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AMA Journal of Ethics Dec 2023When physicians admit patients to a hospital, their decisions about where-and to whose professional stewardship and services-those patients belong are influenced by...
When physicians admit patients to a hospital, their decisions about where-and to whose professional stewardship and services-those patients belong are influenced by federal policies, of which many clinicians are not aware. The distinction between observation and admission has clinical and ethical implications for patients and practices. The evolution of "observation status" from a clinical tool to a catchall of vague and imprecise meaning has been driven by changes to physician payment and compensation structures, particularly Current Procedural Terminology codes and Centers for Medicare and Medicaid Services regulations, and its current value to clinicians and patients is questionable. This article contextualizes clinicians' admission and observation practices and considers how metrics influence patient costs and how clinicians and organizations are compensated.
Topics: Aged; Humans; United States; Medicare; Hospitalization; Hospitals; Centers for Medicare and Medicaid Services, U.S.; Costs and Cost Analysis
PubMed: 38085993
DOI: 10.1001/amajethics.2023.901 -
National Vital Statistics Reports :... Nov 2023Objectives-This report presents complete period life tables for the United States by Hispanic origin and race and sex, based on age-specific death rates in 2021....
Objectives-This report presents complete period life tables for the United States by Hispanic origin and race and sex, based on age-specific death rates in 2021. Methods-Data used to prepare the 2021 life tables are 2021 final mortality statistics; July 1, 2021, population estimates based on the Blended Base population estimates produced by the U.S. Census Bureau; and 2021 Medicare data for people ages 66-99. The methodology used to estimate life tables for the Hispanic population remains unchanged from that developed for the publication of life tables by Hispanic origin for data year 2006. The same methodology is used to estimate life tables for the American Indian and Alaska Native non-Hispanic and Asian non-Hispanic populations. The methodology used to estimate the 2021 life tables for all other groups was first implemented with data year 2008. Results-In 2021, the overall expectation of life at birth was 76.4 years, decreasing 0.6 year from 77.0 in 2020. From 2020 to 2021, life expectancy at birth decreased by 0.7 year for males (from 74.2 to 73.5) and by 0.6 year for females (79.9 to 79.3). Between 2020 and 2021, life expectancy decreased by 1.5 years for the American Indian and Alaska Native non-Hispanic population (67.1 to 65.6), 0.7 year for the White non-Hispanic population (77.4 to 76.7), 0.3 year for the Black non-Hispanic population (71.5 to 71.2), 0.1 year for the Hispanic population (77.9 to 77.8), and 0.1 year for the Asian non-Hispanic population (83.6 to 83.5).
Topics: Aged; Female; Humans; Infant, Newborn; Male; Ethnicity; Hispanic or Latino; Life Expectancy; Life Tables; Medicare; United States; Aged, 80 and over
PubMed: 38048433
DOI: No ID Found -
Health Affairs (Project Hope) Jan 2024Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require...
Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.
Topics: Aged; United States; Female; Pregnancy; Humans; Contraceptive Agents; Medicare Part C; Contraception; Medicaid; Cost Sharing
PubMed: 38190592
DOI: 10.1377/hlthaff.2023.00286 -
The American Journal of Gastroenterology May 2024Cyclic vomiting syndrome (CVS) imposes a substantial burden, but epidemiological data are scarce. This study aimed to estimate the incidence and prevalence of CVS,...
INTRODUCTION
Cyclic vomiting syndrome (CVS) imposes a substantial burden, but epidemiological data are scarce. This study aimed to estimate the incidence and prevalence of CVS, comorbid conditions, and treatment patterns, using administrative databases in the United States.
METHODS
This cross-sectional study used claims data from Merative MarketScan Commercial/Medicare Supplemental and Medicaid databases in all health care settings. Incidence and prevalence rates for 2019 were calculated and stratified by age, sex, region, and race/ethnicity. Patient characteristics were reported among newly diagnosed patients with CVS (i.e., no documented claims for CVS before 2019). CVS was defined as having 1+ inpatient and/or 2+ outpatient CVS claims that were 7+ days apart.
