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Health Services Research Feb 2021To determine the relationship between Medicare's site-based outpatient billing policy and hospital-physician integration.
OBJECTIVE
To determine the relationship between Medicare's site-based outpatient billing policy and hospital-physician integration.
DATA SOURCES
National Medicare claims data from 2010 to 2016.
STUDY DESIGN
For each physician-year, we calculated the disparity between Medicare reimbursement under hospital ownership and under physician ownership. Using logistic regression analysis, we estimated the relationship between these payment differences and hospital-physician integration, adjusting for region, market concentration, and time fixed effects. We measured integration status using claims data and legal tax names.
DATA COLLECTION
The study included integrated and non-integrated physicians who billed Medicare between January 1, 2010, and December 31, 2016 (n = 2 137 245 physician-year observations).
PRINCIPAL FINDINGS
Medicare reimbursement for physician services would have been $114 000 higher per physician per year if a physician were integrated compared to being non-integrated. Primary care physicians faced a 78% increase, medical specialists 74%, and surgeons 224%. These payment differences exhibited a modest positive relationship to hospital-physician vertical integration. An increase in this outpatient payment differential equivalent to moving from the 25th to 75th percentile was associated with a 0.20 percentage point increase in the probability of integrating with a hospital (95% CI: 0.0.10-0.30). This effect was slightly larger among primary care physicians (0.27, 95% CI: 0.18 to 0.35) and medical specialists (0.26, 95% CI: 0.05 to 0.48), while not significantly different from zero among surgeons (-0.02; 95% CI: -0.27 to 0.22).
CONCLUSIONS
The payment differences between outpatient settings were large and grew over time. Even routine annual outpatient payment updates from Medicare may prompt some hospital-physician vertical integration, particularly among primary care physicians and medical specialists.
Topics: Ambulatory Care; Efficiency, Organizational; Hospital-Physician Joint Ventures; Humans; Medicare; Pain Management; Practice Patterns, Physicians'; Private Sector; Reimbursement Mechanisms; United States
PubMed: 33616932
DOI: 10.1111/1475-6773.13613 -
Annals of Internal Medicine Jun 2024
Topics: United States; Humans; Negotiating; Drug Costs; Medicare Part D; Medicare
PubMed: 38684103
DOI: 10.7326/M24-0138 -
Health Affairs (Project Hope) Mar 2020The Affordable Care Act promoted payment reforms directly and through the creation of the Center for Medicare and Medicaid Innovation, which it endowed with the... (Review)
Review
The Affordable Care Act promoted payment reforms directly and through the creation of the Center for Medicare and Medicaid Innovation, which it endowed with the authority to introduce Alternative Payment Models (APMs) into Medicare and Medicaid. We conducted a narrative review of these payment reforms, finding that several programs generated modest savings while maintaining or improving the quality of care, but they had high dropout rates. In general, evidence for other APMs is less conclusive, and whether the reforms spurred similar changes in the private sector remains anecdotal. Despite challenges, APMs provide incentives for efficient care provision and offer providers a way to succeed financially in an environment with slowly rising fee-for-service prices. Thus, we consider the Affordable Care Act's payment reforms to be modestly successful, and we encourage both the purging of initiatives that aren't working and the continued development and study of promising ones.
Topics: Aged; Fee-for-Service Plans; Humans; Medicaid; Medicare; Patient Protection and Affordable Care Act; Private Sector; United States
PubMed: 32119623
DOI: 10.1377/hlthaff.2019.01410 -
The Nurse Practitioner Oct 2019
Topics: Delivery of Health Care; Health Services Accessibility; Humans; Medicare; Nurse Practitioners; Politics; Public Opinion; United States
PubMed: 31568025
DOI: 10.1097/01.NPR.0000580796.97474.91 -
JAMA Oct 2022Prescription drug spending is a topic of increased interest to the public and policymakers. However, prior assessments have been limited by focusing on retail spending...
