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Nature Biotechnology Mar 2024The Inflation Reduction Act (IRA) requires Medicare to negotiate lower prices for some medicines with high Medicare spending. Using historical data from public and... (Review)
Review
The Inflation Reduction Act (IRA) requires Medicare to negotiate lower prices for some medicines with high Medicare spending. Using historical data from public and proprietary sources to apply the IRA's negotiation criteria retrospectively, we identify all drugs that met the eligibility criteria from 2012 to 2021 to classify drugs that would have had a negotiated price in effect in 2022 and to calculate associated decreases in industry revenues. Our results suggest that the IRA's reduction in overall industry revenue will be modest, will not affect most top-selling drugs and will not likely result in large-scale defunding of research and development. Changes in the net present value of drug-development projects will be concentrated in medicines where Medicare is a notable purchaser and where the ratio between expected revenue and development costs was only marginally positive before the IRA. Policymakers considering narrowing or expanding the scope of Medicare negotiation should carefully consider the tradeoffs across medicines with diverse characteristics.
Topics: United States; Medicare; Negotiating; Retrospective Studies; Drug Costs; Pharmaceutical Preparations
PubMed: 38297186
DOI: 10.1038/s41587-023-02096-w -
Psychiatric Services (Washington, D.C.) Aug 2023Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan for individuals who have both Medicare and Medicaid coverage. The authors compared...
OBJECTIVE
Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan for individuals who have both Medicare and Medicaid coverage. The authors compared the breadths of psychiatrist and nonpsychiatrist provider networks in D-SNPs and other MA plans.
METHODS
MA plan provider network data were merged with plan service areas and a nationwide provider database to form a data set with 843 observations on networks subclassified by state and network type (D-SNP or other MA) covering 42 U.S. states and Washington, D.C. Network breadth measured the in-network fraction of clinically active Medicare-accepting psychiatrists and other physician providers in the plans' service areas in each state. Regression analyses were used to compare psychiatrist and nonpsychiatrist network breadth and psychiatrist-nonpsychiatrist breadth differences between D-SNPs and other MA plans, after adjustment for state-level differences.
RESULTS
Mean psychiatrist network breadth was 0.319 in D-SNPs and 0.299 in other MA plans, and nonpsychiatrist network breadth was 0.346 in D-SNPs and 0.358 in other MA plans. Psychiatrist networks were narrower than nonpsychiatrist networks (0.303 vs. 0.355, p<0.001), but mean psychiatrist network breadth did not differ between D-SNPs and other MA plans. In regression analyses, the psychiatrist-nonpsychiatrist breadth difference was smaller in D-SNPs (-0.031) than in other MA plans (-0.060) (p0.002).
CONCLUSIONS
Psychiatrist provider networks in a nationwide sample of D-SNPs had similar breadth as psychiatrist networks used in other MA plans. Special provider network adequacy requirements for psychiatrists in D-SNP networks may be worthy of further consideration given D-SNPs' disproportionate enrollment of adults with serious mental illness who have dual Medicare-Medicaid insurance coverage.
Topics: Aged; Humans; United States; Medicare Part C; Medicaid; Physicians; Psychiatry; Insurance Coverage
PubMed: 36789608
DOI: 10.1176/appi.ps.20220239 -
The American Journal of Managed Care Apr 2024High-need Medicare beneficiaries require elevated levels of care and coordination to manage their conditions. We evaluated the extent to which high-need beneficiaries...
OBJECTIVES
High-need Medicare beneficiaries require elevated levels of care and coordination to manage their conditions. We evaluated the extent to which high-need beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) accountable care organizations (ACOs) relative to TM non-ACOs.
STUDY DESIGN
Using Medicare claims and MA encounter data, we identified 3 groups of high-need beneficiaries: (1) individuals younger than 65 years with a disability or end-stage kidney disease, (2) frail individuals, and (3) older individuals with major complex or multiple noncomplex chronic conditions. For comparison, we included non-high-need beneficiaries in the analysis, including those with minor complex chronic conditions.
METHODS
Descriptive analysis of Medicare enrollment patterns and beneficiary characteristics of high-need and other beneficiaries between 2016 and 2019.
RESULTS
In 2019, high-need beneficiaries accounted for 18 million or 32% of enrollees in TM and MA, an increase of approximately 1 million since 2016, driven by growth in MA. A larger share of beneficiaries in TM ACOs was high need (38%) compared with MA (24%). Although the total count of high-need beneficiaries in TM remained stable from 2016 to 2019, ACOs saw an increase of almost 1.5 million high-need beneficiaries (39% increase), and TM non-ACOs saw a decrease of 1.9 million (23% decrease).
CONCLUSIONS
We found that high-need beneficiaries were more likely to be in TM non-ACOs than in MA through 2019. However, an increasing number of these beneficiaries are enrolling in MA or aligned with a TM ACO. A projected increase in the population of older adults will increase the economic burden of caring for high-need individuals.
Topics: Humans; Aged; United States; Medicare Part C; Multiple Chronic Conditions; Accountable Care Organizations
PubMed: 38603531
DOI: 10.37765/ajmc.2024.89528 -
The American Journal of Nursing Apr 2024
Topics: Humans; United States; Medicare; State Medicine; Universal Health Insurance; Centers for Medicare and Medicaid Services, U.S.
