-
BMC Health Services Research Mar 2022The Hospital Readmissions Reduction Program (HRRP), established by the Centers for Medicare and Medicaid Services (CMS) in March 2010, introduced payment-reduction...
BACKGROUND
The Hospital Readmissions Reduction Program (HRRP), established by the Centers for Medicare and Medicaid Services (CMS) in March 2010, introduced payment-reduction penalties on acute care hospitals with higher-than-expected readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. There is concern that hospitals serving large numbers of low-income and uninsured patients (safety-net hospitals) are at greater risk of higher readmissions and penalties, often due to factors that are likely outside the hospital's control. Using publicly reported data, we compared the readmissions performance and penalty experience among safety-net and non-safety-net hospitals.
METHODS
We used nationwide hospital level data for 2009-2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. We identified as safety-net hospitals the top quartile of hospitals in terms of the proportion of patients receiving income-based public benefits. Using a quasi-experimental difference-in-differences approach based on the comparison of pre- vs. post-HRRP changes in (risk-adjusted) 30-day readmission rate in safety-net and non-safety-net hospitals, we estimated the change in readmissions rate associated with HRRP. We also compared the penalty frequency among safety-net and non-safety-net hospitals.
RESULTS
Our study cohort included 1915 hospitals, of which 479 were safety-net hospitals. At baseline (2009), safety-net hospitals had a slightly higher readmission rate compared to non-safety net hospitals for all three conditions: AMI, 20.3% vs. 19.8% (p value< 0.001); heart failure, 25.2% vs. 24.2% (p-value< 0.001); pneumonia, 18.7% vs. 18.1% (p-value< 0.001). Beginning in 2012, readmission rates declined similarly in both hospital groups for all three cohorts. Based on difference-in-differences analysis, HRRP was associated with similar change in the readmissions rate in safety-net and non-safety-net hospitals for AMI and heart failure. For the pneumonia cohort, we found a larger reduction (0.23%; p < 0.001) in safety-net hospitals. The frequency of readmissions penalty was higher among safety-net hospitals. The proportion of hospitals penalized during all four post-HRRP years was 72% among safety-net and 59% among non-safety-net hospitals.
CONCLUSIONS
Our results lend support to the concerns of disproportionately higher risk of performance-based penalty on safety-net hospitals.
Topics: Aged; Centers for Medicare and Medicaid Services, U.S.; Hospitals; Humans; Medicare; Patient Readmission; Safety-net Providers; United States
PubMed: 35287693
DOI: 10.1186/s12913-022-07741-9 -
The Milbank Quarterly Sep 2020Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment...
UNLABELLED
Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment.
CONTEXT
Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.
METHODS
We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs.
FINDINGS
Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change.
CONCLUSIONS
Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.
Topics: Cost Savings; Hospital Costs; Hospitalization; Humans; Length of Stay; Medicare; Patient Care Bundles; Reimbursement Mechanisms; United States
PubMed: 32820837
DOI: 10.1111/1468-0009.12465 -
JAMA Network Open Sep 2018Low early-life cognitive ability is a potential early marker of dementia risk in later life. Previous studies use only global measures of general intelligence and/or...
IMPORTANCE
Low early-life cognitive ability is a potential early marker of dementia risk in later life. Previous studies use only global measures of general intelligence and/or study this relationship in gender-specific samples. The contribution of early-life performance on specific cognitive abilities, such as language, reasoning, and visualization aptitudes, to indicating future dementia risk is unknown.
OBJECTIVES
To investigate the association between adolescent cognitive ability and Medicare-recorded Alzheimer disease and related disorders (ADRD) using both general and specific measures of cognitive ability and to explore these associations separately in men and women.
DESIGN, SETTING, AND PARTICIPANTS
Population-based cohort study from the Project Talent-Medicare linked data set, a linkage of adolescent sociobehavioral data collected from high school students in 1960 to participants' 2012 to 2013 Medicare Claims and expenditures data. The association between adolescent cognitive ability and risk of ADRD in later life was assessed in a diverse sample of 43 014 men and 42 749 women aged 66 to 73 years using a series of logistic regressions stratified by sex, accounting for demographic characteristics, adolescent socioeconomic status, and regional effects. Data analysis was conducted from November 2017 to March 2018.
MAIN OUTCOMES AND MEASURES
Presence of Medicare-reported ADRD.
