Health and Health Care of Medicare Beneficiaries in 2030

Trends in Medicare utilization and reimbursement for hematology/oncology procedures from 2012 to 2023: A geriatric oncology perspective

Objectives

Given the scarcity of data exploring reimbursement trends in the field of hematology/oncology, we sought to characterize these trends for common procedures in this field from 2012 to 2023.

Methods

Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look-Up Tool we collected reimbursement data for 40 hematology/oncology procedure codes from 2012 to 2023. Data was adjusted to 2023 United States (US) dollars using the Consumer Price Index (CPI).

Results

From 2012 to 2023 gross reimbursement for the facility price decreased 4.4% and increased 9.2% for the non-facility price. When adjusted for inflation, compensation decreased 96.1% and 96.6%, respectively. None of the 40 examined Current Procedural Terminology (CPT) codes increased in net reimbursement over the study period.

Conclusions

Medicare reimbursement for common hematology/oncology procedures decreased from 2012 to 2023. Further research is necessary to explore the implications of these trends on the delivery of patient care.

Integrating Advocacy into Your Practice

In the last 60 years, health care has evolved due to many trends including the introduction of third-party payers, a progressively aging society, advancing technology, emerging recognition of social issues of race/gender/poverty, the relative decline in the physician workforce, rising health care costs, ongoing consolidation of health care entities, and the corporatization of health care delivery. This has led to problems in health care delivery with respect to cost, quality, and access. Many medical leaders feel it is now the duty of the physician to go beyond the classic patient-doctor clinical responsibility and work to advocate for their patients and society regarding economic, financial, educational, and social issues.

The surgical patient of yesterday, today, and tomorrow-a time-trend analysis based on a cohort of 8.7 million surgical patients

BACKGROUND

Global healthcare delivery is challenged by the aging population and the increase in obesity and type 2 diabetes. The extent to which such trends affect the cohort of patients the authors surgically operate on remains to be elucidated. Comprising of 8.7 million surgical patients, the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database can be analyzed to investigate the echo of general population dynamics and forecast future trends.

MATERIAL AND METHODS

The authors reviewed the ACS-NSQIP database (2008-2020) in its entirety, extracting patient age, BMI, and diabetes prevalence. Based on these data, the authors forecasted future trends up to 2030 using a drift model.

RESULTS

During the review period, median age increased by 3 years, and median BMI by 0.9 kg/m2. The proportion of patients with overweight, obesity class I, and class II rates increased. The prevalence of diabetes rose between 2008 (14.9%) and 2020 (15.3%). The authors forecast the median age in 2030 to reach 61.5 years and median BMI to climb to 29.8 kg/m2. Concerningly, in 2030, eight of ten surgical patients are projected to have a BMI above normal. Diabetes prevalence is projected to rise to 15.6% over the next decade.

CONCLUSION

General population trends echo in the field of surgery, with the surgical cohort aging at an alarmingly rapid rate and increasingly suffering from obesity and diabetes. These trends show no sign of abating without dedicated efforts and call for urgent measures and fundamental re-structuring for improved future surgical care.

Medicare Reimbursement in Colorectal Surgery: A Growing Problem

BACKGROUND

Medicare reimbursement rates have decreased across various specialties but have not yet been studied in colorectal surgery.

OBJECTIVE

This study aimed to analyze Medicare reimbursement trends in colorectal surgery.

DESIGN

Observational study.

SETTING

The Centers for Medicare and Medicaid Services' Physician Fee Schedule was evaluated for reimbursement data for the 20 most common colorectal surgery procedures from 2006 to 2020.

MAIN OUTCOME MEASURES

Inflation-adjusted annual percentage change, compound annual growth rate, and total percentage change were the outcome measures. A subanalysis was performed comparing the changes in reimbursement between 2006 to 2016 and 2016 to 2020 because of legislative changes that went into effect in 2016.

RESULTS

During the study period, the inflation-unadjusted mean Medicare reimbursement rate for the 20 most common colorectal surgery procedures increased by +15.6%. This rise was surpassed by the inflation rate of +31.3%. Consequently, the inflation-adjusted reimbursement rate decreased by -11%. The adjusted reimbursement rates decreased the most at -33.8% for a flexible colonoscopy with biopsy and increased the most at +45.3% for a diagnostic rigid proctosigmoidoscopy. Annual percentage change was -0.79%, and the compound annual growth rate was -0.98%. There was an accelerated decrease in annual reimbursement rates from 2016 to 2020 at -2.23% compared to 2006 to 2016 at -0.22% ( p = 0.03). The only procedure that had an increase in adjusted reimbursement rate from 2016 to 2020 was the injection of sclerosing solution for hemorrhoids.

LIMITATIONS

Only Medicare reimbursement data were analyzed.

CONCLUSIONS

Medicare reimbursements for colorectal surgery procedures are decreasing at an accelerating rate. Although this study is limited to Medicare data, it still presents a representation of overall reimbursement changes because Medicare policies have a ripple effect in the commercial insurance market. It is vital to understand the financial trends to be able to structure future patient care teams and to advocate for the sustainability of colorectal surgery practices in the United States. See Video Abstract at http://links.lww.com/DCR/C136 .

