Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.013
Filtrar
1.
JAMA ; 330(24): 2365-2375, 2023 12 26.
Artigo em Inglês | MEDLINE | ID: mdl-38147093

RESUMO

Importance: The effects of private equity acquisitions of US hospitals on the clinical quality of inpatient care and patient outcomes remain largely unknown. Objective: To examine changes in hospital-acquired adverse events and hospitalization outcomes associated with private equity acquisitions of US hospitals. Design, Setting, and Participants: Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity-acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes. Main Outcomes and Measures: Hospital-acquired adverse events (synonymous with hospital-acquired conditions; the individual conditions were defined by the US Centers for Medicare & Medicaid Services as falls, infections, and other adverse events), patient mix, and hospitalization outcomes (including mortality, discharge disposition, length of stay, and readmissions). Results: Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line-associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge. Conclusions and Relevance: Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections. Shifts in patient mix toward younger and fewer dually eligible beneficiaries admitted and increased transfers to other hospitals may explain the small decrease in in-hospital mortality at private equity hospitals relative to the control hospitals, which was no longer evident 30 days after discharge. These findings heighten concerns about the implications of private equity on health care delivery.


Assuntos
Hospitalização , Hospitais Privados , Doença Iatrogênica , Medicare Part A , Avaliação de Resultados em Cuidados de Saúde , Qualidade da Assistência à Saúde , Idoso , Humanos , Hospitais Privados/normas , Hospitais Privados/estatística & dados numéricos , Doença Iatrogênica/epidemiologia , Medicare/normas , Medicare/estatística & dados numéricos , Sepse/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos/epidemiologia , Avaliação de Resultados em Cuidados de Saúde/normas , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Medicare Part A/normas , Medicare Part A/estatística & dados numéricos
3.
Health Serv Res ; 58(1): 186-194, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36303444

RESUMO

OBJECTIVE: To construct a new measure of end-of-life (EoL) spending-the elevated EoL spending-and examine its associations with measures of quality of care and patient and physician preferences in comparison with the commonly used total Medicare EoL spending measures. DATA SOURCES AND STUDY SETTING: Medicare claims data for a 20% random sample of Medicare fee-for-service (FFS) patients, from the health care quality data for 2015-2016, from the Hospital Compare and the Medicare Geographic Variation public use file, and survey data about patient and physician preferences. STUDY DESIGN: We constructed the elevated EoL spending measure as the differential monthly spending between decedents and survivors with the same one-year mortality risk, where the risk was predicted using machine learning models. We then examined the associations of the hospital referral region (HRR)-level elevated EoL spending with various health care quality measures and with the survey-elicited patient and provider preferences. We also examined analogous associations for monthly total EoL spending on decedents. DATA EXTRACTION METHODS: Medicare FFS patients who were continuously enrolled in Medicare Parts A & B in 2015 and were alive as of January 1, 2016. PRINCIPAL FINDINGS: We found a large variation in the elevated EoL spending across HRRs in the United States. There was no evidence of an association between HRR-level elevated EoL spending and established health care quality measures, including those specific to EoL care, whereas total EoL spending was positively associated with certain quality of care measures. We also found no evidence that elevated EoL spending was associated with patient preferences for EoL care. However, elevated EoL spending was positively and significantly associated with physician preferences for treatment intensity. CONCLUSIONS: Our findings suggested that elevated EoL spending captures different resource use from conventional measures of EoL spending and may be more valuable in identifying potentially wasteful spending.


Assuntos
Medicare Part A , Assistência Terminal , Idoso , Humanos , Estados Unidos , Medicare , Gastos em Saúde , Morte
4.
JAMA ; 328(15): 1515-1522, 2022 10 18.
Artigo em Inglês | MEDLINE | ID: mdl-36255428

RESUMO

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.