IMPORTANCE
Prescription drug spending is a topic of increased interest to the public and policymakers. However, prior assessments have been limited by focusing on retail spending (Part D-covered drugs), omitting clinician-administered (Part B-covered) drug spending, or focusing on all fee-for-service Medicare beneficiaries, regardless of their enrollment into prescription drug coverage.
OBJECTIVE
To estimate the proportion of health care spending contributed by prescription drugs and to assess spending for retail and clinician-administered prescriptions.
DESIGN, SETTING, AND PARTICIPANTS
Descriptive, serial, cross-sectional analysis of a 20% random sample of fee-for-service Medicare beneficiaries in the United States from 2008 to 2019 who were continuously enrolled in Parts A (hospital), B (medical), and D (prescription drug) benefits, and not in Medicare Advantage.
EXPOSURE
Calendar year.
MAIN OUTCOMES AND MEASURES
Net spending on retail (Part D-covered) and clinician-administered (Part B-covered) prescription drugs; prescription drug spending (spending on Part B-covered and Part D-covered drugs) as a percentage of total per-capita health care spending. Measures were adjusted for inflation and for postsale rebates (for Part D-covered drugs).
RESULTS
There were 3 201 284 beneficiaries enrolled in Parts A, B, and D in 2008 and 4 502 718 in 2019. In 2019, beneficiaries had a mean (SD) age of 71.7 (12.0) years, documented sex was female for 57.7%, and 69.5% had no low-income subsidies. Total per-capita spending was $16 345 in 2008 and $20 117 in 2019. Comparing 2008 with 2019, per-capita Part A spending was $7106 (95% CI, $7084-$7128) vs $7120 (95% CI, $7098-$7141), Part B drug spending was $720 (95% CI, $713-$728) vs $1641 (95% CI, $1629-$1653), Part B nondrug spending was $5113 (95% CI, $5105-$5122) vs $6702 (95% CI, $6692-$6712), and Part D net spending was $3122 (95% CI, $3117-$3127) vs $3477 (95% CI, $3466-$3489). The proportion of total annual spending attributed to prescription drugs increased from 24.0% in 2008 to 27.2% in 2019, net of estimated rebates and discounts.
CONCLUSIONS AND RELEVANCE
In 2019, spending on prescription drugs represented approximately 27% of total spending among fee-for-service Medicare beneficiaries enrolled in Part D, even after accounting for postsale rebates.
Topics: Aged; Female; Humans; Cross-Sectional Studies; Fee-for-Service Plans; Health Expenditures; Medicare; Medicare Part D; Prescription Drugs; United States; Medicare Part A; Medicare Part B; Male; Middle Aged; Aged, 80 and over
PubMed: 36255428
DOI: 10.1001/jama.2022.17825 -
American Journal of Kidney Diseases :... Aug 2019In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis...
In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.
Topics: Humans; Kidney Failure, Chronic; Medicare; Reimbursement Mechanisms; Renal Dialysis; United States
PubMed: 30922595
DOI: 10.1053/j.ajkd.2019.01.027 -
Medical Care Mar 2022While overall Medicare Part C (Medicare Advantage) enrollment has grown more rapidly than fee-for-service Medicare enrollment, changes in the growth and characteristics... (Observational Study)
Observational Study
BACKGROUND
While overall Medicare Part C (Medicare Advantage) enrollment has grown more rapidly than fee-for-service Medicare enrollment, changes in the growth and characteristics of different enrollee populations have not been examined.
OBJECTIVES
For 2011-2019, to compare changes in the growth and characteristics of younger (age younger than 65) and older (age 65 and older) Medicare beneficiaries enrolled in Medicare Part A only, Medicare Parts A & B, and Medicare Part C.
RESEARCH DESIGN
This was a retrospective, observational study.
SUBJECTS
Medicare beneficiaries who were alive and enrolled in Medicare Part A only, Medicare Parts A & B, or Medicare Part C on June 30 of each year and in no other plan that year.