REEMBOLSO DE MEDICARE EN CIRUGA COLORRECTAL UN PROBLEMA CRECIENTE

ANTECEDENTES: Las tasas de reembolso de Medicare han disminuido en varias especialidades, pero aún no han sido estudiado en cirugía colorrectal.OBJETIVO: Analizar las tendencias de reembolso de Medicare en cirugía colorrectal.DISEÑO: Estudio observacional.CONTEXTO: Se evaluó el programa de tarifas médicas de los Centros de Servicios de Medicare y Medicaid para obtener datos de reembolso de los 20 procedimientos más comunes en cirugía colorrectal entre los años 2006 y 2020.PRINCIPALES MEDIDAS DE RESULTADO: Variación porcentual anual ajustada por inflación, tasa de crecimiento anual compuesta y variación porcentual total. Se realizó un subanálisis comparando los cambios en el reembolso entre los años 2006 a 2016 y 2016 a 2020 debido a los cambios legislativos que entraron en vigencia en 2016.RESULTADOS: Durante el período de estudio, la tasa media de reembolso de Medicare sin ajuste por inflación para los 20 procedimientos más comunes en cirugía colorrectal aumentó en +15,6 %. Esta suba fue superada por la tasa de inflación del +31,3%. En consecuencia, la tasa de reembolso ajustada por inflación disminuyó un -11%. Lo máximo que disminuyeron las tasas ajustadas de reembolso fue a -33,8% para una colonoscopia flexible con biopsia y aumentaron más a +45,3% para una proctosigmoidoscopia rígida de diagnóstico. El cambio porcentual anual fue -0,79% y la tasa de crecimiento anual compuesto fue -0,98%. Hubo una disminución acelerada en las tasas de reembolso anual de 2016 a 2020 a -2,23 % en comparación con 2006 a 2016 a -0,22% ( p = 0,03). El único procedimiento que tuvo un aumento en la tasa de reembolso ajustada de 2016 a 2020 fue la inyección de solución esclerosante para las hemorroides.LIMITACIONES: Solo se analizaron los datos de reembolso de Medicare.CONCLUSIONES: Los reembolsos de Medicare por procedimientos en cirugía colorrectal están disminuyendo a un ritmo acelerado. Aunque este estudio se limita a los datos de Medicare, aún presenta una representación de los cambios generales en los reembolsos, ya que las pólizas de Medicare tienen un efecto dominó en el mercado de seguros comerciales. Es fundamental comprender las tendencias financieras para poder estructurar futuros equipos de atención de pacientes y abogar por la sostenibilidad de las prácticas de cirugía colorrectal en los Estados Unidos. Consulte Video Resumen video en https://links.lww.com/DCR/C136 . (Traducción-Dr. Osvaldo Gauto ).

Treatment Patterns and Population Characteristics of Nonpharmacological Management of Chronic Pain in the United States' Medicare Population: A Scoping Review

Background and Objectives

Clinical practice guidelines recommend noninvasive nonpharmacological pain therapies; however, reviews that assess the literature pertaining to nonpharmacological pain management among older adults and people with long-term disabilities who are disproportionately affected by pain are lacking. This scoping review aimed to systematically map and characterize the existing studies about the receipt of noninvasive, nonpharmacological pain therapies by Medicare beneficiaries.

Research Design and Methods

We conducted a literature search in MEDLINE (PubMed), CINAHL (EBSCO), SocINDEX (EBSCO), Cochrane Library, Web of Science citation indices, and various sources of gray literature. The initial search was conducted on November 2, 2021, and updated on March 9, 2022. Two independent reviewers screened titles, abstracts, and full texts for inclusion and extracted the characteristics of the studies, studied populations, and nonpharmacological pain therapies. Data were summarized using tabular and narrative formats.

Results

The final review included 33 studies. Of these, 24 were quantitative, 7 were qualitative, and 2 were mixed-methods studies. Of 32 studies that focused on Medicare beneficiaries, 10 did not specify the Medicare type, and all but one of the remaining studies were restricted to fee-for-service enrollees. Back and neck pain and arthritis were the most commonly studied pain types. Chiropractic care (n = 19) and physical therapy (n = 17) appeared frequently among included studies. The frequency and/or duration of nonpharmacological treatment were mentioned in 13 studies. Trends in the utilization of nonpharmacological pain therapies were assessed in 6 studies but none of these studies went beyond 2008.

Discussion and Implications

This scoping review found that manipulative therapies, mainly chiropractic, have been the most widely studied approaches for nonpharmacological pain management in the Medicare population. The review also identified the need for future research that updates trend data and addresses contemporary issues such as rising Medicare Advantage enrollment and promulgation of practice guidelines for pain management.

Are older people worse off in 2040 regarding health and resources to deal with it? - Future developments in complex health problems and in the availability of resources to manage health problems in the Netherlands

Introduction

Developing sustainable health policy requires an understanding of the future demand for health and social care. We explored the characteristics of the 65+ population in the Netherlands in 2020 and 2040, focusing on two factors that determine care needs: (1) the occurrence of complex health problems and (2) the availability of resources to manage health and care (e.g., health literacy, social support).

Methods

Estimations of the occurrence of complex health problems and the availability of resources for 2020 were based on registry data and patient-reported data. Estimations for 2040 were based on (a) expected demographic developments, and (b) expert opinions using a two-stage Delphi study with 26 experts from policy making, practice and research in the field of health and social care.

Results

The proportion of people aged 65+ with complex health problems and limited resources is expected to increase from 10% in 2020 to 12% in 2040 based on demographic developments, and to 22% in 2040 based on expert opinions. There was high consensus (>80%) that the proportion with complex health problems would be greater in 2040, and lower consensus (50%) on an increase of the proportion of those with limited resources. Developments that are expected to drive the future changes refer to changes in multimorbidity and in psychosocial status (e.g., more loneliness).

Conclusion

The expected increased proportion of people aged 65+ with complex health problems and limited resources together with the expected health and social care workforce shortages represent large challenges for public health and social care policy.

Cumulative Payments Through the Earned Income Tax Credit Program in Childhood and Criminal Conviction During Adolescence in the US

IMPORTANCE

Childhood poverty is associated with poor health and behavioral outcomes. The Earned Income Tax Credit (EITC), first implemented in 1975, is the largest cash transfer program for working families with low income in the US.

OBJECTIVE

To assess whether cumulative EITC payments received during childhood are associated with the risk of criminal conviction during adolescence.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, the analytic sample consisted of US children enrolled in the 1979 National Longitudinal Study of Youth. The children were born between 1979 and 1998 and were interviewed as adolescents (age 15-19 years) between 1994 and 2016. Data analyses were performed from May 2021 to September 2022.

