-
Journal of Vascular Surgery Jan 2018
Topics: Electronic Health Records; Health Expenditures; Humans; Medicare; Patient-Centered Care; Practice Guidelines as Topic; Quality of Health Care; Reimbursement, Incentive; United States
PubMed: 29268921
DOI: 10.1016/j.jvs.2017.10.047 -
The American Journal of Managed Care Jul 2022To examine the use of step therapy, prior authorization, and Part D formulary exclusion by 4 large Medicare Advantage (MA) insurers to manage 20 physician-administered...
OBJECTIVES
To examine the use of step therapy, prior authorization, and Part D formulary exclusion by 4 large Medicare Advantage (MA) insurers to manage 20 physician-administered drugs with the highest total Medicare expenditures (top 20 drugs).
STUDY DESIGN
We collected data for United Healthcare, CVS/Aetna, Humana, and Kaiser plans to create a database of 2020 Part B coverage restrictions and conducted a retrospective analysis of 2018-2020 Part D formularies.
METHODS
For each insurer, we calculated the number of top 20 physician-administered drugs subject to prior authorization and step therapy. For physician-administered drugs for which there were no similar or interchangeable alternatives, we examined which insurers required prior authorization or step therapy. Finally, we examined whether insurers restricted access to physician-administered drugs by reducing coverage on Part D formularies.
RESULTS
Of the top 20 physician-administered drugs, 17 were subject to prior authorization and 10 were subject to step therapy by at least 1 insurer. For 5 physician-administered drugs without a similar or interchangeable alternative, none were subject to step therapy and all were subject to prior authorization by at least 1 insurer. Across the 4 insurers, 16 physician-administered drugs were covered on all or some of the Part D formularies in 2018, which decreased to 6 in 2020.
CONCLUSIONS
Four large MA insurers managed access to expensive physician-administered drugs with a combination of prior authorization, step therapy, and Part D formulary design. When a low-cost alternative exists, these tools can help reduce wasteful spending, but the administrative barriers may also reduce access.
Topics: Aged; Humans; Insurance Carriers; Medicare Part C; Medicare Part D; Physicians; Prior Authorization; Retrospective Studies; United States
PubMed: 35852888
DOI: 10.37765/ajmc.2022.89184 -
Journal of Oncology Practice Oct 2019The Oncology Care Model (OCM) is Medicare's first bundled payment program for patients with cancer. We examined baseline characteristics of OCM physician participants...
PURPOSE
The Oncology Care Model (OCM) is Medicare's first bundled payment program for patients with cancer. We examined baseline characteristics of OCM physician participants and markets with high OCM physician participation to inform generalizability and complement the ongoing practice-level evaluation of the OCM.
METHODS
In this cross-sectional study, we identified characteristics of US medical oncologists practicing in 2016, using a national telephone-verified physician database. We linked these data with Dartmouth Atlas and Medicare claims data from 2011 through 2016 to identify characteristics of markets with high OCM participation. We used logistic regression to examine relationships between market characteristics and OCM participation.
RESULTS
Of 10,428 US medical oncologists, 2,605 (24.9%) were listed in an OCM practice. There were no differences in sex or medical training between OCM participants and nonparticipants, although OCM participants were slightly younger. OCM participants practiced in larger (median daily patient volume, 80 55 patients) and urban practices (95.2% 90.7%) and were less likely to be part of a health system (41.0% 60.4%) or solo practice (45.5% 67.4%; all < .001). Participation was higher in southern and mid-Atlantic markets. Markets with high OCM physician participation had higher specialist density, hospital care intensity, and acute care use at the end of life (all < .001). Market-level penetration of Accountable Care Organizations (adjusted odds ratio, 4.65; 95% CI 3.31 to 6.56; < .001) and Medicare Advantage (adjusted odds ratio 2.82; 95% CI, 1.97 to 4.06; < .001) were associated with higher OCM participation.
CONCLUSION
In the first description of oncologists participating in the OCM, we found differences in practice demographics, care intensity, and exposure to nontraditional payment models between OCM-participating and nonparticipating physicians. Such provider-level differences may not be captured in Medicare's practice-level analysis.
Topics: Geography, Medical; Medical Oncology; Medicare; Models, Theoretical; Patient Care Bundles; Physicians; Practice Patterns, Physicians'; United States
PubMed: 31393806
DOI: 10.1200/JOP.19.00047 -
JAMA Network Open Apr 2020Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage...
IMPORTANCE
Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage was extended to benzodiazepines in 2013.
OBJECTIVE
To examine whether the expansion of benzodiazepine coverage among Medicare Advantage (MA) beneficiaries was associated with increases in fall-related injuries or overdoses among older adults.
DESIGN, SETTING, AND PARTICIPANTS
This ecological study used interrupted time-series with comparison-series analyses of MA claims data from 4 635 312 age-eligible MA beneficiaries and 940 629 commercially insured individuals (comparison group) stratified by age (65-69, 70-74, 75-79, and ≥80 years) to separately compare trends in fall-related injury and overdose before (January 1, 2010, to December 31, 2012) and after (January 1, 2013, to December 31, 2015) coverage expansion for benzodiazepines. Data analysis was performed from September 1, 2018, to August 31, 2019.
