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Turbow SD, Chehal PK, Culler SD, Vaughan CP, Offutt C, Rask KJ, Perkins MM, Clevenger CK, Ali MK. Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries? Med Care 2024; 62:423-430. [PMID: 38728681 PMCID: PMC11090414 DOI: 10.1097/mlr.0000000000002003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. DATA SOURCE Medicare Fee-for-Service Data, 2018. STUDY DESIGN We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. DATA EXTRACTION METHODS We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. PRINCIPAL FINDINGS In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. CONCLUSIONS There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.
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Affiliation(s)
- Sara D Turbow
- Department of Medicine, Division of General Internal Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Puneet K Chehal
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Camille P Vaughan
- Department of Medicine, Division of Geriatrics & Gerontology, Emory University School of Medicine, Atlanta, GA
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, GA
| | - Christina Offutt
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Molly M Perkins
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Mohammed K Ali
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
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Saharkhiz M, Rao T, Parker-Lue S, Borelli S, Johnson K, Cataife G. Telehealth Expansion and Medicare Beneficiaries' Care Quality and Access. JAMA Netw Open 2024; 7:e2411006. [PMID: 38739388 DOI: 10.1001/jamanetworkopen.2024.11006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Importance Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems. Objective To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use. Design, Setting, and Participants This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B. Exposures Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries. Main Outcomes and Measures The primary outcomes were quality (ambulatory care-sensitive [ACS] hospitalizations and emergency department [ED] visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis. Results In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean [SD] age in 2019, 71.04 [1.67] years; mean [SD] percentage female in 2019, 53.83% [2.14%]) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1.63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1.03-2.22 hospitalizations), more clinician encounters (0.30 additional encounters per beneficiary per semester; 95% CI, 0.23-0.38 encounters), and higher total cost of care ($164.99 higher cost per beneficiary per semester; 95% CI, $101.03-$228.96). There was no statistically significant difference in ACS ED visits between the low and high groups. Conclusions and Relevance In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.
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Affiliation(s)
| | - Tanvi Rao
- American Institutes for Research, Arlington, Virginia
| | | | - Sara Borelli
- American Institutes for Research, Arlington, Virginia
| | - Karin Johnson
- American Institutes for Research, Arlington, Virginia
| | - Guido Cataife
- American Institutes for Research, Arlington, Virginia
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Blue L, Kranker K, Markovitz AR, Powell RE, Williams MV, Pu J, Magid DJ, McCall N, Steiner A, Stewart KA, Rollison JM, Markovich P, Peterson GG. Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial. JAMA 2023; 330:1437-1447. [PMID: 37847273 PMCID: PMC10582785 DOI: 10.1001/jama.2023.19597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/12/2023] [Indexed: 10/18/2023]
Abstract
Importance The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. Objective To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. Design, Setting, and Participants This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Intervention Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Main Outcomes and Measures Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. Results High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). Conclusions and Relevance The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. Trial Registration ClinicalTrials.gov Identifier: NCT04047147.
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Affiliation(s)
| | | | | | - Rhea E. Powell
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Jia Pu
- Mathematica, Oakland, California
| | | | | | | | | | | | - Patricia Markovich
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
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Harris E. Oral Health Worsened, Visits Decreased in Medicare Beneficiaries. JAMA 2023; 329:789. [PMID: 36811931 DOI: 10.1001/jama.2023.2096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Abstract
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.
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Affiliation(s)
- Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Xuanzi Qin
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston Massachusetts
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Mafi JN, Craff M, Vangala S, Pu T, Skinner D, Tabatabai-Yazdi C, Nelson A, Reid R, Agniel D, Tseng CH, Sarkisian C, Damberg CL, Kahn KL. Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021. JAMA 2022; 327:237-247. [PMID: 35040886 PMCID: PMC8767442 DOI: 10.1001/jama.2021.24294] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 12/19/2021] [Indexed: 01/24/2023]
Abstract
Importance Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.
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Affiliation(s)
- John N. Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- RAND Health, RAND Corporation, Santa Monica, California
| | | | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Thomas Pu
- Milliman MedInsight, Seattle, Washington
| | | | | | | | - Rachel Reid
- RAND Health, RAND Corporation, Santa Monica, California
- Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Denis Agniel
- RAND Health, RAND Corporation, Santa Monica, California
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Catherine Sarkisian
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | | | - Katherine L. Kahn
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- RAND Health, RAND Corporation, Santa Monica, California
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Lavergne MR, King C, Peterson S, Simon L, Hudon C, Loignon C, McCracken RK, Brackett A, McGrail K, Strumpf E. Patient characteristics associated with enrolment under voluntary programs implemented within fee-for-service systems in British Columbia and Quebec: a cross-sectional study. CMAJ Open 2022; 10:E64-E73. [PMID: 35105683 PMCID: PMC8812717 DOI: 10.9778/cmajo.20210043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is a paucity of information on patient characteristics associated with enrolment under voluntary programs (e.g. incentive payments) implemented within fee-for-service systems. We explored patient characteristics associated with enrolment under these programs in British Columbia and Quebec. METHODS We used linked administrative data and a cross-sectional design to compare people aged 40 years or more enrolled under voluntary programs to those who were eligible but not enrolled. We examined 2 programs in Quebec (enrolment of vulnerable patients with qualifying conditions [implemented in 2003] and enrolment of the general population [2009]) and 3 in BC (Chronic disease incentive [2003], Complex care incentive [2007] and enrolment of the general population [A GP for Me, 2013]). We used logistic regression to estimate the odds of enrolment by neighbourhood income, rural versus urban residence, previous treatment for mental illness, previous treatment for substance use disorder and use of health care services before program implementation, controlling for characteristics linked to program eligibility. RESULTS In Quebec, we identified 1 569 010 people eligible for the vulnerable enrolment program (of whom 505 869 [32.2%] were enrolled within the first 2 yr of program implementation) and 2 394 923 for the general enrolment program (of whom 352 380 [14.7%] were enrolled within the first 2 yr). In BC, we identified 133 589 people eligible for the Chronic disease incentive, 47 619 for the Complex care incentive and 1 349 428 for A GP for Me; of these, 60 764 (45.5%), 28 273 (59.4%) and 1 066 714 (79.0%), respectively, were enrolled within the first 2 years. The odds of enrolment were higher in higher-income neighbourhoods for programs without enrolment criteria (adjusted odds ratio [OR] comparing highest to lowest quintiles 1.21 [95% confidence interval (CI) 1.20-1.23] in Quebec and 1.67 [95% CI 1.64-1.69] in BC) but were similar across neighbourhood income quintiles for programs with health-related eligibility criteria. The odds of enrolment by urban versus rural location varied by program. People treated for substance use disorders had lower odds of enrolment in all programs (adjusted OR 0.60-0.72). Compared to people eligible but not enrolled, those enrolled had similar or higher numbers of primary care visits and longitudinal continuity of care in the year before enrolment. INTERPRETATION People living in lower-income neighbourhoods and those treated for substance use disorders were less likely than people in higher-income neighbourhoods and those not treated for such disorders to be enrolled in programs without health-related eligibility criteria. Other strategies are needed to promote equitable access to primary care.
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Affiliation(s)
- M Ruth Lavergne
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que.
| | - Caroline King
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Sandra Peterson
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Leora Simon
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Catherine Hudon
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Christine Loignon
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Rita K McCracken
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Austyn Brackett
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Kim McGrail
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Erin Strumpf
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
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Abstract
This study uses Medicare data to assess physician practice interruptions during the 2019-2020 period of the COVID-19 pandemic and provides preliminary evidence on whether those interruptions suggest early retirements or exit from medical practice.
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Affiliation(s)
- Hannah T. Neprash
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Michael E. Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Sood N, Shier V, Huckfeldt PJ, Weissblum L, Escarce JJ. The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities. Health Serv Res 2021; 56:828-838. [PMID: 33969480 PMCID: PMC8522568 DOI: 10.1111/1475-6773.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.
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Affiliation(s)
- Neeraj Sood
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Victoria Shier
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Peter J. Huckfeldt
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | | | - José J. Escarce
- David Geffen School of Medicine at UCLACaliforniaLos AngelesUSA
- UCLA Fielding School of Public Health, Los AngelesCaliforniaUSA
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Ma Q, Sridhar G, Power T, Agiro A. Assessing the downstream value of first-line cardiac positron emission tomography (PET) imaging using real world Medicare fee-for-service claims data. J Nucl Cardiol 2021; 28:2126-2137. [PMID: 31820411 DOI: 10.1007/s12350-019-01974-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/19/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Higher imaging quality makes cardiac positron emission tomography (PET) desirable for evaluation of suspected coronary artery disease (CAD). High cost of PET imaging may be offset by reduced utilization and/or improved outcomes. METHODS This retrospective observational study utilized Medicare fee-for-service dataset. Study participants had no CAD diagnosis within 1 year prior to initial imaging. The PET group (PET imaging) and propensity score matched comparison group (single photon emission computed tomography or stress echocardiography) underwent index imaging between January 2014 and December 2016. Outcomes were analyzed using generalized linear models. RESULTS Among 144,503 study subjects, 4619 (3.2%) had PET and 139,884 (96.8%) had conventional imaging. After matching, each group had 4619 patients (mean age 74 years, 59% female). The PET group had lower radiation exposure (3.8 milliSievert less per year, 95% CI - 3.96 to - 3.64, P < .0001) and unstable coronary syndrome (incidence rate ratio (IRR) 0.77, 95% CI 0.64-0.94, P = .008). The PET group experienced more hospital admissions (IRR 1.10, 95% CI 1.06-1.15, P < .0001), more use of percutaneous coronary intervention (IRR 1.24, 95% CI 1.02-1.50, P = 0.03), while similar mortality rate (hazard ratio 0.95, 95% CI 0.78-1.14, P = 0.55). The PET group had higher medical spending ($2358.2 vs $1774.3, difference = $583.9 per patient per month, P < .0001). CONCLUSIONS First-line PET imaging was not associated with reduced levels of utilization and spending. Clinical outcomes were mostly similar.
