Choosing Outcomes-Based Reimbursement Policies: Should We Worry About Collusion?

References

• Adida E, Bravo F (2019) Contracts for healthcare referral services: Coordination via outcome-based penalty contracts. Management Sci. 65(3):1322–1341.Link, Google Scholar
• Adida E, Bravo F (2023) Primary care first initiative: Impact on care delivery and outcomes. Manufacturing Service Oper. Management 25(4):1471–1488.Google Scholar
• Adida E, Mamani H, Nassiri S (2017) Bundled payment vs. fee-for-service: Impact of payment scheme on performance. Management Sci. 63(5):1271–1656.Google Scholar
• Andritsos DA, Tang CS (2018) Incentive programs for reducing readmissions when patient care is co-produced. Production Oper. Management 27(6):999–1020.Crossref, Google Scholar
• Arifoğlu K, Ren H, Tezcan T (2021) Hospital readmissions reduction program does not provide the right incentives: Issues and remedies. Management Sci. 67(4):2191–2210.Link, Google Scholar
• Aswani A, Shen Z, Siddiq A (2019) Data-driven incentive design in the Medicare shared savings program. Oper. Res. 67(4):1002–1026.Abstract, Google Scholar
• Ata B, Killaly BL, Olsen TL, Parker RP (2013) On hospice operations under Medicare reimbursement policies. Management Sci. 59(5):1027–1044.Link, Google Scholar
• Baliga S, Sjöström T (1998) Decentralization and collusion. J. Econom. Theory 83(2):196–232.Crossref, Google Scholar
• Bastani H, Bayati M, Braverman M, Gummadi R, Johari R (2016) Analysis of Medicare pay-for-performance contracts. Accessed June 29, 2024, https://ssrn.com/abstract=2839143.Google Scholar
• Bond AM, Schpero WL, Casalino LP, Zhang M, Khullar D (2022) Association between individual primary care physician merit-based incentive payment system score and measures of process and patient outcomes. JAMA 328(21):2136–2146.Crossref, Google Scholar
• Bravo F, Levi R, Perakis G, Romero G (2023) Care coordination for healthcare referrals under a shared-savings program. Production Oper. Management 32(1):189–206.Google Scholar
• Burns LR, Pauly MV (2018) Transformation of the health care industry: Curb your enthusiasm? Milbank Quart. 96(1):57–109.Crossref, Google Scholar
• Cebul RD, et al. (2013) Organizational fragmentation and care quality in the US health care system. Elgauge E, ed. The Fragmentation of US Health Care: Causes and Solutions (Oxford University Press, Oxford, UK), 37–61. Google Scholar
• Centers for Medicare & Medicaid Services (CMS) (2020) Medicare program; Modernizing and clarifying the physician self-referral regulations. Federal Register 85(232):77492–77682.Google Scholar
• Cherian LT, Scott GT, Pine SG (2021) White paper: Value-based safe harbors and exceptions to the Anti-Kickback Statute and Stark Law. K&L Gates Hub, Accessed June 27, 2024, https://www.klgates.com/White-Paper-Value-Based-Safe-Harbors-and-Exceptions-to-the-Anti-Kickback-Statute-and-Stark-Law-2-24-2021.Google Scholar
• Christianson JB, Leatherman S, Sutherland K (2008) Lessons from evaluations of purchaser pay-for-performance programs. Medical Care Res. Rev. 65(S6):S5–S35.Crossref, Google Scholar
• CMS (2020) Medicare value based programs. Accessed July 4, 2024, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.Google Scholar
• Dai T, Akan M, Tayur S (2017) Imaging room and beyond: The underlying economics behind physicians’ test-ordering behavior in outpatient services. Manufacturing Service Oper. Management 19(1):99–113.Link, Google Scholar
• Davis J (2024) The MIPS effect: A surprise twist in estimating Medicare payments for clinicians next year. Online Blog. Accessed June 23, 2024, https://www.mcdermottplus.com/blog/regs-eggs/the-mips-effect-a-surprise-twist-in-estimating-medicare-payments-for-clinicians-next-year/.Google Scholar
