Global Budget Revenue Model and Care for Patients Receiving Chemotherapy

Maryland's Global Budget Revenue (GBR) model provided fixed global payments to hospitals, aiming to control revenue growth while improving care quality. The implications of GBR implementation in 2014 for cancer care have not been robustly evaluated.

To examine the association between GBR implementation and subsequent changes in episode-based Medicare payments, hospital utilization, and quality of care among Medicare beneficiaries undergoing systemic therapy for cancer.

This cohort study used a difference-in-differences approach to compare changes in outcome measures from pre-GBR (2011-2013) to post-GBR (2014-2018) implementation periods in Maryland compared with 11 control states. Six-month care episodes were selected for adult fee-for-service Medicare beneficiaries initiating or continuing cytotoxic chemotherapy, immunotherapy, or targeted therapy for cancer between 2011 and 2018. Data were obtained from Medicare claims, including inpatient, outpatient, carrier, durable medical equipment, home health agency, hospice, and Part D event files. All analyses were performed between April 4, 2024, and January 5, 2026.

The primary outcomes were standardized Medicare payments during the 6-month systemic therapy episode, including total, hospital, and professional payments. Also assessed were measures of hospital-based utilization (all-cause hospitalizations and emergency department [ED] visits) and care quality (timely receipt of chemotherapy; chemotherapy-related hospitalizations and ED visits; and measures of high-intensity end-of-life treatment: no or late hospice enrollment, >1 ED visit in the last 30 days of life, intensive care unit stay in the last 30 days of life, and receipt of chemotherapy in the last 14 days of life).

A total of 38 531 chemotherapy episodes in Maryland were matched to 38 531 episodes in control states. Episodes in Maryland were for patients (22 185 females [57.6%]) with a mean (SD) age of 73.3 (8.6) years; in control states, episodes were for patients (21 708 females [56.3%]) with a mean (SD) age of 72.7 (9.1) years. GBR implementation was associated with a reduction of $3075 (95% CI, -$4276 to -$1843; 6.1% savings) in total episode payments, a reduction of $3217 (95% CI, -$4058 to -$2328; 17.3% savings) in hospital payments, and an increase of $1382 (95% CI, $781-$2013; 11.9% increase) in professional payments. There was a reduction of 1.7 (95% CI, -3.0 to -0.5) percentage points in chemotherapy-related hospitalizations. No significant association was found for other hospital-based utilization or care quality measures.

This cohort study of patients with systemic anticancer therapy episodes showed that Maryland's GBR model was associated with substantial reductions in the growth of Medicare payments. These savings may have been achieved by shifting care toward lower-cost treatment settings.