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Affiliation(s)
- Qinli Ma
- HealthCore Inc., 123 Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA.
| | - Gayathri Sridhar
- HealthCore Inc., 123 Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA
| | | | - Abiy Agiro
- HealthCore Inc., 123 Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA
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Ogundeji Y, Clement F, Wellstead D, Farkas B, Manns B. Primary care physicians' perceptions of the role of alternative payment models in recruitment and retention in rural Alberta: a qualitative study. CMAJ Open 2021; 9:E788-E794. [PMID: 34285058 PMCID: PMC8313092 DOI: 10.9778/cmajo.20200202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite well-documented challenges in recruiting physicians to rural practice, few Canadian studies have described the role physician payment models may play in attracting and retaining physicians to rural practice. This study examined the perspectives of rural primary care physicians on the factors that attract and retain physicians in rural locations, including the role that alternative payment models (APMs) might play. METHODS This was a qualitative study involving in-depth, open-ended interviews with rural primary care physicians practising under fee-for-service (FFS) models and APMs in Alberta, Canada. Participants were recruited from the Rural Health Professions Action Plan member list (consisting of physicians practising in rural or remote locations in Alberta) and the College of Physicians and Surgeons of Alberta online database. Interviews were conducted April to June 2020, and data were analyzed using a thematic framework approach. RESULTS Fourteen physicians were interviewed. There were 5 themes identified: factors that attract physicians to rural practice, barriers and challenges associated with rural practice, the potential role of APMs in recruitment and retention, factors that physicians consider in deciding to change payment models, and physician perceptions of APMs compared with FFS models. Participants expressed that APMs may have some role to play in retaining rural physicians but identified professional challenges, and family-related and personal factors as key determinants. Most FFS physicians indicated that they were interested in exploring APMs provided specific concerns were addressed (e.g., clear and adequately compensated APM contracts, and physician involvement in the development of APMs). INTERPRETATION Primary care physicians practising in rural regions in Alberta view payment models as one consideration among many in their decision to pursue rural practice. Alternative payment model contracts designed with the input of physicians may have a role to play in attracting and retaining physicians to rural practice.
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Affiliation(s)
- Yewande Ogundeji
- Departments of Community Health Sciences (Ogundeji, Clement, Wellstead, Farkas, Manns) and Medicine (Clement, Manns), University of Calgary, Calgary, Alta.
| | - Fiona Clement
- Departments of Community Health Sciences (Ogundeji, Clement, Wellstead, Farkas, Manns) and Medicine (Clement, Manns), University of Calgary, Calgary, Alta
| | - Darryn Wellstead
- Departments of Community Health Sciences (Ogundeji, Clement, Wellstead, Farkas, Manns) and Medicine (Clement, Manns), University of Calgary, Calgary, Alta
| | - Brenlea Farkas
- Departments of Community Health Sciences (Ogundeji, Clement, Wellstead, Farkas, Manns) and Medicine (Clement, Manns), University of Calgary, Calgary, Alta
| | - Braden Manns
- Departments of Community Health Sciences (Ogundeji, Clement, Wellstead, Farkas, Manns) and Medicine (Clement, Manns), University of Calgary, Calgary, Alta.
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Malik AT, Khan SN, Voskuil RT, Alexander JH, Drain JP, Scharschmidt TJ. What Is the Value of Undergoing Surgery for Spinal Metastases at Dedicated Cancer Centers? Clin Orthop Relat Res 2021; 479:1311-1319. [PMID: 33543875 PMCID: PMC8133242 DOI: 10.1097/corr.0000000000001640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/17/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases. QUESTION/PURPOSE Is there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals? METHODS The 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs. RESULTS After adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001). CONCLUSION Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Azeem Tariq Malik
- A. T. Malik, S. N. Khan, R. T. Voskuil, J. H. Alexander, J. P. Drain, T. J. Scharschmidt, Department of Orthopaedics, the James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N. Khan
- A. T. Malik, S. N. Khan, R. T. Voskuil, J. H. Alexander, J. P. Drain, T. J. Scharschmidt, Department of Orthopaedics, the James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ryan T. Voskuil
- A. T. Malik, S. N. Khan, R. T. Voskuil, J. H. Alexander, J. P. Drain, T. J. Scharschmidt, Department of Orthopaedics, the James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John H. Alexander
- A. T. Malik, S. N. Khan, R. T. Voskuil, J. H. Alexander, J. P. Drain, T. J. Scharschmidt, Department of Orthopaedics, the James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph P. Drain
- A. T. Malik, S. N. Khan, R. T. Voskuil, J. H. Alexander, J. P. Drain, T. J. Scharschmidt, Department of Orthopaedics, the James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas J. Scharschmidt
- A. T. Malik, S. N. Khan, R. T. Voskuil, J. H. Alexander, J. P. Drain, T. J. Scharschmidt, Department of Orthopaedics, the James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
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Banks J, Hill C, Chi DL. Plan Type and Opioid Prescriptions for Children in Medicaid. Med Care 2021; 59:386-392. [PMID: 33528236 PMCID: PMC8026560 DOI: 10.1097/mlr.0000000000001504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioids are generally an inappropriate acute pain management strategy in children, particularly because of the risk for diversion and subsequent misuse and abuse. OBJECTIVES To examine associations between Medicaid plan type [coordinated care organization (CCO), managed care (MC), fee-for-service (FFS)] and whether a child received an opioid prescription. RESEARCH DESIGN Secondary analysis of Oregon Medicaid data (January 1, 2016 to December 31, 2017). SUBJECTS Medicaid-enrolled children ages 0-17 (N=200,169). MEASURES There were 2 outcomes: whether a child received an opioid prescription from (a) any health provider or (b) from a visit to the dentist. Predictor variables included Medicaid plan type, age, sex, race, and ethnicity. RESULTS About 6.7% of children received an opioid from any health provider and 1.2% received an opioid from a dentist visit. Children in a CCO were significantly more likely than children in a MC (P<0.01) or FFS (P=0.02) plan to receive an opioid from any health provider. Children in a CCO were also significantly more likely than children in MC or FFS to receive an opioid from a dentist visit (P<0.01). CONCLUSIONS Pediatric opioid prescriptions vary by plan type. Future efforts should identify reasons why Medicaid-enrolled children in a CCO plan are more likely to be prescribed opioids.
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Affiliation(s)
- Jordan Banks
- Department of Oral Health Sciences, University of Washington, Seattle, WA
| | - Courtney Hill
- Department of Oral Health Sciences, University of Washington, Seattle, WA
| | - Donald L. Chi
- Department of Oral Health Sciences, University of Washington, Seattle, WA
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Keohane LM, Thomas KS, Rahman M, Trivedi AN. Mandated Copayment Reductions in Medicare Advantage: Effects on Skilled Nursing Care, Hospitalizations, and Plan Exit. Med Care 2021; 59:259-265. [PMID: 33560765 PMCID: PMC7880533 DOI: 10.1097/mlr.0000000000001495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To address concerns that postacute cost-sharing may deter high-need beneficiaries from participating in Medicare Advantage (MA) plans, the Centers for Medicare and Medicaid Services have capped cost-sharing for skilled nursing facility (SNF) services in MA plans since 2011. This study examines whether SNF use, inpatient use, and plan disenrollment changed following stricter regulations in 2015 that required most MA plans to eliminate or substantially reduce cost-sharing for SNF care. DESIGN Difference-in-differences retrospective analysis from 2013 to 2016. SETTING MA plans. PARTICIPANTS Thirty-one million MA members in 320 plans with mandatory cost-sharing reductions and 261 plans without such reductions. MEASUREMENTS Mean monthly number of SNF admissions, SNF days, hospitalizations, and plan disenrollees per 1000 members. RESULTS Mean total cost-sharing for the first 20 days of SNF services decreased from $911 to $104 in affected plans. Relative to concurrent changes in plans without mandated cost-sharing reductions, plans with mandatory cost-sharing reductions experienced no significant differences in the number of SNF days per 1000 members (adjusted between-group difference: 0.4 days per 1000 members [95% confidence interval (95% CI), -5.2 to 6.0, P=0.89], small decreases in the number of hospitalizations per 1000 members [adjusted between-group difference: 0.6 admissions per 1000 members (95% CI, -1.0 to -0.1; P=0.03)], and small decreases in the number of SNF users who disenrolled at year-end [adjusted between-group difference: -16.8 disenrollees per 1000 members (95% CI, -31.9 to -1.8; P=0.03)]. CONCLUSIONS Mandated reductions in SNF cost-sharing may have curbed selective disenrollment from MA plans without significantly increasing use of SNF services.
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Affiliation(s)
- Laura M. Keohane
- Department of Health Policy, Vanderbilt University School of Medicine
| | - Kali S. Thomas
- Department of Health Services, Policy and Practice, Brown University School of Public Health
- Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, RI
| | - Momotazur Rahman
- Department of Health Services, Policy and Practice, Brown University School of Public Health
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, Brown University School of Public Health
- Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, RI
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Frean M, Covington C, Tietschert M, Bahadurzada H, So J, Singer SJ. Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service. Med Care 2021; 59:195-201. [PMID: 33273291 DOI: 10.1097/mlr.0000000000001463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare. OBJECTIVE To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries. DESIGN Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey. SUBJECTS Nationally representative sample of 11,978 Medicare beneficiaries. MEASURES Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4. RESULTS The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA. CONCLUSIONS Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.
