June 2020 | No. 2 Medicare for All and Beyond CONFERENCE BRIEF SERIES PAYMENT AND PRICING DECISIONS IN HEALTH CARE REFORM Rate setting, cost control, and public option proposals EDITOR’S NOTE The financial strain on health systems and providers during the COVID-19 pandemic highlights the fragility of our current payment and pricing models. In February 2020, Penn’s Leonard Davis Institute of Health Economics (LDI) held a conference, Medicare for All and Beyond: Expanding Coverage, Containing Costs, which included a panel discussion on payment and pricing.1 Public and private insurers pay strikingly different prices for the same services; one study estimated that commercial health insurers pay nearly 4-5 times as much as Medicare and Medicaid for the kinds of care COVID-19 patients require.2 The broader issue of payment and pricing will figure heavily in upcoming health care reform debates, and is central to the affordability and sustainability of any proposal. INTRODUCTION Any effort to reform health insurance in the United States must tackle At Penn’s LDI Medicare for All and Beyond conference, a panel of the prices we pay for health care. High prices for drugs, hospital beds, researchers, hospital administrators, and policy experts considered and physician services in the private insurance market have resulted issues related to health care payment and pricing that any health in family premiums that average $20,576 a year and out-of-pocket care reform proposal must address, including the implications of rate costs that can pose a financial barrier to getting needed care.3 There setting for providers and patients.1 At what level should these rates be are many complex challenges to addressing prices. Some proposals set to assure access and quality of care, while incentivizing innovation build on the existing Medicare fee schedule, while others suggest and rewarding excellence? promoting alternative payment mechanisms—or even starting from scratch. The stakes are substantial, as many reform proposals rely on reining in prices to achieve the savings necessary to expand health insurance to the uninsured. LDI.UPENN.EDU | @PENNLDI | UNITEDSTATESOFCARE.ORG | @USOFCARE Medicare for All and Beyond CONFERENCE BRIEF SERIES BACKGROUND: The Current Payment Landscape The U.S. insurance market has three main payers: Medicare (financed At what level should provider rates by the federal government), Medicaid (financed by states and the federal government), and private health insurance (funded by be set to assure access and quality of premiums charged to businesses and households). Overall, Medicare and Medicaid account for 49.4% of all health insurance payments, a care, while incentivizing innovation share that has slowly risen over time.4 and rewarding excellence? Because public payers generally cover higher-cost populations (elderly, disabled, and low-income individuals with complicated social needs), per-person annual spending is much higher in Medicare ($12,784) and Medicaid ($8,201, excluding CHIP) than in private health insurance ($6,199).4 But Medicare and Medicaid have been more successful than private insurers in limiting the growth of spending for their enrollees. per-month fee. The private plans establish networks, pay providers, Since 2008, spending per enrollee has increased the most in employer- and are ultimately responsible for most beneficiary costs. Medicare sponsored insurance (46.4%), followed by Medicare (21.5%), and Advantage can control cost growth through annual payment policy Medicaid (12.5%).5 In 2018, for example, per-enrollee spending grew by updates, though some observers argue that Medicare Advantage 6.7% for private insurers, compared to 3.7% and 2.0% for Medicare and overpays relative to fee-for-service beneficiaries.11 Medicare also Medicaid, respectively.6 So, if the privately insured population tends controls spending through a variety of alternative payment models to be younger and healthier, what is driving the surge in spending? In to control utilization and per-episode costs, such as population- short, it is payment and pricing. based Accountable Care Organizations and episode-based bundled payments.5 State Medicaid programs set base payment rates and annual DIVERGING PUBLIC AND PRIVATE RATES increases to providers and hospitals. Providers in Medicaid are paid through either fee-for-service or managed care arrangements, in Across nearly all services, public programs like