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Health Services Research Feb 2023To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over...
OBJECTIVE
To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016-2020 and to identify the contributors to SNHs' realization of success under the program.
DATA SOURCES/STUDY SETTING
Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association.
STUDY DESIGN
We addressed whether SNHs can achieve progress in financial performance under CJR by focusing on the relative change in reconciliation payments or the difference between episode spending and target prices. We applied the method of dominance analysis to ordinary least squares regression to determine the relative importance of predictors of change in reconciliation payments over time.
PRINCIPAL FINDINGS
Compared to CJR hospitals overall, SNHs were less successful in meeting episode spending targets. Hospital factors dominated socioeconomic factors in explaining progress among SNHs, but not among non-SNHs. The contribution of nurse staffing was negligible across all CJR hospitals.
CONCLUSIONS
The formula used by CMS to determine spending targets may not be sufficient to address disparities in SNH financial performance under mandatory bundled payment.
Topics: Aged; Humans; United States; Safety-net Providers; Medicare; Episode of Care; Arthroplasty, Replacement; Hospitals
PubMed: 35904218
DOI: 10.1111/1475-6773.14042 -
Medical Care Feb 2021Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying...
BACKGROUND
Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences.
RESEARCH OBJECTIVE
Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs).
STUDY DESIGN
Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata.
RESULTS
Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs.
CONCLUSIONS
There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.
Topics: Cross-Sectional Studies; Health Care Costs; Humans; Insurance Benefits; Medicare; Nurse Practitioners; Physicians; Primary Health Care; United States
PubMed: 33273295
DOI: 10.1097/MLR.0000000000001477 -
Research in Social & Administrative... Sep 2020Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older...
BACKGROUND
Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults.
OBJECTIVES
To describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities.
METHODS
This nationally representative cross-sectional study used a 20% random sample of Medicare Part A, B, and D data linked with Part D MTM files. A total of 5,487,343 and 5,822,188 continuously enrolled beneficiaries were included in 2013 and 2014, respectively. CMR use was examined among a subset of 620,164 and 669,254 of these beneficiaries enrolled in the MTM program in 2013 and 2014. Main measures were MTM eligibility, CMR offer, and CMR receipt. The Andersen Behavioral Model of Health Services Use informed covariates selected.
RESULTS
In 2013 and 2014, 505,658 (82%) and 649,201 (97%) MTM eligible beneficiaries were offered a CMR, respectively. Among those, CMR receipt increased from 81,089 (16%) in 2013 to 119,181 (18%) in 2014. The mean age of CMR recipients was 75 years (±7) and the majority were women, White, and without low-income status. In 2014, lower odds of CMR receipt were associated with increasing age (adjusted odds ratio (OR) = 0.99 (95% confidence interval (CI) = 0.994-0.995), male sex (OR = 0.93, 95% CI = 0.926-0.951), being any non-White race/ethnicity except Black, dual-Medicaid status (OR = 0.64, 95% CI = 0.626-0.650), having a hospitalization (OR = 0.87, 95% CI = 0.839-0.893) or emergency department visit (OR = 0.67, 95% CI = 0.658-0.686), and number of comorbidities (OR = 0.90, 95% CI = 0.896-0.905).
CONCLUSIONS
CMR offers and completion rates have increased, but disparities in CMR receipt by age, sex, race, and dual-Medicaid status were evident. Changes to MTM targeting criteria and CMR offer strategies may be warranted to address disparities.
Topics: Aged; Cross-Sectional Studies; Ethnicity; Female; Humans; Male; Medicare Part D; Medication Therapy Management; United States; White People
PubMed: 31859225
DOI: 10.1016/j.sapharm.2019.12.007 -
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 -
Federal Register Dec 2018Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO)...
Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017. Final rules.