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Affiliation(s)
- Molly Frean
- Wharton School, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Jodi So
- Stanford University School of Medicine, Stanford, CA
| | - Sara J Singer
- Stanford University School of Medicine, Stanford, CA
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Li R, Kuklina EV, Ailes EC, Shrestha SS, Grosse SD, Fang J, Wang G, Leung J, Barfield WD, Cox S. Medical expenditures for hypertensive disorders during pregnancy that resulted in a live birth among privately insured women. Pregnancy Hypertens 2021; 23:155-162. [PMID: 33418425 PMCID: PMC10423979 DOI: 10.1016/j.preghy.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/17/2020] [Accepted: 12/08/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To estimate the excess maternal health services utilization and direct maternal medical expenditures associated with hypertensive disorders during pregnancy and one year postpartum among women with private insurance in the United States. STUDY DESIGN We used 2008-2014 IBM MarketScan® Commercial Databases to identify women aged 15-44 who had a pregnancy resulting in live birth during 1/1/09-12/31/13 and were continuously enrolled with non-capitated or partially capitated coverage from 12 months before pregnancy through 12 months after delivery. Hypertensive disorders identified by diagnosis codes were categorized into three mutually exclusive types: preeclampsia and eclampsia, chronic hypertension, and gestational hypertension. Multivariate negative binomial and generalized linear models were used to estimate service utilization and expenditures, respectively. MAIN OUTCOME MEASURES Per person excess health services utilization and medical expenditures during pregnancy and one year postpartum associated with hypertensive disorders (in 2014 US dollars). RESULTS Women with preeclampsia and eclampsia, chronic hypertension, and gestational hypertension had $9,389, $6,041, and $2,237 higher mean medical expenditures compared to women without hypertensive disorders ($20,252), respectively (ps < 0.001). One-third (36%) of excess expenditure associated with hypertensive disorders during pregnancy was attributable to outpatient services. CONCLUSIONS Hypertensive disorders during pregnancy were associated with significantly higher health services utilization and medical expenditures among privately insured women with hypertensive disorders. Medical expenditures varied by types of hypertensive disorders. Stakeholders can use this information to assess the potential economic benefits of interventions that prevent these conditions or their complications.
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Affiliation(s)
- Rui Li
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States.
| | - Elena V Kuklina
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Elizabeth C Ailes
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, United States
| | - Sundar S Shrestha
- Office on Smoking Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA, United States
| | - Scott D Grosse
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, United States
| | - Jing Fang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA, United States
| | - Guijing Wang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA, United States
| | - Jessica Leung
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, GA, United States
| | - Wanda D Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
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Abstract
BACKGROUND Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.
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Affiliation(s)
- Liying Jia
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
- NHC Key Lab for Health Economics and Policy Research, Shandong University, Jinan, China
| | - Qingyue Meng
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Carlton, Melbourne, Australia
| | - Beibei Yuan
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Lu Zhang
- Weihai Health Care Security Administration, Weihai, China
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Colla C, Yang W, Mainor AJ, Meara E, Ouayogode MH, Lewis VA, Shortell S, Fisher E. Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries. Health Serv Res 2020; 55 Suppl 3:1085-1097. [PMID: 33104254 PMCID: PMC7720705 DOI: 10.1111/1475-6773.13580] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. DATA SOURCES Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. STUDY DESIGN Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. DATA COLLECTION/EXTRACTION METHODS 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions). PRINCIPAL FINDINGS Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]). CONCLUSIONS Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.
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Affiliation(s)
- Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
| | - Wendy Yang
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
| | - Alexander J. Mainor
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
| | - Ellen Meara
- Department of Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusettsUSA
| | - Marietou H. Ouayogode
- Department of Population Health SciencesUniversity of Wisconsin MadisonMadisonWisconsinUSA
| | - Valerie A. Lewis
- Department of Health Policy and ManagementGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Elliott Fisher
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
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Mack DS, Baek J, Tjia J, Lapane KL. Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at Admission. J Am Geriatr Soc 2020; 68:2787-2796. [PMID: 33270223 PMCID: PMC8127623 DOI: 10.1111/jgs.16777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness. DESIGN Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files. SETTING U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092). PARTICIPANTS Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247). MEASUREMENTS Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission. RESULTS Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status. CONCLUSION Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.
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Affiliation(s)
- Deborah S Mack
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jonggyu Baek
- Division of Biostatistics and Health Services Research, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Ibrahim AM, Nuliyalu U, Lawton EJ, O’Neil S, Dimick JB, Gulseren B, Sinha SS, Hollingsworth JM, Engler TA, Ryan AM. Evaluation of US Hospital Episode Spending for Acute Inpatient Conditions After the Patient Protection and Affordable Care Act. JAMA Netw Open 2020; 3:e2023926. [PMID: 33226430 PMCID: PMC7684450 DOI: 10.1001/jamanetworkopen.2020.23926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Under the Patient Protection and Affordable Care Act (ACA), US hospitals were exposed to a number of reforms intended to reduce spending, many of which, beginning in 2012, targeted acute care hospitals and often focused on specific diagnoses (eg, acute myocardial infarction, heart failure, and pneumonia) for Medicare patients. Other provisions enacted in the ACA and under budget sequestration (beginning in 2013) mandated Medicare fee cuts. OBJECTIVE To evaluate the association between the enactment of ACA reforms and 30-day price-standardized hospital episode spending. DESIGN, SETTING, AND PARTICIPANTS This policy evaluation included index discharges between January 1, 2008, and August 31, 2015, from a national random 20% sample of Medicare beneficiaries. Data analysis was performed from February 1, 2019 to July 8, 2020. EXPOSURE Payment reforms after passage of the ACA. MAIN OUTCOMES AND MEASURES 30-day price-standardized episode payments. Three alternative estimation approaches were used to evaluate the association between reforms following the ACA and episode spending: (1) a difference-in-difference (DID) analysis among acute care hospitals, comparing spending for diagnoses commonly targeted by ACA programs with nontargeted diagnoses; (2) a DID analysis comparing acute care hospitals and critical access hospitals (not exposed to reforms); and (3) a generalized synthetic control analysis, comparing acute care and critical access hospitals. Supplemental analysis examined the degree to which Medicare fee cuts contributed to spending reductions. RESULTS A total of 7 634 242 index discharges (4 525 630 [59.2%] female patients; mean [SD] age, 79.31 [8.02] years) were included. All 3 approaches found that reforms following the ACA were associated with a significant reduction in episode spending. The DID estimate comparing targeted and untargeted diagnoses suggested that reforms following the ACA were associated with a -$431 (95% CI, -$492 to -$369; -2.87%) change in total spending, while the generalized synthetic control analysis suggested that reforms were associated with a -$1232 (95% CI, -$1488 to -$965; -10.12%) change in total episode spending, amounting in a total annual savings of $5.68 billion. Cuts to Medicare fees accounted for most of these savings. CONCLUSIONS AND RELEVANCE In this policy evaluation, the ACA was associated with large reductions in US hospital episode spending.
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Affiliation(s)
- Andrew M. Ibrahim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ushapoorna Nuliyalu
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | | | - Justin B. Dimick
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Baris Gulseren
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Shashank S. Sinha
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Tedi A. Engler
- School of Public Health, University of Michigan, Ann Arbor
| | - Andrew M. Ryan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
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21
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Park S, Larson EB, Fishman P, White L, Coe NB. Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare. Med Care 2020; 58:1004-1012. [PMID: 32925471 PMCID: PMC7572707 DOI: 10.1097/mlr.0000000000001390] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to determine differences in health care utilization, process of diabetes care, care satisfaction, and health status for Medicare Advantage (MA) and traditional Medicare (TM) beneficiaries with and without diabetes. METHODS Using the 2010-2016 Medicare Current Beneficiary Survey, we identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, we used an instrumental variable approach. Using marginal effects, we estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes. RESULTS Our instrumental variable analysis showed that compared with TM beneficiaries with diabetes, MA beneficiaries with diabetes had less annual health care utilization, including -22.4 medical provider visits [95% confidence interval (CI): -23.6 to -21.1] and -3.4 outpatient hospital visits (95% CI: -3.8 to -3.0). A significant difference between MA and TM beneficiaries without diabetes was only observed in medical provider visits and the difference was greater among beneficiaries with diabetes than beneficiaries without diabetes (-12.5 medical provider visits; 95% CI: -15.9 to -9.2). While we did not detect significant differences in 5 measures of the process of diabetes care between MA and TM beneficiaries with diabetes, there were inconsistent results in the other 3 measures. There were no or marginal differences in care satisfaction and health status between MA and TM beneficiaries with and without diabetes. CONCLUSIONS MA enrollment was associated with lower health care utilization without compromising care satisfaction and health status, particularly for beneficiaries with diabetes. MA may have a more efficient care delivery system for beneficiaries with diabetes.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington
| | | | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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McDonald T, Lethebe BC, Green LA. Calculating physician supply using a service day method and the income percentiles method: a descriptive analysis. CMAJ Open 2020; 8:E747-E753. [PMID: 33234581 PMCID: PMC7721248 DOI: 10.9778/cmajo.20200037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND It is important to have an accurate count of physicians and a measurable understanding of their service provision for physician resource planning. Our objective was to compare 2 methods (income percentiles [IP] and service day activities [SVD]) for calculating the supply of full-time (FT) and part-time (PT) primary care physicians (PCPs) as measures of both physician supply counts and level of provider continuity. METHODS Using an observational study design, we compared 2 methods of calculating the supply of PT and FT PCPs for 2011-2015. For the IP approach, the Canadian Institute for Health Information's method was applied to Alberta Health billing data. The SVD method calculated annual service days for fee-for-service PCPs. A simple descriptive analysis was conducted of the supply of PT and FT PCPs. RESULTS The 2 methods agreed on the FT versus PT status of 85.2% of PCPs in 2015 but disagreed on the status of 490 PCPs. A total of 239 PCPs were classified as working FT by the IP method but PT by the SVD method. Two hundred and fifty-one PCPs were classified as working PT according by the IP method but FT by the SVD method. The former group of 239 PCPs worked fewer days per week (3.22 v. 4.1) and fewer weekend days per year (8.6 v. 24.1), billed more per year ($300 327 v. $201 834) and saw more patients per day (26.8 v. 17.8) with less continuity of care (38.0% v. 72.0%) than the latter group of 251 PCPs. INTERPRETATION The SVD method provides a valid alternative to calculating GP supply that distinguishes groups of physicians that the standard IP methodology does not. Those groups provide very different service; policy-makers may benefit from distinguishing them.