Medicare pay, which the state sets a per-enrollee capitated payment to a Medicaid on average, substantially less than private insurers. A recent managed care organization (MCO) to organize and deliver care.12 literature review found that private insurers pay roughly double Fee-for-service rates are set by Medicaid administrators, who Medicare rates for hospital services and 40% above Medicare rates typically use a percentage of Medicare’s fees or a state-developed for physician services.7 Private prices vary tremendously by hospital, fee schedule. Capitated rates to MCOs are based on those fees and with one study finding that negotiated prices are from 150% to 400% expected utilization.13 Annual fee increases are controlled by state higher than Medicare rates across different health systems.8 Medicaid programs, at the direction of state governments. States may also experiment with alternative payment models through the federal Why are private payment rates so much higher than public ones? waiver process. Many policymakers cite the increasing consolidation of hospitals, which decreases market competition.9 There is strong evidence that Medicaid base payment rates alone do not represent the full payment hospital mergers raise prices, and much of the recent price increases to providers.14 A 2017 MACPAC analysis found that in 2011, Medicaid appear concentrated in hospitals.10 Additionally, as hospitals buy fee-for-service base payment rates averaged 78% of Medicare rates.15 and integrate physician practices, the bargaining (i.e., price control) Medicaid base payment rates are supplemented through other power of private insurers continues to shrink relative to Medicare and programs, such as the Medicaid Disproportionate Share Hospital Medicaid, who continue to set prices themselves. (DSH) payment, which goes to hospitals serving high proportions of Medicaid or low-income patients. Whether these supplemental payments are sufficient is a contentious issue, but a 2016 MACPAC analysis of disproportionate share hospitals found that total Medicaid LIMITING THE GROWTH OF COSTS payments (including supplemental payments) covered an average of Any sustainable health care reform plan must consider how to 107% of patient costs, with a range of 81% to 130% across states.16 control cost growth and set initial rates. In fee-for-service Medicare, the Centers for Medicare and Medicaid Services (CMS) sets base Private insurers, in contrast, try to control costs by negotiating directly payment rates and annual fee increases. Payments to hospitals are with providers, and by forming networks of providers that agree made based on diagnosis-related groups (DRGs), a prospective, to accept their rates. Private payers and providers may rely on the capped payment for inpatient services based on a patient’s diagnosis published Medicare rate as a benchmark during these negotiations, and complexity. In the managed care Medicare Advantage program, but ultimately the levels are determined by market conditions and Medicare pays private plans a capitated, risk-adjusted per-member- relative bargaining power.17, 18 Medicare for All and Beyond CONFERENCE BRIEF SERIES RATE SETTING AND COST CONTROL: hospitals, there is a “floor” of at least 101% of private allowable costs State-based Public Options (i.e., private negotiated rates). For primary care providers, payments must be at least 135% of Medicare rates.27 In effect, many primary In response to rising costs and an unclear outlook for federal health care providers and critical access hospitals will have minimal changes care reform, states have taken the lead in enacting reforms to in payment rates. Unlike Colorado, which sets rates for each service, provide consumers with an affordable coverage option. While these Washington does not specify a cap for each service. Rather, the initiatives are new, they provide a window into how rate setting could aggregate cap averages total costs across all services provided and work under a federal Medicare for All system. In particular, panelists allows insurers the flexibility to negotiate individual rates to meet the discussed public option plans for the individual market that passed in benchmark.28 Washington and were proposed in Colorado. In the debate over these reforms, states had to wrestle with, and decide on, how to set rates Additionally, hospitals are not compelled to participate in and control costs in a new program. Washington’s public