RESULTS
The estimated prevalence of CVS was 16.7 (Commercial/Medicare) and 42.9 (Medicaid) per 100,000 individuals. The incidence of CVS was estimated to be 10.6 (Commercial/Medicare) and 26.6 (Medicaid) per 100,000 individuals. Both prevalence and incidence rates were higher among female individuals (for both Commercial/Medicare and Medicaid). Comorbid conditions were common and included abdominal pain (56%-64%), anxiety (32%-39%), depression (26%-34%), cardiac conditions (39%-42%), and gastroesophageal reflux disease (30%-40%). Despite a diagnosis of CVS, only 32%-35% had prescriptions for prophylactic treatment and 47%-55% for acute treatment within the first 30-day period following diagnosis.
DISCUSSION
This study provides the first population-level estimates of CVS incidence and prevalence in the United States. Comorbid conditions are common, and most patients with CVS do not receive adequate treatment. These findings underscore the need for improving disease awareness and developing better screening strategies and effective treatments.
Topics: Humans; United States; Female; Male; Vomiting; Cross-Sectional Studies; Comorbidity; Prevalence; Middle Aged; Adult; Incidence; Aged; Adolescent; Young Adult; Child; Child, Preschool; Infant; Databases, Factual; Medicare; Medicaid; Aged, 80 and over
PubMed: 38088366
DOI: 10.14309/ajg.0000000000002628 -
Journal of Voice : Official Journal of... Sep 2023To study the geographic utilization of videolaryngostroboscopy (VLS) with the hypothesis that office-based voice care is unevenly distributed across the United States.
PURPOSE
To study the geographic utilization of videolaryngostroboscopy (VLS) with the hypothesis that office-based voice care is unevenly distributed across the United States.
MATERIALS AND METHODS
This is a cross-sectional database analysis of Medicare beneficiaries. The Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Physician and Other Supplier Public Use File from 2012 to 2017 was analyzed to evaluate VLS utilization. VLS distribution was assessed by calculating the density of VLS in each of the 306 hospital referral regions (HRRs) nationally. Associations between VLS density and population demographics and health system factors were assessed using Pearson correlation and multivariate regression analyses.
RESULTS
In total, 957,648 outpatient VLS were billed to Medicare part B between 2012 and 2017. The annual VLS density per HRR ranged from 0 to 38.2 per 1,000 enrollees. Pearson correlation revealed positive correlations between VLS density and number of Medicare enrollees (r = 0.2584, P < 0.001), income (r = 0.1913, P = 0.0008), education (r = 0.2089, P = 0.0002), and density of otolaryngologists (r = 0.1589, P = 0.0053) and medical specialists (r = 0.2326, P < 0.0001). A negative Pearson correlation was observed between VLS density and percent male (r = -0.1338, P = 0.0192) and Medicare mortality rate (r = -0.1628, P = 0.0043). On multivariate regression positive associations between VLS and number of Medicare enrollees (P = 0.002) and otolaryngologists (P = 0.049), and negative association with Medicare mortality rates (P = 0.032) remained significant.
CONCLUSIONS
The distribution of office-based voice care varies widely across the country, even when analysis by HRR should have homogenized access to specialty care. Greater availability of VLS is seen in HRRs with more Medicare enrollees, greater density of otolaryngologists, and lower mortality rates.
Topics: Aged; Humans; Male; United States; Medicare; Regression Analysis; Income; Physicians
PubMed: 34158210
DOI: 10.1016/j.jvoice.2021.05.002 -
Journal of the American Geriatrics... Sep 2023Understanding the impacts of Medicare coverage among immigrants is of high policy importance, but there is currently limited evidence. In this study, we examined the...
BACKGROUND
Understanding the impacts of Medicare coverage among immigrants is of high policy importance, but there is currently limited evidence. In this study, we examined the effects of near universal access to Medicare coverage at age 65 years between immigrants and US-born residents.
METHODS
Using the 2007-2019 Medical Expenditure Panel Survey, we employed a regression discontinuity design, which exploits the eligibility for Medicare at age 65 years. Our outcomes were health insurance coverage, healthcare spending, access to and use of health care, and self-reported health status.
