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JAMA Network Open Oct 2021This cross-sectional study examines the accessibility of the Medicare Diabetes Prevention Program and investigates whether there are disparities in access among racial...
This cross-sectional study examines the accessibility of the Medicare Diabetes Prevention Program and investigates whether there are disparities in access among racial and ethnic minority beneficiaries at the state level.
Topics: Cross-Sectional Studies; Diabetes Mellitus; Humans; Medicare; Preventive Medicine; Racial Groups; State Health Plans; United States
PubMed: 34623412
DOI: 10.1001/jamanetworkopen.2021.28797 -
The American Journal of Managed Care Mar 2019Although use of the Medicare Annual Wellness Visit (AWV) is increasing nationally, it remains unclear whether it can help contain healthcare costs and improve quality....
OBJECTIVES
Although use of the Medicare Annual Wellness Visit (AWV) is increasing nationally, it remains unclear whether it can help contain healthcare costs and improve quality. In the context of 2 primary care physician-led accountable care organizations (ACOs), we tested the hypothesis that AWVs can improve healthcare costs and clinical quality.
STUDY DESIGN
A retrospective cohort study using propensity score matching and quasi-experimental difference-in-differences regression models comparing the differential changes in cost, emergency department (ED) visits, and hospitalizations for those who received an AWV versus those who did not from before until after the AWV. Logistic regressions were used for quality measures.
METHODS
Between 2014 and 2016, we examined the association of an AWV with healthcare costs, ED visits, hospitalizations, and clinical quality measures. The sample included Medicare beneficiaries attributed to providers across 44 primary care clinics participating in 2 ACOs.
RESULTS
Among 8917 Medicare beneficiaries, an AWV was associated with significantly reduced spending on hospital acute care and outpatient services. Patients who received an AWV in the index month experienced a 5.7% reduction in adjusted total healthcare costs over the ensuing 11 months, with the greatest effect seen for patients in the highest hierarchical condition category risk quartile. AWVs were not associated with ED visits or hospitalizations. Beneficiaries who had an AWV were also more likely to receive recommended preventive clinical services.
CONCLUSIONS
In a setting that prioritizes care coordination and utilization management, AWVs have the potential to improve healthcare quality and reduce cost.
Topics: Accountable Care Organizations; Aged; Aged, 80 and over; Female; Health Expenditures; Health Services; Humans; Insurance Claim Review; Logistic Models; Male; Medicare; Patient Acceptance of Health Care; Preventive Health Services; Primary Health Care; Quality of Health Care; Retrospective Studies; Socioeconomic Factors; United States
PubMed: 30875175
DOI: No ID Found -
Journal of General Internal Medicine Nov 2019The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive...
BACKGROUND
The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services.
OBJECTIVE
To understand how Medicare ACOs provide preventive care services to their attributed patients.
DESIGN
Mixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs.
PARTICIPANTS
ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.
MAIN MEASURES
Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services.
KEY RESULTS
Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients' preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets.
CONCLUSIONS
ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.
Topics: Accountable Care Organizations; Humans; Medicare; Patient Protection and Affordable Care Act; Preventive Health Services; Qualitative Research; Secondary Prevention; Surveys and Questionnaires; United States
PubMed: 31432439
DOI: 10.1007/s11606-019-05271-5 -
JAMA Dec 2022Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for... (Comparative Study)
Comparative Study
IMPORTANCE
Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown.
OBJECTIVE
To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.
DESIGN, SETTING, AND PARTICIPANTS
Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019).
EXPOSURES
Enrollment in Medicare Advantage vs traditional Medicare.
MAIN OUTCOMES AND MEASURES
The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions).
RESULTS
The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]).
CONCLUSIONS AND RELEVANCE
Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.
Topics: Aged; Female; Humans; Male; Aftercare; Medicare; Medicare Part C; Patient Discharge; Retrospective Studies; ST Elevation Myocardial Infarction; Treatment Outcome; United States
PubMed: 36472594
DOI: 10.1001/jama.2022.20982 -
The Journal of Ambulatory Care... 2020One of the most controversial areas in discussions of single-payer approaches for the United States, such as "Medicare for All," concerns its implications for costs....
One of the most controversial areas in discussions of single-payer approaches for the United States, such as "Medicare for All," concerns its implications for costs. Confusion over differences between federal and total spending and effects of lower patient cost sharing gets in the way of "apples-to-apples" comparisons. Key areas with potential to lower costs are lower administrative costs and lower provider prices. But cost reduction would likely be smaller than some envision, especially in the price area because of the need for a long process to gradually allow providers to adjust to lower prices and Americans' unique attitudes toward regulation.
Topics: Cost Sharing; Costs and Cost Analysis; Health Expenditures; Humans; Medicare; Single-Payer System; United States; Universal Health Insurance
PubMed: 32467433
DOI: 10.1097/JAC.0000000000000338 -
Health Services Research Jun 2023To evaluate whether Medicare's Hospital Readmissions Reduction Program (HRRP) is associated with increased observation stay use.
OBJECTIVE
To evaluate whether Medicare's Hospital Readmissions Reduction Program (HRRP) is associated with increased observation stay use.
DATA SOURCES AND STUDY SETTING
A nationally representative sample of fee-for-service Medicare claims, January 2009-September 2016.