EXPOSURE

Cumulative simulated EITC received by the individual's family from birth through age 14 years.

MAIN OUTCOMES AND MEASURES

The main outcome was dichotomous, self-reported conviction for a crime during adolescence (age 14-18 years). A cumulative, simulated measure of mean EITC benefits received by a child's family from birth through age 14 years was derived from federal, state, and family-size differences in EITC eligibility and payments during the study period to capture EITC benefit variation due to differences in policy parameters but not endogenous factors such as changes in household income. Logistic regression models with fixed effects for state and year and robust SEs clustered by mother estimated relative risk of adolescent conviction. Models were adjusted for state-, mother-, and child-level covariates.

RESULTS

The analytical sample consisted of 5492 adolescents born between 1979 and 1998; 2762 (50.3%) were male, 1648 (30.0%) were Black, 1125 (20.5%) were Hispanic, and 2719 (49.5%) were not Black or Hispanic. Each additional $1000 of EITC received during childhood was associated with an 11% lower risk of self-reported criminal conviction during adolescence (adjusted odds ratio, 0.89; 95% CI, 0.84-0.95). Adjusted risk differences were larger among boys (-14.2 self-reported convictions per 1000 population [95% CI, -22.0 to -6.3 per 1000 population]) than among girls (-6.2 per 1000 population [95% CI, -10.7 to -1.6 per 1000 population]).

CONCLUSIONS AND RELEVANCE

The findings suggest that income support from the EITC may be associated with reduced youth involvement with the criminal justice system in the US. Cost-benefit analyses of the EITC should consider these longer-term and indirect outcomes.

Identifying Medicare Beneficiaries With Delirium

BACKGROUND

Each year, thousands of older adults develop delirium, a serious, preventable condition. At present, there is no well-validated method to identify patients with delirium when using Medicare claims data or other large datasets. We developed and assessed the performance of classification algorithms based on longitudinal Medicare administrative data that included International Classification of Diseases, 10th Edition diagnostic codes.

METHODS

Using a linked electronic health record (EHR)-Medicare claims dataset, 2 neurologists and 2 psychiatrists performed a standardized review of EHR records between 2016 and 2018 for a stratified random sample of 1002 patients among 40,690 eligible subjects. Reviewers adjudicated delirium status (reference standard) during this 3-year window using a structured protocol. We calculated the probability that each patient had delirium as a function of classification algorithms based on longitudinal Medicare claims data. We compared the performance of various algorithms against the reference standard, computing calibration-in-the-large, calibration slope, and the area-under-receiver-operating-curve using 10-fold cross-validation (CV).

RESULTS

Beneficiaries had a mean age of 75 years, were predominately female (59%), and non-Hispanic Whites (93%); a review of the EHR indicated that 6% of patients had delirium during the 3 years. Although several classification algorithms performed well, a relatively simple model containing counts of delirium-related diagnoses combined with patient age, dementia status, and receipt of antipsychotic medications had the best overall performance [CV- calibration-in-the-large <0.001, CV-slope 0.94, and CV-area under the receiver operating characteristic curve (0.88 95% confidence interval: 0.84-0.91)].

CONCLUSIONS

A delirium classification model using Medicare administrative data and International Classification of Diseases, 10th Edition diagnosis codes can identify beneficiaries with delirium in large datasets.

Size and characteristics of family caregiving for people with serious illness: A population-based survey

OBJECTIVES

Family caregivers play a vital role in care for people with serious illness. Reliable population-level information on family caregiving is scarce. We describe the socio-demographic and family caregiving characteristics and experiences of family caregivers of people with serious illness in the adult population.

METHOD

We performed a secondary analysis of the cross-sectional population-based 19th Social-Cultural Changes survey. A random sample of 2,581 Dutch-speaking people aged 18-95, living in Flanders or Brussels, were contacted for participation in the survey between March and July 2014 using a stratified two-step sample. Differences between groups are described using Pearson chi-square tests and analysis of variance.

RESULTS

Response rate was 58.7% (1,515/2,581). Over a 12-month period, 7.6% of respondents provided family care for someone with a serious illness (n = 114). They were most often aged 55-74 (36.0%), women (57.9%), worked full-time (42.3%); 31.8% provided at least 10 h of family care each week. Family caregivers of people with serious illness, compared with family caregivers of people with other conditions, provided more medical and nursing care (33.3% vs. 22.5%, p = 0.027), and experienced a higher burden of family caregiving (p = 0.038) but a similarly high meaningfulness of family caregiving.

SIGNIFICANCE OF RESULTS

A considerable part of the adult working population provides family care for someone with serious illness. While family caregiving for someone with serious illness shows similarities with family caregiving for people with other conditions in terms of caregiver characteristics and the impact of caregiving on work-life balance and the meaning derived from it, it is also associated with increased burden.

Projecting future health and service use among older people in Ireland: an overview of a dynamic microsimulation model in The Irish Longitudinal Study on Ageing (TILDA)

Background: Demographic ageing is a population health success story but poses unprecedented policy challenges in the 21st century. Policymakers must prepare health systems, economies and societies for these challenges. Policy choices can be usefully informed by models that evaluate outcomes and trade-offs in advance under different scenarios. Methods: We developed a dynamic demographic-economic microsimulation model for the population aged 50 and over in Ireland: the Irish Future Older Adults Model (IFOAM).  Our principal dataset was The Irish Longitudinal Study on Ageing (TILDA). We employed first-order Markovian competing risks models to estimate transition probabilities of TILDA participants to different outcomes: diagnosis of serious diseases, functional limitations, risk-modifying behaviours, health care use and mortality. We combined transition probabilities with the characteristics of the stock population to estimate biennial changes in outcome state.   Results: IFOAM projections estimated large annual increases in total deaths, in the number of people living and dying with serious illness and functional impairment, and in demand for hospital care between 2018 and 2040.  The most important driver of these increases is the rising absolute number of older people in Ireland as the population ages. The increasing proportion of older old and oldest old citizens is projected to increase the average prevalence of chronic conditions and functional limitations. We deemed internal validity to be good but lacked external benchmarks for validation and corroboration of most outcomes. Conclusion: We have developed and validated a microsimulation model that projects health and related outcomes among older people in Ireland.  Future research should address identified policy questions. The model enhances the capacity of researchers and policymakers to quantitatively forecast health and economic dynamics among older people in Ireland, to evaluate ex ante policy responses to these dynamics, and to collaborate internationally on global challenges associated with demographic ageing.