• de Vericourt F, Gurkan H, Wang S (2021) Informing the public about a pandemic. Management Sci. 67(10):6350–6357.Link, Google Scholar
• Dyer O (2015) US crackdown on cash for referrals brings more arrests. BMJ 351:h6269.Crossref, Google Scholar
• Eijkenaar F, Emmert M, Scheppach M, Schöffski O (2013) Effects of pay for performance in health care: A systematic review of systematic reviews. Health Policy 110(2–3):115–130.Crossref, Google Scholar
• Fanburg JD, Bibet-Kalinyak I, Dornfeld LM, Gorrell JM (2022) Federal stark law and anti-kickback statute changes for 2022 and beyond. Brach Eichler LLC, Accessed June 27, 2024, https://www.bracheichler.com/wp-content/uploads/2022/03/031522_Stark-Law-Antikickback-Statute_3.15.22-FINAL.pdf.Google Scholar
• Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK (2016) Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: Observational study. BMJ 353:i2214.Crossref, Google Scholar
• Gadre A (2015) India’s private healthcare sector treats patients as revenue generators. BMJ 350:h826.Crossref, Google Scholar
• Ghamat S, Zaric GS, Pun H (2021) Care-coordination: Gain-sharing agreements in bundled payment models. Production Oper. Management 30(5):1457–1478.Crossref, Google Scholar
• Grossman M (1972) On the concept of health capital and the demand for health. J. Political Econom. 80(2):223–255.Crossref, Google Scholar
• Guo P, Tang CS, Wang Y, Zhao M (2019) The impact of reimbursement policy on social welfare, revisit rate, and waiting time in a public healthcare system: Fee-for-service versus bundled payment. Manufacturing Service Oper. Management 21(1):154–170.Link, Google Scholar
• Gupta D, Mehrotra M (2015) Bundled payments for healthcare services: Proposer selection and information sharing. Oper. Res. 63(4):772–788.Link, Google Scholar
• Gupta D, Mehrotra M, Tang X (2021) Gainsharing contracts for CMS’ episode-based payment models. Production Oper. Management 30(5):1290–1312.Google Scholar
• Hölmstrom B (1982) Moral hazard in teams. Bell J. Econom. 13(2):324–340.Crossref, Google Scholar
• Hsieh HM, He JS, Shin SJ, Chiu HC, Lee TC (2017) A diabetes pay-for-performance program and risks of cancer incidence and death in patients with type 2 diabetes in Taiwan. Preventing Chronic Disease 14:E88.Crossref, Google Scholar
• Hwang W, Jónasson JO, Peura H (2025) Favorable risk selection in Medicare Advantage: The effect of allowing non-medical services. Manufacturing Service Oper. Management. Forthcoming.Google Scholar
• ICHOM (2021) International consortium for outcomes measurement. https://www.ichom.org/.Google Scholar
• Iino H, Hashiguchi M, Hori S (2022) Estimating the range of incremental cost-effectiveness thresholds for healthcare based on willingness to pay and GDP per capita: A systematic review. PLoS One 17(4):e0266934.Crossref, Google Scholar
• Jiang H, Pang Z, Savin S (2012) Performance-based contracts for outpatient medical services. Manufacturing Service Oper. Management 14(4):654–669.Link, Google Scholar
• Koff E, Lyons N (2020) Implementing value-based health care at scale: The NSW experience. Med. J. Australia 212(3):104–106.Crossref, Google Scholar
• Laffont JJ, Martimort D (1998) Collusion and delegation. RAND J. Econom. 29(2):280–305.Crossref, Google Scholar
• Lee DK, Zenios SA (2012) An evidence-based incentive system for Medicare’s end-stage renal disease program. Management Sci. 58(6):1092–1105.Link, Google Scholar
• Lim JM, Moon K, Savin S (2023) Searching for the best yardstick: Cost of quality improvements in the US hospital industry. Management Sci. 70(6):3769–3788.Link, Google Scholar