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Affiliation(s)
- Terrence McDonald
- Department of Family Medicine (McDonald), and Clinical Research Unit (Lethebe), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Medicine (Green), University of Alberta, Edmonton, Alta.
| | - Brendan Cord Lethebe
- Department of Family Medicine (McDonald), and Clinical Research Unit (Lethebe), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Medicine (Green), University of Alberta, Edmonton, Alta
| | - Lee A Green
- Department of Family Medicine (McDonald), and Clinical Research Unit (Lethebe), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Medicine (Green), University of Alberta, Edmonton, Alta
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Domino ME, Norton EC, Yoon J, Cuddeback GS, Morrissey JP. Putting Providers At-Risk through Capitation or Shared Savings: How Strong are Incentives for Upcoding and Treatment Changes? J Ment Health Policy Econ 2020; 23:81-91. [PMID: 32853157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/17/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.
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Affiliation(s)
- Marisa Elena Domino
- Department of Health Policy and Management and Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC 27599-7411, USA,
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Toth M, Moore P, Tant E, Rutledge R, Beil H, Arbes S, West N, West SL. Early impact of the implementation of Medicaid episode-based payment reforms in Arkansas. Health Serv Res 2020; 55:556-567. [PMID: 32438480 PMCID: PMC7376005 DOI: 10.1111/1475-6773.13296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate episode-based payments for upper respiratory tract infections (URI) and perinatal care in Arkansas's Medicaid population. STUDY SETTING Upper respiratory infection and perinatal episodes among Medicaid-covered individuals in Arkansas and comparison states from fiscal year (FY) 2011 to 2014. STUDY DESIGN Cross-sectional observational analysis using a difference-in-difference design to examine outcomes associated with URI and perinatal episodes of care (EOC) from 2011 to 2014. Key dependent variables include antibiotic use, emergency department visits, physician visits, hospitalizations, readmission, and preventive screenings. DATA COLLECTION Claims data from the Medicaid Analytic Extract for Arkansas, Mississippi, and Missouri from 2010 to 2014 with supplemental county-level data from the Area Health Resource File (AHRF). PRINCIPAL FINDINGS The URI EOC reduced the probability of antibiotic use (marginal effect [ME] = -1.8, 90% CI: -2.2, -1.4), physician visits (ME = 0.6, 90% CI: -0.8, -0.4), improved the probability of strep tests for children diagnosed with pharyngitis (ME = 9.4, 90% CI: 8.5, 10.3), but also increased the probability of an emergency department (ED) visit (ME = 0.1, 90% CI: 0.1, 0.2), relative to the comparison group. For perinatal EOCs, we found a reduced probability of an ED visit during pregnancy (ME = 0.1, 90% CI: -0.2, -0.0), an increased probability of screening for HIV (ME = 6.2, 90% CI: 4.0, 8.5), chlamydia (ME = 9.5, 90% CI: 7.2, 11.8), and group B strep-test (ME = 2.6, 90% CI: 0.5, 4.6), relative to the comparison group. Predelivery and postpartum hospitalizations also increased (ME = 1.2, 90% CI: 0.4, 2.0; ME = 0.4, 90% CI: 0.0, 0.8, respectively), relative to the comparison group. CONCLUSION Upper respiratory infection and perinatal EOCs for Arkansas Medicaid beneficiaries produced mixed results. Aligning shared savings with quality metrics and cost-thresholds may help achieve quality targets and disincentivize over utilization within the EOC, but may also have unintended consequences.
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Affiliation(s)
- Matt Toth
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Paul Moore
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Elizabeth Tant
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | | | - Heather Beil
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Sam Arbes
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Nathan West
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
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Lo-Ciganic WH, Huang JL, Zhang HH, Weiss JC, Kwoh CK, Donohue JM, Gordon AJ, Cochran G, Malone DC, Kuza CC, Gellad WF. Using machine learning to predict risk of incident opioid use disorder among fee-for-service Medicare beneficiaries: A prognostic study. PLoS One 2020; 15:e0235981. [PMID: 32678860 PMCID: PMC7367453 DOI: 10.1371/journal.pone.0235981] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/25/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To develop and validate a machine-learning algorithm to improve prediction of incident OUD diagnosis among Medicare beneficiaries with ≥1 opioid prescriptions. METHODS This prognostic study included 361,527 fee-for-service Medicare beneficiaries, without cancer, filling ≥1 opioid prescriptions from 2011-2016. We randomly divided beneficiaries into training, testing, and validation samples. We measured 269 potential predictors including socio-demographics, health status, patterns of opioid use, and provider-level and regional-level factors in 3-month periods, starting from three months before initiating opioids until development of OUD, loss of follow-up or end of 2016. The primary outcome was a recorded OUD diagnosis or initiating methadone or buprenorphine for OUD as proxy of incident OUD. We applied elastic net, random forests, gradient boosting machine, and deep neural network to predict OUD in the subsequent three months. We assessed prediction performance using C-statistics and other metrics (e.g., number needed to evaluate to identify an individual with OUD [NNE]). Beneficiaries were stratified into subgroups by risk-score decile. RESULTS The training (n = 120,474), testing (n = 120,556), and validation (n = 120,497) samples had similar characteristics (age ≥65 years = 81.1%; female = 61.3%; white = 83.5%; with disability eligibility = 25.5%; 1.5% had incident OUD). In the validation sample, the four approaches had similar prediction performances (C-statistic ranged from 0.874 to 0.882); elastic net required the fewest predictors (n = 48). Using the elastic net algorithm, individuals in the top decile of risk (15.8% [n = 19,047] of validation cohort) had a positive predictive value of 0.96%, negative predictive value of 99.7%, and NNE of 104. Nearly 70% of individuals with incident OUD were in the top two deciles (n = 37,078), having highest incident OUD (36 to 301 per 10,000 beneficiaries). Individuals in the bottom eight deciles (n = 83,419) had minimal incident OUD (3 to 28 per 10,000). CONCLUSIONS Machine-learning algorithms improve risk prediction and risk stratification of incident OUD in Medicare beneficiaries.
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Affiliation(s)
- Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - James L. Huang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Hao H. Zhang
- Department of Mathematics, University of Arizona, Tucson, Arizona, United States of America
| | - Jeremy C. Weiss
- Carnegie Mellon University, Heinz College, Pittsburgh, Pennsylvania, United States of America
| | - C. Kent Kwoh
- Division of Rheumatology, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
- The University of Arizona Arthritis Center, University of Arizona, Tucson, Arizona, United States of America
| | - Julie M. Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Adam J. Gordon
- Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, University of Utah, Salt Lake City, Utah, United States of America
- Informatics, Decision-Enhancement, and Analytic Sciences Center, Salt Lake City VA Health Care System, Salt Lake City, Utah, United States of America
| | - Gerald Cochran
- Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, University of Utah, Salt Lake City, Utah, United States of America
| | - Daniel C. Malone
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, United States of America
| | - Courtney C. Kuza
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Walid F. Gellad
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United Sates of America
- Center for Health Equity Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
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Abstract
IMPORTANCE Rates of total knee arthroplasty vary widely across the United States. Whether this variation is associated with differences in patient characteristics or physician practice is unknown. OBJECTIVES To determine regional variations in rates of total knee arthroplasty after accounting for the prevalence of knee arthritis and other potentially associated patient risk factors and to assess the correlation of these variations with measures of access to care and surgical indications. DESIGN, SETTING, AND PARTICIPANTS This retrospective national cohort study used Medicare data on more than 24 million deidentified beneficiaries annually from 2011 to 2015. Individuals included had fee-for-service coverage, were 65 to 89 years of age, and resided in 1 of 306 health referral regions. Data were analyzed from September 13, 2018, to August 15, 2019. MAIN OUTCOMES AND MEASURES Rate of primary total knee arthroplasty indexed to the national rate using observed to expected ratios. The expected numbers of arthroplasty procedures were derived from estimates based on beneficiaries' demographic and clinical characteristics. Observed to expected ratios were confounded by race/ethnicity; thus race/ethnicity-stratified analyses were conducted. RESULTS In 2011, there were 218 282 total knee arthroplasty procedures among 24 583 706 white Medicare beneficiaries (mean [SD] age 74.2 [6.9] years; 54.6% women). The rate of arthroplasty during the study period (5 years) was 9.3 per 1000 person-years. Adjustment for clinical characteristics reduced the spread in observed to expected ratios among regions by 29% compared with adjustment for age and sex alone. However, substantial variation remained, with observed to expected ratios that ranged from 0.61 in Newark, New Jersey, to 1.82 in Idaho Falls, Idaho. High ratios were primarily present in the upper Midwest, Great Plains, and Mountain West regions. Higher ratios were associated with regions where beneficiaries had fewer outpatient visits (Spearman correlation [r], -0.64; 95% CI, -0.70 to -0.56) and with regions having more surgeons per capita who performed knee arthroplasty (r = 0.27; 95% CI, 0.16-0.37). Higher ratios were associated with higher rates of arthroplasty procedures among beneficiaries with dementia (r = 0.36; 95% CI, 0.25-0.46), peripheral vascular disease (r = 0.52; 95% CI, 0.42-0.61), and skin ulcers (r = 0.43; 95% CI, 0.32-0.53), which are relative contraindications to arthroplasty. CONCLUSIONS AND RELEVANCE Substantial regional variation in rates of total knee arthroplasty remained after adjustment for patient characteristics. Coexistence of high observed to expected ratios and high rates among patients at greater surgical risk suggested overuse of knee arthroplasty in some regions.
