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JAMA Dermatology Aug 2023The number of advanced practice clinicians (APCs, including nurse practitioners and physician assistants) in the US is increasing. The effect this has on dermatology is...
IMPORTANCE
The number of advanced practice clinicians (APCs, including nurse practitioners and physician assistants) in the US is increasing. The effect this has on dermatology is unclear.
OBJECTIVE
To develop a method to identify APCs practicing dermatology in claims data and to evaluate the contribution of dermatology APCs to the dermatology workforce and how this has changed over time.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study used the Medicare Provider Utilization and Payment Data Public Use files (2013 to 2020). As APCs are not listed by specialty, a method to identify APCs practicing dermatology was developed and validated using common dermatology procedural codes. The data were analyzed from November 2022 to April 2023.
MAIN OUTCOMES AND MEASURES
The proportion of clinicians and office visits by dermatology APCs and physician dermatologists were evaluated using Mann-Kendall tests. Joinpoint analysis was also used to compare the average annual percentage change of dermatology procedures and clinicians in rural-urban areas between dermatology APCs and physician dermatologists.
RESULTS
The method to identify APCs practicing dermatology had 96% positive predictive value, 100% negative predictive value, 100% sensitivity, and 100% specificity. Between 2013 and 2020, 8444 dermatology APCs and 14 402 physician dermatologists were identified. They provided 109 366 704 office visits in Medicare. The percentage of dermatology clinicians who were APCs increased over time, from 27.7% in 2013 to 37.0% in 2020 (P = .002). The proportion of dermatologic office visits provided by APCs also increased over time, from 15.5% in 2013 to 27.4% in 2020 (P = .002). For all procedure categories, the average annual percentage change was positive for dermatology APCs (range, 10.05%-12.65%) and was higher than that of physician dermatologists. For all rural-urban designations, the average annual percentage change was positive for dermatology APCs (range, 2.03%-8.69%) and was higher than metropolitan, micropolitan, and small-town areas from that of physician dermatologists.
CONCLUSIONS AND RELEVANCE
In this retrospective cohort study, there was a temporal increase in the amount of dermatologic care provided by APCs in Medicare. These findings demonstrate changes in the dermatology workforce and may have implications for dermatology as a specialty.
Topics: Aged; Humans; United States; Dermatology; Retrospective Studies; Medicare
PubMed: 37405748
DOI: 10.1001/jamadermatol.2023.1843 -
Journal of the American Pharmacists... 2023Medicare Advantage Part D plans and stand-alone Part D prescription drug plans are required by the Centers for Medicare and Medicaid Services to have qualified...
INTRODUCTION
Medicare Advantage Part D plans and stand-alone Part D prescription drug plans are required by the Centers for Medicare and Medicaid Services to have qualified providers, including pharmacists, and offer annual comprehensive medication reviews (CMRs) for eligible Medicare beneficiaries. Although guidance on the components of a CMR is available, providers have flexibility in how to deliver the CMR to patients and which content to cover. With the variety of patient needs, CMR content is not always consistently delivered in practice. Our research group performed an extensive evaluation to create and test an ideal CMR content coverage checklist for CMR provision.
CMR CONTENT CHECKLIST
The CMR Content Checklist can be used for quality improvement purposes to evaluate the comprehensiveness of pharmacist services-to assess either within pharmacist variation across patients or within organization variations between pharmacists or sites.
INCORPORATING THE CMR CONTENT CHECKLIST INTO PRACTICE
Testing in a real-world setting demonstrated where gaps in service coverage existed. The CMR Content Checklist could be used as the first step for quality improvement given that it provides details on the key aspects of the service that can inform quality measure development.
Topics: Aged; Humans; United States; Medication Therapy Management; Checklist; Medication Review; Medicare Part D; Prescription Drugs; Pharmacists
PubMed: 37394060
DOI: 10.1016/j.japh.2023.06.020 -
American Journal of Surgery Oct 2023This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how...
This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how surgical disparities contribute to excessive spending. Prior studies have focused primarily on individual social factors, yet this study takes into consideration the financial implications of disparities from multiple levels. Black patients face more challenges in cancer care in part due to late stage presentation and diagnosis, as well as increased exposure to risk factors that place them under a disproportionate burden of disease and risk of post-operative complications. We commend the authors for broaching this rarely discussed and costly combination of minority race and dual eligibility contributing to a "multiple hit" phenomenon that our most vulnerable patients face.
Topics: Aged; Humans; United States; Medicare; Patients; Healthcare Disparities
PubMed: 37500300
DOI: 10.1016/j.amjsurg.2023.07.021 -
Journal of Health Politics, Policy and... Dec 2023The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders...
The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance. The authors analyze the statute underlying these three design features and explore legislative and regulatory strategies for improving Medicare Advantage. They conclude that regulatory approaches for improving risk adjustment and for recouping overpayments from risk-score gaming have the highest potential impact and are the most feasible improvement measures to implement.
Topics: Aged; Humans; United States; Medicare Part C; Policy
PubMed: 37497876
DOI: 10.1215/03616878-10852628 -
The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019).Annals of Emergency Medicine Dec 2023We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care,...
STUDY OBJECTIVE
We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments.