Assuntos
Planos de Pagamento por Serviço Prestado , Gastos em Saúde , Medicare , Medicamentos sob Prescrição , Idoso , Feminino , Humanos , Estudos Transversais , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/tendências , Gastos em Saúde/estatística & dados numéricos , Gastos em Saúde/tendências , Medicare/economia , Medicare/estatística & dados numéricos , Medicare/tendências , Medicare Part D/economia , Medicare Part D/estatística & dados numéricos , Medicare Part D/tendências , Medicamentos sob Prescrição/economia , Estados Unidos/epidemiologia , Medicare Part A/economia , Medicare Part A/estatística & dados numéricos , Medicare Part A/tendências , Medicare Part B/economia , Medicare Part B/estatística & dados numéricos , Medicare Part B/tendências , Masculino , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais
5.
Health Aff (Millwood) ; 40(6): 1000-1005, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34097507

RESUMO

The proliferation of "ultra-expensive" drugs has sparked debate on their sustainability and affordability. Medicare Part D's share of annual spending on these drugs increased by 1,170 percent between 2012 and 2018, largely because the number of beneficiaries receiving them increased during this period.


Assuntos
Medicare Part A , Medicare Part D , Preparações Farmacêuticas , Idoso , Humanos , Estados Unidos
6.
Am J Manag Care ; 27(4): e123-e129, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33877779

RESUMO

OBJECTIVES: Proponents of a single-payer or public option health care system often cite the lower administrative expenses in public Medicare compared with those in private Medicare, claiming that this difference represents efficiency. We check the validity of this comparison in terms of accuracy and definitions and suggest expanding its scope to include expanded financial data of the 2 Medicare systems. STUDY DESIGN: Using annual Medicare Boards of Trustees and National Health Expenditure Accounts data from CMS and health insurers' financial statement data, we compare the level and percentage of the administrative expenses of the Medicare systems and show incompatible and not reconcilable definitions of administrative expenses. We expand our analysis to income, benefits, gains and losses, and loss ratios of the programs. METHODS: Our methodology is a careful comparison of categories of expenses between public and private insurers using official data sources. The comparison is both qualitative and quantitative. RESULTS: We validate the low administrative expenses of Medicare parts A, B, and D (1.35% of benefits in 2018) compared with Medicare Part C (10.86% of benefits without loss adjustment expenses [LAE] and 14.84% with LAE for 2018). Expanding the focus, the income and benefits per beneficiary grew faster and larger in Medicare parts A, B, and D than in Medicare Part C-a reversal of earlier trends. The public Medicare program suffered losses in 11 years during 2002-2018, whereas private insurers' Medicare remained solvent with about an 85% loss ratio. CONCLUSIONS: Comparisons of the systems in the United States would benefit from expanding the focus beyond incomparable administrative expenses. For the current period of coronavirus disease 2019, if the trends continue, public Medicare may suffer greater deficits relative to the private Medicare Part C.


Assuntos
Custos e Análise de Custo , Medicare Part A/economia , Medicare Part B/economia , Medicare Part C/economia , Medicare Part D/economia , Humanos , Setor Privado/economia , Setor Público/economia , Estados Unidos
7.
JAMA Netw Open ; 3(11): e2025488, 2020 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-33231638

RESUMO

Importance: Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers. Objective: To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending. Design, Setting, and Participants: This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending. Exposure: Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial. Main Outcomes and Measures: Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility. Results: This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03). Conclusions and Relevance: This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending. Trial Registration: ClinicalTrials.gov Identifier: NCT03952728.


Assuntos
Terapia Comportamental/métodos , Diabetes Mellitus Tipo 2/terapia , Dietoterapia/métodos , Terapia por Exercício/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Estilo de Vida , Medicare/economia , Idoso , Peso Corporal , Aconselhamento/métodos , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/metabolismo , Avaliação da Deficiência , Definição da Elegibilidade , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hemoglobinas Glicadas/metabolismo , Gastos em Saúde , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare Part A/economia , Medicare Part B/economia , Medicare Part D/economia , Pessoa de Meia-Idade , Estados Unidos
8.
Health Aff (Millwood) ; 38(11): 1927-1935, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31682513

RESUMO

Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.