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Affiliation(s)
- Michael M. Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Abhijit Dasgupta
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
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Reich AJ, Jin G, Gupta A, Kim D, Lipstiz S, Prigerson HG, Tjia J, Ladin K, Halpern SD, Cooper Z, Weissman JS. Utilization of ACP CPT codes among high-need Medicare beneficiaries in 2017: A brief report. PLoS One 2020; 15:e0228553. [PMID: 32023311 PMCID: PMC7001931 DOI: 10.1371/journal.pone.0228553] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/17/2020] [Indexed: 01/03/2023] Open
Abstract
Importance Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service. Objective To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population. Design Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries. Setting Nationally representative FFS Medicare 20% sample Participants Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016–2017. Exposure Receipt of a billed ACP discussion, CPT codes 99497 or 99498. Main outcome and measure Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region. Results Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs). Conclusions and relevance While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant.
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Affiliation(s)
- Amanda J. Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
- * E-mail:
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Avni Gupta
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Health Policy, College of Global Public Health, New York University, New York, NY, United States of America
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States of America
| | - Stuart Lipstiz
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Holly G. Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY, United States of America
| | - Jennifer Tjia
- Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Keren Ladin
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
- Research on Ethics, Aging, and Community Health (REACH), Tufts University, Boston, MA, United States of America
| | - Scott D. Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, United States of America
- The Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America
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Weissman GE, Kerlin MP, Yuan Y, Kohn R, Anesi GL, Groeneveld PW, Werner RM, Halpern SD. Potentially Preventable Intensive Care Unit Admissions in the United States, 2006-2015. Ann Am Thorac Soc 2020; 17:81-88. [PMID: 31581801 PMCID: PMC6944341 DOI: 10.1513/annalsats.201905-366oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/24/2019] [Indexed: 11/20/2022] Open
Abstract
Rationale: Increasing intensive care unit (ICU) beds and the critical care workforce are often advocated to address an aging and increasingly medically complex population. However, reducing potentially preventable ICU stays may be an alternative to ensure adequate capacity.Objectives: To determine the proportions of ICU admissions meeting two definitions of being potentially preventable using nationally representative U.S. claims databases.Methods: We analyzed claims from 2006 to 2015 from all Medicare Fee-for-Service (FFS) beneficiaries and from a large national payer offering a private insurance (PI) plan and a Medicare Advantage (MA) plan. Potentially preventable hospitalizations were identified using existing definitions for ambulatory care sensitive conditions (ACSCs) and life-limiting malignancies (LLMs).Results: We analyzed 420,369,434 person-years of insurance coverage, during which there were 99,793,416 acute inpatient hospitalizations, of which 16,646,977 (16.7%) were associated with an ICU admission. Of these, the proportions with an ACSC were 12.9%, 12.7%, and 15.8%, and with an LLM were 5.2%, 5.4%, and 6.4%, among those with PI, MA, and FFS, respectively. Over 10 years, the absolute percentages of ACSC-associated ICU stays declined (PI = -1.1%, MA -6.4%, FFS -6.4%; all P < 0.001 for all trends). Smaller changes were noted among LLM-associated ICU stays, declining in the MA cohort (-0.8%) and increasing in the FFS (+0.3%) and PI (+0.2%) populations (P < 0.001 for all trends).Conclusions: An appreciable proportion of U.S. ICU admissions may be preventable with community-based interventions. Investment in the outpatient infrastructure required to prevent these ICU admissions should be considered as a complementary, if not alternative, strategy to expanding ICU capacity to meet future demand.
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Affiliation(s)
- Gary E. Weissman
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Meeta Prasad Kerlin
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Yihao Yuan
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel Kohn
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - George L. Anesi
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Peter W. Groeneveld
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Rachel M. Werner
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Scott D. Halpern
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Brennan JM, Wruck L, Pencina MJ, Clare RM, Lopes RD, Alexander JH, O'Brien S, Krucoff M, Rao SV, Wang TY, Curtis LH, Newby LK, Granger CB, Patel M, Mahaffey K, Ross JS, Normand SL, Eloff BC, Caños DA, Lokhnygina YV, Roe MT, Califf RM, Marinac-Dabic D, Peterson ED. Claims-based cardiovascular outcome identification for clinical research: Results from 7 large randomized cardiovascular clinical trials. Am Heart J 2019; 218:110-122. [PMID: 31726314 DOI: 10.1016/j.ahj.2019.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Medicare insurance claims may provide an efficient means to ascertain follow-up of older participants in clinical research. We sought to determine the accuracy and completeness of claims- versus site-based follow-up with clinical event committee (+CEC) adjudication of cardiovascular outcomes. METHODS We performed a retrospective study using linked Medicare and Duke Database of Clinical Trials data. Medicare claims were linked to clinical data from 7 randomized cardiovascular clinical trials. Of 52,476 trial participants, linking resulted in 5,839 (of 10,497 linkage-eligible) Medicare-linked trial participants with fee-for-service A and B coverage. Death, myocardial infarction (MI), stroke, and revascularization incidences were compared using Medicare inpatient claims only, site-reported events (+CEC) only, or a combination of the 2. Randomized treatment effects were compared as a function of whether claims-based, site-based (+CEC), or a combined system was used for event detection. RESULTS Among the 5,839 study participants, the annual event rates were similar between claims- and site-based (+CEC) follow-up: death (overall rate 5.2% vs 5.2%; adjusted κ 0.99), MI (2.2% vs 2.3%; adjusted κ 0.96), stroke (0.7% vs 0.7%; adjusted κ 0.99), and any revascularization (7.4% vs 7.9%; adjusted κ 0.95). Of events detected by claims yet not reported by CEC, a minority were reported by sites but negatively adjudicated by CEC (39% of MIs and 18% of strokes). Differences in individual case concordance led to higher event rates when claims- and site-based (+CEC) systems were combined. Randomized treatment effects were similar among the 3 approaches for each outcome of interest. CONCLUSIONS Claims- versus site-based (+CEC) follow-up identified similar overall cardiovascular event rates despite meaningful differences in the events detected. Randomized treatment effects were similar using the 2 methods, suggesting claims data could be used to support clinical research leveraging routinely collected data. This approach may lead to more effective evidence generation, synthesis, and appraisal of medical products and inform the strategic approaches toward the National Evaluation System for Health Technology.
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Affiliation(s)
| | - Lisa Wruck
- Duke University School of Medicine, Durham, NC
| | | | | | | | | | | | | | - Sunil V Rao
- Duke University School of Medicine, Durham, NC
| | | | | | | | | | | | | | | | | | - Benjamin C Eloff
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Daniel A Caños
- Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services, Baltimore, MD
| | | | | | | | - Danica Marinac-Dabic
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
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Wibbelsman TD, Pandit RR, Xu D, Jenkins TL, Mellen PL, Soares RR, Obeid A, Levin H, Hsu J, Ho AC. Trends in Retina Specialist Imaging Utilization from 2012 to 2016 in the United States Medicare Fee-for-Service Population. Am J Ophthalmol 2019; 208:12-18. [PMID: 31265802 DOI: 10.1016/j.ajo.2019.06.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/21/2019] [Accepted: 06/21/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE To characterize temporal trends and regional variance in retinal imaging utilization in the United States Medicare fee-for-service population from 2012-2016. DESIGN Cross-sectional, retrospective database analysis. METHODS This study addresses office or operating-room based retinal imaging. Our study population included retina specialists, defined as ophthalmologists performing either intravitreal anti-vascular endothelial growth factor injections or posterior segment laser photocoagulation and no neodymium-doped yttrium aluminum garnet laser capsulotomy. We recorded fundus photography, optical coherence tomography (OCT), intravenous fluorescein angiography (IVFA), indocyanine-green angiography, and ophthalmic ultrasound (B-scan) billed in the Medicare fee-for-service population from 2012-2016. Imaging obtained on any platform or device was eligible for inclusion (eg, posterior pole imaging vs ultrawidefield imaging). The main outcome measure was the relative utilization of retinal imaging modalities. RESULTS National relative utilization of OCT increased from 61.5% in 2012 to 70.5% in 2016 (P < .001), while IVFA fell from 20.9% to 15.1% over the same interval (P < .001). Fundus photography decreased from 14.6% in 2012 to 11.7% in 2016 (P < .001). By 2016, the Midwest region had the highest relative utilization of OCT (75.2%) and lowest of IVFA (12.0%), while the West region had the lowest OCT (68.4%) and highest IVFA (17.0%). CONCLUSIONS Among retina specialists, OCT usage increased while the utilization of fundus photography and IVFA has declined. The Midwest region had the highest utilization of OCT and lowest of IVFA.