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. The policies included in this final rule provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. This final rule also provides new tools to support coordination of care across settings and strengthen beneficiary engagement; and ensure rigorous benchmarking. In this final rule, we also respond to public comments we received on the extreme and uncontrollable circumstances policies for the Shared Savings Program that were used to assess the quality and financial performance of ACOs that were subject to extreme and uncontrollable events, such as Hurricanes Harvey, Irma, and Maria, and the California wildfires, in performance year 2017, including the applicable quality data reporting period for performance year 2017.
Topics: Accountable Care Organizations; Benchmarking; Cost Savings; Disasters; Fee-for-Service Plans; Forecasting; Health Policy; Humans; Medicare; Medicare Part A; Medicare Part B; Quality Assurance, Health Care; United States
PubMed: 30596411
DOI: No ID Found -
Health Services Research Apr 2022To examine the effects of hospital membership in affiliation networks-franchise-like networks sponsored by high-quality health systems in which affiliate hospitals pay...
OBJECTIVE
To examine the effects of hospital membership in affiliation networks-franchise-like networks sponsored by high-quality health systems in which affiliate hospitals pay an annual fee for access to sponsor's operational and clinical resources-on clinical quality, patient experience ratings, and financial performance of affiliates and their competitors.
DATA SOURCES
Network membership data from press releases and websites of four sponsors (Mayo Clinic, Cleveland Clinic, MD Anderson, Memorial Sloan Kettering), American Hospital Association's Annual Survey, Centers for Medicare & Medicaid Services' Hospital Compare, and Healthcare Cost Report Information System, all for 2005-2016.
STUDY DESIGN
We used a quasi-experimental design and estimated hospital-level regressions with hospital-fixed effects. Dependent variables were measures of clinical quality, patient experience, and financial performance. Independent variables included an indicator for affiliate versus nonaffiliate and fixed effects for hospital characteristics and year. To analyze effects on competitors, we repeated analyses by comparing hospitals in the same county as an affiliate to nonaffiliated, noncompetitor hospitals.
DATA COLLECTION
Membership was obtained through press releases and network websites then linked across datasets by name and Medicare's identification number.
PRINCIPAL FINDINGS
Across networks, affiliates (N = 199) experienced insignificant clinical quality changes but increased net income by $38,500 and operating margin by 6.6% (p values = 0.01-0.08) compared to nonaffiliates. Multispecialty affiliates improved on no measures. Cancer-specific affiliates improved their net income ($96,900) and operating margin (3.6%; p-values < 0.05). Affiliates' competitors experienced mixed changes in clinical measures relative to hospitals without affiliates in market (p-value < 0.05) but no financial effects. Affiliation was not associated with patient experience ratings for affiliates nor competitors.
CONCLUSIONS
Despite quality-focused missions, affiliation networks are not guaranteed to improve public measures of quality in affiliated hospitals, although hospitals in these communities improve financially. Future research should assess the conditions and mechanisms by which affiliation improves quality consistently and which forms of quality.
Topics: Aged; Hospitals; Humans; Medicare; Surveys and Questionnaires; United States
PubMed: 34490641
DOI: 10.1111/1475-6773.13876 -
The American Journal of Managed Care Sep 2019We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient... (Comparative Study)
Comparative Study
OBJECTIVES
We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries.
STUDY DESIGN
For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began.
METHODS
We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes.
RESULTS
Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations.
CONCLUSIONS
Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.
Topics: Aged; Aged, 80 and over; Fee-for-Service Plans; Female; Health Expenditures; Humans; Male; Medicare; Primary Health Care; Quality of Health Care; United States
PubMed: 31518094
DOI: No ID Found -
Neurology Aug 2020To determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by...
OBJECTIVE
To determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012-2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File).
METHODS
Individual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services.
RESULTS
We identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (-6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially.
CONCLUSIONS
The Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.
Topics: Humans; Medicare; Physicians; Policy; Practice Patterns, Physicians'; Reimbursement Mechanisms; Retrospective Studies; United States
PubMed: 32680949
DOI: 10.1212/WNL.0000000000010090 -
JAMA Surgery May 2022The time involved in performing a procedure is a key factor in determining physician payments by Medicare. However, there are long-standing concerns regarding the...