EXPOSURES
Expansion of benzodiazepine coverage in Medicare Part D in 2013.
MAIN OUTCOMES AND MEASURES
Monthly rate of fall-related injury and overdose.
RESULTS
In 2012 (the year before the policy change), women constituted 57.5% of the MA group and 47.4% of the comparison group. A total of 25.8% of individuals in the MA group were aged 65 to 69 years, and 29.3% were 80 years or older (mean [SD], 75.1 [6.4] years); 56.7% of individuals in the comparison group were aged 65 to 69 years, and 15.1% were 80 years or older (mean [SD] age, 70.9 [6.5] years). In the MA group, 4 635 312 individuals contributed 156 754 749 person-months from 2010 through 2015; in the comparison group, 940 629 individuals contributed 25 104 534 person-months. After coverage of benzodiazepines began, the rate (ie, slope) of fall-related injury among MA beneficiaries increased from before to after coverage among all age groups. Compared with the comparison group, the increase in rate was statistically significant for those 80 years or older (rate changes for the MA vs comparison groups: 0.12 [95% CI, 0.07 to 0.17] vs -0.01 [95% CI, -0.11 to 0.10]; P = .04 for interaction). The overdose trend changed from decreasing to increasing among MA beneficiaries after coverage for all age groups, with a statistically significant increase compared with the comparison group among those aged 65 to 69 years (rate changes for the MA vs comparison groups: 0.23 [95% CI, 0.17 to 0.30] vs 0.02 [95% CI, -0.06 to 0.11]; P < .001 for interaction) and among those 80 years or older (rate changes for the MA vs comparison groups: 0.07 [95% CI, 0.00 to 0.14] vs -0.20 [95% CI, -0.35 to -0.05]; P = .002 for interaction). Results among MA beneficiaries were consistent when stratified by sex and when limited to those prescribed opioids.
CONCLUSIONS AND RELEVANCE
Medicare's expansion of benzodiazepine coverage may have been associated with increases in the rates of overdose among adults ages 65 to 69 years and in the rates of overdose and fall-related injury among those 80 years or older.
Topics: Accidental Falls; Aged; Aged, 80 and over; Algorithms; Benzodiazepines; Case-Control Studies; Drug Overdose; Female; Humans; Insurance Benefits; Insurance Coverage; Interrupted Time Series Analysis; Male; Medicare Part C; Medicare Part D; Patient Safety; Prescription Drugs; United States
PubMed: 32242907
DOI: 10.1001/jamanetworkopen.2020.2051 -
Journal of the American Pharmacists... 2020To describe the national delivery of medication therapy management (MTM) to Medicare beneficiaries in 2013 and 2014.
OBJECTIVE
To describe the national delivery of medication therapy management (MTM) to Medicare beneficiaries in 2013 and 2014.
METHODS
Descriptive cross-sectional study using the 100% sample of 2013 and 2014 Part D MTM data files. We quantified descriptive statistics (counts and percentages, in addition to means and standard deviations) to summarize the delivery of these services and compare delivery between 2013 and 2014.
RESULTS
Medicare beneficiaries eligible for MTM increased from 4,281,733 in 2013 to 4,552,547 in 2014. Among eligible beneficiaries, the number and percentage who were offered a comprehensive medication review (CMR) increased from 3,473,004 (81.1%) to 4,394,822 (96.5%), and beneficiaries receiving a CMR increased from 526,203 (12.3%) to 767,286 (16.9%). In 2014, CMRs were most frequently delivered by telephone (83.2%) and provided by either a plan sponsor (29.0%) or an MTM vendor in-house pharmacist (35.0%). In 2014, pharmacists provided 93.5% of all CMRs, and other providers (e.g., nurses and physicians) provided 6.5% of CMRs. Few patients who received a CMR received more than 1 within the same year (2.2% in 2014). Medication therapy problem (MTP) resolution among patients receiving a CMR stayed roughly the same between 2013 and 2014 (19.2% vs. 18.7%, respectively; P < 0.001). Finally, most beneficiaries (96.9% in 2014) received a targeted medication review, regardless of whether a CMR was offered or provided.
CONCLUSION
More than 4 million Medicare beneficiaries were enrolled in Part D MTM in both 2013 and 2014. However, less than 20% of eligible beneficiaries received a CMR during those years, and rates of MTP resolution were low. Future evaluation of Part D MTM delivery should examine changes in eligibility criteria and delivery over time to inform MTM policy and changes in practice.
Topics: Aged; Cross-Sectional Studies; Humans; Medicare Part D; Medication Therapy Management; Pharmacists; Prescription Drugs; United States
PubMed: 31926872
DOI: 10.1016/j.japh.2019.12.002 -
Journal of Managed Care & Specialty... May 2018In 2007, the Centers for Medicare & Medicaid Services (CMS) instituted a star rating system using performance outcome measures to assess Medicare Advantage Prescription... (Comparative Study)
Comparative Study
BACKGROUND
In 2007, the Centers for Medicare & Medicaid Services (CMS) instituted a star rating system using performance outcome measures to assess Medicare Advantage Prescription Drug (MAPD) and Prescription Drug Plan (PDP) providers.
