@article {635805,
	title = {Changes in Health Care Use Associated With the Introduction of Hospital Global Budgets in Maryland},
	journal = {JAMA Internal Medicine },
	volume = {178},
	number = {2},
	year = {2018},
	pages = {260-268},
	abstract = {IMPORTANCE:In 2014, the State of\&nbsp;Maryland\&nbsp;placed the majority of its hospitals under all-payer\&nbsp;global\&nbsp;budgets\&nbsp;for inpatient,\&nbsp;hospitaloutpatient, and emergency department\&nbsp;care. Goals of the program included reducing unnecessary\&nbsp;hospital\&nbsp;utilization and encouraging greater use of primary\&nbsp;care.OBJECTIVE:To compare\&nbsp;changes\&nbsp;in\&nbsp;hospital\&nbsp;and primary\&nbsp;care\&nbsp;use through the first 2 years of\&nbsp;Maryland{\textquoteright}s\&nbsp;hospital\&nbsp;global\&nbsp;budget program among fee-for-service Medicare beneficiaries in\&nbsp;Maryland\&nbsp;vs matched control areas.DESIGN, SETTING, AND PARTICIPANTS:We matched 8\&nbsp;Maryland\&nbsp;counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland\&nbsp;control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared\&nbsp;changes\&nbsp;in\&nbsp;hospital\&nbsp;and primary\&nbsp;care\&nbsp;use in\&nbsp;Maryland\&nbsp;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\&nbsp;Maryland\&nbsp;and the control counties would have remained constant past 2014 had\&nbsp;Maryland\&nbsp;not implemented\&nbsp;global\&nbsp;budgets\&nbsp;(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\&nbsp;stays (defined as admissions and observation stays); return\&nbsp;hospital\&nbsp;stays within 30 days of a prior\&nbsp;hospital\&nbsp;stay; emergency department visits that did not result in admission; price-standardized\&nbsp;hospital\&nbsp;outpatient department (HOPD) utilization; and visits with primary\&nbsp;care\&nbsp;physicians (overall and within 7 days of a\&nbsp;hospital\&nbsp;stay).RESULTS:We matched 8\&nbsp;Maryland\&nbsp;counties with hospitals in the program (94 967 beneficiaries; 41.8\% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland\&nbsp;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\&nbsp;Maryland\&nbsp;of -0.47 annual\&nbsp;hospital\&nbsp;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\&nbsp;Maryland\&nbsp;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\&nbsp;care\&nbsp;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\&nbsp;changes\&nbsp;in emergency department visits, return\&nbsp;hospital\&nbsp;stays, HOPD use, or posthospitalization primary\&nbsp;care\&nbsp;visits\&nbsp;associated\&nbsp;with\&nbsp;Maryland{\textquoteright}s program.CONCLUSIONS AND RELEVANCE:We did not find consistent evidence that\&nbsp;Maryland{\textquoteright}s\&nbsp;hospital\&nbsp;global\&nbsp;budget program was\&nbsp;associated\&nbsp;with reductions in\&nbsp;hospital\&nbsp;use or increases in primary\&nbsp;care\&nbsp;visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.},
	author = {Roberts ET and McWilliams JM and Hatfield LA and Gerovich S and Chernew ME and Gilstrap LG and Mehrotra A}
}