RESULTS
Medicare eligibility at age 65 led to significant increases in Medicare coverage among immigrants and US-born residents (74.6 [95% CI: 71.6-77.5] and 81.6 [95% CI: 80.5-82.7] percentage points). Medicare enrollment at age 65 decreased total healthcare spending and out-of-pocket spending by $1579 (95% CI: -2092 to 1065) and $423 (95% CI: -544 to 303) for immigrants and $1186 (95% CI: -2359 to 13) and $450 (95% CI: -774 to 127) for US-born residents. After Medicare enrollment at age 65, immigrants reported only limited improvements in overall access to and use of health care, but they reported significant increases in the use of high-value care (11.5 [95% CI: 6.8-16.2], 8.3 [95% CI: 6.0-10.6], 8.4 [95% CI: 1.0-15.8], and 2.3 [95% CI: 0.9-3.7] percentage points increase for colorectal cancer screening, eye examination for diabetes, influenza vaccine, and cholesterol measurement) and improvements in self-reported health (5.9 [95% CI: 0.9-10.8] and 4.8 [95% CI: 0.5-9.0] percentage points increase for good perceived physical and mental health). Medicare enrollment also increased prescription drug spending by $705 (95% CI: 292-1117), despite the unchanged use of prescription drugs. For US-born residents, use of high-value care, self-reported health, and prescription drug use and spending did not change substantially after Medicare enrollment.
CONCLUSION
Medicare has the potential to improve care among older adult immigrants.
Topics: Humans; Aged; United States; Medicare; Prescription Drugs; Emigrants and Immigrants; Health Expenditures; Diabetes Mellitus
PubMed: 37073412
DOI: 10.1111/jgs.18380 -
The Milbank Quarterly Dec 2023Policy Points The increasing number of drugs granted accelerated approval by the Food and Drug Administration (FDA) has challenged the Medicare program, which often pays...
UNLABELLED
Policy Points The increasing number of drugs granted accelerated approval by the Food and Drug Administration (FDA) has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We recommend several administrative and legislative approaches for improving FDA-Centers for Medicare and Medicaid Services (CMS) coordination around accelerated-approval drugs, including promoting earlier discussions among the FDA, the CMS, and drug companies; strengthening Medicare's coverage with evidence development program; linking Medicare payment to evidence generation milestones; and ensuring that the CMS has adequate staffing and resources to evaluate new therapies. These activities can help improve the integrity; transparency; and efficiency of approval, coverage, and payment processes for drugs granted accelerated approval.
CONTEXT
The Food and Drug Administration (FDA)'s accelerated-approval pathway expedites patient access to promising treatments. However, increasing use of this pathway has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We examined approaches to improve coordination between the FDA and Centers for Medicare and Medicaid Services (CMS) for drugs granted accelerated approval.
METHODS
We argue that policymakers have focused on expedited pathways at the FDA without sufficient attention to complementary policies at the CMS. Although differences between the FDA and CMS decisions are to be expected given the agencies' different missions and statutory obligations, procedural improvements can ensure that Medicare beneficiaries have timely access to novel therapies that are likely to improve health outcomes. To inform policy options and recommendations, we conducted semistructured interviews with stakeholders to capture diverse perspectives on the topic.
FINDINGS
We recommend ten areas for consideration: clarifying the FDA's evidentiary standards; strengthening FDA authorities; promoting earlier discussions among the FDA, the CMS, and drug companies; improving Medicare's coverage with evidence development program; tying Medicare payment for accelerated-approval drugs to evidence generation milestones; issuing CMS guidance on real-world evidence; clarifying Medicare's "reasonable and necessary" criteria; adopting lessons from international regulatory-reimbursement harmonization efforts; ensuring that the CMS has adequate staffing and expertise; and emphasizing equity.
CONCLUSIONS
Better coordination between the FDA and CMS could improve the transparency and predictability of drug approval and coverage around accelerated-approval drugs, with important implications for patient outcomes, health spending, and evidence generation processes. Improved coordination will require reforms at both the FDA and CMS, with special attention to honoring the agencies' distinct authorities. It will require administrative and legislative actions, new resources, and strong leadership at both agencies.
