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JAMA Health Forum Sep 2023Medicare Part B drug expenditures have increased in recent years. This trend is likely to persist given the increased use and availability of biologics.
IMPORTANCE
Medicare Part B drug expenditures have increased in recent years. This trend is likely to persist given the increased use and availability of biologics.
OBJECTIVES
To assess the extent to which Medicare Part B spending growth was associated with changes in price vs quantity, and how these trends interacted with entry of new drugs into the marketplace.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study quantified the degree of spending concentration and the association between price and use of Part B drugs among fee-for-service Medicare beneficiaries. Data on use and spending for separately payable Part B drugs were included. Source data were aggregated to the drug-year level and reported from 2016 to 2020. Descriptive decomposition and index analyses quantified the relative association of price and use changes separately for existing single-source drugs, existing drugs that faced competition, and new drugs that entered the market. Data analysis was performed from June to December 2022.
MAIN OUTCOMES AND MEASURES
Part B drug spending by the fee-for-service Medicare program and beneficiaries, as well as use, defined as dosage units and beneficiaries using the drugs.
RESULTS
The study included 535 unique Part B drug products. From 2016 to 2020, 15 or fewer products comprised half of all Part B drug expenditures. The set of 7 drugs that comprised the top 25% of spending was very consistent over time, and all were biologics. Part B drug products that cost $1.85 or less per administration accounted for more than half of the doses administered in 2020. Spending on Part B drugs increased by $15 billion from 2016 to 2020. The entry of new, nonbiosimilar drugs during this period accounted for $12 billion of this increased spending (80%), while shifts in use and price increases among existing single-source brand drugs accounted for the remaining increase in spending. Part B spending decreased among the subset of existing drugs facing generic or biosimilar competition. Among single-source drugs on the market in 2016, the index that varied dosage units exceeded the index that varied price in all years, confirming that changes in use were associated more with spending growth for those drugs.
CONCLUSIONS AND RELEVANCE
In this cross-sectional study of Medicare Part B drug expenditures, spending was found to be concentrated among a small number of drugs. The entry of new products was a key factor associated with recent increases in Part B drug spending. These findings suggest that policies targeting top-selling drugs may have greater potential to curb Part B drug spending than those targeting price growth.
Topics: Aged; United States; Humans; Pharmaceutical Preparations; Cross-Sectional Studies; Medicare Part B; Drugs, Generic; Biosimilar Pharmaceuticals
PubMed: 37682554
DOI: 10.1001/jamahealthforum.2023.2941 -
Medical Care Dec 2023Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and...
BACKGROUND
Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation.
OBJECTIVE
To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries.
RESEARCH DESIGN
We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data.
PARTICIPANTS
North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017.
MEASURES
We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS).
RESULTS
Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older.
CONCLUSIONS
Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.
Topics: Adult; Humans; Aged; United States; Medicaid; Medicare; Home Care Services; Costs and Cost Analysis; Patient Outcome Assessment
PubMed: 37963032
DOI: 10.1097/MLR.0000000000001895 -
JAMA Health Forum Dec 2023The Medicare Shared Savings Program (MSSP) is the largest and most important alternative payment model that has been implemented by the Centers for Medicare & Medicaid...
IMPORTANCE
The Medicare Shared Savings Program (MSSP) is the largest and most important alternative payment model that has been implemented by the Centers for Medicare & Medicaid Services (CMS). Its budgetary impact to CMS is not well understood.
OBJECTIVE
To evaluate the association between the MSSP and net savings to CMS for performance years 2013 to 2021.
DESIGN, SETTING, AND PARTICIPANTS
The economic evaluation used publicly reported data on the MSSP from April 1, 2012, to December 31, 2021, and estimates extracted from 2 prior studies.
MAIN OUTCOMES AND MEASURES
Net savings to CMS, calculated as the difference between incentive payments to MSSP accountable care organizations and gross spending reductions. Incentive payments were calculated using the publicly reported data. The association of the MSSP with gross medical spending in traditional Medicare was extracted from 2 prior studies. Spillovers of the MSSP to Medicare Advantage (MA) were estimated by evaluating how gross spending reductions from the MSSP impacted benchmark payments to MA plans. Savings from traditional Medicare and MA were then combined.
RESULTS
The MSSP was associated with net losses to traditional Medicare of between $584 million and $1.423 billion over the study period. Savings from MSSP-related reductions to MA benchmarks totaled between $4.480 billion and $4.923 billion. Across traditional Medicare and MA, the MSSP was associated with savings of between $3.057 billion and $4.339 billion. This represents approximately 0.075% of combined spending for traditional Medicare and MA over the study period.
