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Journal of Surgical Orthopaedic Advances 2019Financial success in a bundled payment system requires knowledge of the costs of care throughout the period of risk. Understanding the significant cost-drivers of total... (Review)
Review
Financial success in a bundled payment system requires knowledge of the costs of care throughout the period of risk. Understanding the significant cost-drivers of total joint arthroplasty (TJA) is crucial in this effort. This article inspects the basics of reimbursement under Medicare's bundled care programs as well as some common investigative tools used in the literature to measure cost. Additionally, the effects of standardized enhanced recovery clinical pathways on costs are reviewed. Finally, drivers of implant costs and several proven measures for implant cost-reduction are evaluated. This review provides surgeons and hospitals successful measures to reduce the cost of TJA via enhanced recovery pathways and reduced implant pricing. (Journal of Surgical Orthopaedic Advances 28(4):241-249, 2019).
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Critical Pathways; Medicare; Patient Care Bundles; United States
PubMed: 31886758
DOI: No ID Found -
JAMA Network Open Sep 2022Medicare's Oncology Care Model (OCM) was an alternative payment model that tied performance-based payments to cost and quality goals for participating oncology...
IMPORTANCE
Medicare's Oncology Care Model (OCM) was an alternative payment model that tied performance-based payments to cost and quality goals for participating oncology practices. A major concern about the OCM regarded inclusion of high-cost cancer therapies, which could potentially disincentivize oncologists from prescribing novel therapies.
OBJECTIVE
To examine whether oncologist participation in the OCM changed the likelihood that patients received novel therapies vs alternative treatments.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study of Surveillance, Epidemiology, and End Results (SEER) Program data and Medicare claims compared patient receipt of novel therapies for patients treated by oncologists participating vs not participating in the OCM in the period before (January 2015-June 2016) and after (July 2016-December 2018) OCM initiation. Participants included Medicare fee-for-service beneficiaries in SEER registries who were eligible to receive 1 of 10 novel cancer therapies that received US Food and Drug Administration approval in the 18 months before implementation of the OCM. The study excluded the Hawaii registry because complete data were not available at the time of the data request. Patients in the OCM vs non-OCM groups were matched on novel therapy cohort, outcome time period, and oncologist specialist status. Analysis was conducted between July 2021 and April 2022.
EXPOSURES
Oncologist participation in the OCM.
MAIN OUTCOMES AND MEASURES
Preplanned analyses evaluated patient receipt of 1 of 10 novel therapies vs alternative therapies specific to the patient's cancer for the overall study sample and for racial subgroups.
RESULTS
The study included 2839 matched patients (760 in the OCM group and 2079 in the non-OCM group; median [IQR] age, 72.7 [68.3-77.6] years; 1591 women [56.0%]). Among patients in the non-OCM group, 33.2% received novel therapies before and 40.1% received novel therapies after the start of the OCM vs 39.9% and 50.3% of patients in the OCM group (adjusted difference-in-differences, 3.5 percentage points; 95% CI, -3.7 to 10.7 percentage points; P = .34). In subgroup analyses, second-line immunotherapy use in lung cancer was greater among patients in the OCM group vs non-OCM group (adjusted difference-in-differences, 17.4 percentage points; 95% CI, 4.8-30.0 percentage points; P = .007), but no differences were seen in other subgroups. Over the entire study period, patients with oncologists participating in the OCM were more likely to receive novel therapies than those with oncologists who were not participating (odds ratio, 1.47; 95% CI, 1.09-1.97; P = .01).
CONCLUSIONS AND RELEVANCE
This study found that participation in the OCM was not associated with oncologists' prescribing novel therapies to Medicare beneficiaries with cancer. These findings suggest that OCM financial incentives did not decrease patient access to novel therapies.
Topics: Aged; Cohort Studies; Female; Humans; Medical Oncology; Medicare; Neoplasms; Oncologists; United States
PubMed: 36173630
DOI: 10.1001/jamanetworkopen.2022.34161 -
JAMA Nov 2023
Topics: Drug Costs; Medicare; Negotiating; Prescription Drugs; Prescriptions; United States
PubMed: 37728954
DOI: 10.1001/jama.2023.19506 -
Health Services Research Aug 2018To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary...
OBJECTIVES
To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms.
DATA SOURCES/STUDY SETTING
Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013).
STUDY DESIGN
We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures.
DATA COLLECTION/EXTRACTION METHODS
We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey.
PRINCIPAL FINDINGS
There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001).
CONCLUSIONS
Physicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.
Topics: Accountable Care Organizations; Benchmarking; Efficiency, Organizational; Humans; Meaningful Use; Medicare; Motivation; Organizational Culture; Patient Safety; Physicians; Quality of Health Care; Regression Analysis; Reimbursement, Incentive; United States
PubMed: 28748535
DOI: 10.1111/1475-6773.12743 -
Journal of Nuclear Cardiology :... Dec 2019
Topics: Decision Support Systems, Clinical; Diagnostic Imaging; Hospitals; Humans; Medicare; Nuclear Medicine; Outpatients; Prior Authorization; Prospective Payment System; United States
PubMed: 31686325
DOI: 10.1007/s12350-019-01942-2 -
Journal of Medical Systems Jul 2018System improvements to Medicare are critical to ensure a stable and sustainable future. Measures and outcomes in Medicare are collaborative in foundation and have the...