IMPORTANCE
The time involved in performing a procedure is a key factor in determining physician payments by Medicare. However, there are long-standing concerns regarding the accuracy of the time estimates generated by the American Medical Association/Specialty Society Relative Value Scale Update Committee surveys that are used in the valuation process, and there have been calls to use other data sources to estimate procedure times.
OBJECTIVE
To compare estimated procedure times that come from claims with the times used in Medicare's valuation process.
DESIGN AND SETTING
Building off prior work using Medicare fee-for-service claims, procedure times were estimated from linked anesthesia claims data for 1349 different Current Procedure Terminology codes that are typically performed with anesthesia. All procedures in the nation performed in 2018 for Medicare fee-for-service beneficiaries were included in the analysis. These estimated times were compared with the times used in the valuation process. Analysis took place from February to November 2021.
MAIN OUTCOMES AND MEASURES
Estimated procedure times using anesthesia claims were compared with the procedure time used in valuation by calculating an estimated-to-valuation procedure time ratio for each code. The valuation procedure time is publicly reported by Medicare. The mean and median ratio are presented over all procedures and for select high-volume codes as well as by patient characteristics (age, sex, and risk score) and specialty of the physician performing the procedure.
RESULTS
Across 4.9 million procedures in this analysis, the mean estimated procedure time was 27% lower than the time used in the valuation process. There were notable exceptions, for which the mean estimated procedure time equaled or exceeded the valuation time including total hip arthroplasty (5% longer) and total knee arthroplasty (equal duration). Within a given code, older patients and those with more illness had longer procedure times. There was substantial variation across specialties in the percent difference between mean estimated and valuation procedure times ranging from gastroenterology (36% shorter) and ophthalmology (35% shorter) to cardiac surgery (2% longer) and thoracic surgery (7% longer).
CONCLUSIONS AND RELEVANCE
Claims-based procedure times could be used to improve the accuracy of valuations for procedures.
Topics: Aged; Fee-for-Service Plans; Humans; Medicare; Operative Time; Relative Value Scales; Surgeons; United States
PubMed: 35234831
DOI: 10.1001/jamasurg.2022.0099 -
Health Services Research Aug 2021To compare the predictive accuracy of two approaches to target price calculations under Bundled Payments for Care Improvement-Advanced (BPCI-A): the traditional Centers...
OBJECTIVE
To compare the predictive accuracy of two approaches to target price calculations under Bundled Payments for Care Improvement-Advanced (BPCI-A): the traditional Centers for Medicare and Medicaid Services (CMS) methodology and an empirical Bayes approach designed to mitigate the effects of regression to the mean.
DATA SOURCES
Medicare fee-for-service claims for beneficiaries discharged from acute care hospitals between 2010 and 2016.
STUDY DESIGN
We used data from a baseline period (discharges between January 1, 2010 and September 30, 2013) to predict spending in a performance period (discharges between October 1, 2015 and June 30, 2016). For 23 clinical episode types in BPCI-A, we compared the average prediction error across hospitals associated with each statistical approach. We also calculated an average across all clinical episode types and explored differences by hospital size.
DATA COLLECTION/EXTRACTION METHODS
We used a 20% sample of Medicare claims, excluding hospitals and episode types with small numbers of observations.
PRINCIPAL FINDINGS
The empirical Bayes approach resulted in significantly more accurate episode spending predictions for 19 of 23 clinical episode types. Across all episode types, prediction error averaged $8456 for the CMS approach versus $7521 for the empirical Bayes approach. Greater improvements in accuracy were observed with increasing hospital size.
CONCLUSIONS
CMS should consider using empirical Bayes methods to calculate target prices for BPCI-A.
Topics: Bayes Theorem; Centers for Medicare and Medicaid Services, U.S.; Costs and Cost Analysis; Fee-for-Service Plans; Humans; Insurance Claim Review; Medicare; Patient Care Bundles; Reimbursement Mechanisms; United States
PubMed: 34080188
DOI: 10.1111/1475-6773.13675