Topics: Aged; Humans; United States; Medicare; Pharmaceutical Preparations; Centers for Medicare and Medicaid Services, U.S.; United States Food and Drug Administration; Drug Approval
PubMed: 37644739
DOI: 10.1111/1468-0009.12670 -
JAMA Oct 2023The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown.
OBJECTIVE
To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years.
DESIGN, SETTING, AND PARTICIPANTS
This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018.
INTERVENTION
Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%).
MAIN OUTCOMES AND MEASURES
Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021.
RESULTS
High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85).
CONCLUSIONS AND RELEVANCE
The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT04047147.
Topics: Aged; Female; Humans; Male; Fee-for-Service Plans; Health Expenditures; Medicare; Myocardial Infarction; Patient Care; Stroke; United States; Models, Cardiovascular; Adult; Middle Aged; Risk Assessment
PubMed: 37847273
DOI: 10.1001/jama.2023.19597 -
Medicare, Medicaid, and dual enrollment for adults with intellectual and developmental disabilities.Health Services Research Jun 2024Given high rates of un- and underemployment among disabled people, adults with intellectual and developmental disabilities rely on Medicaid, Medicare, or both to pay for...
OBJECTIVE
Given high rates of un- and underemployment among disabled people, adults with intellectual and developmental disabilities rely on Medicaid, Medicare, or both to pay for healthcare. Many disabled adults are Medicare eligible before the age of 65 but little is known as to why some receive Medicare services while others do not. We described the duration of Medicare enrollment for adults with intellectual and developmental disabilities in 2019 and then compared demographics by enrollment type (Medicare-only, Medicaid-only, dual-enrolled). Additionally, we examined the percent in each enrollment type by state, and differences in enrollment type for those with Down syndrome.
DATA SOURCES AND STUDY SETTING
2019 Medicare and Medicaid claims data for all adults (≥18 years) in the US with claim codes for intellectual disability, Down syndrome, or autism at any time between 2011 and 2019.
STUDY DESIGN
Administrative claims cohort.
DATA COLLECTION AND ABSTRACTION METHODS
Data were from the Transformed Medicaid Statistical Information System Analytic Files and Medicare Beneficiary Summary files.
PRINCIPLE FINDINGS
In 2019, Medicare insured 582,868 adults with identified intellectual disability, autism, or Down syndrome. Of 582,868 Medicare beneficiaries, 149,172 were Medicare only and 433,396 were dual-enrolled. Most Medicare enrollees were enrolled as child dependents (61.5%) Medicaid-only enrollees (N = 819,256) were less likely to be white non-Hispanic (58.5% white non-Hispanic vs. 72.9% white non-Hispanic in dual-enrolled), more likely to be Hispanic (19.6% Hispanic vs. 9.2% Hispanic in dual-enrolled) and were younger (mean 34.2 years vs. 50.5 years dual-enrolled).
CONCLUSION
There is heterogeneity in public insurance enrollment which is associated with state and disability type. Action is needed to ensure all are insured in the program that works for their healthcare needs.
Topics: Humans; United States; Intellectual Disability; Medicare; Medicaid; Male; Female; Developmental Disabilities; Middle Aged; Adult; Aged; Down Syndrome; Disabled Persons; Eligibility Determination; Young Adult; Insurance Claim Review
PubMed: 38264862
DOI: 10.1111/1475-6773.14287 -
Cutis Oct 2023This article provides a discussion of the proposed Medicare physician fee schedule (MPFS) published by the Centers for Medicare & Medicaid Services (CMS) in July 2023,...
This article provides a discussion of the proposed Medicare physician fee schedule (MPFS) published by the Centers for Medicare & Medicaid Services (CMS) in July 2023, which will negatively impact dermatology practices starting in 2024. An overview of physician payment policy, legislative updates affecting dermatology, and the overall outlook for 2024 for dermatologists also is presented.
Topics: Aged; Humans; United States; Medicare; Dermatology; Fee Schedules; Physicians
PubMed: 37988311
DOI: 10.12788/cutis.0871