Decreasing Medicare Utilization, Reimbursement, and Reimbursement-to-Charge Ratio of Reconstructive Plastic Surgery Procedures: 2010 to 2019

BACKGROUND

This study aimed to evaluate recent trends in utilization, reimbursement, and charges for reconstructive plastic surgery procedures billed to Medicare.

METHODS

We queried the Physician/Supplier Procedure Summary from the Centers for Medicare and Medicaid Services for procedures billed by plastic surgeons to Medicare Part B between 2010 and 2019. We collected service counts, charges, and reimbursements. We adjusted utilization by Medicare enrollment and adjusted monetary values for inflation. We calculated the weighted mean charge and reimbursement, which were used to calculate the reimbursement-to-charge ratio (RCR). We examined trends over time by calculating differences and performing correlation analyses of utilization, charges, reimbursement, and RCR for all procedures and for different procedural categories.

RESULTS

From 2010 to 2019, the overall enrollment-adjusted utilization for 912 reconstructive procedures decreased by 6.6% (r2 = 0.46). Utilization increased in certain procedural categories such as skin debridement (+36.9%, r2 = 0.48) and procedures of the breast (+114.9%, r2 = 0.48). Charges increased by 32.9% (r2 = 0.99), reimbursement decreased by 5.3% (r2 = 0.84), and RCR decreased by 28.7% (r2 = 0.99). Skin replacement/flaps/grafts procedures underwent the greatest relative decrease in reimbursement (-26.8%, r2 = 0.87). Reimbursement-to-charge ratio decreased for all procedural categories except for procedures of the auditory system.

CONCLUSIONS

In the past decade, Medicare utilization and reimbursement for reconstructive plastic surgery procedures decreased, whereas charges increased. This resulted in decreasing reimbursement relative to charged amounts. These findings raise concerns regarding the economic viability of providing plastic surgery services to an aging population and may impact patients' ability to access affordable plastic surgical care.

Projecting future health and service use among older people in Ireland: an overview of a dynamic microsimulation model in The Irish Longitudinal Study on Ageing (TILDA)

Background: Demographic ageing is a population health success story but poses unprecedented policy challenges in the 21st century. Policymakers must prepare health systems, economies and societies for these challenges. Policy choices can be usefully informed by models that evaluate outcomes and trade-offs in advance under different scenarios.

Methods: We developed a dynamic demographic-economic microsimulation model for the population aged 50 and over in Ireland: the Irish Future Older Adults Model (IFOAM).  Our principal dataset was The Irish Longitudinal Study on Ageing (TILDA). We employed first-order Markovian competing risks models to estimate transition probabilities of TILDA participants to different outcomes: diagnosis of serious diseases, functional limitations, risk-modifying behaviours, health care use and mortality. We combined transition probabilities with the characteristics of the stock population to estimate biennial changes in outcome state.  

Results: IFOAM projections estimated large annual increases in total deaths, in the number of people living and dying with serious illness and functional impairment, and in demand for hospital care between 2018 and 2040.  The most important driver of these increases is the rising absolute number of older people in Ireland as the population ages. The increasing proportion of older old and oldest old citizens is projected to increase the average prevalence of chronic conditions and functional limitations. We deemed internal validity to be good but lacked external benchmarks for validation and corroboration of most outcomes.

Conclusion: We have developed and validated a microsimulation model that predicts future health and related outcomes among older people in Ireland.  Future research should address identified policy questions. The model enhances the capacity of researchers and policymakers to quantitatively forecast future health and economic dynamics among older people in Ireland, to evaluate ex ante policy responses to these dynamics, and to collaborate internationally on global challenges associated with demographic ageing.

Inflation-Adjusted Medicare Reimbursement Has Decreased for Orthopaedic Sports Medicine Procedures: Analysis From 2000 to 2020

Background:

Decreases in Medicare reimbursement have been noted among many medical specialties. An in-depth analysis of the subspecialty of orthopaedic sports medicine is needed to determine changes in Medicare reimbursement in this field.

Purpose/Hypothesis:

The purpose was to elucidate the trends in inflation-adjusted Medicare reimbursement for orthopaedic sports medicine procedures between 2000 and 2020. It was hypothesized that Medicare reimbursement decreased substantially during the study period.

Study Design:

Economic decision and analysis; Level of evidence, 4.

Methods:

The Physician Fee Schedule Look-up Tool was used to extract Medicare reimbursement information between 2000 and 2020 for 67 procedures related to orthopaedic sports medicine. These values were adjusted for inflation using the Consumer Price Index. The compound annual growth rate (CAGR) was calculated to measure the annual rate of change, and descriptive analyses were performed using the Student t test.

Results:

Between 2000 and 2020, inflation-adjusted Medicare reimbursement for the 67 included procedures decreased by an average of 33% (CAGR = –2.2%; R 2 = 0.78). Reimbursement decreased for procedures related to the shoulder and elbow by 34% (CAGR = –2.3%; R 2 = 0.80), for hip-related procedures by 23% (CAGR = –1.4%; R 2 = 0.77), for knee-related procedures by 31% (CAGR = –2.0%; R 2 = 0.81), and for procedures relating to the foot and ankle by 38% (CAGR = –2.5%; R 2 = 0.79).

Conclusion:

Study findings indicated that inflation-adjusted Medicare reimbursement decreased substantially between 2000 and 2020 for orthopaedic sports medicine procedures, ranging from a 23% decrease for hip-related procedures to a 38% decrease for foot and ankle–related procedures. The results of this study could be used to provide further context for health care policy decisions and help ensure sustainable financial environments for orthopaedic sports medicine surgeon.