option, as they would be in Colorado. This may have decreased hospital opposition to rate setting, but the In May 2019, Colorado Governor Jared Polis signed legislation that tradeoff is greater risk that insurers will not be able to build out directed state officials to design a plan for a public health insurance adequate provider networks. It is too early to tell how these different option.19 State lawmakers introduced legislation (HB 1349) to create approaches will affect the affordability and accessibility of care in a Colorado Health Care Option in March 2020.20, 21 However, in public option plans. May 2020, the bill’s sponsors announced they would withdraw the legislation due to the COVID-19 pandemic, with the intention of re- Legislators in Washington and Colorado have attempted to blend introducing it in 2021.22 both private and public approaches to rate setting and cost control. Minimum and maximum per-service and aggregate payments are set Under the proposed option, regulators design the insurance plan, as a multiple of Medicare rates (like many Medicaid programs), but including coverage requirements, premiums, and the medical loss the actual negotiation of those rates and establishment of networks is ratio. Private insurers administer it through the state’s insurance left to insurers, akin to Medicare Advantage. marketplace. Hospitals in Colorado would be required to accept public option plans with state-mandated rates. As a result, rate setting State legislators also explored how to build on alternative payment was a contentious, political exercise; state officials held over a dozen models when designing rates and ensuring adequate network size. stakeholder meetings and received hundreds of letters. The final rates Colorado’s proposal mandated participation by hospitals, which is were a political compromise to ensure that physicians, critical access similar to how hospitals and doctors generally have no choice but to hospitals, and providers with high shares of Medicaid and Medicare accept fee-for-service Medicare. Washington, in contrast, is relying patients would stay financially healthy. on private insurers to establish adequate networks. In both cases, rates had to be set well above the existing Medicare fee schedule. Colorado’s proposed plan sets a base payment rate for all services Both states require state agencies or insurers to promote value-based at 155% of Medicare rates, with upward adjustments, including rate insurance design, but the specific mechanisms to do so are vague. increases for critical access hospitals and providers with large shares of Medicaid patients, as well as incentives for efficiently managing costs.23 After taking these adjustments into account, the actual payment rate ranges from 155%-238% of Medicare, down from CONSIDERATIONS FOR RATE SETTING an average of 269% of Medicare rates that private insurers paid in What can we learn from these state experiences in setting payment 2017.23, 24 As a result, the plan is expected to save consumers between rates for a public option? Because these plans have yet to launch, we 7% and 20% on premiums, largely due to rate setting.25 do not yet know the extent to which they produce adequate networks, Washington took a slightly different approach to rate setting. In are attractive to consumers, and control costs for consumers and state May 2019, Governor Jay Inslee signed legislation to create Cascade budgets. Nevertheless, the process of rate setting did generate some Care, a privately-administered public option for the individual insights. marketplace in 2021. Similar to Colorado’s proposal, the state will First, state governments created public options without overhauling procure subsidized plans from private health insurers. As in Colorado, the existing system. Both Washington and Colorado’s plans leveraged residents can use Affordable Care Act subsidies to purchase the plan. the existing state-based marketplaces and relied on private insurers However, as hospitals and physician practices face financial strains due to administer plans. While both states faced considerable pressure to COVID-19, there has been renewed pushback against the proposal from hospitals and physicians’ groups to not set rates too low (i.e., at and requests to delay its implementation.26 the current Medicare level), political leadership was able to see the To control costs, Washington set an aggregate spending cap of 160% process through to