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Affiliation(s)
| | - Ravi R Pandit
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - David Xu
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas L Jenkins
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Phoebe L Mellen
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Rebecca R Soares
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Anthony Obeid
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Hannah Levin
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Jason Hsu
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Allen C Ho
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA.
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Rosenthal M, Shortell S, Shah ND, Peiris D, Lewis VA, Barrera JA, Usadi B, Colla CH. Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data. Health Serv Res 2019; 54:1214-1222. [PMID: 31742688 PMCID: PMC6863236 DOI: 10.1111/1475-6773.13238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent). STUDY DESIGN Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.
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Affiliation(s)
- Meredith Rosenthal
- Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusetts
| | | | - Nilay D. Shah
- Division of Health Care Policy & ResearchMayo ClinicRochesterMinnesota
| | - David Peiris
- Health Systems ScienceUniversity of New South Wales Faculty of MedicineSydneyNSWAustralia
| | - Valerie A. Lewis
- Health Policy and ManagementUniversity of North Carolina at Chapel Hill Gillings School of Global Public HealthChapel HillNorth Carolina
| | - Jacob A. Barrera
- Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusetts
| | - Benjamin Usadi
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew Hampshire
| | - Carrie H. Colla
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew Hampshire
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Somé NH, Devlin RA, Mehta N, Zaric G, Li L, Shariff S, Belhadji B, Thind A, Garg A, Sarma S. Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada. Health Econ 2019; 28:1418-1434. [PMID: 31523891 DOI: 10.1002/hec.3951] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 07/30/2019] [Accepted: 08/17/2019] [Indexed: 06/10/2023]
Abstract
We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.
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Affiliation(s)
- Nibene H Somé
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, ON, Canada
| | - Nirav Mehta
- Department of Economics, University of Western Ontario, London, ON, Canada
| | - Greg Zaric
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Richard Ivey School of Business, University of Western Ontario, London, ON, Canada
| | - Lihua Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Salimah Shariff
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | | | - Amardeep Thind
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Centre for Studies in Family Medicine, University of Western Ontario, ON, Canada
| | - Amit Garg
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
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Lundeen EA, Wittenborn J, Benoit SR, Saaddine J. Disparities in Receipt of Eye Exams Among Medicare Part B Fee-for-Service Beneficiaries with Diabetes - United States, 2017. MMWR Morb Mortal Wkly Rep 2019; 68:1020-1023. [PMID: 31725705 PMCID: PMC6855512 DOI: 10.15585/mmwr.mm6845a3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Abstract
IMPORTANCE Owing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date. OBJECTIVE To determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019. EXPOSURES Eligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits). MAIN OUTCOMES AND MEASURES Age- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing. RESULTS Mean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P < .001) and then declined to 316 in 2016 (P < .001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P < .001) and heart failure (72.6% to 80.1%; P < .001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P < .001) but then declined to 2.5% in 2016 (P < .001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P = .03) but then declined to 30.8% in 2014 (P < .001). CONCLUSIONS AND RELEVANCE Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.
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Affiliation(s)
- Vinay Kini
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Timea Viragh
- Northwestern University School of Education and Social Policy, Evanston, Illinois
| | - David Magid
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Frederick A. Masoudi
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Ali Moghtaderi
- George Washington University School of Public Health, Washington, DC
| | - Bernard Black
- Institute for Policy Research and Kellogg School of Management, Northwestern University Pritzker School of Law, Chicago, Illinois
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Gidwani-Marszowski R, Asch SM, Mor V, Wagner TH, Faricy-Anderson K, Illarmo S, Hsin G, Patel MI, Ramchandran K, Lorenz KA, Needleman J. Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services. JAMA Netw Open 2019; 2:e1912161. [PMID: 31560384 PMCID: PMC6777391 DOI: 10.1001/jamanetworkopen.2019.12161] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services. OBJECTIVE To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019. EXPOSURES American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days. MAIN OUTCOMES AND MEASURES Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region. RESULTS Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P < .001). The biggest contributor to these differences was $21 093 (95% CI, $20 364-$21 689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001). CONCLUSIONS AND RELEVANCE Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.
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Affiliation(s)
- Risha Gidwani-Marszowski
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Steven M. Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Katherine Faricy-Anderson
- Providence VA Medical Center, Providence, Rhode Island
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Gary Hsin
- Division of Primary Care and Population Health, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Palo Alto, California
| | - Manali I. Patel
- VA Palo Alto Health Care System, Palo Alto, California
- Division of Medical Oncology, Stanford University, Stanford, California
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | | | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles
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McGarry BE, Grabowski DC. Managed care for long-stay nursing home residents: an evaluation of Institutional Special Needs Plans. Am J Manag Care 2019; 25:438-443. [PMID: 31518093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the patterns of clinical service use for long-term nursing home residents enrolled in UnitedHealthcare's Medicare Advantage Institutional Special Needs Plans (I-SNPs), which provide on-site direct coordinated care for beneficiaries through the use of advanced practice clinicians. STUDY DESIGN Observational analysis of 8052 I-SNP members and 12,982 Medicare fee-for-service (FFS) long-term nursing home residents across 13 states. METHODS Multivariate analyses were performed to compare rates of emergency department (ED), inpatient, and skilled nursing facility (SNF) use between I-SNP members and Medicare FFS long-term nursing home residents. RESULTS In comparison with FFS institutionalized Medicare beneficiaries, I-SNP members had 51% lower ED use, 38% fewer hospitalizations, and 45% fewer readmissions, whereas their SNF use was 112% higher. CONCLUSIONS "At-risk" models, administered through specialized Medicare Advantage plans, that invest in clinical management in the nursing home setting have the potential to allow individuals to receive care on-site and avoid costly inpatient transfers.
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Affiliation(s)
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115-5899.
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Leung M, Beadles C, Romaire M, Gulledge M. Multi-Payer Advanced Primary Care Practice Demonstration on quality of care. Am J Manag Care 2019; 25:444-449. [PMID: 31518094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries. STUDY DESIGN For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began. METHODS We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes. RESULTS Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations. CONCLUSIONS Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.
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Affiliation(s)
- Musetta Leung
- RTI International, 307 Waverley Oaks Rd, Ste 101, Waltham, MA 02452.
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Kern LM, Rajan M, Pincus HA, Casalino LP, Stuard SS. Changes in ambulatory utilization after switching from Medicaid fee-for-service to managed care. Am J Manag Care 2019; 25:e254-e260. [PMID: 31518096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To observe any change in ambulatory care utilization after switching from Medicaid fee-for-service (FFS) to Medicaid managed care (MC). STUDY DESIGN We conducted a statewide longitudinal study of 21,048 adult Medicaid beneficiaries in New York State who switched from FFS to MC in 2011 or 2012, with 2 sets of controls (n = 21,048 with continuous FFS; n = 21,048 with continuous MC) who were matched on age, gender, dual-eligible status, and number of chronic conditions. METHODS We measured ambulatory care utilization in the 12 months before and 12 months after the switch date, using regression to adjust for case mix and account for matching. RESULTS Overall, switching from Medicaid FFS to Medicaid MC was associated with greater absolute decreases over time in ambulatory visits and providers compared with controls (-1.49 visits vs continuous FFS and -1.60 visits vs continuous MC; each P <.0001; -0.10 providers vs continuous FFS and -0.12 providers vs continuous MC; each P <.0001). The subset of switchers with 5 or more chronic conditions had the greatest absolute decreases in visits (-5.88 visits vs continuous FFS and -5.98 visits vs continuous MC; each P <.0001) and providers (-1.37 providers vs continuous FFS and -1.39 providers vs continuous MC; each P <.0001). Significant decreases in visits and providers were also observed for switchers with 3 to 4 chronic conditions but not for those with 0 to 2 chronic conditions. CONCLUSIONS Switching from Medicaid FFS to Medicaid MC was associated with a decrease in ambulatory utilization, especially for the sickest patients.
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Affiliation(s)
- Lisa M Kern
- Weill Cornell Medicine, 420 E 70th Street, Box 331, New York, NY 10021.
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Leighton C, Cole E, James AE, Driessen J. Medicare Shared Savings Program ACO network comprehensiveness and patient panel stability. Am J Manag Care 2019; 25:e267-e273. [PMID: 31518098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The current Medicare Shared Savings Program (MSSP) accountable care organization (ACO) attribution methodology creates unpredictability for ACOs that are developing and deploying strategic initiatives aimed at improving value. The goal of this study is to determine if ACO network comprehensiveness is associated with the stability of assigned Medicare beneficiaries from 2013 to 2014. STUDY DESIGN We utilized a beneficiary-level logistic regression model to determine association of network comprehensiveness with stable attribution to an MSSP ACO. METHODS Using 2013 and 2014 Medicare fee-for-service beneficiary and provider files, we developed a measure of network comprehensiveness based on 2013 provider contracts, determined beneficiary attribution, and generated market-level measures. Additional population and quality measures were obtained from the US Census and the ACO Public Use File. RESULTS Of the 1,317,858 observed beneficiaries, 84.38% were attributed to the same ACO in 2013 and 2014, and mean (SD) ACO network comprehensiveness was 0.30 (0.20). We found that a 0.10 increase in network comprehensiveness score significantly increased the odds of remaining attributed to the same ACO by 4.5% (P = .001). Patient panel stability was significantly associated with improved diabetes (P = .01) and hypertension (P = .02) control, timely access to care (P = .001), and delivery of health education (P = .03) over the 2-year period. CONCLUSIONS The comprehensiveness of an MSSP ACO's contracted provider network is associated with stable patient assignment year to year. Patient panel stability may aid in the longitudinal management of some conditions.