Decline in Medicare Utilization and Reimbursement Rates in Ophthalmic Plastic and Reconstructive Surgery: 2010-2019

BACKGROUND

Analysis of current and past reimbursement patterns for federally funded programs is crucial to develop sustainable future payment models.

METHODS

The Centers for Medicare and Medicaid Services Physician Fee Schedule was used to evaluate 26 common ophthalmic plastic and reconstructive surgery (OPRS) procedures. From 2010 to 2019, compound annual growth rate, total percent change, and annual percent change were calculated using inflation-adjusted reimbursement rates. Centers for Medicare and Medicaid Services' Physician/Supplier Procedure Summary was used to assess the surgical volume of the 26 procedures in ophthalmology and plastic surgery services.

RESULTS

From 2010 to 2019, total billed surgical procedures in OPRS decreased by 57.0%, affecting both ophthalmologists (-54.3%) and plastic surgeons (-80.1%). Over the study period, inflation-adjusted reimbursement rates decreased by 5.6%. Compound annual growth rate was -0.66%, and annual percent change was -0.62%. From 2010 to 2013, reimbursement rates increased by 1.8% each year. In contrast, from 2013 to 2019, reimbursement rates decreased by 1.7% each year (P < 0.0001).

CONCLUSIONS

From 2010 to 2019, Medicare utilization has substantially declined for OPRS procedures. Inflation-adjusted Medicare reimbursement rates have decreased for the majority of common procedures since 2013. Surgeons and policymakers need to be aware of these trends to ensure future availability of subspecialty surgical services.

Predicting quantity and quality of life with the Future Elderly Model

The Future Elderly Model (FEM) is a microsimulation model designed to forecast health status, longevity, and a variety of economic outcomes. Compared to traditional actuarial models, microsimulation models provide greater opportunities for policy forecasting and richer detail, but they typically build upon smaller samples of data that may mitigate forecasting accuracy. We perform validation analyses of the FEM's mortality and quality of life forecasts using a version of the FEM estimated exclusively on early waves of data from the Health and Retirement Study. First, we compare FEM mortality and longevity projections to the actual mortality and longevity experience observed over the same period of time. We also compare the FEM results to actuarial forecasts of mortality and longevity during the same time. We find that FEM projections are generally in line with observed mortality rates and closely match longevity. Then, we assess the FEM's performance at predicting quality of life and longitudinal outcomes, two features missing from traditional actuarial models. Our analysis suggests the FEM performs at least as well as actuarial forecasts of mortality, while providing policy simulation features that are not available in actuarial models.

The burden of prosthetic hip dislocations in the United States is projected to significantly increase by 2035

INTRODUCTION

Prosthetic hip dislocation is a common, costly complication of total hip arthroplasty (THA). Despite this, the national burden of prosthetic hip dislocations remains uncharacterised in the United States, especially pertaining to injuries occurring years after the index procedure. This study examines historical and projected national estimates of prosthetic hip dislocations presenting to U.S. emergency departments between 2000 and 2035.

METHODS

We conducted a cross-sectional, retrospective epidemiological study using narratives in the National Electronic Injury Surveillance System (NEISS) database (2000-2017) to identify an estimated 64,671 prosthetic hip implant dislocations presenting to U.S. emergency departments. Estimates for the prevalence of individuals living with a total hip implant were derived from the literature.

RESULTS

The national estimate of prosthetic hip dislocations presenting to U.S. emergency departments rose significantly (p < 0.001) between 2000 (n = 2395; 95% CI, 1264-3526) and 2017 (n = 8094; 95% CI, 4276-11,912). These increases are likely driven by increased numbers of people living with THA overall, since between 2000 and 2017, the average incidence of prosthetic hip dislocation (0.14%; CI 0.08-0.21%) in patients living with hip implants has not changed significantly. Linear regression modeling (R² = 0.7, p < 0.01) projected an increasing number of dislocations through 2035, predicting 10,446 national cases per year by this date.

CONCLUSIONS

Driven by increases in THA, the annual volume of prosthetic hip dislocations presenting to U.S. emergency departments has increased significantly since 2000 and is projected to continue to rise sharply. Future advances in surgical technique, prosthesis design, and injury prevention policies aimed at decreasing the rate of THA dislocation would help alleviate this mounting national health burden.

Medicare Reimbursement Trends for Hospital-Based Oral Maxillofacial Surgery Procedures: 2003 to 2020

PURPOSE

To evaluate recent trends in Medicare reimbursement rates for common hospital-based oral-maxillofacial surgery procedures.

METHODS

Physician Fee Schedule Look-Up Tool by the Centers for Medicare and Medicaid Services was searched for reimbursement rates for the 20 most performed oral-maxillofacial surgery procedures between 2003 and 2020. Total percent change, annual percent change, and compound annual growth rate (CAGR) were calculated using the adjusted reimbursement rates over the study period. Annual changes in reimbursement rates before and after 2016 were compared.

RESULTS

After adjusting for inflation, average reimbursement rates for procedures decreased by 13.4%. Annual percent change and CAGR were -0.79 and -0.88%, respectively. Annual reimbursements decreased more between 2016 to 2020 (-1.83%,) than from 2003 to 2016 (-0.49%; P value = .003).

CONCLUSION

Inflation-adjusted Medicare reimbursement rates for oral-maxillofacial surgery procedures have decreased from 2003 to 2020. The rate of reimbursement decreases has accelerated in recent years.

Ninety-Day Readmission in Elective Revision Lumbar Fusion Surgery in the Inpatient Setting

STUDY DESIGN

Retrospective review.

OBJECTIVES

(1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days.

METHODS

Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted.

RESULTS

In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted.

CONCLUSION

Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

Economic aspects of insomnia medication treatment among Medicare beneficiaries

STUDY OBJECTIVES

To examine economic aspects of insomnia and insomnia medication treatment among a nationally representative sample of older adult Medicare beneficiaries.