Assuntos
Detecção Precoce de Câncer , Gastos em Saúde , Medicare Part A , Medicare Part B , Visita a Consultório Médico , Aceitação pelo Paciente de Cuidados de Saúde , Encaminhamento e Consulta , Idoso , Serviço Hospitalar de Emergência , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Revisão da Utilização de Seguros , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estados Unidos
9.
Am Surg ; 85(10): 1079-1082, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657298

RESUMO

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Especialidades Cirúrgicas/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Feminino , Cirurgia Geral/estatística & dados numéricos , Humanos , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Razão de Chances , Sistema de Registros , Estudos Retrospectivos , Cirurgiões/classificação , Cirurgia Torácica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
10.
Am J Manag Care ; 25(2): 78-83, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30763038

RESUMO

OBJECTIVES: To assess the extent to which medication adherence in congestive heart failure (CHF) and diabetes may serve as a measure of physician-level quality. STUDY DESIGN: A retrospective analysis of Medicare data from 2007 to 2009, including parts A (inpatient), B (outpatient), and D (pharmacy). METHODS: For each disease, we assessed the correlation between medication adherence and health outcomes at the physician level. We controlled for selection bias by first regressing patient-level outcomes on a set of covariates including comorbid conditions, demographic attributes, and physician fixed effects. We then classified physicians into 3 levels of average patient medication adherence-low, medium, and high-and compared health outcomes across these groups. RESULTS: There is a clear relationship between average medication adherence and patient health outcomes as measured at the physician level. Within the diabetes sample, among physicians with high average adherence and controlling for patient characteristics, 26.3 per 1000 patients had uncontrolled diabetes compared with 45.9 per 1000 patients among physicians with low average adherence. Within the CHF sample, also controlling for patient characteristics, the average rate of CHF emergency care usage among patients seen by physicians with low average adherence was 16.3% compared with 13.5% for doctors with high average adherence. CONCLUSIONS: This study's results establish a physician-level correlation between improved medication adherence and improved health outcomes in the Medicare population. Our findings suggest that medication adherence could be a useful measure of physician quality, at least for chronic conditions for which prescription medications are an important component of treatment.


Assuntos
Adesão à Medicação , Médicos/normas , Indicadores de Qualidade em Assistência à Saúde , Idoso , Feminino , Humanos , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Medicare Part D/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
11.
Am Heart J ; 207: 19-26, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30404047

RESUMO

BACKGROUND: A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates. METHODS: We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4). RESULTS: Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007). CONCLUSIONS: Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Admissão do Paciente/estatística & dados numéricos , Organizações de Assistência Responsáveis/classificação , Organizações de Assistência Responsáveis/normas , Idoso , Algoritmos , Análise de Variância , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Feminino , Insuficiência Cardíaca/diagnóstico , Hospitalização/estatística & dados numéricos , Humanos , Classificação Internacional de Doenças , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/normas , Assistência Centrada no Paciente/estatística & dados numéricos , Distribuição por Sexo , Fatores de Tempo , Estados Unidos
12.
Issue Brief (Commonw Fund) ; 2018: 1-15, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30211508

RESUMO

Issue: An estimated 40 percent of low-income Medicare beneficiaries spend 20 percent or more of their incomes on premiums and health care costs. Low-income beneficiaries with multiple chronic conditions or high need are at particular risk of financial hardship. High cost burdens reflect Medicare premiums and cost-sharing, gaps in benefits, and limited assistance. Existing policies to help people with low incomes are fragmented ­ meaning that beneficiaries apply separately, sometimes to different offices ­ and require Medicare beneficiaries to navigate complex applications. Goals: With the goal of enhancing access and affordability for people vulnerable due to low incomes and poor health, this issue brief proposes a policy that would reduce Medicare's cost-sharing and premiums for beneficiaries with incomes below 150 percent of the federal poverty level. Methods: Profile current cost burdens by income groups and assess the potential impact of a policy to expand cost-sharing and premium assistance using the 2012 Medicare Current Beneficiary Survey projected to 2016. Results and Conclusion: The policy described could help 8.1 million low-income beneficiaries, significantly lowering their risk of high cost burdens. It also could simplify the administration of assistance provided to these enrollees.


