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Inquiry : a Journal of Medical Care... 2019The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of...
The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of delivering better care at lower cost. Policymakers must reverse this trend and ensure parity between traditional Medicare and MA rather than encourage it through legislation that only benefits MA. Furthermore, as discussions of expanding health insurance coverage through Medicare intensify, policymakers should explore what version of Medicare they wish to expand.
Topics: Humans; Medicare; Medicare Part C; Privatization; United States
PubMed: 31382843
DOI: 10.1177/0046958019867612 -
Health Affairs (Project Hope) Apr 2019
Review
Topics: Aged; Eligibility Determination; Foundations; Health Expenditures; Humans; Medicare; Organizational Innovation; Quality Improvement; Research Support as Topic; United States
PubMed: 30933587
DOI: 10.1377/hlthaff.2019.00255 -
Journal of the American Geriatrics... Dec 2021
Topics: Aged; Humans; Medicare; Patient Care Bundles; Reimbursement Mechanisms; Subacute Care; United States
PubMed: 34510413
DOI: 10.1111/jgs.17439 -
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 -
Medical Care Jan 2022The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce...
BACKGROUND
The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019.
OBJECTIVE
The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative.
STUDY DESIGN
A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample.
SUBJECTS
A total of 761 PTN practices and 3451 non-PTN practices.
MEASURES
To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics.
RESULTS
The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541).
CONCLUSIONS
TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.
Topics: Cohort Studies; Family Practice; Humans; Longitudinal Studies; Medicare; Patient Acceptance of Health Care; United States
PubMed: 34739412
DOI: 10.1097/MLR.0000000000001662 -
JAMA Jul 2023
Topics: Aged; Humans; Fee Schedules; Medicare; Medicare Part B; Physicians; Relative Value Scales; United States; Ethics, Medical
PubMed: 37347479
DOI: 10.1001/jama.2023.6154 -
BMJ Quality & Safety Jun 2019Publicly reported quality data can help consumers make informed choices about where to seek medical care. The Centers for Medicare and Medicaid Services developed a...
BACKGROUND
Publicly reported quality data can help consumers make informed choices about where to seek medical care. The Centers for Medicare and Medicaid Services developed a composite Hospital Compare Overall Star Rating for US acute-care hospitals in 2016. However, patterns of performance and improvement have not been previously described.
OBJECTIVE
To characterise high-quality and low-quality hospitals as assessed by Star Ratings.
DESIGN
We performed a retrospective cross-sectional study of 3429 US acute-care hospitals assigned Overall Star Ratings in both 2016 and 2017. We used multivariable logistic regression models to identify characteristics associated with receiving 4 or 5 stars.
RESULTS
Small hospitals were more likely to receive 4 or 5 stars in 2016 (33% of small hospitals, 26% of medium hospitals and 21% of large hospitals, OR for medium 0.78, p=0.02, and for large, 0.61, p=0.003). Non-profit status (OR 1.37, p=0.01), midwest region (OR=2.30, p<0.001), west region (OR 1.30 in 2016, p=0.06) and system membership (OR 1.33, p=0.003) were associated with higher odds of achieving a higher Star Rating. Hospitals with the most Medicaid patients were markedly less likely to receive 4 or 5 stars (OR for highest quartile=0.32, p<0.001), and hospitals with the highest proportion of Medicare patients were somewhat less likely to do so (OR for highest quartile=0.68, p=0.01). These associations remained largely consistent over the first two years of reporting and were also associated with the highest likelihood of improvement.
CONCLUSIONS
Small hospitals with fewer Medicaid patients had the highest odds of performing well on Star Ratings. Further monitoring of these trends is needed as patients, clinicians and policymakers strive to use this information to promote high-quality care.
Topics: Acute Disease; Cross-Sectional Studies; Hospitals; Humans; Medicare; Quality Improvement; Retrospective Studies; United States
PubMed: 30530807
DOI: 10.1136/bmjqs-2018-008384 -
Annals of Surgery Feb 2022To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care.
OBJECTIVE
To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care.
SUMMARY OF BACKGROUND DATA
Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement.
METHODS
Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models.
RESULTS
Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001).
CONCLUSIONS AND RELEVANCE
In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.
Topics: Adult; Aged; Bariatric Surgery; Episode of Care; Female; Health Expenditures; Humans; Male; Medicare; Middle Aged; Obesity, Morbid; Quality of Health Care; Retrospective Studies; Treatment Outcome; United States
PubMed: 33055585
DOI: 10.1097/SLA.0000000000003979 -
BMC Health Services Research Jul 2022Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care...
BACKGROUND
Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare's P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare's P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus.
METHODS
We used 2007-2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007-2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients.
RESULTS
Medicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare's P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results.
CONCLUSIONS
Consistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.
Topics: Hospitals; Humans; Inpatients; Medicare; Patient Protection and Affordable Care Act; Quality of Health Care; Reimbursement, Incentive; United States
PubMed: 35902910
DOI: 10.1186/s12913-022-08348-w -
Physical Therapy May 2019Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood. (Observational Study)
Observational Study
BACKGROUND
Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood.
OBJECTIVE
The objectives of this study were to examine variations in annual outpatient physical therapy expenditures of Medicare fee-for-service beneficiaries by primary diagnosis and baseline functional mobility, and to assess whether case mix groups based on primary diagnosis and functional mobility scores would be useful for expenditure differentiation.
DESIGN
This was an observational, longitudinal study.
METHODS
Volunteer providers in community settings participated in data collection with Continuity Assessment Record and Evaluation-Community (CARE-C) assessments for Medicare fee-for-service beneficiaries. Annual outpatient physical therapy expenditures were calculated using allowed charges on Medicare claims; primary diagnosis and baseline functional mobility were obtained from CARE-C assessments. Whether annual expenditures varied significantly across primary diagnosis groups and within diagnosis groups by functional mobility was examined.
RESULTS
Data for 4210 patients (mean [SD] age = 72.9 [9.9] years; 64.6% women) from 127 providers were included. Mean expenditures differed significantly across 12 primary diagnosis groups created from CARE-C clinician-reported diagnoses (F = 12.73; df = 11). Twenty-five pairwise differences in 66 pairwise diagnosis group comparisons were statistically significant. Within 8 diagnosis groups, expenditures were significantly higher for low-mobility subgroups than for high-mobility subgroups; borderline significance was achieved for 1 diagnosis group.
LIMITATIONS
The small convenience sample limited the statistical power and the generalizability of the results.
CONCLUSIONS
Significant variations in physical therapy expenditures based on primary diagnosis and baseline functional mobility support the use of these variables in predicting outpatient physical therapy expenditures. Although Medicare's annual therapy spending cap was repealed effective January 2018, the data from this study provide an initial foundation to inform any future policy efforts, such as targeted medical review, risk-adjusted therapy payments, or case mix groups as potential payment alternatives. Additional research with larger samples is needed to further develop and test case mix groups and improve generalizability to the national population. Refined case mix groups could also help providers prognosticate physical therapy expenditures based on patient profiles.
Topics: Aged; Diagnosis-Related Groups; Fee-for-Service Plans; Female; Health Expenditures; Humans; Longitudinal Studies; Male; Medicare; Mobility Limitation; Outpatients; Physical Therapy Modalities; United States
PubMed: 30801639
DOI: 10.1093/ptj/pzz023