RESULTS
Overall, 1239 men (2.9%) and 1416 women (3.3%) developed ADRD. Lower mechanical reasoning was associated with increased odds of ADRD in men (odds ratio, 1.17; 95% CI, 1.05-1.29), and lower memory for words in adolescence was associated with increased odds of ADRD in women (odds ratio, 1.16; 95% CI, 1.05-1.28). Lower performance on several other language, reasoning, visualization, and mathematic aptitudes in adolescence showed prominent, but weaker, associations with odds of ADRD.
CONCLUSIONS AND RELEVANCE
This work contributes to the understanding of early-life origins of ADRD risk. The results suggest specific measures of cognitive ability may contribute to very early identification of at-risk subgroups who may benefit from prevention or intervention efforts.
Topics: Adolescent; Aged; Alzheimer Disease; Cognition; Cohort Studies; Educational Measurement; Educational Status; Female; Humans; Logistic Models; Male; Medicare; Risk; United States
PubMed: 30646141
DOI: 10.1001/jamanetworkopen.2018.1726 -
Annals of Family Medicine 2015
Topics: Comprehensive Health Care; Female; Health Expenditures; Humans; Male; Medicare; Physicians, Family
PubMed: 25964396
DOI: 10.1370/afm.1788 -
JAMA Apr 2023The Inflation Reduction Act of 2022 authorizes Medicare to negotiate prices of top-selling drugs based on several factors, including therapeutic benefit compared with...
IMPORTANCE
The Inflation Reduction Act of 2022 authorizes Medicare to negotiate prices of top-selling drugs based on several factors, including therapeutic benefit compared with existing treatment options.
OBJECTIVE
To determine the added therapeutic benefit of the 50 top-selling brand-name drugs in Medicare in 2020, as assessed by health technology assessment (HTA) organizations in Canada, France, and Germany.
DESIGN, SETTING, AND PARTICIPANTS
In this cross-sectional study, publicly available therapeutic benefit ratings, US Food and Drug Administration documents, and the Medicare Part B and Part D prescription drug spending dashboards were used to determine the 50 top-selling single-source drugs used in Medicare in 2020 and to assess their added therapeutic benefit ratings through 2021.
MAIN OUTCOMES AND MEASURES
Ratings from HTA bodies in Canada, France, and Germany were categorized as high (moderate or greater) or low (minor or no) added benefit. Each drug was rated based on its most favorable rating across countries, indications, subpopulations, and dosage forms. We compared the use and prerebate and postrebate (ie, net) Medicare spending between drugs with high vs low added benefit.
RESULTS
Forty-nine drugs (98%) received an HTA rating by at least 1 country; 22 of 36 drugs (61%) received a low added benefit rating in Canada, 34 of 47 in France (72%), and 17 of 29 in Germany (59%). Across countries, 27 drugs (55%) had a low added therapeutic rating, accounting for $19.3 billion in annual estimated net spending, or 35% of Medicare net spending on the 50 top-selling single-source drugs and 11% of total Medicare net prescription drug spending in 2020. Compared with those with high added benefit, drugs with a low added therapeutic rating were used by more Medicare beneficiaries (median 387 149 vs 44 869) and had lower net spending per beneficiary (median $992 vs $32 287).
CONCLUSIONS AND RELEVANCE
Many top-selling Medicare drugs received low added benefit ratings by the national HTA organizations of Canada, France, and Germany. When negotiating prices for these drugs, Medicare should ensure they are not priced higher than reasonable therapeutic alternatives.
Topics: Cross-Sectional Studies; Drug Costs; Drugs, Generic; Health Expenditures; Medicare Part B; Medicare Part D; National Health Programs; Prescription Drugs; United States; Patents as Topic; Canada; France; Germany
PubMed: 37071095
DOI: 10.1001/jama.2023.4034 -
Annals of Family Medicine 2024Procedures are manual technical skills clinicians perform for their patients. Family physicians (FPs) acquire these skills during residency; most are undertaken in... (Observational Study)
Observational Study
PURPOSE
Procedures are manual technical skills clinicians perform for their patients. Family physicians (FPs) acquire these skills during residency; most are undertaken in outpatient settings. We performed a retrospective observational cohort study to describe the extent to which FPs perform the core procedures recommended by the Council of Academic Family Medicine (CAFM) and how this might have changed over time.