METHODS

Using a random 5% sample of Medicare administrative data (2006-2013), insomnia was defined using International Classification of Disease, Version 9, Clinical Modification diagnostic codes. Treatment was operationalized as one or more prescription fills for an US Food and Drug Administration (FDA)-approved insomnia medication following diagnosis, in previously untreated individuals. To evaluate the economic impact of insomnia treatment on healthcare utilization (HCU) and costs in the year following insomnia diagnosis, a difference-in-differences approach was implemented using generalized linear models.

RESULTS

A total of 23 079 beneficiaries with insomnia (M age = 71.7 years) were included. Of these, 5154 (22%) received one or more fills for an FDA-approved insomnia medication following insomnia diagnosis. For both treated and untreated individuals, HCU and costs increased during the 12 months prior to diagnosis. Insomnia treatment was associated with significantly increased emergency department visits and prescription fills in the year following insomnia diagnosis. After accounting for pre-diagnosis differences between groups, no significant differences in pre- to post-diagnosis costs were observed between treated and untreated individuals.

CONCLUSIONS

These results advance previous research into economics of insomnia disorder by evaluating the impact of medication treatment and highlighting important differences between treated and untreated individuals. Future studies should seek to understand why some individuals diagnosed with insomnia receive treatment but others do not, to identify clinically meaningful clusters of older adults with insomnia, and to explore the economic impact of insomnia and insomnia treatment among subgroups of individuals with insomnia, such as those with cardiovascular diseases, mood disorders, and neurodegenerative disease.

Family Caregiving in Serious Illness in the United States: Recommendations to Support an Invisible Workforce

Family caregivers provide the vast majority of care for individuals with serious illness living in the community but are not often viewed as full members of the healthcare team. Family caregivers are increasingly expected to acquire a sophisticated understanding of the care recipient's condition and new skills to execute complex medical or nursing tasks, often without adequate preparation and support, and with little choice in taking on the role. This review draws on peer-reviewed literature, government reports, and other publications to summarize the challenges faced by family caregivers of older adults in the context of serious illness and to identify opportunities to better integrate them into the healthcare workforce. We discuss promising approaches such as inclusion of family caregivers in consensus-based practice guidelines; the "no wrong door" function, directing consumers to needed resources, regardless of where initial contact is made; and caregiver-friendly workplace policies allowing flexible arrangements. We present specific recommendations focusing on research, clinical practice, and policy changes that promote family-centered care and improve outcomes for caregivers as well as persons with serious illness. J Am Geriatr Soc 67:S451-S456, 2019.

Economics of Palliative Care for Cancer: Interpreting Current Evidence, Mapping Future Priorities for Research

The National Cancer Institute estimates that $154 billion will be spent on care for people with cancer in 2019, distributed across the year after diagnosis (31%), the final year of life (31%), and continuing care between those two (38%). Projections of future costs estimate persistent growth in care expenditures. Early research studies on the economics of palliative care have reported a general pattern of cost savings during inpatient hospital admissions and the end-of-life phase. Recent research has demonstrated more complex dynamics, but expanding palliative care capacity to meet clinical guidelines and population health needs seems to save costs. Quantifying these cost savings requires additional research, because there is significant variance in estimates of the effects of treatment on costs, depending on the timing of intervention, the primary diagnosis, and the overall illness burden. Because ASCO guidelines state that palliative care should be provided concurrently with other treatment from the point of diagnosis onward for all metastatic cancer, new and ambitious research is required to evaluate the cost effects of palliative care across the entire disease trajectory. We propose a series of ways to reach the guideline goals.

18F-Labeled, PSMA-Targeted Radiotracers: Leveraging the Advantages of Radiofluorination for Prostate Cancer Molecular Imaging

Prostate-specific membrane antigen (PSMA)-targeted PET imaging for prostate cancer with 68Ga-labeled compounds has rapidly become adopted as part of routine clinical care in many parts of the world. However, recent years have witnessed the start of a shift from 68Ga- to 18F-labeled PSMA-targeted compounds. The latter imaging agents have several key advantages, which may lay the groundwork for an even more widespread adoption into the clinic. First, facilitated delivery from distant suppliers expands the availability of PET radiopharmaceuticals in smaller hospitals operating a PET center but lacking the patient volume to justify an onsite 68Ge/68Ga generator. Thus, such an approach meets the increasing demand for PSMA-targeted PET imaging in areas with lower population density and may even lead to cost-savings compared to in-house production. Moreover, 18F-labeled radiotracers have a higher positron yield and lower positron energy, which in turn decreases image noise, improves contrast resolution, and maximizes the likelihood of detecting subtle lesions. In addition, the longer half-life of 110 min allows for improved delayed imaging protocols and flexibility in study design, which may further increase diagnostic accuracy. Moreover, such compounds can be distributed to sites which are not allowed to produce radiotracers on-site due to regulatory issues or to centers without access to a cyclotron. In light of these advantageous characteristics, 18F-labeled PSMA-targeted PET radiotracers may play an important role in both optimizing this transformative imaging modality and making it widely available. We have aimed to provide a concise overview of emerging 18F-labeled PSMA-targeted radiotracers undergoing active clinical development. Given the wide array of available radiotracers, comparative studies are needed to firmly establish the role of the available 18F-labeled compounds in the field of molecular PCa imaging, preferably in different clinical scenarios.

Regulation of the Nurse Practitioner Workforce: Implications for Care Across Settings

Introduction

The current shortage of physicians in the United States has potential to dramatically limit access to healthcare. Nurse practitioners (NPs) can provide a cost-effective solution to the shortage, yet few states allow NPs to practice independently.

Purpose

The purpose of this study was to provide an up-to-date description of the NP workforce and to identify the professional and organizational factors associated with NP care quality.

