Krinsky, Evangelos Kontopantelis, Tim Doran

 

2014

Methods for Evaluating Changes in Health Care Policy: The Difference-in-Differences Approach (Justin B Dimick, Andrew M Ryan)  

 

Funding

Our center is funded by the grants listed below:

National Institute on Aging: The Comparative Effectiveness of Sequential Implementation of Hospital Value-Based Purchasing

 Despite the widespread use of financial incentives to improve value in health care, the comparative
effectiveness and unintended consequences of alternative designs of these programs remains unclear. The
Patient Protection and Affordable Care Act established Hospital Value-Based Purchasing (HVBP), making
Medicare payment subject to quality performance for Acute Care Hospitals in the United States. The objective
of the current project is to apply econometric methods to longitudinal Medicare data and primary data from a
national survey of hospital administrators to compare the effectiveness and unintended consequences of the
alternative incentive structures of HVBP as the program evolves in its first five years of implementation. The
following three aims will be addressed: 1) Evaluate the comparative effectiveness of alternative incentive
designs of HVBP. It is expected that HVBP will have a greater impact on patient mortality and patient
experience as the financial incentives increase over time and performance measures shift from a focus on
compliance with evidence-based medicine (process measures) to a focus on mortality and patient experience.
The analysis strategy will take two general approaches, testing for differences in performance improvement for
the incentivized measures between hospitals exposed and not exposed to HVBP, and testing for differences in
performance improvement between diagnoses that are incentivized and not incentivized under HVBP; 2)
Evaluate the unintended consequences of alternative incentive designs of HVBP. It is expected that the
unintended consequences of HVBP – including the distribution of incentive payments away from hospitals
caring for disadvantaged patients and attenuated improvements in care for patients treated in these hospitals –
will become more severe over time as incentives increase and are shifted toward outcome performance; 3)
Understand the barriers and facilitators to value improvement in HVBP. The study team will field a national
survey to assess hospital administrators' knowledge of HVBP, perceptions of the costs and benefits of value
improvement, perceptions of unintended consequences, perceptions of the barriers and facilitators to value
improvement, and the specific strategies used for value improvement in HVBP. We will contrast survey
responses between high and low performing hospitals in HVBP. The proposed research is significant because
it will provide crucial information to inform the incentive structure in future years of HVBP to increase value for
Medicare while minimizing unintended consequences for hospitals and patients. Our national survey of hospital
administrators is innovative because it would provide the first estimates of how hospitals responded to the
incentives of HVBP. Approximately 190,000 Medicare patients admitted to hospitals each year with heart
attack, heart failure, or pneumonia die within 30 days of admission. A 1% reduction in 30-day mortality rates
would leave 1,900 of these patients alive after 30 days. This potential impact of HVBP underscores the
importance of understanding how HVBP can be optimally designed to improve care.

Agency for Healthcare Research and Quality: Changes in Hospital Quality, Safety, and Spending under the Hospital Acquired Condition Reduction Program

Hospital acquired conditions (HACs) are common, costly, and deadly. Despite recent reductions, HACs still
occur at a rate of 121 events per 1,000 discharges. Building on previous payment reforms to reduce HACs, the
Centers for Medicare and Medicaid Services initiated the Hospital Acquired Condition Reduction Program
(HACRP). However, the effect of expanding incentives for patient safety under the new HACRP is unknown.
The objective of the current proposal is to understand the impact of the HACRP on patient and system
outcomes and the specific strategies used by successful hospitals to improve under the program. Our proposal
will address the following three aims: Aim 1: Evaluate the effects of the Hospital Acquired Condition
Reduction Program on patient outcomes. We will evaluate the effects of the HACRP on both targeted
measures (e.g. patient safety indicators) and downstream outcomes (e.g. 30-day mortality and readmission).
We will examine how much administrative changes (e.g. increases in coded severity and changes to
denominator criteria) explain the impact of the HACRP. We hypothesize that the HACRP will lead to decreases
in targeted measures but will have an attenuated effect on downstream outcomes. We also hypothesize that
hospitals with more revenue at risk under the program and hospitals that are engaged in more value-based
reforms will experience greater improvements in targeted outcomes; Aim 2: Evaluate the effects of the
Hospital Acquired Condition Reduction Program on spending. We will evaluate the effects of the HACRP
on 30-day total episode spending as well as spending related to the index hospitalization, physician services,
readmissions, hospital outpatient care, and post-acute care services. We hypothesize that the HACRP will lead
to decreases in total episode spending as well as the downstream components of episode spending; Aim 3:
Evaluate the factors responsible for improvement under the Hospital Acquired Condition Reduction
Program. We will perform a case study analysis of hospitals in Michigan that participate in the Michigan Value
Collaborative, a partnership between BlueCross BlueShield of Michigan and 75 acute care hospitals in
Michigan working to improve quality and value. We hypothesize that hospitals that are engaged in systematic
quality improvement efforts will experience greater improvements on both targeted performance measures and
downstream patient outcomes. Our study is significant because our findings will be used to inform decision
makers at the CMS about the impact of new reimbursement mechanisms on quality, safety, and spending. Our
findings will also provide hospitals and clinician leaders with actionable insights about how to improve HACs.
Our study is innovative because it uses unique data linkages, provider collaboratives, and multiple methods to
evaluate upstream and downstream effects of a key policy reform.