STUDY DESIGN
Using a difference-in-difference (DID) design, we modeled changes in observation stays as a proportion of total hospitalizations, separately comparing the initial (acute myocardial infarction, pneumonia, heart failure) and subsequent (chronic obstructive pulmonary disease) target conditions with a control group of nontarget conditions. Each model used 3 time periods: baseline (15 months before program announcement), an intervening period between announcement and implementation, and a 2-year post-implementation period, with specific dates defined by HRRP policies.
DATA COLLECTION/EXTRACTION METHODS
We derived a 20% random sample of all hospitalizations for beneficiaries continuously enrolled for 12 months before hospitalization (N = 7,162,189).
PRINCIPAL FINDINGS
Observation stays increased similarly for the initial HRRP target and nontarget conditions in the intervening period (0.01% points per month [95% CI -0.01, 0.3]). Post-implementation, observation stays increased significantly more for target versus nontarget conditions, but the difference is quite small (0.02% points per month [95% CI 0.002, 0.04]). Results for the COPD analysis were statistically insignificant in both policy periods.
CONCLUSIONS
The increase in observation stays is likely due to other factors, including audit activity and clinical advances.
Topics: Aged; United States; Humans; Patient Readmission; Medicare; Hospitalization; Fee-for-Service Plans; Heart Failure; Pulmonary Disease, Chronic Obstructive
PubMed: 36755372
DOI: 10.1111/1475-6773.14142 -
The New England Journal of Medicine Jun 2016The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care...
BACKGROUND
The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support.
METHODS
We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices.
RESULTS
During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively).
CONCLUSIONS
Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).
Topics: Centers for Medicare and Medicaid Services, U.S.; Comprehensive Health Care; Fee-for-Service Plans; Health Care Costs; Humans; Medicare; Primary Health Care; Quality of Health Care; United States
PubMed: 27074035
DOI: 10.1056/NEJMsa1414953 -
The American Journal of Managed Care Feb 2022Three different out-of-pocket (OOP) maximums in Medicare Part D have been proposed: $2000 by the House of Representatives, $3100 by the Senate Finance Committee, and the...
OBJECTIVES
Three different out-of-pocket (OOP) maximums in Medicare Part D have been proposed: $2000 by the House of Representatives, $3100 by the Senate Finance Committee, and the beginning of catastrophic coverage by the Medicare Payment Advisory Commission. However, little is known about how beneficiaries would be affected.
STUDY DESIGN
We estimated multivariate linear regression models to determine which beneficiary characteristics were associated with the greatest savings under each proposed OOP maximum and simulated a potential behavioral response by beneficiaries.
METHODS
Using Part D 2017 claims data for beneficiaries in stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans, we estimated the number of beneficiaries affected, their demographic characteristics, and their drug utilization patterns. We then simulated a potential behavioral response by beneficiaries.
RESULTS
Under the $2000 OOP proposed threshold, only 7% of PDP and 4% of MA-PD plan beneficiaries would have spending high enough to reach the OOP maximum. Annual mean (SD) savings would be $1301 ($1849) for PDP beneficiaries and $1363 ($1888) for MA-PD plan beneficiaries, concentrated among beneficiaries taking specialty drugs. As the threshold increases, fewer beneficiaries would accrue savings, but savings would increase. For the highest proposed OOP maximum, mean (SD) savings would be $2720 ($3465) and $2473 ($2805) for PDP and MA-PD plan beneficiaries, respectively. In our simulations, we estimated that the number of beneficiaries affected by an OOP maximum could increase by 2% to 11%, depending on the magnitude of response, but changes in savings would be minimal.
CONCLUSIONS
As currently drafted, proposed OOP maximums would reduce OOP spending for a small population of Part D beneficiaries, with savings concentrated among beneficiaries with the very highest costs who are taking specialty medications.
Topics: Aged; Health Expenditures; Humans; Medicare Part C; Medicare Part D; Medicare Payment Advisory Commission; Prescription Drugs; United States
PubMed: 35139297
DOI: 10.37765/ajmc.2022.88828 -
Health Services Research Jun 2021To assess changes in physicians' provision of care to duals (low-income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully...
OBJECTIVE
To assess changes in physicians' provision of care to duals (low-income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare's cost sharing for office visits with these patients. This policy-a provision of the Affordable Care Act-effectively increased payments for office visits with duals by 0%-20%, depending on the state, in 2013 and 2014.
DATA SOURCES
Fee-for-service claims for a 5% random sample of Medicare beneficiaries in 2010-2016.
STUDY DESIGN
We conducted a difference-in-differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)-the largest subpopulation of duals for whom payment rates were affected by this policy-to changes among other low-income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple-differences analysis that compared changes between QMBs and other low-income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases.
DATA COLLECTION
The study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low-income Medicare beneficiaries (1 914 073 beneficiary-years from 2010 to 2016).
PRINCIPAL FINDINGS
Nationally, we did not find a differential increase in office visits among QMBs versus other low-income beneficiaries that coincided with this payment change. In the triple-differences analysis, we did not observe a greater increase in visits among QMBs vs other low-income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple-differences estimate: -0.12 annual visits, 95% CI: -0.28, 0.04; P = 0.15).
CONCLUSIONS
Physicians' provision of care to low-income Medicare beneficiaries may not be responsive to short-run payment changes.
Topics: Aged; Aged, 80 and over; Cost Sharing; Fee-for-Service Plans; Female; Humans; Insurance Claim Review; Male; Medicaid; Medicare; Physicians; Poverty; Quality of Health Care; Socioeconomic Factors; United States
PubMed: 33778957
DOI: 10.1111/1475-6773.13650 -
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