Methods

Cross-sectional survey data from a sample of NPs actively employed in four states with reduced or restricted practice (California, Florida, New Jersey, and Pennsylvania) was used. NPs were categorized into acute and primary care. Regression models were fit to estimate the odds of three measures of care quality: overall quality of patient care, NP confidence that patients and their caregivers can manage their care at home, and whether NPs would recommend their practice facility to family and friends.

Results

Receiving support from administrative staff and physicians was associated with an increase in the three measures of quality. The greatest effects were seen in primary care settings.

Conclusion

It is imperative that legislators and healthcare administrators implement policies that provide NPs with an environment that supports clinical practice and enhances care delivery.

The making of occupation-based models and diagrams: History and semiotic analysis

BACKGROUND.

Models provide a structure for organizing knowledge and facilitating learning and are upheld by occupational therapy as epitomizing the cornerstones of its practice.

PURPOSE.

This article briefly examines the scientific history of occupation-based model development in the 1950s before addressing the process of conceptual model making in occupational therapy. Using the theory of semiosis, it explains and takes a critical perspective on conceptual model building in occupational therapy.

KEY ISSUES.

Since the surge of development in the mid-1970s, models have grown and undergone some revision. However, while the profession has often contested the definitions of its core terms, it has not challenged the accepted models and diagrams that present the constituents of practice.

IMPLICATIONS.

Examining the processes of conceptual model development from a critical, semiotic point of view foregrounds models in the historico-theoretical literature and brings into scrutiny a model's relevancy in current practice.

Untreated insomnia increases all-cause health care utilization and costs among Medicare beneficiaries

STUDY OBJECTIVES

To examine the impact of untreated insomnia on health care utilization (HCU) among a nationally representative sample of Medicare beneficiaries.

METHODS

Our data source was a random 5% sample of Medicare administrative data for years 2006-2013. Insomnia was operationalized as the presence of at least one claim containing an insomnia-related diagnosis in any given year based on International Classification of Disease, Version 9, Clinical Modification codes or at least one prescription fill for an insomnia-related medication in Part D prescription drug files in each year. We compared HCU in the year prior to insomnia diagnosis to HCU among to non-sleep disordered controls during the same period.

RESULTS

A total of 151 668 beneficiaries were found to have insomnia. Compared to controls (n = 333 038), beneficiaries with insomnia had higher rates of HCU across all point of service locations. Rates of HCU were highest for inpatient care (rate ratio [RR] 1.61; 95% confidence interval [CI] 1.59, 1.64) and lowest for prescription fills (RR 1.17; 95% CI 1.16, 1.17). Similarly, compared to controls, beneficiaries with insomnia demonstrated $63,607 (95% CI $60,532, $66,685) higher all-cause costs, which were driven primarily by inpatient care ($60,900; 95% CI $56,609, $65,191). Emergency department ($1,492; 95% CI $1,387, $1,596) and prescription costs ($486; 95% CI $454, $518) were also elevated among cases relative to controls.

CONCLUSIONS

In this randomly selected and nationally representative sample of older Medicare beneficiaries and compared to non-sleep disordered controls, individuals with untreated insomnia demonstrated increased HCU and costs across all points of service.

Trends in Insomnia Diagnosis and Treatment Among Medicare Beneficiaries, 2006-2013

OBJECTIVE

Insomnia is an important clinical problem affecting the elderly. We examined trends in insomnia diagnosis and treatment among Medicare beneficiaries over an eight-year period.

METHODS

This was a time-series analysis of Medicare administrative data for years 2006-2013. Insomnia was defined as the presence of at least one claim containing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 307.41, 307.42, 307.49, 327.00, 327.01, 327.09, 780.52, or V69.4 in any given year. Insomnia medications were identified by searching the Part D prescription drug files in each year for barbiturates, benzodiazepines, chloral hydrate, hydroxyzine, nonbenzodiazepine sedative hypnotics, and sedating antidepressants.

RESULTS

Prevalence of physician-assigned insomnia diagnoses increased from 3.9% in 2006 to 6.2% in 2013. Prevalence of any insomnia medication use ranged from 21.0% in 2006 to 29.6% in 2013 but remained steady. A sharp increase in use of benzodiazepines from 2012-2013 (1.1% to 17.6%) drove up total insomnia medication use for 2013. Prevalence of both insomnia diagnosis and medication use ranged from 3.5% in 2006 to 5.5% in 2013, while prevalence of either insomnia diagnosis or medication use ranged from 22.7% in 2006 to 31.0% in 2013.

CONCLUSION

In this large national analysis of Medicare beneficiaries, prevalence of physician-assigned insomnia diagnoses was low but increased over time. Prevalence of insomnia medication use was up to four-times higher than insomnia diagnoses and remained steady over time. Notably, prevalence of benzodiazepine use increased dramatically from 2012-2013 after these medications were included in the Medicare Part D formulary.

Exploring Early Adopter Baby Boomers' Approach to Managing Their Health and Healthcare

The Patient 3.0 Profile is used to explore to the patient engagement strategies of early adopter baby boomers' in three domains: 1) patient relationships, 2) health information use and 3) consumer health technology (CHT) use. Findings from six focus groups with early adopter boomers challenge prior notions about older adults' passive approach to patient engagement. Baby boomers want to make final healthcare decisions with input from providers. While adept at finding and critically assessing online health information for self-education and self-management, boomers want providers to curate relevant and trustworthy information. Boomers embrace CHTs offered through providers (i.e., patient portals, email and text messaging) and sponsored by wellness programs (i.e., diet and activity devices and apps). However, there is no indication they add information to their online medical records or use CHT for diagnosis, treatment or disease management. Additional resources are needed to encourage widespread adoption, support patient effectiveness, and confirm cost-benefit.