Assuntos
Política de Saúde/economia , Acesso aos Serviços de Saúde/economia , Medicare Part A/economia , Medicare Part B/economia , Medicare/economia , Custo Compartilhado de Seguro/economia , Humanos , Múltiplas Afecções Crônicas/economia , Pobreza , Estados Unidos
13.
Health Serv Res ; 53 Suppl 3: 5181-5200, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29896771

RESUMO

OBJECTIVE: Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS: The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS: Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS: VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.


Assuntos
Medicare Part A/estatística & dados numéricos , United States Department of Veterans Affairs/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Nível de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros , Masculino , Medicina/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Polimedicação , Fatores Socioeconômicos , Meios de Transporte , Estados Unidos , Saúde dos Veteranos
14.
Med Care ; 56(6): 484-490, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29613873

RESUMO

OBJECTIVE: To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians. DATA SOURCES: Medicare part A and part B claims during 2012-2013. STUDY DESIGN: Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening. EXTRACTION METHODS: Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians. PRINCIPAL FINDINGS: Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening. CONCLUSIONS: The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.


Assuntos
Medicare/normas , Profissionais de Enfermagem/organização & administração , Padrões de Prática em Enfermagem/organização & administração , Padrões de Prática Médica/organização & administração , Atenção Primária à Saúde/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Humanos , Medicare Part A , Medicare Part B , Médicos de Atenção Primária/organização & administração , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Estados Unidos
15.
Health Serv Res ; 53(5): 3507-3527, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29512154

RESUMO

OBJECTIVES: To analyze the sources of per-beneficiary Medicare spending growth between 2007 and 2014, including the role of demographic characteristics, attributes of Medicare coverage, and chronic conditions. DATA SOURCES: Individual-level Medicare spending and enrollment data. STUDY DESIGN: Using an Oaxaca-Blinder decomposition model, we analyzed whether changes in price-standardized, per-beneficiary Medicare Part A and B spending reflected changes in the composition of the Medicare population or changes in relative spending levels per person. DATA EXTRACTION METHODS: We identified a 5 percent sample of fee-for-service Medicare beneficiaries age 65 and above from years 2007 to 2014. RESULTS: Mean payment-adjusted Medicare per-beneficiary spending decreased by $180 between the 2007-2010 and 2011-2014 time periods. This decline was almost entirely attributable to lower spending levels for beneficiaries. Notably, declines in marginal spending levels for beneficiaries with chronic conditions were associated with a $175 reduction in per-beneficiary spending. The decline was partially offset by the increasing prevalence of certain chronic diseases. Still, we are unable to attribute a large share of the decline in spending levels to observable beneficiary characteristics or chronic conditions. CONCLUSIONS: Declines in spending levels for Medicare beneficiaries with chronic conditions suggest that changing patterns of care use may be moderating spending growth.


Assuntos
Gastos em Saúde/tendências , Medicare Part A/economia , Medicare Part B/economia , Idoso , Feminino , Humanos , Masculino , Modelos Econômicos , Estados Unidos
16.
Geriatr Nurs ; 39(4): 371-375, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29275990

RESUMO

Octogenarians receiving cardiac valve surgery is increasing and recovery is challenging. Post-acute care (PAC) services assist with recovery, yet services provided in facilities do not provide adequate cardiac-focused care or long-term self-management support. The purpose of the paper was to report post-acute care discharge rates in octogenarians and propose clinical implications to improve PAC services. Using a 2003 Medicare Part A database, we studied post-acute care service use in octogenarians after cardiac valve surgery. We propose expansion of the Geriatric Cardiac Care model to include broader clinical therapy dynamics. The sample (n = 10,062) included patients over 80 years discharged from acute care following valve surgery. Post-acute care services were used by 68% of octagarians following cardiac valve surgery (1% intermediate rehabilitation, 35% skilled nursing facility, 32% home health). The large percentage of octagarians using PAC point to the importance of integrating geriatric cardiac care into post-acute services to optimize recovery outcomes.