System improvements to Medicare are critical to ensure a stable and sustainable future. Measures and outcomes in Medicare are collaborative in foundation and have the potential to become even stronger. Utilization research, comparative effectiveness research and regulatory considerations must strive for best practice for the Medicare population. Government, regulatory, industry and academia should continue to work together for cost effective approaches that yield evidence-based interventions for positive health outcomes. Recommendations for improvements to the Medicare program are abundant and show strong potential to positively impact all of healthcare. These improvements will establish and maintain an even greater trust and positive view on what many consider a popular, vital social healthcare program in the U.S.
Topics: Forecasting; Medicare; United States
PubMed: 29987476
DOI: 10.1007/s10916-018-1012-8 -
Health Services Research Dec 2017To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs.
OBJECTIVE
To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs.
DATA SOURCES/STUDY SETTING
Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida.
STUDY DESIGN
We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences.
DATA COLLECTION/EXTRACTION METHODS
Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims.
PRINCIPAL FINDINGS
Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons.
CONCLUSIONS
Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Humans; Medicare; Medicare Part C; Medicare Part D; Middle Aged; Patient Satisfaction; Quality Indicators, Health Care; Risk Adjustment; United States; Young Adult
PubMed: 29130269
DOI: 10.1111/1475-6773.12787 -
The American Journal of Managed Care Jun 2024This analysis examines the implications of new Alzheimer disease drugs in the era of the Inflation Reduction Act (IRA). It focuses on balancing innovation in Alzheimer... (Review)
Review
OBJECTIVES
This analysis examines the implications of new Alzheimer disease drugs in the era of the Inflation Reduction Act (IRA). It focuses on balancing innovation in Alzheimer disease treatment with affordability and access, assessing the impact on Medicare's budget, patient cost, and health care system readiness.
STUDY DESIGN
A comprehensive review was conducted, synthesizing information from recent FDA drug approvals, drug pricing models, Medicare coverage policies, and the updated regulations under the IRA. This analysis reflects on the broader clinical and economic consequences of introducing new Alzheimer disease treatments.
METHODS
The study employs a qualitative review of existing literature, policy documents, and economic data. It explores the implications of Alzheimer disease drugs on health care policy, analyzing the economic and clinical impacts within the current health care landscape in the US.
RESULTS
The study highlights the economic challenges posed by the high costs of new Alzheimer disease drugs, contrasting with their moderate clinical benefits and potential risks. It discusses the limitations of the IRA in regulating drug prices and the resulting implications for Medicare's budget. Additionally, it examines disparities in health care access and system preparedness for these new treatments.
CONCLUSIONS
The study findings underscore the need for a comprehensive approach to ensure fair pricing and equitable access to Alzheimer disease treatments. It suggests the application of frameworks such as the ISPOR Value Flower, focusing on diversity, equity, and comprehensive economic evaluations, to navigate the evolving landscape of Alzheimer disease treatment in the context of the IRA.
Topics: Alzheimer Disease; Humans; United States; Medicare; Health Services Accessibility; Drug Costs; Drug Approval
PubMed: 38912930
DOI: 10.37765/ajmc.2024.89563 -
The American Journal of Managed Care Sep 2019To explore whether the Affordable Care Act (ACA)'s Medicare Advantage (MA) payment cuts were associated with changes in enrollees' access to and affordability of... (Comparative Study)
Comparative Study
OBJECTIVES
To explore whether the Affordable Care Act (ACA)'s Medicare Advantage (MA) payment cuts were associated with changes in enrollees' access to and affordability of healthcare relative to traditional Medicare (TM).
STUDY DESIGN
Descriptive analyses of changes in access and affordability in MA relative to TM between 2009 and 2017 and between 2011 and 2017.
METHODS
Respondents who reported Medicare coverage on the National Health Interview Survey were divided into MA and TM enrollees. Using multivariate regression to adjust for demographic, economic, and health status changes over time, we compared changes in healthcare access and affordability for the 2 groups between 2009 and 2017, as the ACA payment cuts were implemented. For some measures, the analysis covers 2011 to 2017.
RESULTS
Between 2009 and 2017, MA respondents did not report statistically significant changes in healthcare access or affordability after adjusting for demographic, socioeconomic, and health status changes in the MA population. There were no statistically significant differences between changes in access and affordability for beneficiaries in MA relative to those in TM over this period.
CONCLUSIONS
Although MA payment cuts were expected to reduce the attractiveness of the MA program to both plans and enrollees, the program's enrollment grew steadily from 2009 to 2017. Over this period, plans reduced their costs for providing Part A and Part B benefits to their enrollees, thereby preserving room for rebates. Our findings show that plans made such cost reductions without significantly affecting enrollees' access to or affordability of care compared with TM beneficiaries.
Topics: Aged; Aged, 80 and over; Costs and Cost Analysis; Female; Forecasting; Health Services Accessibility; Humans; Male; Medicare; Medicare Part C; Patient Protection and Affordable Care Act; United States
PubMed: 31518097
DOI: No ID Found -
JAMA Health Forum Oct 2021
Topics: Delivery of Health Care; Health Facilities; Medicare; United States
PubMed: 36218896
DOI: 10.1001/jamahealthforum.2021.3017