METHODS
We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance.
RESULTS
In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion.
CONCLUSION
Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.
Topics: Aged; Humans; United States; Medicare; Cost Allocation; Insurance, Health; Medicaid; Medically Uninsured; Emergency Service, Hospital
PubMed: 37330720
DOI: 10.1016/j.annemergmed.2023.04.026 -
Health Affairs (Project Hope) Sep 2023The use of home-based medical care differed in Medicare Advantage and traditional Medicare in 2018. Having exactly one such visit was thirty-one times as likely for...
The use of home-based medical care differed in Medicare Advantage and traditional Medicare in 2018. Having exactly one such visit was thirty-one times as likely for Medicare Advantage beneficiaries (18.6 percent) as for traditional Medicare beneficiaries (0.6 percent), likely reflecting incentives in the Medicare Advantage program to code all accurate diagnoses. Multiple home-based medical care visits were less likely in Medicare Advantage than in traditional Medicare (1.6 percent versus 2.1 percent of beneficiaries, respectively).
Topics: Aged; United States; Humans; Medicare Part C; House Calls; Patient Care
PubMed: 37669486
DOI: 10.1377/hlthaff.2023.00376 -
Health Affairs (Project Hope) Sep 2023Medicare Advantage (MA) has grown rapidly over the course of the past two decades and is projected to continue to grow. We examined sources of new enrollment in MA and...
Medicare Advantage (MA) has grown rapidly over the course of the past two decades and is projected to continue to grow. We examined sources of new enrollment in MA and analyzed the switching patterns between MA and traditional fee-for-service Medicare, using more recent and more detailed data than in previous analyses. We found that switching from fee-for-service Medicare to MA more than tripled between 2006 and 2022, whereas switching from MA to fee-for-service Medicare decreased, with the change rates accelerating since 2019. The share of switchers among all new MA enrollees rose from 61 percent in 2011 to 80 percent in 2022. Black, dual-eligible, and disabled beneficiaries had higher odds of switching in both directions, whereas younger and healthier beneficiaries had higher odds of switching from fee-for-service Medicare to MA but lower odds of switching from MA to fee-for-service Medicare. Two-thirds of annual switching between MA and fee-for-service Medicare in 2022 occurred in January, likely reflecting the open enrollment period.
Topics: Aged; United States; Humans; Medicare Part C; Fee-for-Service Plans; Health Status
PubMed: 37669490
DOI: 10.1377/hlthaff.2023.00224 -
The American Journal of Managed Care Nov 2023To measure the prevalence of non-Medicare value-based contracting and participation in contracts with downside risk among organizations participating in the Medicare...
OBJECTIVES
To measure the prevalence of non-Medicare value-based contracting and participation in contracts with downside risk among organizations participating in the Medicare Shared Savings Program (MSSP).
STUDY DESIGN
Cross-sectional analysis of 2022 accountable care organization (ACO) survey.
METHODS
The author analyzed surveys from 100 organizations participating in the MSSP that reported the number of covered lives they have in value-based contracts in traditional Medicare (ACOs), Medicare Advantage (MA), commercial payers, Medicaid managed care organizations, Medicaid, and direct-to-employer arrangements. We analyzed the distribution of covered lives across shared-savings, shared-risk, and full-risk contracts and analyzed changes between 2018 and 2022.
RESULTS
Respondents reported 15.5 million covered lives in value-based contracts. All respondents have Medicare ACO contracts, and roughly 75% reported value-based contracts with commercial and MA plans. Approximately one-third reported such contracts with Medicaid managed care plans. Seventy percent of covered lives in respondents' Medicare ACO contracts included downside risk for losses compared with 51% of lives in commercial plans and 45% in MA plans. Compared with a similar 2018 survey, the proportion of respondents in value-based MA contracts doubled, and the proportion in commercial contracts rose by half.
CONCLUSIONS
Organizations that participate in Medicare ACO models have substantially increased their participation in value-based contracts with other payers. They reported a higher proportion of Medicare ACO covered lives in downside risk arrangements than in commercial or MA contracts.
Topics: Aged; Humans; United States; Medicare; Cross-Sectional Studies; Medicaid; Accountable Care Organizations; Contracts; Cost Savings
PubMed: 37948647
DOI: 10.37765/ajmc.2023.89456 -
Dental Clinics of North America Jan 2024The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate... (Review)
Review
The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate attention, and mortality and morbidity rates. Historically, OMS specialists have made significant contributions to modern anesthesia; however, recent changes in Centers for Medicare and Medicaid Services have led to increased scrutiny of the OMS anesthesia model. Proponents argue that the model is safe and effective, thanks to well-trained Dental Anesthesia Assistants and OMS surgeons' extensive experience in dental anesthesia cases.
Topics: Aged; Humans; United States; Medicare; Surgery, Oral; Anesthesia; Medicaid; Patient Safety
PubMed: 37951639
DOI: 10.1016/j.cden.2023.07.006 -
JAMA Nov 2023
Topics: Aged; Humans; Fee Schedules; Medicare; Medicare Part B; Physicians; Relative Value Scales; United States
PubMed: 37988095
DOI: 10.1001/jama.2023.18963