final passage in Washington State and gain strong of what Medicare would pay for the same set of services, excluding support in Colorado. prescription drugs. However, for critical access and sole community Medicare for All and Beyond CONFERENCE BRIEF SERIES However, to move public options towards the finish line, policymakers A few states have also implemented payment alternatives that a had to set baseline rates higher than the current Medicare fee Medicare for All plan would need to consider. Maryland, for example, schedule, though they are not necessarily as generous as private has a longstanding all-payer rate setting system.33 More recently, the insurers. This is likely a product of both political realities, and for some state implemented a global budget for hospitals that caps annual providers, economic necessity. cost growth.34 In the future, to reap the benefits of these payment experiments, a Medicare for All program would have to carefully Additionally, state public option plans had to make adjustments for incorporate elements of the current alternative payment landscape. different types of providers. In the context of national Medicare for Policymakers must consider how a national public option or single- All, this may require higher rates based on hospital teaching status, payer program would preserve or enhance innovative experiments research focus, and pre-existing market share to avoid severe fiscal that go beyond adjusting payment rates for specific services. shocks—to name a few. For example, many safety-net hospitals would be unable to operate without supplemental DSH payments to cover shortfalls from Medicaid and uninsured patients. A relatively tight range of payment rates may reduce the incentives for health care HOW FEDERAL REFORMS STACK UP systems to invest in biomedical, clinical, and operations research. No How have policymakers approached rate setting and cost control state has contended with how to incentivize scientific research as part in recent legislative and campaign proposals for national health of rate setting. How those—and other—supplemental payments would care reforms? In Congress, national single-payer proposals from interact with public option rates remains an open question. Senator Sanders and Representative Jayapal require Medicare to Developing a national health care reform plan would involve a similar set a fee schedule similar to current Medicare rates. These plans also back and forth with stakeholders in the health system. On the one rely on global hospital budgets set by the government to control hand, reform efforts will likely fail without stakeholder input, for both overall spending. Both plans update how fees are set and introduce political and administrative reasons. On the other hand, it is important mechanisms for some negotiations between the government and that government rate setting does not entrench the problems it is providers, but in general, they would shift nearly all provider payment seeking to reform. The U.S. Government Accountability Office much closer to current Medicare rates.35 (GAO) finds that some medical societies (such as surgeons) may Proposals focused on creating a public option, such as the Center have outsized influence in setting Medicare rates.29 One panelist put for American Progress’ (CAP) “Medicare Extra” plan and the issue succinctly: “[e]ntrenched interests really dictate how policy is Bennet-Kaine-Delgado’s “Medicare-X” plan, have similar approaches written…we can’t seem to bring the health care sector under control in to rate setting, in that they assume that a new public option would the way that we would like.” have to pay above current Medicare rates. In the case of Medicare Finally, layered on top of the discussion of rates is the reality that the Extra, rates would be set at the average of Medicare, Medicaid, and health care system is shifting towards alternative payment models, such commercial insurance rates, with adjustments in favor of primary as bundles, ACOs, and other pay-for-performance mechanisms. These care. The Center for American Progress estimates this would result models range from modest quality bonuses built on a fee-for-service in payment rates of 108% and 132% of Medicare rates for physicians chassis to population-based, capitated programs. Many of these and hospitals, respectively.36 The Medicare-X proposal allows the models do not approach cost control through rate setting. Rather, they