PubMed: 38511685
DOI: 10.1097/01.NAJ.0001010484.53902.6c -
The New England Journal of Medicine Dec 2023
Topics: Aged; Humans; Medicare Part C; United States
PubMed: 38091536
DOI: 10.1056/NEJMhpr2302315 -
Journal of Biomedical Informatics Sep 2023International Classification of Disorders version 10 (ICD-10) codes contribute heavily to healthcare data. Medicare claims and other data-sources are used to constitute...
OBJECTIVE
International Classification of Disorders version 10 (ICD-10) codes contribute heavily to healthcare data. Medicare claims and other data-sources are used to constitute study populations and appraise healthcare processes. How variability in claims-per-beneficiary impacts diagnostic determinations is inadequately understood. The objective of this study is so assess distributional properties of Medicare claims, and examine claim rates impact on code utilization and rate determinations.
METHODS
The study population was Medicare beneficiaries aged 75-79.99 with claim(s) in the 5% standard analytical Carrier and Outpatient files, alive and participating in Medicare part B for all 12 months of 2017. Medicare beneficiary files were processed to create records containing all ICD-10 codes specified, key demographics, Part B and vital status, and the total claims for each 2017 beneficiary. Claim number cohorts were characterized.
RESULTS
Beneficiaries meeting inclusion criteria totaled 221,625, these having 7,617,503 claims; 96.4% had between 1 and 120 claims. Median claims were 24 for males (females 25); modal claims were 11 (13). Average distinct codes per beneficiary increased with claims number. The assignment of ICD-10 codes, i.e., 'diagnostic rate estimates' (DRE), increased as claim numbers increased for most codes among those most commonly utilized. For some conditions, mostly benign and age-related, DREs plateaued as claim numbers increased. For other conditions, typically associated with clinical acuity, e.g., chest pain, DREs increased steeply with claims.
CONCLUSIONS
Older adult Medicare beneficiaries aged 75-80 exhibited varying claims activity over the course of a year. Although DRE dependence on claim numbers varies across ICD-10 codes, rate estimates are higher for beneficiaries with claim numbers above the median.
Topics: Male; Female; Humans; Aged; United States; Medicare; Delivery of Health Care; International Classification of Diseases; Insurance Claim Review; Records
PubMed: 37517509
DOI: 10.1016/j.jbi.2023.104463 -
Family Practice Management Jan 2024
Topics: Aged; United States; Humans; Medicare; Physicians, Family
PubMed: 38194303
DOI: No ID Found -
JAMA Health Forum Sep 2023
Topics: Aged; United States; Humans; Medicaid; Medicare; Classification
PubMed: 37682555
DOI: 10.1001/jamahealthforum.2023.2957 -
The American Surgeon Nov 2023One of the heroes in American history, Associate Supreme Court Justice Thurgood Marshall (1908-1993) sought legal remedies against racial discrimination in education and...
One of the heroes in American history, Associate Supreme Court Justice Thurgood Marshall (1908-1993) sought legal remedies against racial discrimination in education and health care. As director of the Legal Defense Fund (LDF) of NAACP from 1940 to 1961, his success in integrating law schools in Texas led to the first black medical student admitted to a state medical school in the South. Representing doctors and dentists needing a facility to perform surgery, the LDF brought cases before the courts in North Carolina that moved the country toward justice in health care. His ultimate legal victory came in 1954, , the decision that declared racial segregation in public schools unconstitutional. In 1964, the LDF under Jack Greenberg, Marshall's successor as director, won , a decision that held that hospitals accepting federal funds had to admit black patients. The two decisions laid the judicial foundation for the laws and administrative acts that changed America's racial history, the Civil Rights Act of 1964 and the Social Security Act Amendments of 1965 that established Medicare and Medicaid. His achievements came during the hottest period of the American civil rights movement of the 1950s and 1960s. Well past the middle of the twentieth century, black Americans were denied access to the full resources of American medicine, locked in a "separate-but-equal" system woefully inadequate in every respect. In abolishing segregation, Marshall initiated the long overdue remedy of the unjust legacies of slavery and Jim Crow.
Topics: Aged; Humans; Black or African American; Civil Rights; Delivery of Health Care; Education; Education, Medical; Educational Status; History, 20th Century; Human Rights; Medicare; Racial Groups; Supreme Court Decisions; United States; Lawyers
PubMed: 36148654
DOI: 10.1177/00031348221129503 -
Medical Care Research and Review : MCRR Aug 2023Medicare's Annual Wellness Visit (AWV) was introduced in 2011 to encourage the utilization of preventive services, but many clinicians and patients still do not...
Medicare's Annual Wellness Visit (AWV) was introduced in 2011 to encourage the utilization of preventive services, but many clinicians and patients still do not participate in the visit. We qualitatively and quantitatively assessed motivations and clinical and financial value of AWVs from a primary care perspective using interviews and Medicare claims from 2012 to 2019. Primary care providers with the highest acuity patients had AWV utilization rates 11.2 percentage points lower than providers with the lowest acuity patients; utilization rates were 3.8 percentage points lower in rural counties. Adoption was motivated by patient needs and financial incentives. AWVs closed gaps in preventive care, strengthened patient-provider relationships, facilitated advance care planning, and provided an opportunity to improve quality metrics. Overall, the AWV has the potential to increase the use of high-value preventive services although not all clinics have an economic incentive to adopt the visit, which may explain some of the variability in utilization rates.
Topics: Aged; Humans; United States; Medicare; Preventive Health Services; Fee-for-Service Plans
PubMed: 37098854
DOI: 10.1177/10775587231166037