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Principal Investigator: ANAEZE C OFFODILE
Organization: SLOAN-KETTERING INST CAN RESEARCH
Fiscal Year: 2024
Award: $494,244
Funding agency: National Cancer Institute
Project Summary/Abstract
In 2014, the state of Maryland, under a federal waiver, enacted an all-payer Global Budget Revenue (GBR)
model that prospectively set limits on hospital revenue. It also required the state to limit growth in per-capita
spending and mandated reductions in preventable complications and readmissions. GBR implementation was
associated with savings to the Medicare Trust Fund and considerations are now underway to expand the
program to other regions. However, there is limited understanding of GBR’s impact on the delivery of cancer-
related services. It is possible that while GBR may incentivize reduced healthcare expenditures and care
improvements on average, it could be associated with unintended effects and poor performance for cancer
patients by limiting access to effective cancer treatments. GBR may have deleterious effects on prevailing
cancer care inequities by encouraging adverse patient selection towards racial minorities and patients with
socioeconomic vulnerability due to concerns about higher spending and worse clinical outcomes. Current
evaluations of the GBR program have not examined these impacts. We aim to address this evidence gap in
this proposal. Our research is important because acute hospital care, the focus of GBR incentives, is a key
driver of overall spending and regional variation in spending for patients with cancer.
The objective of this proposal is to systematically examine, via a difference-in-differences design, the impact
of the GBR model on spending, quality-of-care, and utilization among fee-for-service Medicare beneficiaries
and nonelderly Medicaid and commercial insurance beneficiaries with cancer in Maryland compared with
similar patients in control states. Our central hypothesis is that the financial incentives in GBR will lower
spending, improve care quality, and facilitate a shift in the site of care for chemotherapy administration across
our populations of interest. Additionally, we hypothesize that GBR implementation will lead to relatively worse
clinical outcomes and relatively greater spending for historically marginalized patients. We will test our
hypotheses and achieve our objectives with the following specific aims: Aim 1: Quantify the impact of GBR on
risk-adjusted spending for beneficiaries undergoing chemotherapy. Aim 2: Assess the impact of GBR on the
likelihood of chemotherapy receipt and on care quality for beneficiaries undergoing chemotherapy. Aim
3: Assess the impact of GBR on the type of chemotherapy (physician-administered vs. oral) and site of
physician-administered chemotherapy (hospital outpatient department vs. physician office setting). Aim 4:
Assess the differential effects of GBR implementation on care delivery for historically marginalized patients,
based on area-level deprivation, race and ethnicity, and dual-eligible status, who are undergoing
chemotherapy. Our findings will meaningfully advance our understanding of how to deliver efficient, high-
quality cancer care to adult patients. It will also provide timely information to policy-makers that would guide
updates to GBR and mitigate the risk of unintended consequences in future global budget initiatives.
Terms: <21+ years old><Accident and Emergency department><Acute><Address><Adopted><Adult><Adult Human><Adverse effects><Affect><Area><Budgets><Cancer Patient><Cancer Treatment><Cancers><Caring><Centers for Medicare and Medicaid Services><Clinical><Consultations><Cost Containment><Cost Control><Drug Therapy><Drugs><ED visit><ER visit><Emergency Department><Emergency care visit><Emergency department visit><Emergency hospital visit><Emergency room><Emergency room visit><Ethnic Origin><Ethnicity><Evaluation><Fee-for-Service Plans><Fees for Service><Funding><Future><Generalized Growth><Growth><Health Care Financing Administration><Health Expenditures><Health Insurance for Aged and Disabled, Title 18><Health Insurance for Disabled Title 18><Healthcare><Hospital Admission><Hospitalization><Hospitals><Immune mediated therapy><Immunologically Directed Therapy><Immunotherapy><Incentives><Individual><Inequity><Infusion><Infusion procedures><Institute of Medicine><Institute of Medicine (U.S.)><Insurance><Light><Malignant Neoplasm Therapy><Malignant Neoplasm Treatment><Malignant Neoplasms><Malignant Tumor><Maryland><Medicaid><Medical><Medicare><Medication><Modeling><NAS/IOM><Oncologist><Oncology><Oncology Cancer><Oral><Out-patients><Outcome><Outpatients><Patient Care><Patient Care Delivery><Patient Selection><Patients><Performance><Pharmaceutical Preparations><Pharmacotherapy><Photoradiation><Physicians><Physicians' Offices><Policy Maker><Population><Price><Provider><Public Health><QOC><Quality of Care><Quasi-experiment><Quasi-experimental analysis><Quasi-experimental approach><Quasi-experimental design><Quasi-experimental methods><Quasi-experimental research><Quasi-experimental study><Quasi-experimental technique><Race><Races><Reporting><Research><Risk><Risk Adjustment><Savings><Services><Site><Structure><System><Testing><Time><Tissue Growth><Title 18><Trust><United States><United States Centers for Medicare and Medicaid Services><United States Health Care Financing Administration><Update><Variant><Variation><Visit><access disparities><access restrictions><accessibility disparities><acute care><adulthood><anti-cancer therapy><beneficiary><cancer care><cancer therapy><cancer-directed therapy><care delivery><care episode><care for patients><care of patients><care outcomes><caring for patients><chemotherapy><consultation><cost><deprivation><design><designing><disparities in access><drug treatment><drug/agent><dual eligible><end of life><end-of-life><financial incentive><financial reward><health care><health care expenditure><health care outcomes><health insurance for disabled><healthcare expenditure><healthcare outcomes><hospice enrollment><hospice use><hospice utilization><hospital care><hospital re-admission><hospital readmission><hospital services><immune therapeutic approach><immune therapeutic interventions><immune therapeutic regimens><immune therapeutic strategy><immune therapy><immune-based therapies><immune-based treatments><immuno therapy><improved><inequality in access><inequity in access><inequity in accessibility><infusions><inpatient care><inpatient service><interest><malignancy><marginalization><marginalized group><marginalized individual><marginalized people><marginalized population><medical expenditure><monetary incentive><mortality><neoplasm/cancer><ontogeny><outpatient programs><outpatient services><patient centered><patient oriented><payment><prevent><preventing><pricing><programs><prospective><racial><racial background><racial minority><racial origin><re-admission><re-hospitalization><readmission><rehospitalization><response><risk mitigation><social><socio-economic><socio-economically><socioeconomically><socioeconomics><targeted drug therapy><targeted drug treatments><targeted therapeutic><targeted therapeutic agents><targeted therapy><targeted treatment><waiver>