Secretary of Health and Human Services to establish reimbursement set targets for cost and quality and put financial risk on providers for rates up to 125% of Medicare rates for services in underserved areas, hitting those benchmarks. Some of these payment reforms have begun but otherwise relies on the existing fee schedule.35 to yield reduced costs with either neutral or positive impacts on quality, While most plans put forward during the 2020 Democratic primary while others have had little impact thus far.30-32 did not propose specific fee schedules, they all relied on Medicare’s ability to set rates. As in his Congressional proposal, Senators Sanders argued for a national health care budget to control costs, with payments based on current Medicare rates. Senator Warren’s Entrenched interests really dictate plan proposed paying providers higher than Medicare (though the specific rates were not given), and suggested those rates would be much closer to Medicare’s fee schedule than private insurance rates.37 how policy is written … we can’t seem Former Vice President Biden’s public option offers little detail on rate setting, but it indicates that it “[w]ill reduce costs for patients to bring the health care sector under by negotiating lower prices from hospitals and other health care providers.”38 control in the way that we would like. Medicare for All and Beyond CONFERENCE BRIEF SERIES These proposals differ from recent state experiences, in which REFERENCES private insurers set up networks and negotiate rates for publicly sponsored plans. While state regulators set guidelines for rates, the 1. Penn LDI. (2020). Medicare for All and Beyond: Expanding Coverage, Containing Costs. Philadelphia, PA: University of Pennsylvania. Retrieved from https://ldi.upenn. implementation was left to insurers. Additionally, states found rate edu/hcreform2020 setting to be politically contentious, and it is not clear that current 2. Glied, S., & Levy, H. (2020). The Potential Effects of Coronavirus on National Health national proposals would easily pass if payment rates were near Expenditures. JAMA, 323(20), 2001-2002. current Medicare levels. 3. Claxton, G., Rae, M., Damico, A., Young, G., McDermott, D., & Whitmore, H. (2019). 2019 Employer Health Benefits Survey. Kaiser Family Foundation. Retrieved from http://files.kff.org/attachment/ Report-Employer-Health-Benefits-Annual- Survey-2019 CONCLUSION 4. Hartman, M., Martin, A. B., Benson, J., & Catlin, A. (2020). National Health Care Controlling health care spending and careful approaches to rate Spending In 2018: Growth Driven By Accelerations In Medicare And Private Insurance Spending. Health Affairs, 39(1), 8-17. setting are key to the success of any national health care reform effort. 5. Glickman, A., & Weiner, J. (2020). Health Care Cost Drivers and Options for Cost Many Medicare for All proposals at the federal level leave these Control. Penn LDI Issue Brief, Vol. 23 No. 4. Retrieved from https://ldi.upenn.edu/ crucial questions unanswered. brief/health-care-cost-drivers-and-options-control Recent state experiences with a public option show that base rates 6. The Centers for Medicare and Medicaid Services (2019). National Health Expenditures 2018 Highlights. Retrieved from https://www. cms.gov/files/document/ had to be set higher than current Medicare rates, with a highly diverse highlights.pdf set of adjustments based on provider types. Some federal proposals 7. Lopez, E., Neuman, T., Jacboson, G., & Levitt, L. (2020). How Much More assume rates can be far closer to current Medicare fees. Current Than Medicare Do Private Insurers Pay? A Review of the Literature. Kaiser Family proposals differ in the extent to which they acknowledge the need for Foundation. Retrieved from https://www.kff.org/medicare/issue-brief/how-much- higher rates and specific adjustments, such as rate enhancements for more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/ primary care and rural hospitals. For reasons of both economic and 8. White, C., & Whaley, C. (2019). Prices Paid to Hospitals by Private Health Plans political feasibility, far more work remains to be done. Are High Relative to Medicare and Vary Widely: Findings from an Employer-Led Transparency Initiative. RAND Corporation. Retrieved from https://www.rand.org/ Additionally, policymakers will need to incorporate successful pubs/research_reports/ RR3033.html value-based payment strategies into rate setting decisions