• Mannava KA, Bercovitch L, Grant-Kels JM (2013) Kickbacks, Stark violations, client billing, and joint ventures: Facts and controversies. Clin. Dermatol. 31(6):764–768.Crossref, Google Scholar
• Mathur R, Bhaskaran K, Edwards E, Lee H, Chaturvedi N, Smeeth L, Douglas I (2017) Population trends in the 10-year incidence and prevalence of diabetic retinopathy in the UK: A cohort study in the Clinical Practice Research Datalink 2004–2014. BMJ Open 7(2):e014444.Crossref, Google Scholar
• McGuire TG (2000) Physician agency. Culyer AJ, Newhouse JP, eds. Handbook Health Econom. vol. 1 (Part A) (Elsevier, Amsterdam), 461–536. Google Scholar
• Moberly T, Stahl-Timmins W (2019) QOF now accounts for less than 10% of GP practice income. BMJ 365:l1489.Crossref, Google Scholar
• NEJM Catalyst (2018) What are bundled payments? https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0247.Google Scholar
• Office of Inspector General (OIG) (2020) Medicare and state health care programs: Fraud and abuse; revisions to safe harbors under the Anti-Kickback Statute, and civil monetary penalty rules regarding beneficiary inducements. Federal Register 85(232):77684–77895.Google Scholar
• Pauly MV (1979) The ethics and economics of kickbacks and fee splitting. Bell J. Econom. 10(1):344–352.Crossref, Google Scholar
• Pauly M, Redisch M (1973) The not-for-profit hospital as a physicians’ cooperative. Amer. Econom. Rev. 63(1):87–99.Google Scholar
• Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S (2006) Does pay-for-performance improve the quality of health care? Ann. Intern. Med. 145(4):265–272.Crossref, Google Scholar
• Porter ME (2010) What is value in health care? New England J. Med. 363(26):2477–2481.Crossref, Google Scholar
• Rajagopalan S, Tong C (2022) Payment models to coordinate healthcare providers with partial attribution of outcome costs. Manufacturing Service Oper. Management 24(1):600–616.Link, Google Scholar
• Rathi VK, McWilliams JM (2019) First-year report cards from the merit-based incentive payment system (MIPS): What will be learned and what next? JAMA 321(12):1157–1158.Crossref, Google Scholar
• Reddig K (2019) Participation and performance in accountable care organizations. Accessed July 4, 2024, https://api.semanticscholar.org/CorpusID:211806093.Google Scholar
• Reid RO, Tom AK, Ross RM, Duffy EL, Damberg CL (2022) Physician compensation arrangements and financial performance incentives in US health systems. JAMA Health Forum 3(1):e214634.Crossref, Google Scholar
• Rodwin MA (1995) Medicine, Money, and Morals: Physicians’ Conflicts of Interest (Oxford University Press on Demand, Oxford, UK).Google Scholar
• Rosenthal MB, Dudley RA (2006) Pay for performance: A decision guide for purchasers. Agency Healthcare Res. Quality (AHRQ) (6):1–47.Google Scholar
• Rosenthal MB, Dudley RA (2007) Pay-for-performance: Will the latest payment trend improve care? JAMA 297(7):740–744.Crossref, Google Scholar
• Ryan AM, Krinsky S, Maurer KA, Dimick JB (2017) Changes in hospital quality associated with hospital value-based purchasing. New England J. Med. 376(24):2358–2366.Crossref, Google Scholar
• Sanderson M, Allen P, Gill R, Garnett E (2018) New models of contracting in the public sector: A review of alliance contracting, prime contracting and outcome‐based contracting literature. Soc. Policy Admin. 52(5):1060–1083.Crossref, Google Scholar
• She Z, Ayer T, Montanera D (2022) Can big data cure risk selection in healthcare capitation programs? A game theoretical analysis. Manufacturing Service Oper. Management 24(6):3117–3134.Link, Google Scholar
• So KC, Tang CS (2000) Modeling the impact of an outcome-oriented reimbursement policy on clinic, patients, and pharmaceutical firms. Management Sci. 46(7):875–892.Link, Google Scholar