METHODS
The CAFM recommended a list of procedures all FP residents should perform competently after graduation. We modified this list for Medicare beneficiaries to enable matching with Current Procedural Terminology codes. We probed Medicare Part B databases for modified CAFM procedure claims submitted by FPs in 2021 and how these claims changed from 2014 to 2021.
RESULTS
In 2021, there were 904,278 modified CAFM procedures filed by 9,410 FPs in the outpatient setting. All procedures were clustered with respect to organ system (eg, musculoskeletal, skin, pulmonary). Beginning in 2014 and continuously through 2021, there was a 33% decrease in outpatient procedures filed and a 36% decrease in the number of FPs filing them.
CONCLUSIONS
Office-based procedures are integral to a primary care physician's role, although the activity is rarely analyzed. At a time when the Medicare population is growing, the number of available FPs and the number of procedures they perform are not. This decrease might result from the changing scope of FP practice, new referral patterns, task shifting, and/or increased delegation to physician associates and nurse practitioners.
Topics: Humans; United States; Retrospective Studies; Family Practice; Physicians, Family; Medicare; Clinical Competence; Female; Male; Medicare Part B
PubMed: 38806267
DOI: 10.1370/afm.3096 -
Medical Care Aug 2019To develop and validate a measure that estimates individual level poverty in Medicare administrative data that can be used in studies of Medicare claims.
OBJECTIVE
To develop and validate a measure that estimates individual level poverty in Medicare administrative data that can be used in studies of Medicare claims.
DATA SOURCES
A 2008 to 2013 Medicare Current Beneficiary Survey linked to 2008 to 2013 Medicare fee-for-service beneficiary summary file and census data.
STUDY DESIGN AND METHODS
We used the Medicare Current Beneficiary Survey to define individual level poverty status and linked to Medicare administrative data (N=38,053). We partitioned data into a measure derivation dataset and a validation dataset. In the derivation data, we used a logistic model to regress poverty status on measures of dual eligible status, part D low-income subsidy, and demographic and administrative data, and modeled with and without linked census and nursing home data. Each beneficiary receives a predicted poverty score from the model. Performance was evaluated in derivation and validation data and compared with other measures used in the literature. We present a measure for income-only poverty as well as one for income and asset poverty.
PRINCIPAL FINDINGS
A score (predicted probability of income poverty) >0.5 yielded 58% sensitivity, 94% specificity, and 84% positive predictive value in the derivation data; our score yielded very similar results in the validation data. The model's c-statistic was 0.84. Our poverty score performed better than Medicaid enrollment, high zip code poverty, and zip code median income. The income and asset version performed similarly well.
CONCLUSIONS
A poverty score can be calculated using Medicare administrative data for use as a continuous or binary measure. This measure can improve researchers' ability to identify poverty in Medicare administrative data.
Topics: Aged; Aged, 80 and over; Cross-Sectional Studies; Female; Humans; Income; Male; Medicare; Middle Aged; Poverty; Reproducibility of Results; United States
PubMed: 31295189
DOI: 10.1097/MLR.0000000000001154 -
Medical Care Apr 2020The Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of...
BACKGROUND
The Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of communities and may inadvertently penalize hospitals that service disadvantaged neighborhoods.
OBJECTIVE
This study examines the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare's Hospital Compare Program.
RESEARCH DESIGN
2017 Medicare Hospital Compare ratings were linked with block group data from the 2015 American Community Survey to assess hospital ratings as a function of neighborhood SRFs.
SUBJECTS
A total of 3608 Medicare-certified hospitals in 50 US states.
MEASURES
Hospital summary scores and 7 quality group scores (100 percentile scale), including effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care, and timeliness of care.
RESULTS
Lower hospital summary scores were associated with caring for neighborhoods with higher social risk, including a reduction in hospital score for every 10% of residents who reported dual-eligibility for Medicare/Medicaid [-3.3%; 95% confidence interval (CI), -4.7 to -2.0], no high-school diploma (-0.8%; 95% CI, -1.5 to -0.1), unemployment (-1.2%; 95% CI, -1.9 to -0.4), black race (-1.2%; 95% CI, -1.7 to -0.8), and high travel times to work (-2.5%; 95% CI, -3.3 to -1.6). Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups; and smallest in the safety, efficiency, and effectiveness of care groups.
