Person: Song, Zirui
Loading...
Email Address
AA Acceptance Date
Birth Date
Research Projects
Organizational Units
Job Title
Last Name
Song
First Name
Zirui
Name
Song, Zirui
6 results
Search Results
Now showing 1 - 6 of 6
Publication Financial Incentives in Health Care Reform: Evaluating Payment Reform in Accountable Care Organizations and Competitive Bidding in Medicare(2013-02-25) Song, Zirui; Chernew, Michael Esman; Ayanian, John; Newhouse, Joseph; McGuire, ThomasAmidst mounting federal debt, slowing the growth of health care spending is one of the nation’s top domestic priorities. This dissertation evaluates three current policy ideas: (1) global payment within an accountable care contracting model, (2) physician fee cuts, and (3) expanding the role of competitive bidding in Medicare. Chapter one studies the effect of global payment and pay-for-performance on health care spending and quality in accountable care organizations. I evaluate the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which was implemented in 2009 with seven provider organizations comprising 380,000 enrollees. Using claims and quality data in a quasi-experimental difference-in-differences design, I find that the AQC was associated with a 1.9 percent reduction in medical spending and modest improvements in quality of chronic care management and pediatric care in year one. Chapter two studies Medicare’s elimination of payments for consultations in the 2010 Medicare Physician Fee Schedule. This targeted fee cut (largely to specialists) was accompanied by a fee increase for office visits (billed more often by primary care physicians). Using claims data for 2.2 million Medicare beneficiaries, I test for discontinuities in spending, volume, and coding of outpatient physician encounters with an interrupted time series design. I find that spending on physician encounters increased 6 percent after the policy, largely due to a coding effect and higher office visit fees. Slightly more than half of the increase was accounted for by primary care physician visits, with the rest by specialist visits. Chapter three examines competitive bidding, which is at the center of several proposals to reform Medicare into a premium support program. In competitive bidding, private plans submit prices (bids) they are willing to accept to insure a Medicare beneficiary. In perfect competition, plans bid costs and thus bids are insensitive to the benchmark. Under imperfect competition, bids may move with the benchmark. I study the effect of benchmark changes on plan bids using Medicare Advantage data in a longitudinal market-level model. I find that a $1 increase in the benchmark leads to about a $0.50 increase in bids among Medicare managed care plans.Publication Payment Reform in Massachusetts: Health Care Spending and Quality in Accountable Care Organizations Four Years into Global Payment(2014-07-07) Song, ZiruiBackground: The United States health care system faces two fundamental challenges: a high growth rate of health care spending and deficiencies in quality of care. The growth rate of health care spending is the dominant driver of our nation’s long-term federal debt, while the inconsistent quality of care hinders the ability of the health care system to maximize value for patients. To address both of these challenges, public and private payers are increasingly changing the way they pay providers—moving away from fee-for-service towards global payment contracts for groups of providers coming together as accountable care organizations. This thesis evaluates the change in health care spending and in quality of care associated with moving to global payment for accountable care organizations in Massachusetts in the first 4 years. This thesis studies the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), a global payment contract that provider organizations in Massachusetts began to enter in 2009. The AQC pays provider organizations a risk-adjusted global budget for the entire continuum of care for a defined population of enrollees insured by Blue Cross Blue Shield of Massachusetts. It also awards substantial pay-for-performance incentives for organizations meeting performance thresholds on quality measures. This work assesses its effect on spending and quality through the first 4 years of the contract. Methods: Enrollee-level claims data from 2006-2012 were used with a difference-in-differences design to evaluate the changes in spending and quality associated with the Alternative Quality Contract over the first 4 years. The study population consisted of enrollees in Blue Cross Blue Shield of Massachusetts plans (intervention group) and enrollees in commercial employer-sponsored plans across 5 comparison states (control group). Unadjusted and adjusted results are reported for each comparison between intervention and control. Changes in spending for all 4 AQC cohorts relative to control were evaluated. In adjusted analyses of spending, I used a multivariate linear model at the enrollee-quarter level, controlling for age, sex, risk score, indicators for intervention, quarters of the study period, the post-intervention period, and the appropriate interactions. For analyses of quality, an analogous model at the enrollee-year level was used. Process and outcome quality were evaluated. Results: Seven provider organizations joined the AQC in 2009, with a total of 490,167 individuals who were enrolled for at least 1 calendar year in the study period. The control group had 966,813 unique individuals enrolled for at least 1 year during the study period. Average age, sex, and risk scores before and after the AQC were similar between the two groups. In the 2009 cohort, claims spending grew on average $62.21 per enrollee per quarter less than control over 4 years (p<0.001), a 6.8% savings. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (p<0.001), 9.1% (p<0.001), and 5.8% (p=0.04), respectively, by the end of 2012. Savings on claims were concentrated in the outpatient facility setting, specifically procedures, imaging, and tests (8.7%, 10.9%, and 9.7%, respectively, p<0.001). Organizations with and without risk-contracting experience saw similar average savings of 6.3% and 7.7%, respectively, over 4 years (p<0.001). About 40% of savings were explained by lower volume. Pre-intervention trends were not statistically different between intervention and control (-$4.57, p=0.86), suggesting savings were not driven by inherently different trajectories of spending. No differences in coding intensity were found. In sensitivity analyses, estimates were robust to alterations in the model, variables, and sample. Notably, claims savings were exceeded by incentive payments to providers (shared savings and quality bonuses) in 2009-2011, but exceeded incentives payments in 2012, generating net savings. Improvements in quality among intervention cohorts generally exceeded New England and national comparisons. Quality performance on chronic care measures increased from 79.6% pre-intervention to 84.5% post-intervention in the 2009 cohort, compared to 79.8% to 80.8% for the HEDIS national average, a 3.9 percentage-point relative increase over the 4 years. Analogously, preventive care and pediatric care measures increased 2.7 and 2.4 percentage points relative to control, respectively. On outcome measures, achievement of hemoglobin A1c, LDL cholesterol, and blood pressure control grew by 2.1 percentage points per year in the 2009 cohort after the AQC, while HEDIS averages remained largely unchanged (Figure). Conclusion: After 4 years, physician organizations in the AQC had lower spending growth relative to control and generally outperformed national averages on quality measures. Shared savings coupled with quality bonuses can exceed savings on claims in initial years, but over time, savings on claims may outgrow incentive payments. Incentive payments themselves may serve meaningful purposes, as quality measures may protect against stinting and shared savings may help ease providers into risk contracts. Changes in utilization suggest that this payment model can help modify underlying care patterns, a likely prerequisite for sustainable reform. The AQC experience may be useful to policymakers, insurers, and providers embarking on payment reform. Combining global budgets with pay-for- performance may encourage organizations to embark on the delivery system reforms necessary to slow spending and improve quality.Publication Potentially disruptive life events: what are the immediate impacts on chronic disease management? A case-crossover analysis(BMJ Publishing Group, 2016) Lauffenburger, Julie; Gagne, Joshua; Song, Zirui; Brill, Gregory; Choudhry, NiteeshObjective: To explore the association between unexpected potentially disruptive life events in a patient or family member that may challenge an individual's ability to take medications as prescribed and the discontinuation of evidence-based medications for common, chronic conditions. Understanding the relationship between medication adherence and life stressors, especially those that can be identified using administrative data, may help identify patients at risk of non-adherence. Design: Observational self-controlled case-crossover design. Setting: Individuals in a nationally representative US commercial health insurance database. Participants: Adult individuals who initiated an oral hypoglycaemic, antihypertensive and/or statin and subsequently stopped the medication for ≥90 days. Main outcome measure Potentially disruptive life events among patients and their family members measured in the 30 days just before the medication was discontinued (‘hazard period’) compared with the 30 days before this period (‘control period’). These events included personal injury, hospitalisation, emergency room visits, changes in insurance coverage, acute stress or acute anxiety. Results: Among the 326 519 patients meeting study criteria who discontinued their chronic disease medications, 88 896 (27.2%) experienced at least one potentially disruptive life event. Newly experiencing an injury (OR: 1.26, 95% CI 1.12 to 1.42), an emergency room visit (OR: 1.19, 95% CI 1.13 to 1.26) and acute stress (OR: 1.19, 95% CI 1.08 to 1.31) were associated with discontinuation. Life events among patients’ family members did not appear to be associated with medication discontinuation or occurred less frequently just prior to discontinuation. Conclusions: Potentially disruptive life events among individuals identified using routinely collected claims data are associated with discontinuation of chronic disease medications. Awareness of these events may help providers or payers identify patients at risk of non-adherence to maximise patient outcomes.Publication Potential Consequences of Reforming Medicare Into a Competitive Bidding System(American Medical Association (AMA), 2012) Song, Zirui; Cutler, David; Chernew, MichaelPublication Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices(American College of Physicians, 2015) Basu, Sanjay; Phillips, Russell; Bitton, Asaf; Song, Zirui; Landon, BruceBackground: Physicians have traditionally been reimbursed for face-to-face visits. A new non–visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. Objective: To estimate financial implications of CCM payment for primary care practices. Design: Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. Data Sources: National Ambulatory Medical Care Survey and other published sources. Target Population: Medicare patients. Time Horizon: 10 years. Perspective: Practice-level. Intervention: Comparison of CCM delivery approaches by staff and physicians. Outcome Measures: Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. Results of Base-Case Analysis: If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 000 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. Results of Sensitivity Analysis: If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. Limitation: The CCM program may alter long-term primary care use, which is difficult to predict. Conclusion: Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. Primary Funding Source: None.Publication Workplace Wellness Programs Can Generate Savings(Project HOPE, 2010) Baicker, Katherine; Cutler, David; Song, ZiruiWith health care expenditures soaring, there is increasing interest in workplace-based disease prevention and health promotion as a means of improving health while lowering costs. We conduct a critical meta-analysis of the literature on costs and savings associated such programs, focusing on studies with particularly rigorous methods and examining effects on health care costs and absenteeism. We find that medical costs fall about $3.27 for every dollar spent on wellness programs, and absentee day costs fall by about $2.73 for every dollar spent. This average return on investment suggests that the wider adoption of such programs could prove beneficial for budgets and productivity as well as health outcomes.