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Journal of Hospice and Palliative... Aug 2021Integrative hospice and palliative care is a philosophy of treatment framing patients as whole persons composed of interrelated systems. The interdisciplinary treatment...
Integrative hospice and palliative care is a philosophy of treatment framing patients as whole persons composed of interrelated systems. The interdisciplinary treatment team is subsequently challenged to consider ethical and effective provision of holistic services that concomitantly address these systems at the end of life through cotreatment. Nurses and music therapists, as direct care professionals with consistent face-to-face contact with patients and caregivers, are well positioned to collaborate in providing holistic care. This article introduces processes of referral, assessment, and treatment that nurses and music therapists may engage in to address family support, spirituality, bereavement, and telehealth. Clinical vignettes are provided to illustrate how cotreatment may evolve and its potential benefits given diverse circumstances. As part of this framing, music therapy is positioned as a core-rather than alternative or complementary-service in hospice that satisfies the required counseling services detailed in Medicare's Conditions of Participation for hospice providers. The systematic and intentional partnering of nurses and music therapists can provide patients and caregivers access to quality comprehensive care that can cultivate healthy transitions through the dying process.
Topics: Aged; Hospice Care; Hospices; Humans; Medicare; Music Therapy; Palliative Care; United States
PubMed: 33631776
DOI: 10.1097/NJH.0000000000000747 -
The American Journal of Managed Care Mar 2021To examine changes in hospital outpatient surgery trends and case mix for Medicare and privately insured patients needing total knee arthroplasty (TKA) following...
OBJECTIVES
To examine changes in hospital outpatient surgery trends and case mix for Medicare and privately insured patients needing total knee arthroplasty (TKA) following Medicare's removal of TKA from its Inpatient Only list on January 1, 2018.
STUDY DESIGN
A retrospective analysis of all hospital discharge records in Florida from 2012 through 2018.
METHODS
We tracked inpatient vs outpatient performance of TKAs at the state and hospital levels. We also combined our primary data with physician practice organization information to assess variation in the policy response according to physician-hospital ownership status. Supplementary analyses examined policy-induced changes in inpatient TKA case mix.
RESULTS
We observed an immediate shift of roughly 15% of Medicare TKA cases to the outpatient setting. Importantly, there was a simultaneous near doubling of the number of TKAs performed as a hospital outpatient procedure among privately insured patients younger than 60 years. Hospitals allocated a similar proportion of TKA cases to the outpatient setting across the 2 payer groups, and we found evidence of selection against the potentially riskiest Medicare TKA patients for outpatient delivery. Vertically integrated orthopedic physicians retained their Medicare and privately insured TKA cases within the inpatient (higher-cost) setting.
CONCLUSIONS
Market and financial pressures are encouraging more outpatient care delivery; however, the speed of transition is dictated, in part, by regulatory constraints. Our results suggest that Medicare policy may influence surgical treatment approaches for Medicare and privately insured patients. Spillover implications need to be considered when weighing future Medicare regulatory decisions.
Topics: Aged; Arthroplasty, Replacement, Knee; Humans; Inpatients; Medicare; Outpatients; Retrospective Studies; United States
PubMed: 33720667
DOI: 10.37765/ajmc.2021.88598 -
JAMA Oct 2022
Topics: Medicare; Reimbursement Mechanisms; United States; Patient Care Bundles
PubMed: 36282270
DOI: 10.1001/jama.2022.18191 -
Health Services Research Feb 2021To determine the relationship between Medicare's site-based outpatient billing policy and hospital-physician integration.
OBJECTIVE
To determine the relationship between Medicare's site-based outpatient billing policy and hospital-physician integration.
DATA SOURCES
National Medicare claims data from 2010 to 2016.
STUDY DESIGN
For each physician-year, we calculated the disparity between Medicare reimbursement under hospital ownership and under physician ownership. Using logistic regression analysis, we estimated the relationship between these payment differences and hospital-physician integration, adjusting for region, market concentration, and time fixed effects. We measured integration status using claims data and legal tax names.
DATA COLLECTION
The study included integrated and non-integrated physicians who billed Medicare between January 1, 2010, and December 31, 2016 (n = 2 137 245 physician-year observations).
PRINCIPAL FINDINGS
Medicare reimbursement for physician services would have been $114 000 higher per physician per year if a physician were integrated compared to being non-integrated. Primary care physicians faced a 78% increase, medical specialists 74%, and surgeons 224%. These payment differences exhibited a modest positive relationship to hospital-physician vertical integration. An increase in this outpatient payment differential equivalent to moving from the 25th to 75th percentile was associated with a 0.20 percentage point increase in the probability of integrating with a hospital (95% CI: 0.0.10-0.30). This effect was slightly larger among primary care physicians (0.27, 95% CI: 0.18 to 0.35) and medical specialists (0.26, 95% CI: 0.05 to 0.48), while not significantly different from zero among surgeons (-0.02; 95% CI: -0.27 to 0.22).
CONCLUSIONS
The payment differences between outpatient settings were large and grew over time. Even routine annual outpatient payment updates from Medicare may prompt some hospital-physician vertical integration, particularly among primary care physicians and medical specialists.