Federal and Individual Spending on the 10 Costliest Medications in Medicare Part D from 2011 to 2015

Access to prescription medications is critical as the U.S. population ages. Escalating drug costs have garnered mounting attention from the public with increasing federal scrutiny. The Medicare Part D program will increasingly be relied upon to support the health of our nation's older people. We reviewed the publically available Medicare Part D usage data from 2011 to 2015 to quantify the cost of the 10 costliest medications for Part D, evaluated the number of beneficiaries treated with these medications, and measured beneficiaries' out-of-pocket costs. We observed over the analysis period, an increase in spending for these medications, a reduction in number of patients that received them, with increased out-of-pocket costs for the patient. In 2015 U.S. dollars, the amount Medicare Part D spent on the 10 costliest medications increased from $21.5 billion in 2011 to $28.4 billion in 2015-a 32% increase. The number of beneficiaries who received 1 of the 10 costliest medications fell from 12,913,003 in 2011 to 8,818,471-a 32% drop, with an average annual decrease of 7.9%. Out of pocket spending by patients that use these medications increased over the study period. For beneficiaries without the low-income subsidy, the average out-of-pocket cost share for 1 of the 10 costliest medications increased from $375 in 2011 to $1,366 in 2015-a 264% increase overall and an average 66% increase per year. Specialty medications are a growing portion of the costliest medications. As medication costs continue to escalate, and specialty medications become more common, the U.S. will be increasingly challenged with devising mechanisms to access sustainable, affordable medications for all older adults.

Innovation in Heart Failure Treatment: Life Expectancy, Disability, and Health Disparities

OBJECTIVES

The goal of this study was to illustrate the potential benefit of effective congestive heart failure (CHF) treatment in terms of improved health, greater social value, and reduced health disparities between black and white subpopulations.

BACKGROUND

CHF affects 5.7 million Americans, costing $32 billion annually in treatment expenditures and lost productivity. CHF also contributes to health disparities between black and white Americans: black subjects develop CHF at a younger age and are more likely to be hospitalized and die of this disease. Improved CHF treatment could generate significant health benefits and reduce health disparities.

METHODS

We adapted an established economic-demographic microsimulation to estimate scenarios in which a hypothetical innovation eliminates the incidence of CHF and, separately, 6 other diseases in patients 51 to 52 years of age in 2016. This cohort was followed up until death. We estimated total life years, quality-adjusted life years, and disability-free life years with and without the innovation, for the population overall and for race- and sex-defined subpopulations.

RESULTS

CHF prevalence among 65- to 70-year-olds increased from 4.3% in 2012 to 8.5% in 2030. Diagnosis with CHF coincided with significant increases in disability and medical expenditures, particularly among black subjects. Preventing CHF among those 51 to 52 years of age in 2016 would generate nearly 2.9 million additional life years, 1.1 million disability-free life years, and 2.1 million quality-adjusted life years worth $210 to $420 billion. These gains are greater among black subjects than among white subjects.

CONCLUSIONS

CHF prevalence will increase substantially over the next 2 decades and will affect black Americans more than white Americans. Improved CHF treatment could generate significant social value and reduce existing health disparities.

Modeling Health Care Spending Growth of Older Adults

OBJECTIVE

To forecast out-of-pocket health care spending among older adults. Long-term forecasts allow policy makers to explore potential impacts of policy scenarios, but existing microsimulations do not incorporate details of supplemental insurance coverage and income effects on health care spending.

DATA SOURCES

Dynamic microsimulation calibrated to survey and administrative data.

STUDY DESIGN

We augment Urban Institute's Dynamic Simulation of Income Model (DYNASIM) with modules that incorporate demand responses and economic equilibria, with dynamics driven by exogenous technological change. A lengthy technical appendix provides details of the microsimulation model and economic assumptions for readers interested in applying these techniques.

PRINCIPAL FINDINGS

The model projects total out-of-pocket spending (point of care plus premiums) as a share of income for adults aged 65 and older. People with lower incomes and poor health fare worse, despite protections of Medicaid. Spending rises 40 percent from 2012 to 2035 (from 10 to 14 percent of income) for the median beneficiary, but it increases from 5 to 25 percent of income for low-income beneficiaries and from 23 to 29 percent for the near poor who are in fair/poor health.

CONCLUSIONS

Despite Medicare coverage, near-poor seniors will face out-of-pocket spending that would render them, in practical terms, underinsured.

The Long-Term Benefits of Increased Aspirin Use by At-Risk Americans Aged 50 and Older

BACKGROUND

The usefulness of aspirin to defend against cardiovascular disease in both primary and secondary settings is well recognized by the medical profession. Multiple studies also have found that daily aspirin significantly reduces cancer incidence and mortality. Despite these proven health benefits, aspirin use remains low among populations targeted by cardiovascular prevention guidelines. This article seeks to determine the long-term economic and population-health impact of broader use of aspirin by older Americans at higher risk for cardiovascular disease.

METHODS AND FINDINGS

We employ the Future Elderly Model, a dynamic microsimulation that follows Americans aged 50 and older, to project their lifetime health and spending under the status quo and in various scenarios of expanded aspirin use. The model is based primarily on data from the Health and Retirement Study, a large, representative, national survey that has been ongoing for more than two decades. Outcomes are chosen to provide a broad perspective of the individual and societal impacts of the interventions and include: heart disease, stroke, cancer, life expectancy, quality-adjusted life expectancy, disability-free life expectancy, and medical costs. Eligibility for increased aspirin use in simulations is based on the 2011-2012 questionnaire on preventive aspirin use of the National Health and Nutrition Examination Survey. These data reveal a large unmet need for daily aspirin, with over 40% of men and 10% of women aged 50 to 79 presenting high cardiovascular risk but not taking aspirin. We estimate that increased use by high-risk older Americans would improve national life expectancy at age 50 by 0.28 years (95% CI 0.08-0.50) and would add 900,000 people (95% CI 300,000-1,400,000) to the American population by 2036. After valuing the quality-adjusted life-years appropriately, Americans could expect $692 billion (95% CI 345-975) in net health benefits over that period.

CONCLUSIONS

Expanded use of aspirin by older Americans with elevated risk of cardiovascular disease could generate substantial population health benefits over the next twenty years and do so very cost-effectively.