# Global Budget Revenue Model and Care for Patients Receiving Chemotherapy

## TL;DR

A study found that Maryland's Global Budget Revenue model reduced Medicare payments and chemotherapy-related hospitalizations for cancer patients without affecting care quality.

## Contribution

The study evaluates the impact of Maryland's GBR model on Medicare payments and care quality for cancer patients, providing new empirical evidence on its effectiveness.

## Key findings

- GBR implementation reduced total Medicare payments by $3075 per episode and hospital payments by $3217.
- Chemotherapy-related hospitalizations decreased by 1.7 percentage points under the GBR model.
- Care quality measures remained unchanged despite cost reductions.

## Abstract

This cohort study examines changes in Medicare payments, hospital utilization, and care quality for anticancer therapy after the 2014 implementation of the Global Budget Revenue program in Maryland.

How did Maryland’s Global Budget Revenue (GBR) model affect the payments, hospital utilization, and quality of care for Medicare beneficiaries undergoing systemic therapy for cancer?

In this cohort study of 77 062 total chemotherapy episodes, the GBR model’s implementation was associated with a relative reduction in total Medicare payments, hospital-based payments, and chemotherapy-related hospitalizations in Maryland compared with control states, along with a larger increase in professional payments during 6 months of systemic therapy episodes. Measures of quality of care did not change.

The findings of this study suggest that Maryland’s GBR model achieved substantial reductions in the growth of Medicare payments for patients undergoing systemic therapy for cancer, possibly by shifting care toward lower-cost treatment settings.

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.