Topics: Ambulatory Care; Efficiency, Organizational; Hospital-Physician Joint Ventures; Humans; Medicare; Pain Management; Practice Patterns, Physicians'; Private Sector; Reimbursement Mechanisms; United States
PubMed: 33616932
DOI: 10.1111/1475-6773.13613 -
The Health Care Manager 2019The cost of health care within the United States has continued to increase, whereas the quality of patient care has generally decreased in some areas. With the continued... (Review)
Review
The cost of health care within the United States has continued to increase, whereas the quality of patient care has generally decreased in some areas. With the continued use of Medicare's former physician reimbursement algorithm, termed sustainable growth rate, national expenditures within the United States have been expected to increase 5.6% annually. To modernize the delivery and financing of care, Congress has introduced the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which has permanently eliminated and replaced the sustainable growth rate. The purpose of this study was to review MACRA and its implementation to determine how it would financially impact rural hospitals. Two reimbursement pathways have been created for physicians under the MACRA. In addition, the financing and competition among facilities created by the act have been expected to impact physicians and health care organizations. Rural hospitals have been set to receive reduced government reimbursements and have been predicted to compete poorly with larger hospitals and health care corporations. Furthermore, the payment tracks available through the act have been projected to impact solo and small practice physicians negatively.
Topics: Hospitals, Rural; Humans; Medicare; Medicare Access and CHIP Reauthorization Act of 2015; Physicians; Reimbursement Mechanisms; United States
PubMed: 31344000
DOI: 10.1097/HCM.0000000000000267 -
JAMA Sep 2023
Topics: Aged; Humans; Conflict of Interest; Equipment and Supplies; Medicare; United States; Insurance Coverage
PubMed: 37589985
DOI: 10.1001/jama.2023.14414 -
The Annals of Thoracic Surgery Oct 2015
Topics: Budgets; Humans; Medicare; Physicians; Reimbursement Mechanisms
PubMed: 26434422
DOI: 10.1016/j.athoracsur.2015.08.026 -
Archives of Physical Medicine and... Dec 2022In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment,...
In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment, and therefore are non-covered items. Yet, power seat elevation systems are covered by other funding sources, and many power wheelchair users utilize these systems regularly when performing tasks such as transferring, reaching, and looking at objects in environments designed for ambulatory people. Adjusting for height when performing these tasks may reduce the onset of pain and comorbidities. To improve access to power seat elevation systems, a clinical team of 4 Clinician Task Force members investigated applicable literature, compiled evidence, and evaluated existing policies to explain the medical nature of power seat elevation systems as a part of a greater interprofessional effort. This manuscript aims to analyze Medicare's policy decision that power seat elevation systems are not primarily medical in nature using Bardach's 8-step framework. As a special communication, this will inform health care professionals of the medical nature of power seat elevation systems and the evidence-based conditions under which power wheelchair users may need power seat elevation systems, as well as empower clinicians to engage in policy directives to affect greater change.
Topics: Aged; Humans; United States; Wheelchairs; Medicare; Policy Making; Equipment Design
PubMed: 35525300
DOI: 10.1016/j.apmr.2022.04.003 -
The American Journal of Geriatric... Jun 2024
Topics: Humans; United States; Medicare Part C; Health Expenditures; Medicare; Mental Disorders; Aged; Financial Stress
PubMed: 38350832
DOI: 10.1016/j.jagp.2024.01.227 -
The Milbank Quarterly Dec 2023Policy Points The increasing number of drugs granted accelerated approval by the Food and Drug Administration (FDA) has challenged the Medicare program, which often pays...
UNLABELLED
Policy Points The increasing number of drugs granted accelerated approval by the Food and Drug Administration (FDA) has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We recommend several administrative and legislative approaches for improving FDA-Centers for Medicare and Medicaid Services (CMS) coordination around accelerated-approval drugs, including promoting earlier discussions among the FDA, the CMS, and drug companies; strengthening Medicare's coverage with evidence development program; linking Medicare payment to evidence generation milestones; and ensuring that the CMS has adequate staffing and resources to evaluate new therapies. These activities can help improve the integrity; transparency; and efficiency of approval, coverage, and payment processes for drugs granted accelerated approval.
CONTEXT
The Food and Drug Administration (FDA)'s accelerated-approval pathway expedites patient access to promising treatments. However, increasing use of this pathway has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We examined approaches to improve coordination between the FDA and Centers for Medicare and Medicaid Services (CMS) for drugs granted accelerated approval.
METHODS
We argue that policymakers have focused on expedited pathways at the FDA without sufficient attention to complementary policies at the CMS. Although differences between the FDA and CMS decisions are to be expected given the agencies' different missions and statutory obligations, procedural improvements can ensure that Medicare beneficiaries have timely access to novel therapies that are likely to improve health outcomes. To inform policy options and recommendations, we conducted semistructured interviews with stakeholders to capture diverse perspectives on the topic.
FINDINGS
We recommend ten areas for consideration: clarifying the FDA's evidentiary standards; strengthening FDA authorities; promoting earlier discussions among the FDA, the CMS, and drug companies; improving Medicare's coverage with evidence development program; tying Medicare payment for accelerated-approval drugs to evidence generation milestones; issuing CMS guidance on real-world evidence; clarifying Medicare's "reasonable and necessary" criteria; adopting lessons from international regulatory-reimbursement harmonization efforts; ensuring that the CMS has adequate staffing and expertise; and emphasizing equity.
CONCLUSIONS
Better coordination between the FDA and CMS could improve the transparency and predictability of drug approval and coverage around accelerated-approval drugs, with important implications for patient outcomes, health spending, and evidence generation processes. Improved coordination will require reforms at both the FDA and CMS, with special attention to honoring the agencies' distinct authorities. It will require administrative and legislative actions, new resources, and strong leadership at both agencies.
Topics: Aged; Humans; United States; Medicare; Pharmaceutical Preparations; Centers for Medicare and Medicaid Services, U.S.; United States Food and Drug Administration; Drug Approval
PubMed: 37644739
DOI: 10.1111/1468-0009.12670