CONCLUSIONS
Hospitals serving communities with higher social risk may have lower ratings because of neighborhood factors. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.
Topics: Aged; Centers for Medicare and Medicaid Services, U.S.; Female; Hospitals; Humans; Male; Medicare; Poverty Areas; Quality Indicators, Health Care; Risk Factors; United States
PubMed: 31895306
DOI: 10.1097/MLR.0000000000001283 -
Journal of General Internal Medicine Sep 2022The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major... (Review)
Review
The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations - a "Reverse Robin Hood" effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.
Topics: Aged; Ethnicity; Humans; Internal Medicine; Medicare; Minority Groups; Patient Protection and Affordable Care Act; Reimbursement, Incentive; United States
PubMed: 35768676
DOI: 10.1007/s11606-022-07698-9 -
Health Care Expenses and Financial Hardship Among Medicare Beneficiaries With Functional Disability.JAMA Network Open Jun 2024Medicare beneficiaries with functional disabilities often require more medical care, leading to substantial financial hardship. However, the precise magnitude and...
IMPORTANCE
Medicare beneficiaries with functional disabilities often require more medical care, leading to substantial financial hardship. However, the precise magnitude and sources of this hardship remain unknown.
OBJECTIVES
To quantify the financial burden from health care expenses by functional disability levels among Medicare beneficiaries.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study used data, including demographic and socioeconomic characteristics, health status, and health care use, from a nationally representative sample of Medicare beneficiaries from the 2013 to 2021 Medical Expenditure Panel Survey. Functional disability was measured using 6 questions and categorized into 3 levels: none (no difficulties), moderate (1-2 difficulties), and severe (≥3 difficulties). Data were analyzed from December 2023 to March 2024.
MAIN OUTCOMES AND MEASURES
Financial hardship from health care expenses was assessed using objective measures (annual out-of-pocket spending, high financial burden [out-of-pocket spending exceeding 20% of income], and catastrophic financial burden [out-of-pocket spending exceeding 40% of income]) and subjective measures (difficulty paying medical bills and paying medical bills over time). We applied weights to produce results representative of national estimates.
RESULTS
The sample included 31 952 Medicare beneficiaries (mean [SD] age, 71.1 [9.7] years; 54.6% female). In weighted analyses, severe functional disability was associated with a significantly higher financial burden from health care expenses, with out-of-pocket spending reaching $2137 (95% CI, $1943-$2330) annually. This exceeded out-of-pocket spending for those without functional disability by nearly $700 per year ($1468 [95% CI, $1311-$1625]) and for those with moderate functional disability by almost $500 per year ($1673 [95% CI, $1620-$1725]). The primary factors that played a role in this difference were home health care ($399 [95% CI, $145-$651]) and equipment and supplies ($304 [95% CI, $278-$330]). Beneficiaries with severe functional disability experienced significantly higher rates of both high and catastrophic financial burden than those without disability and those with moderate disability (13.2% [12.2%-14.1%] vs 9.1% [95% CI, 8.6%-9.5%] and 9.4% [95% CI, 9.1%-9.7%] for high financial burden, respectively, and 8.9% [95% CI, 7.8%-10.1%] vs 6.4% [95% CI, 6.1%-6.8%] and 6.0% [95% CI, 5.6%-6.4%] for catastrophic financial burden, respectively). Similar associations were observed in subjective financial hardship. For example, 11.8% (95% CI, 10.3%-13.3%) of those with severe functional disability experienced problems paying medical bills, compared with 7.7% (95% CI, 7.6%-7.9%) and 9.3% (95% CI, 9.0%-9.6%) of those without functional disability and those with moderate functional disability, respectively. Notably, there were no significant differences in financial hardship among those with Medicaid based on functional disability levels.
CONCLUSIONS AND RELEVANCE
In this cross-sectional study of Medicare beneficiaries, those with severe functional disability levels experienced a disproportionate burden from health care costs. However, Medicaid played a pivotal role in reducing the financial strain. Policymakers should explore interventions that effectively relieve the financial burden of health care in this vulnerable population.
Topics: Humans; United States; Medicare; Female; Male; Cross-Sectional Studies; Aged; Disabled Persons; Health Expenditures; Financial Stress; Aged, 80 and over; Cost of Illness
PubMed: 38884997
DOI: 10.1001/jamanetworkopen.2024.17300