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Is Maryland's all-payer/global budget program an incremental step toward single payer?

Changes in Health Care Use Associated With the Introduction of Hospital Global Budgets in Maryland

By Eric T. Roberts, PhD; J. Michael McWilliams, MD, PhD; Laura A. Hatfield, PhD; Sule Gerovich, PhD; Michael E. Chernew, PhD; Lauren G. Gilstrap, MD; Ateev Mehrotra, MD, MPH
JAMA Internal Medicine, January 16, 2018

Abstract

Importance 

In 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program included reducing unnecessary hospital utilization and encouraging greater use of primary care.

Objective 

To compare changes in hospital and primary care use through the first 2 years of Maryland’s hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas.

Design, Setting, and Participants 

We matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption).

Main Outcomes and Measures 

Hospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay).

Results 

We matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean [SD] age, 71.7 [12.5] years). Assuming parallel trends, we estimated a differential change in Maryland of −0.47 annual hospital stays per 100 beneficiaries (95% CI, −1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of −1.24 stays per 100 beneficiaries (95% CI, −2.46 to −0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (−0.8 visits/100 beneficiaries; 95% CI, −10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland’s program.

Conclusions and Relevance 

We did not find consistent evidence that Maryland’s hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.

https://jamanetwork.com...

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Comment:

By Don McCanne, M.D.

Making health care payment rates the same for all payers, public and private, and establishing global budgets for hospitals seem like reasonable steps toward establishing a single payer system. So how has Maryland done so far with this program?

The stated goals were to reduce unnecessary hospital utilization and to encourage greater use of primary care. But they "did not find consistent evidence that Maryland’s hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years." As is typical of unsuccessful policy studies, an accompanying editorial suggests that we should give the study five or ten years before we expect to see any transformation of the delivery system. Sure.

This has in common with other health policy studies the major defect that an isolated policy is studied within the background of our highly dysfunctional, fragmented, multipayer system. You cannot study a universal single payer system unless you have a universal single payer system to study (and they do exist elsewhere).

Right now we are seeing proposals such as a public option, a Medicare or Medicaid buy-in, or a change in the age of Medicare eligibility, all of which some hope eventually would lead to single payer. But when added to our current dysfunctional system, little benefit will be evident because the fundamental defects will remain extant. Each such step will reinforce the views of those who profess that single payer can't work because our system will still be overpriced, too many will still be uninsured or underinsured, and patients will still be deprived of choices of their health care professionals and institutions.

Currently in California there is a proposal for a Medi-Cal Public Option as an incremental step to single payer. That seems to be so far off track that it constitutes a derailment of the Single Payer Express.

We need to end this nonsense of spoon-fed policy and move forward with comprehensive policy that we know works - a single payer national health program. Now. Full steam ahead.

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