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Affiliation(s)
- Cassandra Leighton
- Health Policy Institute, University of Pittsburgh, Scaife Hall, Ste S310, 3550 Terrace St, Pittsburgh, PA 15261.
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Nam CS, Mehta A, Hammett J, Kim FY, Filson CP. Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries. JAMA Netw Open 2019; 2:e198956. [PMID: 31397864 PMCID: PMC6692839 DOI: 10.1001/jamanetworkopen.2019.8956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/20/2019] [Indexed: 12/02/2022] Open
Abstract
Importance Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries. Objective To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists. Design, Setting, and Participants This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019. Main Outcomes and Measures Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified. Results Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist. Conclusions and Relevance Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.
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Affiliation(s)
- Catherine S. Nam
- Department of Urology, Emory University School of Medicine, Atlanta, Georgia
| | - Akanksha Mehta
- Department of Urology, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica Hammett
- Department of Urology, Emory University School of Medicine, Atlanta, Georgia
| | - Frances Y. Kim
- Department of Urology, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher P. Filson
- Department of Urology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute, Emory Healthcare, Atlanta, Georgia
- Department of Urology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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Rivera-Hernandez M, Rahman M, Mor V, Trivedi AN. Racial Disparities in Readmission Rates among Patients Discharged to Skilled Nursing Facilities. J Am Geriatr Soc 2019; 67:1672-1679. [PMID: 31066913 PMCID: PMC6684399 DOI: 10.1111/jgs.15960] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Prior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black-white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30-day rehospitalization directly from SNFs among fee-for-service and Medicare Advantage patients. DESIGN A cross-sectional study of admissions to SNFs in 2015 was conducted. SETTING SNFs across the United States. PARTICIPANTS The sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs. MEASUREMENTS The main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30 days of admission, as indicated on the Minimum Data Set discharge assessment. RESULTS Overall readmission rates for fee-for-service patients were 16.7% (95% confidence interval [CI] = 16.7%-16.8%) for whites, 18.8% (95% CI = 18.7%-19.0%) for African Americans, and 17.4% (95% CI = 17.1%-17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI = 14.5%-14.8%) for whites, 16.8% (95% CI = 16.6%-17.1%) for African Americans, and 15.3% (95% CI = 14.9%-15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within-SNF racial disparities in Medicare Advantage compared with Medicare fee-for-service. CONCLUSION We found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee-for-service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672-1679, 2019.
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Affiliation(s)
- Maricruz Rivera-Hernandez
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Amal N Trivedi
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
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Weinhandl ED, Ray D, Kubisiak KM, Collins AJ. Contemporary Trends in Clinical Outcomes among Dialysis Patients with Medicare Coverage. Am J Nephrol 2019; 50:63-71. [PMID: 31203279 DOI: 10.1159/000500943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The dialysis patient population in the United States continues to grow. Trends in rates of death and hospitalization among dialysis patients have important consequences for outpatient dialysis capacity and Medicare spending. OBJECTIVES To estimate contemporary trends in rates of death and hospitalization among dialysis patients in the United States, overall and within subgroups. METHODS We used Medicare Limited Data Sets (100% sample) in 2014-2017 to estimate trends in rates of death and hospitalization among dialysis patients with Medicare Parts A and B enrollment. We used seasonal autoregressive integrated moving average models to identify secular trends in the incidence of outcomes. RESULTS There were 631,075 unique patients; 222,924 deaths; and 1,876,779 hospital admissions. Weekly risks of both death and hospitalization exhibited strong seasonality. However, overall weekly risks of death were 34.9, 35.4, 35.2, and 35.7 deaths per 10,000 patients in 2014-2017, respectively (p = 0.47, from a likelihood ratio test of secular trend). The overall weekly risk of hospitalization was 3.08, 3.05, 3.11, and 3.11% in 2014, 2015, 2016, and 2017, respectively (p = 0.30). There were significant secular trends in risk of death in subgroups defined by black race and residency in South Atlantic states (p < 0.05). There were also secular trends in risk of hospitalization in subgroups defined by age 20-44 years, concurrent enrollment in Medicaid, and residency in South Central states. CONCLUSION For the first time since the beginning of this century, rates of both death and hospitalization among dialysis patients with Medicare fee-for-service coverage have stagnated. The reasons for this change are unknown and require detailed assessment. Persistent lack of change in clinical outcomes may alter the future expectations about dialysis patient population growth.
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Affiliation(s)
- Eric D Weinhandl
- NxStage Medical, Medical Affairs, Lawrence, Massachusetts, USA,
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA,
| | - Debabrata Ray
- NxStage Medical, Medical Affairs, Lawrence, Massachusetts, USA
| | | | - Allan J Collins
- NxStage Medical, Medical Affairs, Lawrence, Massachusetts, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Shooshtari A, Kalidindi Y, Jung J. Cancer care spending and use by site of provider-administered chemotherapy in Medicare. Am J Manag Care 2019; 25:296-300. [PMID: 31211557 PMCID: PMC6582993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To compare cancer care spending and utilization by site of provider-administered chemotherapy in Medicare. STUDY DESIGN A retrospective analysis using 2010-2013 Medicare claims. METHODS The study population was a random sample of Medicare fee-for-service beneficiaries with cancer who initiated provider-administered chemotherapy in a hospital outpatient department (HOPD) or physician office (PO). We assessed the following outcomes during the 6-month follow-up period: (1) spending on cancer-related outpatient services excluding chemotherapy, (2) spending on cancer-related inpatient services, (3) utilization of select cancer-related outpatient services (evaluation and management, commonly used expensive billing codes, and radiation therapy sessions), and (4) the number of cancer-related hospitalizations. We used regression analyses to adjust for patient health risk factors and market characteristics. RESULTS During the 6-month follow-up period, risk-adjusted spending on nonchemotherapy outpatient services was slightly lower among patients receiving chemotherapy in HOPDs than in POs ($12,183 [95% CI, $12,008-$12,358] vs $12,444 [95% CI, $12,313-$12,575]; P <.05). Risk-adjusted cancer-related inpatient spending was higher in the HOPD group than in the PO group ($3996 [95% CI, $3837-$4156] vs $3168 [95% CI, $3067-$3268]; P <.01). The HOPD group had fewer visits in all select outpatient services but had a higher number of hospitalizations than the PO group. CONCLUSIONS Differences in cancer care spending by site of chemotherapy (HOPDs vs POs) vary by service type. Those differences are partially driven by utilization differences. As the site of chemotherapy shifts from POs to HOPDs, spending and utilization patterns in both settings need to be monitored.
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Affiliation(s)
| | - Yamini Kalidindi
- Pennsylvania State University, 501-G Ford Bldg, University Park, PA 16802.
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Whitcomb WF, Lucas JE, Tornheim R, Chiu JL, Hayward P. Association of decision support for hospital discharge disposition with outcomes. Am J Manag Care 2019; 25:288-294. [PMID: 31211556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To assess the association of a clinical decision support (CDS) algorithm for hospital discharge disposition with spending, readmissions, and postdischarge emergency department (ED) use. STUDY DESIGN A retrospective study in a cohort of fee-for-service Medicare patients 65 years or older linked to a database of patients receiving CDS. METHODS We evaluated (1) patients whose discharge disposition was concordant with the CDS recommendation versus those whose disposition was not and (2) patients receiving CDS for discharge disposition versus those not receiving CDS, regardless of concordance. Outcomes were spending over a 90-day episode, 90-day readmissions, and postdischarge ED utilization not associated with a readmission. RESULTS Analysis of concordant versus discordant cases showed decreased spending for concordant cases ($860 savings; 95% CI, $162-$1558; P = .016), a decrease in readmissions (adjusted odds ratio [OR], 0.920; 95% CI, 0.850-0.995; P = .038), and no change in rate of postdischarge ED use (adjusted OR, 0.990; 95% CI, 0.882-1.110; P = .858). Analysis of patients receiving CDS versus not receiving CDS showed no significant difference in spending ($221 savings; 95% CI, -$115 to $557; P = .198), ED use (adjusted OR, 0.959; 95% CI, 0.908-1.012; P = .128), or readmission rate (adjusted OR, 1.004; 95% CI, 0.966-1.043; P = .840). CONCLUSIONS Following the recommendation of a CDS algorithm for hospital discharge disposition was associated with lower spending, fewer readmissions, and no change in ED use over a 90-day episode of care.
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Abstract
Managed care plans often attempt to control health care costs through strategies designed to decrease health care utilization. However, the extent to which the resulting patterns of utilization represent high-quality care (compared to fee-for-service products) remains controversial. The authors sought to compare patterns of ambulatory care (including how diffuse or fragmented the care patterns were) for Medicaid fee-for-service beneficiaries vs. Medicaid managed care beneficiaries. A serial cross-sectional study of adults (≥18 years old) was conducted using statewide Medicaid claims from New York State for calendar years 2010-2013. Beneficiaries were required to be continuously enrolled and have ≥4 ambulatory visits for each year they contributed data, yielding a sample of more than 1 million beneficiaries per year. Beneficiaries were characterized by age, sex, and case mix. For each year, ambulatory care patterns were compared across subgroups of beneficiaries using Poisson models (for numbers of visits and providers) and bounded Tobit models (for fragmentation scores). In 2010, among those who were not dual eligible, managed care beneficiaries had on average fewer visits (10.9 visits vs. 11.4 visits [P < 0.0001]) but more providers (3.8 providers vs. 3.3 providers [P < 0.0001]) and therefore more fragmentation (0.58 vs. 0.51 [P < 0.0001]) than fee-for-service beneficiaries, adjusting for age, sex, and case mix. These patterns persisted throughout the follow-up period and in sensitivity analyses. Less utilization is not necessarily more efficient care; a smaller number of visits spread across a larger number of providers creates more challenges for care coordination.