in public 9. Xu, T., Wu, A. W., & Makary, M. A. (2015). The Potential Hazards of Hospital Consolidation: Implications for Quality, Access, and Price. JAMA, 314(13), 1337-1338. plans. While many value-based programs are relatively new, it will be important to build in the flexibility to include value-based payments as 10. Scheffler, R. M., Arnold, D. R., & Whaley, C. M. (2018). Consolidation Trends In California’s Health Care System: Impacts On ACA Premiums And Outpatient Visit evidence of their effectiveness mounts. Prices. Health Affairs, 37(9), 1409-1416. Finally, policymakers will have to consider the current state of 11. McGuire, T. G., & Newhouse, J. P. (2018). Medicare Advantage: Regulated Competition in the Shadow of a Public Option. In Risk Adjustment, Risk Sharing and hospital finances, especially during and following the significant Premium Regulation in Health Insurance Markets (pp. 563-598): Elsevier. financial challenges hospitals have faced in the ongoing response to 12. Medicaid and CHIP Payment and Access Commission. (2011). June 2011 Report to COVID-19. As panelists noted, some hospitals might not survive if Congress: The Evolution of Managed Care in Medicaid. Retrieved from https://www. the payer mix rapidly shifted to Medicare at existing rates. Moving macpac.gov/publication/report-to-congress-the-evolution-of-managed-care-in- from current proposals to realistic policy will entail accounting for medicaid/ varying levels of provider consolidation, existing hospital margins, and 13. Medicaid and CHIP Payment and Access Commission. (2013). Issues in Setting incentives for innovation. Medicaid Capitation Rates for Integrated Care Plans. Retrieved from https://www. macpac.gov/publication/ch-5-issues-in-setting-medicaid-capitation-rates-for- integrated-care-plans/ 14. Medicaid and CHIP Payment and Access Commission. (2020). Medicaid Base and Supplemental Payments to Hospitals. Retrieved from https://www.macpac.gov/ Policymakers will have to consider the publication/medicaid-base-and-supplemental-payments-to-hospitals/ 15. Medicaid and CHIP Payment and Access Commission. (2017). Medicaid Hospital current state of hospital finances, especially Payment: A Comparison across States and to Medicare. Retrieved from https://www.macpac.gov/wp-content/uploads/2017/04/Medicaid- Hospital- Payment-A-Comparison-across-States-and-to-Medicare.pdf during and following the significant 16. Medicaid and CHIP Payment and Access Commission. (2016). Improving Data as the First Step to a More Targeted Disproportionate Share Hospital Policy. Retrieved challenges hospitals have faced in the from https://www.macpac.gov/wp-content/uploads/2016/03/ Improving-Data-as- the-First-Step-to-a-More-Targeted-Disproportionate-Share- Hospital-Policy.pdf ongoing response to COVID-19. 17. Gesme, D. H., & Wiseman, M. (2010). How to negotiate with health care plans. Journal of Oncology Practice, 6(4), 220-222. Medicare for All and Beyond CONFERENCE BRIEF SERIES 18. LaPointe, J. (2018). Key Terms, Components of Payer Contracts Providers Should Know. Revcycle Intelligence. Retrieved from https://revcycleintelligence.com/news/ key-terms-components-of-payer- LEONARD DAVIS contracts-providers-should-know INSTITUTE OF HEALTH 19. HB20-1349: Colorado Affordable Health Care Option. Retrieved from https://leg.colorado.gov/bills/ ECONOMICS hb20-1349 Since 1967, the University of Pennsylvania’s 20. Huppert, E., & Hagan, L. (2020). Colorado Achieves Mile High Milestone by Introducing State Leonard Davis Institute of Health Economics Coverage Option Legislation. United States of Care. Retrieved from https://unitedstatesofcare.org/ blog/colorado-achieves-mile-high-milestone-introducing-state-coverage-option-legislation/ (Penn LDI) has been the leading university institute dedicated to data-driven, policy- 21. Conway, M., & Bemestefer, K. (2019). Final Report for Colorado’s Public Option. Retrieved from focused research that improves our nation’s https://www.colorado.gov/pacific/sites/default/files/Final%20Report%20for%20Colorados%20 Public%20Option.pdf health and health care. Penn LDI works on issues concerning care for vulnerable 22. Hindi, S. (2020). Colorado lawmakers shelve contentious hybrid public option bill amid pandemic populations; coverage and access to health The Denver Post. Retrieved from https://www.denverpost.com/2020/05/04/public-option-health- insurance-colorado-coronavirus/ care; improving care for older adults; and the