OBJECTIVE
To assess the relationship between 2 performance outcome measures for Medicare insurance providers, comprehensive medication reviews (CMRs), and high-risk medication use.
METHODS
This cross-sectional study included Medicare Part C and Part D performance data from the 2014 and 2015 calendar years. Performance data were downloaded per Medicare contract from the CMS. We matched Medicare insurance provider performance data with the enrollment data of each contract. Mann Whitney U and Spearman rho tests and a hierarchical linear regression model assessed the relationship between provider characteristics, high-risk medication use, and CMR completion rate outcome measures.
RESULTS
In 2014, an inverse correlation between CMR completion rate and high-risk medication use was identified among MAPD plan providers. This relationship was further strengthened in 2015. No correlation was detected between the CMR completion rate and high-risk medication use among PDP plan providers in either year. A multivariate regression found an inverse association with high-risk medication use among MAPD plan providers in comparison with PDP plan providers in 2014 (beta = -0.358, P < 0.001) and 2015 (beta = -0.350, P < 0.001), the CMR completion rate in 2015 (beta = -0.221, P < 0.001), and enrollee population size in 2015 (beta = -0.203, P = 0.001).
CONCLUSIONS
This study found that MAPD plan providers and higher CMR completion rates were associated with lower use of high-risk medications among beneficiaries.
DISCLOSURES
No outside funding supported this study. Silva Almodovar reports a fellowship funded by SinfoniaRx, Tucson, Arizona, during the time of this study. The other authors have nothing to disclose.
Topics: Centers for Medicare and Medicaid Services, U.S.; Contract Services; Cross-Sectional Studies; Drug Utilization Review; Insurance Benefits; Medicare Part C; Medicare Part D; Medication Therapy Management; Outcome Assessment, Health Care; Pharmaceutical Services; Prescription Drugs; United States
PubMed: 29694292
DOI: 10.18553/jmcp.2018.24.5.416 -
Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans.Medical Care Feb 2021In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions.... (Review)
Review
BACKGROUND
In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments. Recently the Government Accountability Office released a report raising concerns about the use of these chart reviews as a potential tool for upcoding.
OBJECTIVES
To measure the extent to which plans receive additional payments for chart reviews, and the variation in chart reviews across plans.
RESEARCH DESIGN
In this cross-sectional study we use 2015 MA Encounter data to calculate how many additional diagnoses codes were added for each enrollee using chart reviews. We then calculate how these additional diagnosis codes translate to additional reimbursements across plans.
SUBJECTS
A total of 14,021,692 beneficiaries enrolled in 510 MA contracts in 2015.
MEASURES
Individual and contract level hierarchical condition category codes, total plan reimbursement.
RESULTS
Chart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans.
CONCLUSIONS
Given the substantial and highly variable increase in payments attributable to chart review, further investigation of the validity of this practice and its implications for Medicare spending is needed.
Topics: Cross-Sectional Studies; Health Care Costs; Humans; Insurance Coverage; Insurance, Health; Medicare; United States
PubMed: 32925467
DOI: 10.1097/MLR.0000000000001412 -
Inquiry : a Journal of Medical Care... 2022Medicare's Hospital Trust Fund is projected to become insolvent sometime during 2028 and there will be insufficient funds to cover the costs of beneficiaries' care if...
Medicare's Hospital Trust Fund is projected to become insolvent sometime during 2028 and there will be insufficient funds to cover the costs of beneficiaries' care if reforms are not made before then. Many options have been proposed on ways to extend the trust fund's solvency. Some proposals focus on controlling costs and other proposals include options for raising revenues. A fresh perspective on this policy dilemma may arise by considering Japan's statutory health insurance (SHI) and its financing mechanisms. Japan could be a useful model because it has an older population and it is facing similar fiscal challenges before Medicare. Japan could offer some useful perspectives from its cost containment efforts to extend Medicare's solvency.
Topics: United States; Aged; Humans; Medicare; Financial Management; Cost Control; National Health Programs; Trust
PubMed: 36510414
DOI: 10.1177/00469580221143631 -
Health Affairs (Project Hope) Jun 2018We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's... (Comparative Study)
Comparative Study
We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost. These findings suggest that while both voluntary and mandatory approaches can play a role in engaging hospitals in bundled payment, mandatory programs can produce more robust, generalizable evidence. Either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payment programs.
Topics: Arthroplasty, Replacement; Databases, Factual; Episode of Care; Female; Health Expenditures; Humans; Insurance, Health; Male; Mandatory Programs; Medicare; Orthopedics; Outcome Assessment, Health Care; Patient Care Bundles; Retrospective Studies; Statistics, Nonparametric; United States
PubMed: 29863929
DOI: 10.1377/hlthaff.2017.1358 -
Journal of General Internal Medicine Feb 2020
Topics: Aged; Contract Services; Humans; Medicare Part C; Medicare Part D; United States
PubMed: 31093841
DOI: 10.1007/s11606-019-05036-0