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Affiliation(s)
- Lisa M Kern
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Mangala Rajan
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Harold A Pincus
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lawrence P Casalino
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
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Di Guida S, Gyrd-Hansen D, Oxholm AS. Testing the myth of fee-for-service and overprovision in health care. Health Econ 2019; 28:717-722. [PMID: 30854756 DOI: 10.1002/hec.3875] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/19/2018] [Accepted: 02/04/2019] [Indexed: 06/09/2023]
Abstract
Paying on the basis of fee-for-service (FFS) is often associated with a risk of overprovision. Policymakers are therefore increasingly looking to other payment schemes to ensure a more efficient delivery of health care. This study tests whether context plays a role for overprovision under FFS. Using a laboratory experiment involving medical students, we test the extent of overprovision under FFS when the subjects face different fee sizes, patient types, and market conditions. We observe that decreasing the fee size has an effect on overprovision under both market conditions. We also observe that patients who are harmed by excess treatment are at little risk of overprovision. Finally, when subjects face resource constraints but still have an incentive to overprovide high-profit services, they hesitate to do so, implying that the presence of opportunity costs in terms of reduced benefits to other patients protects against overprovision. Thus, this study provides evidence that the risk of overprovision under FFS depends on fee sizes, patients' health profiles, and market conditions.
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Affiliation(s)
- Sibilla Di Guida
- Department of Business and Economics, University of Southern Denmark, Odense, Denmark
| | - Dorte Gyrd-Hansen
- Department of Public Health, DaCHE - Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Anne Sophie Oxholm
- Department of Public Health, DaCHE - Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
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Jung J, Feldman R, Kalidindi Y. The impact of integration on outpatient chemotherapy use and spending in Medicare. Health Econ 2019; 28:517-528. [PMID: 30695812 PMCID: PMC6405302 DOI: 10.1002/hec.3860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/01/2018] [Accepted: 01/03/2019] [Indexed: 05/19/2023]
Abstract
Hospital-physician integration has substantially grown in the United States for the past decade, particularly in certain medical specialties, such as oncology. Yet evidence is scarce on the relation between integration and outpatient specialty care use and spending. We analyzed the impact of oncologist integration on outpatient provider-administered chemotherapy use and spending in Medicare, where prices do not depend on providers' integration status or negotiating power. We addressed oncologists' selective integration and patients' nonrandom choice of oncologists using an instrumental variables method. We found that integrated oncologists reduced the quantity of outpatient chemotherapy drugs but used more expensive treatments. This led to an increase in chemotherapy-drug spending after integration. These findings suggest that changes in treatment patterns-treatment mix and quantity-may be an important mechanism by which integration increases spending. We also found that integration increased spending on chemotherapy administration (the act of injection). This is because integration shifted billing of chemotherapy to hospital outpatient departments, where Medicare payments for chemotherapy administration are higher than those in physician offices. As integration increases, efforts should continue to assess how integration influences patient care and explore policy options to ensure desirable outcomes from integration.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, The Pennsylvania State University, 604 Ford Building, University Park, PA 16802, USA, Phone: 814-863-8129, Fax: 814-863-2905,
| | - Roger Feldman
- Division of Health Policy and Management, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Yamini Kalidindi
- Department of Health Policy and Administration, The Pennsylvania State University, 604 Ford Building, University Park, PA 16802, USA,
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Vlaanderen FP, Tanke MA, Bloem BR, Faber MJ, Eijkenaar F, Schut FT, Jeurissen PPT. Design and effects of outcome-based payment models in healthcare: a systematic review. Eur J Health Econ 2019; 20:217-232. [PMID: 29974285 PMCID: PMC6438941 DOI: 10.1007/s10198-018-0989-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 06/22/2018] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. METHODS We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. RESULTS We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. DISCUSSION Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
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Affiliation(s)
- F P Vlaanderen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands.
| | - M A Tanke
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
| | - B R Bloem
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
| | - M J Faber
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboudumc, Nijmegen, The Netherlands
| | - F Eijkenaar
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - F T Schut
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - P P T Jeurissen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
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Rathish D, Hemachandra R, Premadasa T, Ramanayake S, Rasangika C, Roshiban R, Jayasumana C. Comparison of medication adherence between type 2 diabetes mellitus patients who pay for their medications and those who receive it free: a rural Asian experience. J Health Popul Nutr 2019; 38:4. [PMID: 30678724 PMCID: PMC6346564 DOI: 10.1186/s41043-019-0161-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/15/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Treatment plans fail if patients have poor medication adherence. Our aim was to compare medication adherence, reasons for non-adherence, and satisfaction with community support among type 2 diabetes mellitus patients who pay for their medications and those who receive it free. METHODS A descriptive cross-sectional study was conducted at Anuradhapura, Sri Lanka, among patients who were on oral anti-diabetic drugs for at least 3 months. They were grouped into two: universal-free group and fee-paying group. Three different scales were used to score medication adherence, reasons for non-adherence, and satisfaction with community support. Fisher's exact test was performed to determine if there was a significant difference between the two groups (p < 0.05) concerning medication adherence and satisfaction with community support. RESULTS The median (IQR) medication adherence scores for fee-paying group and universal-free group were 3 (2-3) and 3 (3-3), respectively; the median (IQR) scores for satisfaction with community support were 5 (2-6) and 4 (4-6), respectively. Both the adherence and the satisfaction failed to show a significant difference between the two groups. Forgetfulness, being away from home, complex drug regime, and willingness to avoid side effects were common reasons of non-adherence for both the groups. CONCLUSIONS There was no significant difference in medication adherence between the universal-free group and fee-paying group, despite of having a significantly different income. The universal-free health service would be a probable reason.
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Affiliation(s)
- Devarajan Rathish
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Ruvini Hemachandra
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Thilini Premadasa
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Sasini Ramanayake
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Chathuri Rasangika
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Ravi Roshiban
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Channa Jayasumana
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
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Roland CL, Ye X, Stevens V, Oderda GM. The Prevalence and Cost of Medicare Beneficiaries Diagnosed and At Risk for Opioid Abuse, Dependence, and Poisoning. J Manag Care Spec Pharm 2019; 25:18-27. [PMID: 30589633 PMCID: PMC10397651 DOI: 10.18553/jmcp.2019.25.1.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Reliance on prescription opioids to manage pain has been associated with increases in diversion, overdose, and addiction. Prevalence of misuse and abuse has been shown to be higher among government-insured populations than commercially insured populations. However, the prevalence and costs of misuse/abuse among the Medicare fee-for-service (FFS) population has not been studied. OBJECTIVES To (a) determine the prevalence and costs of prescription opioid misuse/abuse and (b) evaluate the prevalence and costs associated with those identified as at risk for opioid misuse/abuse in Medicare FFS beneficiaries. METHODS This retrospective case-control study used Medicare claims data for the calendar years of 2010 and 2011 and included Medicare beneficiaries aged at least 18 years. The index date was the date of first diagnosed misuse/abuse or at risk for abuse and had to occur between July 1, 2010, and June 30, 2011, and beneficiaries had to have at least 6 months continuous eligibility before and after the index date. Matching (1:1) was used for comparing opioid misusers/abusers with nonabuser controls, as well as comparing patients at risk for opioid abuse with controls not at risk for abuse. Controls were matched to cases by gender, age, disability, and geographic region. The index date of the control patient was set equal to the index date of the matched case. RESULTS Prevalence of misuse/abuse in the Medicare FFS population was 13.1 per 1,000 persons, with the majority among patients receiving Medicare based on disability (76.2%). The prevalence of at risk for misuse/abuse was 117.4 per 1,000 persons. Approximately half of the Medicare FFS patients used an opioid. Overall total annual unadjusted mean costs of health care resources were significantly greater for abusers than for matched controls ($46,194 vs. $21,964; P < 0.0001), with a mean annual excess cost of $24,230. The overall total adjusted 6-month post-index mean costs of health care resources for abusers was significantly greater than that of matched controls ($33,942 vs. $10,754; P < 0.0001), with a mean excess cost of $23,188. CONCLUSIONS The prevalence of diagnosed abuse among Medicare FFS population (13.1 per 1,000 persons) was higher than other payer groups studied using similar ICD-9-CM codes, and the majority of abuse was among those receiving Medicare based on disability (76.2%). The prevalence of at-risk abuse was 9 times higher than the prevalence of diagnosed abuse. As with other studies, health care resource utilization and costs were significantly greater for diagnosed abuse than matched controls. DISCLOSURES This study was sponsored by Pfizer. Roland is a Pfizer employee and stockholder and was involved in all aspects of the study as part of a mid-career fellowship in pharmacoeconomics with the University of Utah. Ye and Stevens are employees of University of Utah, and Oderda was an employee of University of Utah, which received financial support from Pfizer in connection with the development of this manuscript. Oderda also reports consulting fees from Pfizer, Trevena, and Pacira, unrelated to this study. The results of this study were presented at the Academy of Managed Care Pharmacy Nexus 2015; October 26-29, 2015; Orlando, FL, and the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA.
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Affiliation(s)
| | - Xiangyang Ye
- Pharmacotherapy Outcomes Research Center, University of Utah College of Pharmacy, Salt Lake City
| | - Vanessa Stevens
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Gary M. Oderda
- Pharmacotherapy Outcomes Research Center, University of Utah College of Pharmacy, Salt Lake City
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