CONCLUSIONS AND RELEVANCE
This economic evaluation found that the MSSP was associated with net losses to traditional Medicare, net savings to MA, and overall net savings to CMS. The total budget impact of the MSSP to CMS was small and continues to be uncertain due to challenges in estimating the effects of the MSSP on gross spending, particularly in recent years.
Topics: Aged; United States; Humans; Medicare Part C; Accountable Care Organizations; Benchmarking; Budgets; Cost-Benefit Analysis
PubMed: 38100095
DOI: 10.1001/jamahealthforum.2023.4449 -
JAMA Network Open Aug 2023Reducing Medicare expenditures is a key objective of Medicare's transition to value-based reimbursement models. Improving access to primary care is an important way to...
IMPORTANCE
Reducing Medicare expenditures is a key objective of Medicare's transition to value-based reimbursement models. Improving access to primary care is an important way to reduce expenditures, yet less is known about how visits should be organized to maximize savings.
OBJECTIVE
To examine the association between Medicare savings and primary care visit patterns.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study used data from a 5% sample of traditional Medicare claims from 2016 to 2019. Participants had at least 3 primary care visits with at least 180 days between the first and the last visit, were not enrolled in Medicare Advantage, did not have end-stage kidney disease, and were not institutionalized. Data were analyzed from June 2022 to April 2023.
EXPOSURES
Primary care visit patterns: visit frequency, regularity, continuity of care.
MAIN OUTCOMES AND MEASURES
Savings in Medicare expenditures; risk-adjusted Medicare expenditures, number of emergency department (ED) visits, and hospitalizations.
RESULTS
Among 504 471 beneficiaries (298 422 [59.16%] women; mean [SD] age, 74.26 [10.41] years), temporally regular visits with higher continuity were associated with the highest savings. For these patients, the savings increased with increasing visit frequencies, with peak savings observed at higher visit frequencies as clinical complexity increased. As regularity and continuity decreased, the association between savings and visit frequencies progressively inverted. The group with a regular and highly continuous pattern was associated with greater savings (175.87%; 95% CI, 167.40% to 184.33%; P < .001), lower risk-adjusted expenditures (-16.61%; 95% CI, -16.73% to -16.48%; P < .001), fewer risk-adjusted ED visits (-40.49%; 95% CI, -40.55% to -40.43%; P < .001), and fewer risk-adjusted hospitalizations (-53.32%; 95% CI, -53.49% to -53.14%; P < .001) compared with the irregular noncontinuous group.
CONCLUSIONS AND RELEVANCE
In this cohort study, savings in Medicare expenditures and improvements in acute care utilization were associated with visit frequency, regularity, and continuity in primary care in an interrelated fashion such that optimization of primary care visit patterns along each axis were associated with the largest improvement in outcomes. Demonstrating the magnitude and interdependence of these associations is useful for health care professionals and policymakers as Medicare continues its transition to value-based reimbursement models.
Topics: United States; Humans; Aged; Female; Male; Medicare; Cohort Studies; Retrospective Studies; Continuity of Patient Care; Critical Care
PubMed: 37603335
DOI: 10.1001/jamanetworkopen.2023.29991 -
Health Affairs (Project Hope) Oct 2023
Topics: Aged; Humans; United States; Medicare Part C; Costs and Cost Analysis; Fee-for-Service Plans
PubMed: 37782869
DOI: 10.1377/hlthaff.2023.00992 -
Journal of Neurointerventional Surgery Sep 2023This study aims to define the proportion of Medicare neuroendovascular procedures performed by different specialists from 2013 to 2019, map the geographic distribution...
BACKGROUND
This study aims to define the proportion of Medicare neuroendovascular procedures performed by different specialists from 2013 to 2019, map the geographic distribution of these specialists, and trend reimbursement for these procedures.
METHODS
The Medicare Provider Utilization Database was queried for recognized neuroendovascular procedures. Data on specialists and their geographic distribution were tabulated. Reimbursement data were gathered using the Physician Fee Schedule Look-Up Tool and adjusted for inflation using the United States Bureau of Labor Statistics' Consumer Price Index Inflation calculator.