opioid epidemic. Penn LDI connects 23. Advisory Board. (2020). Colorado’s public option health plan would pay hospitals 155% of Medicare all twelve of Penn’s schools, the University rates. Retrieved from https://www.advisory.com/daily-briefing/2020/02/26/colorado-public-option of Pennsylvania Health System, and the 24. Expected Hospital-Specific Reimbursement Rates Under Colorado Affordable Health Care Option. Children’s Hospital of Philadelphia through (2020). Retrieved from https://static1.squarespace.com/static/5e14a77768676674b8d2fd55/t/5e66b73 its more than 300 Senior Fellows. b02c95959ada58566/1583789883941/Expected+Hospital+Reimbursement+Rates+-+Colorado+Affor dable+Health+Care+Option+%282%29.pdf LDI.UPENN.EDU 25. Hospital Reimbursement under the Colorado Health Insurance Option Recommendation. (2020). @PENNLDI Retrieved from https://www.colorado.gov/pacific/sites/default/files/Colorado%27s%20Health%20 Insurance%20Option%20Hospital%20Reimbursement%20One%20Pager.pdf 26. Shukovsky, P. (2020). Washington State ‘Public Option’ Health Plan Faces Pushback (Corrected). Bloomberg Law. Retrieved from https://news.bloomberglaw.com/health-law-and-business/ washington-state-public-option-health-plan-faces-pushback UNITED STATES OF CARE 27. inal Bill Report ESSB 5526. (2019). Retrieved from http://lawfilesext.leg.wa.gov/biennium/2019-20/ F United States of Care is a non-partisan non- Pdf/Bill%20Reports/Senate/5526-S.E%20SBR%20FBR%2019.pdf profit organization mobilizing stakeholders to achieve long-lasting solutions that make 28. Capretta, J. C. (2020). Washington State’s Quasi-Public Option. Milbank Quarterly, 98(1), 14-17. health care better for all. United States 29. Cosgrove, J. (2015). Medicare Physician Payment Rates: Better Data and Greater Transparency Could of Care aims to ensure every American Improve Accuracy. U.S. Government Accountability Office. Retrieved from https://www.gao.gov/ has access to an affordable regular source products/GAO-15-434 of health care; protection from financial 30. Dummit, L. A., Kahvecioglu, D., Marrufo, G., Rajkumar, R., Marshall, J., Tan, E., . . . Conway, P. H. devastation due to illness or injury; and to (2016). Association Between Hospital Participation in a Medicare Bundled Payment Initiative and accomplish this in an economically and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes. JAMA, 316(12), 1267-1278. politically sustainable fashion. 31. Navathe, A. S., Liao, J. M., Dykstra, S. E., Wang, E., Lyon, Z. M., Shah, Y., . . . Emanuel, E. J. (2018). UNITEDSTATESOFCARE.ORG Association of Hospital Participation in a Medicare Bundled Payment Program With Volume and @USOFCARE Case Mix of Lower Extremity Joint Replacement Episodes. JAMA, 320(9), 901-910. 32. Joynt Maddox, K. E., Orav, E. J., Zheng, J., & Epstein, A. M. (2018). Evaluation of Medicare’s Bundled Payments Initiative for Medical Conditions. The New England Journal of Medicine, 379(3), 260-269. 33. Golshan, T. (2020). The answer to America’s health care cost problem might be in Maryland. Vox. AUTHOR Retrieved from https://www.vox.com/policy-and-politics/2020/1/22/21055118/maryland-health-care- global-hospital-budget Aaron Glickman, MPA 34. Shah, A., Bishop, S., Ramsay, C., & Schneider, E. C. (2018). Maryland’s Global Budget Program: Policy Analyst Still an Option for Containing Costs. The Commonwealth Fund. Retrieved from https://www. Leonard Davis Institute of Health Economics commonwealthfund.org/ blog/2018/marylands-global-budget-program-still-option-containing-costs University of Pennsylvania 35. Kaiser Family Foundation. (2019). Compare Medicare-for-all and Public Plan Proposals. Retrieved from https://www.kff.org/ interactive/compare-medicare-for-all-public-plan-proposals/ 36. Center for American Progress. (2018). Medicare Extra for All. Retrieved from https://www. americanprogress.org/issues/ healthcare/reports/2018/02/22/447095/medicare-extra-for-all/ THANK YOU 37. Scott, D. (2019). The real differences between the 2020 Democrats’ health care plans, explained. Vox. We thank our conference speakers for their Retrieved from https://www.vox.com/policy-and-politics/2019/12/19/21005124/2020- presidential- valuable insights and contributions to the candidates-health-care-democratic-debate panel: Julian Harris, MD, MBA (moderator); 38. ealth Care. (2020). Retrieved from https://joebiden.com/healthcare/ H Gerard Anderson, PhD; Miriam Laugesen, PhD; Kevin Mahoney, MBA, DBA; and Kavita Patel, MD.