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Journal of Hospice and Palliative... Aug 2021Integrative hospice and palliative care is a philosophy of treatment framing patients as whole persons composed of interrelated systems. The interdisciplinary treatment...
Integrative hospice and palliative care is a philosophy of treatment framing patients as whole persons composed of interrelated systems. The interdisciplinary treatment team is subsequently challenged to consider ethical and effective provision of holistic services that concomitantly address these systems at the end of life through cotreatment. Nurses and music therapists, as direct care professionals with consistent face-to-face contact with patients and caregivers, are well positioned to collaborate in providing holistic care. This article introduces processes of referral, assessment, and treatment that nurses and music therapists may engage in to address family support, spirituality, bereavement, and telehealth. Clinical vignettes are provided to illustrate how cotreatment may evolve and its potential benefits given diverse circumstances. As part of this framing, music therapy is positioned as a core-rather than alternative or complementary-service in hospice that satisfies the required counseling services detailed in Medicare's Conditions of Participation for hospice providers. The systematic and intentional partnering of nurses and music therapists can provide patients and caregivers access to quality comprehensive care that can cultivate healthy transitions through the dying process.
Topics: Aged; Hospice Care; Hospices; Humans; Medicare; Music Therapy; Palliative Care; United States
PubMed: 33631776
DOI: 10.1097/NJH.0000000000000747 -
The American Journal of Managed Care Mar 2021To examine changes in hospital outpatient surgery trends and case mix for Medicare and privately insured patients needing total knee arthroplasty (TKA) following...
OBJECTIVES
To examine changes in hospital outpatient surgery trends and case mix for Medicare and privately insured patients needing total knee arthroplasty (TKA) following Medicare's removal of TKA from its Inpatient Only list on January 1, 2018.
STUDY DESIGN
A retrospective analysis of all hospital discharge records in Florida from 2012 through 2018.
METHODS
We tracked inpatient vs outpatient performance of TKAs at the state and hospital levels. We also combined our primary data with physician practice organization information to assess variation in the policy response according to physician-hospital ownership status. Supplementary analyses examined policy-induced changes in inpatient TKA case mix.
RESULTS
We observed an immediate shift of roughly 15% of Medicare TKA cases to the outpatient setting. Importantly, there was a simultaneous near doubling of the number of TKAs performed as a hospital outpatient procedure among privately insured patients younger than 60 years. Hospitals allocated a similar proportion of TKA cases to the outpatient setting across the 2 payer groups, and we found evidence of selection against the potentially riskiest Medicare TKA patients for outpatient delivery. Vertically integrated orthopedic physicians retained their Medicare and privately insured TKA cases within the inpatient (higher-cost) setting.
CONCLUSIONS
Market and financial pressures are encouraging more outpatient care delivery; however, the speed of transition is dictated, in part, by regulatory constraints. Our results suggest that Medicare policy may influence surgical treatment approaches for Medicare and privately insured patients. Spillover implications need to be considered when weighing future Medicare regulatory decisions.
Topics: Aged; Arthroplasty, Replacement, Knee; Humans; Inpatients; Medicare; Outpatients; Retrospective Studies; United States
PubMed: 33720667
DOI: 10.37765/ajmc.2021.88598 -
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 -
Journal of the American Geriatrics... Dec 2021Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs)...
BACKGROUND
Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs) accountable for 90-day costs of care. Its overall impact on Medicare spending and clinical outcomes is unknown.
METHODS
Retrospective cohort study using Medicare claims from 2012 to 2017. We used an interrupted time-series design to compare participating vs matched control SNFs on total 90-day Medicare payments and payment components (initial SNF stay, readmissions, and outpatient/clinician), case mix (volume, proportion Medicaid, proportion black, number of comorbidities), and clinical outcomes (90-day readmission, mortality and healthy days at home, and length of initial SNF stay), overall and among key subgroups with frailty or dementia, for 47 of the 48 conditions in the program (excluding major lower extremity joint replacement).
RESULTS
Our sample included 1001 participating and 3873 matched control SNFs. At baseline, total Medicare institutional payments were increasing at BPCI SNFs at a rate of $121 per episode per quarter; during the intervention period, payments decreased at a rate of -$398/episode/quarter. Among controls, payments were stable in the baseline period (+$17/episode/quarter) but decreased at -$424/episode/quarter during the intervention period, yielding a nonsignificant difference in slope changes of -$79/episode/quarter (95% confidence interval [CI] -$188, $31, p = 0.16). However, among patients with frailty, spending declined by $620/episode/quarter in the BPCI group, compared with $330/episode/quarter in the non-BPCI group, for a difference in slope changes of -$289 (95% CI -$482, -$96, p = 0.003). There were no differences in the change in slopes in case selection or clinical outcomes overall or in any clinical subgroup.
CONCLUSIONS
SNF participation in BPCI was associated with no overall differential change in total Medicare payments per episode, case selection, or clinical outcomes. Exploratory analyses revealed a decrease in Medicare payments in patients with frailty that may warrant further study.