RESULTS
The neuroendovascular workforce in 2013 and 2019, respectively, was as follows: radiologists (46% vs 44%), neurosurgeons (45% vs 35%), and neurologists (9% vs 21%). Neurologists increased proportionally (p=0.03). Overall procedure numbers increased across each specialty: radiology (360%; p=0.02), neurosurgery (270%; p<0.01), and neurology (1070%; p=0.03). Neuroendovascular revascularization (CPT 61645) increased in all fields: radiology (170%; p<0.01), neurosurgery (280%; p<0.01), neurology (240%; p<0.01); central nervous system (CNS) permanent occlusion/embolization (CPT61624) in neurosurgery (67%; p=0.03); endovascular temporary balloon artery occlusion (CPT61623) in neurology (29%; p=0.04). In 2019, radiologists were the most common neuroendovascular specialists everywhere except in the Northeast where neurosurgeons predominated. Inflation adjusted reimbursement decreased for endovascular temporary balloon occlusion (CPT61623, -13%; p=0.01), CNS transcatheter permanent occlusion or embolization (CPT61624, -13%; p=0.02), non-CNS transcatheter permanent occlusion or embolization (CPT61626, -12%; p<0.01), and intracranial stent placement (CPT61635, -12%; p=0.05).
CONCLUSIONS
The number of neuroendovascular procedures and specialists increased, with neurologists becoming more predominant. Reimbursement decreased. Coordination among neuroendovascular specialists in terms of training and practice location may maximize access to acute care.
Topics: Aged; Humans; United States; Medicare; Neurosurgery; Neurosurgical Procedures; Neurology; Vascular Diseases; Endovascular Procedures
PubMed: 35961665
DOI: 10.1136/jnis-2022-019297 -
Health Affairs (Project Hope) Sep 2023Of people appointed to the Department of Health and Human Services between 2004 and 2020, 15 percent had been employed in private industry immediately before their...
Of people appointed to the Department of Health and Human Services between 2004 and 2020, 15 percent had been employed in private industry immediately before their appointment. At the end of their tenure, 32 percent exited to industry. The greatest net exits to industry were from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services.
Topics: Aged; United States; Humans; Medicare; Centers for Disease Control and Prevention, U.S.; Centers for Medicare and Medicaid Services, U.S.; Health Facilities
PubMed: 37669494
DOI: 10.1377/hlthaff.2023.00418 -
Mayo Clinic Proceedings Jan 2024Today, approximately 50% of patients eligible for Medicare have opted for Medicare Advantage as their primary coverage. Whereas Medicare Advantage is a reasonable option... (Review)
Review
Today, approximately 50% of patients eligible for Medicare have opted for Medicare Advantage as their primary coverage. Whereas Medicare Advantage is a reasonable option for healthy senior Americans, issues arise once they have serious or chronic medical problems, which are prevalent among older Americans. This review details the pros and cons of standard Medicare vs Medicare Advantage. The authors recommend considering standard Medicare as a better form of insurance coverage. In addition, patients should also enroll in Medicare Part D to get prescription drug coverage; buy a supplemental MediGap policy; and buy additional coverage for hearing, vision, and dental care. Although this is a more complicated process, it is also a better one until Medicare Advantage revises its plans to address the current issues facing Americans on such plans who have serious illnesses.
Topics: Aged; Humans; United States; Medicare Part C; Insurance, Medigap; Insurance Coverage; Leukemia; Neoplasms
PubMed: 38108685
DOI: 10.1016/j.mayocp.2023.11.004 -
The Journal of Arthroplasty Sep 2023Understanding mark-up ratios (MRs), the ratio between a healthcare institution's submitted charge and the Medicare payment received, for high-volume orthopaedic...
BACKGROUND
Understanding mark-up ratios (MRs), the ratio between a healthcare institution's submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions.
METHODS
A large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons.
RESULTS
For knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures.
CONCLUSION
The MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.
Topics: Aged; Humans; United States; Medicare; Arthroplasty, Replacement, Knee; Arthroplasty, Replacement, Hip; Knee Joint; Knee Prosthesis; Reoperation
PubMed: 36972856
DOI: 10.1016/j.arth.2023.03.058 -
American Journal of Surgery Aug 2023In conclusion, billing trends reflect declining reimbursement and utilization of hernia repair, and increasing markup ratios may create a financial barrier to accessing...
In conclusion, billing trends reflect declining reimbursement and utilization of hernia repair, and increasing markup ratios may create a financial barrier to accessing hernia for uninsured and underinsured patients. As a new set of hernia repair CPT codes are used in practice, close attention should be paid to the downstream effects of billing practices in hernia repair on physician and patient alike.
Topics: Aged; Humans; United States; Herniorrhaphy; Medicare; Surgeons
PubMed: 36935284
DOI: 10.1016/j.amjsurg.2023.03.015