• Suen S, Negoescu D, Goh J (2022) Design of incentive programs for optimal medication adherence in the presence of observable consumption. Oper. Res. 70(3):1691–1716.Link, Google Scholar
• Thornton D, Mueller RM, Schoutsen P, van Hillegersberg J (2013) Predicting healthcare fraud in Medicaid: A multidimensional data model and analysis techniques for fraud detection. Procedia Tech. 9:1252–1264.Crossref, Google Scholar
• Tezcan T (2023) Navigating incentive challenges in capitation payment models: A novel retrospective payment model. Preprint, submitted November 1, http://dx.doi.org/10.2139/ssrn.4615485.Google Scholar
• Tirole J (1986) Hierarchies and bureaucracies: On the role of collusion in organizations. J. Law., Econom., Organ. 2(2):181–214.Google Scholar
• UK BMA (2023) Quality and outcomes framework (QOF). British Medical Association. Accessed June 29, 2024, https://www.bma.org.uk/advice-and-support/gp-practices/funding-and-contracts/quality-and-outcomes-framework-qof.Google Scholar
• UK NHS (2023) QOF 2022-23 results. United Kingdom National Health Service. Accessed June 29, 2024, http://content.digital.nhs.uk/qof.Google Scholar
• US DoJ (2021) Justice department recovers over $2.2 billion from false claims act cases in fiscal year 2020. U.S. Department of Justice. Public Release. Accessed June 28, 2024, https://www.justice.gov/opa/pr/justice-department-recovers-over-22-billion-false-claims-act-cases-fiscal-year-2020.Google Scholar
• US DoJ (2022) Justice department’s false claims act settlements and judgments exceed $5.6 billion in fiscal year 2021. U.S. Department of Justice. Public Release. Accessed June 28, 2024, https://www.justice.gov/opa/pr/justice-department-s-false-claims-act-settlements-and-judgments-exceed-56-billion-fiscal-year.Google Scholar
• US DoJ (2023) False claims act settlements and judgments exceed $2 billion in fiscal year 2022. U.S. Department of Justice. Public Release. Accessed June 28, 2024, https://www.justice.gov/opa/pr/false-claims-act-settlements-and-judgments-exceed-2-billion-fiscal-year-2022.Google Scholar
• US DoJ (2024) False claims act settlements and judgments exceed $2.68 billion in fiscal year 2023. U.S. Department of Justice. Public Release. Accessed June 28, 2024, https://www.justice.gov/opa/pr/false-claims-act-settlements-and-judgments-exceed-268-billion-fiscal-year-2023.Google Scholar
• US Senate (2016) Examining the stark law: Current issues and opportunities. U.S. Senate Hearing 114-668. Accessed June 28, 2024, https://www.congress.gov/event/114th-congress/senate-event/LC52008/text.Google Scholar
• WEF (2018) Value in healthcare: Mobilizing cooperation for health system transformation. World Economic Forum. Accessed July 4, 2024, https://www.weforum.org/reports/value-in-healthcare-mobilizing-cooperation-for-health-system-transformation.Google Scholar
• Woolhandler S, Himmelstein DU (2004) The high costs of for-profit care. Canadian Med. Assoc. J. 170(12):1814–1815.Crossref, Google Scholar
• Zhang C, Atasu A, Ayer T, Toktay LB (2020) Truthful mechanisms for medical surplus product allocation. Manufacturing Service Oper. Management 22(4):735–753.Link, Google Scholar
• Zhang DJ, Gurvich I, Van Mieghem JA, Park E, Young RS, Williams MV (2016) Hospital readmissions reduction program: An economic and operational analysis. Management Sci. 62(11):3351–3371.Link, Google Scholar
• Zhu J, Park C, Gupta L, Mukherjee D (2020) New payment models in MedTech. Deloitte Insights. Accessed January 26, 2023, https://www2.deloitte.com/us/en/insights/industry/life-sciences/medical-device-business-model-payments.html.Google Scholar