Topics: Aged; Aged, 80 and over; Case-Control Studies; Diagnosis-Related Groups; Episode of Care; Female; Health Expenditures; Humans; Interrupted Time Series Analysis; Male; Medicare; Outcome Assessment, Health Care; Patient Care Bundles; Reimbursement Mechanisms; Retrospective Studies; Skilled Nursing Facilities; United States
PubMed: 34379323
DOI: 10.1111/jgs.17409 -
Journal of General Internal Medicine Nov 2017Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around... (Review)
Review
Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around program scope (broad vs. narrow); selecting absolute or relative performance targets; rewarding improvement, achievement, or both; and offering penalties, rewards, or both. We examined and classified current Medicare payment models-the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing Program (HVBP), Hospital-Acquired Conditions Reduction Program (HACRP), Medicare Advantage Quality Star Rating program, Physician Value-Based Payment Modifier (VM) and its successor, the Merit-Based Incentive Payment System (MIPS), and the Medicare Shared Savings Program (MSSP) on these elements of program design and reviewed the literature to place findings in context. We found that current Medicare payment models vary significantly across each parameter of program design examined. For example, in terms of scope, the HRRP focuses exclusively on risk-standardized excess readmissions and the HACRP on patient safety. In contrast, HVBP includes 21 measures in five domains, including both quality and cost measures. Choices regarding penalties versus bonuses are similarly variable: HRRP and HACRP are penalty-only; HVBP, VM, and MIPS are penalty-or-bonus; and the MSSP and MA quality star rating programs are largely bonus-only. Each choice has distinct pros and cons that impact program efficacy. Unfortunately, there are scant data to inform which program design choice is best. While no one approach is clearly superior to another, the variability contained within these programs provides an important opportunity for Medicare and others to learn from these undertakings and to use that knowledge to inform future policymaking.
Topics: Humans; Medicare; Patient Readmission; Program Evaluation; Reimbursement, Incentive; United States; Value-Based Purchasing
PubMed: 28717900
DOI: 10.1007/s11606-017-4125-8 -
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 -
The Permanente Journal 2020Previous research has reported switching from traditional Medicare (TM) to Medicare Advantage (MA) plans increased from 2006 to 2011 at the aggregate level, and...
INTRODUCTION
Previous research has reported switching from traditional Medicare (TM) to Medicare Advantage (MA) plans increased from 2006 to 2011 at the aggregate level, and switching from MA plans to TM also increased. However, little is known about switching behavior among individuals with specific chronic diseases.
OBJECTIVE
To examine disease-specific switching patterns between TM and MA to understand the impact on MA plans.
METHODS
Using the 2006 to 2012 Medicare Current Beneficiary Survey, we examined disease-specific switching rates between TM and MA and disease-specific ratios of mean baseline total Medicare expenditures of beneficiaries remaining in the same plan (stayers) vs those switching to another plan (switchers), respectively. We focused on beneficiaries with 1 or more of 10 incident diagnoses.
RESULTS
Beneficiaries with a new diagnosis of Alzheimer disease and related dementias, hypertension, and psychiatric disorders had relatively high rates of switching into MA plans and low rates of switching out of MA plans. Among those with new diagnoses of psychiatric disorders and diabetes, more costly beneficiaries (those with higher costs) switched into MA plans. For cancer, more costly beneficiaries remained in MA plans.
CONCLUSION
Together, these results suggest that MA plans may have not only higher caseloads but also a more costly case mix of beneficiaries with certain diseases than historically was the case. Our findings can help inform MA plans to understand their beneficiaries' disease burden and prepare for provision of relevant services.
Topics: Aged; Chronic Disease; Female; Health Expenditures; Humans; Male; Medicare; Medicare Part C; United States
PubMed: 31852048
DOI: 10.7812/TPP/19.059 -
Annals of Internal Medicine Jul 2019Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.
BACKGROUND
Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.
OBJECTIVE
To compare readmission rates between Medicare Advantage and traditional Medicare.
DESIGN
Retrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS).
SETTING
4748 U.S. acute care hospitals.
PATIENTS
Patients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014.
MEASUREMENTS
30-day readmissions.
RESULTS
Among admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014.
LIMITATION
Potential unobserved differences between populations.
CONCLUSION
The HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries.
PRIMARY FUNDING SOURCE
National Institute on Aging.
Topics: Aged; Female; Heart Failure; Humans; Male; Medicare; Medicare Part C; Myocardial Infarction; Patient Readmission; Pneumonia; Retrospective Studies; United States
PubMed: 31234205
DOI: 10.7326/M18-1795 -
JAMA Internal Medicine Sep 2017Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services....
IMPORTANCE
Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear.
OBJECTIVE
To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans.
DESIGN, SETTING, AND PARTICIPANTS
Retrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries.
EXPOSURES
Enrollment in an MA plan.
MAIN OUTCOMES AND MEASURES
Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care.
RESULTS
The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%).
CONCLUSIONS AND RELEVANCE
Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.
Topics: Health Care Costs; Health Expenditures; Humans; Insurance, Health, Reimbursement; Insurance, Physician Services; Medicare; Medicare Part C; Needs Assessment; United States
PubMed: 28692718
DOI: 10.1001/jamainternmed.2017.2679 -
Annual Review of Public Health Apr 2020Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this... (Review)
Review
Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.
Topics: Aged; Aged, 80 and over; Delivery of Health Care; Female; Humans; Male; Medicare; Reimbursement Mechanisms; United States; Value-Based Health Insurance
PubMed: 32237986
DOI: 10.1146/annurev-publhealth-040119-094327