MEASURES
For each plan type and age group the numbers and mean ages of enrollees and the proportion of enrollees who were: black, female, concurrently enrolled in Medicaid, and (for older enrollees), whose initial reason for eligibility was old age and survivors' benefits.
RESULTS
Between 2011 and 2019, Medicare Part C experienced rapid expansions of 85.0% among older and 109.5% among younger enrollees. Part C enrollees were increasingly likely to be dually enrolled in Medicaid, Black and, among younger enrollees, female.
CONCLUSIONS
Trends in demographic characteristics and changes in policy and growth in employer group plan offerings will likely continue to impact health care service utilization and costs in the Medicare population. Particularly as Medicare expansion to younger age groups is considered, future research should explore disparities in risk scores and care equity, quality, and costs across different Medicare enrollment options.
Topics: Aged; Fee-for-Service Plans; Female; Humans; Male; Medicare; Medicare Part C; Middle Aged; Patient Acceptance of Health Care; Retrospective Studies; United States
PubMed: 34984991
DOI: 10.1097/MLR.0000000000001680 -
Archives of Physical Medicine and... Dec 2022In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment,...
In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment, and therefore are non-covered items. Yet, power seat elevation systems are covered by other funding sources, and many power wheelchair users utilize these systems regularly when performing tasks such as transferring, reaching, and looking at objects in environments designed for ambulatory people. Adjusting for height when performing these tasks may reduce the onset of pain and comorbidities. To improve access to power seat elevation systems, a clinical team of 4 Clinician Task Force members investigated applicable literature, compiled evidence, and evaluated existing policies to explain the medical nature of power seat elevation systems as a part of a greater interprofessional effort. This manuscript aims to analyze Medicare's policy decision that power seat elevation systems are not primarily medical in nature using Bardach's 8-step framework. As a special communication, this will inform health care professionals of the medical nature of power seat elevation systems and the evidence-based conditions under which power wheelchair users may need power seat elevation systems, as well as empower clinicians to engage in policy directives to affect greater change.
Topics: Aged; Humans; United States; Wheelchairs; Medicare; Policy Making; Equipment Design
PubMed: 35525300
DOI: 10.1016/j.apmr.2022.04.003 -
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 Network Open May 2021Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in...
IMPORTANCE
Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in graduate medical education (GME) payments to teaching hospitals, including explicit support for dental and podiatry programs, little is known about the level or distribution of this public investment in the oral health and podiatry workforce.
OBJECTIVE
To examine Medicare GME payments to teaching hospitals for dental and podiatry residents from 1998 to 2018, as well as the distribution of federal support among states, territories, and the District of Columbia.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study was conducted using data from 1252 US teaching hospitals. Data were analyzed from May through August 2020.
EXPOSURES
Dental and podiatry residency training.
MAIN OUTCOMES AND MEASURES
Medicare dental and podiatry GME payments were examined.
RESULTS
Among 1252 teaching hospitals, Medicare provided nearly $730 million in dental and podiatry GME payments in 2018. From 1998 to 2018, the number of residents supported more than doubled, increasing from 2340 residents to 4856 residents, for a 2.1-fold increase, while Medicare payments for dental and podiatry GME increased from $279 950 531 to $729 277 090, for a 2.6-fold increase. In 2018, an estimated 3504 of 4856 supported positions (72.2%) were dental. Medicare GME payments varied widely among states, territories, and the District of Columbia, with per capita payments by state, territory, and district population ranging from $0.05 in Puerto Rico to $14.24 in New York, while 6 states received no support for dental or podiatry residency programs.
CONCLUSIONS AND RELEVANCE
These findings suggest that dental and podiatry GME represents a substantial public investment, and deliberate policy decisions are needed to target this nearly $730 million and growing investment to address the nation's priority oral and podiatry health needs.
Topics: Adult; Cross-Sectional Studies; Education, Dental, Graduate; Education, Medical, Graduate; Female; Humans; Male; Medicare; Podiatry; United States; Young Adult
PubMed: 34042989
DOI: 10.1001/jamanetworkopen.2021.11797