Assuntos
Assistência ao Convalescente/organização & administração , Valvas Cardíacas/cirurgia , Alta do Paciente , Reabilitação/organização & administração , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Humanos , Medicare Part A/estatística & dados numéricos , Estados Unidos
17.
Health Serv Res ; 53(2): 711-729, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28295261

RESUMO

OBJECTIVE: To isolate the effect of greater inpatient cost-sharing on Medicaid entry among Medicare beneficiaries. DATA SOURCES: Medicare administrative data (years 2007-2010) were linked to nursing home assessments and area-level socioeconomic indicators. STUDY DESIGN: Medicare beneficiaries who are readmitted to a hospital must pay an additional deductible ($1,100 in 2010) if their readmission occurs more than 59 days following discharge. In a regression discontinuity analysis, we take advantage of this Medicare benefit feature to test whether beneficiaries with greater cost-sharing have higher rates of Medicaid enrollment. DATA EXTRACTION METHODS: We identified 221,248 Medicare beneficiaries with an initial hospital stay and a readmission 53-59 days later (no deductible) or 60-66 days later (charged a deductible). PRINCIPAL FINDINGS: Among beneficiaries in low-socioeconomic areas with two hospitalizations, those readmitted 60-66 days after discharge were 21 percent more likely to join Medicaid compared with those readmitted 53-59 days following their initial hospitalization (absolute difference in adjusted risk of Medicaid entry: 3.7 percent vs. 3.1 percent, p = .01). CONCLUSIONS: Increasing Medicare cost-sharing requirements may promote Medicaid enrollment among low-income beneficiaries. Potential savings from an increased cost-sharing in the Medicare program may be offset by increased Medicaid participation.


Assuntos
Custo Compartilhado de Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Custo Compartilhado de Seguro/economia , Feminino , Financiamento Pessoal/economia , Financiamento Pessoal/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Medicare Part A/economia , Medicare Part A/estatística & dados numéricos , Readmissão do Paciente/economia , Análise de Regressão , Características de Residência , Fatores Socioeconômicos , Estados Unidos
18.
Fed Regist ; 83(249): 67816-8082, 2018 12 31.
Artigo em Inglês | MEDLINE | ID: mdl-30596411

RESUMO

Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. The policies included in this final rule provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. This final rule also provides new tools to support coordination of care across settings and strengthen beneficiary engagement; and ensure rigorous benchmarking. In this final rule, we also respond to public comments we received on the extreme and uncontrollable circumstances policies for the Shared Savings Program that were used to assess the quality and financial performance of ACOs that were subject to extreme and uncontrollable events, such as Hurricanes Harvey, Irma, and Maria, and the California wildfires, in performance year 2017, including the applicable quality data reporting period for performance year 2017.


Assuntos
Organizações de Assistência Responsáveis/economia , Redução de Custos/economia , Planos de Pagamento por Serviço Prestado/economia , Medicare Part A/economia , Medicare Part B/economia , Medicare/economia , Organizações de Assistência Responsáveis/legislação & jurisprudência , Benchmarking , Redução de Custos/legislação & jurisprudência , Desastres , Planos de Pagamento por Serviço Prestado/tendências , Previsões , Política de Saúde , Humanos , Medicare/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Estados Unidos
20.
World Neurosurg ; 104: 68-73, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28502681

RESUMO

BACKGROUND: Adult spinal deformity (ASD) is an important problem to consider in the elderly. Although studies have examined the complications of ASD surgery and have compared functional and radiographic results of primary surgery versus revision, no studies have compared the costs of primary procedures with revisions. We assessed the in-hospital costs of these 2 surgery types in patients with ASD. METHODS: The PearlDiver Database, a database of Medicare records, was used in this study. Mutually exclusive groups of patients undergoing primary or revision surgery were identified. Patients in each group were queried for age, sex, and comorbidities. Thirty-day readmission rates, 30-day and 90-day complication rates, and postoperative costs of care were assessed with multivariate analysis. For analyses, significance was set at P < 0.001. RESULTS: The average reimbursement of the primary surgery cohort was $57,078 ± $30,767. Reimbursement of revision surgery cohort was $52,999 ± $27,658. The adjusted difference in average costs between the 2 groups is $4773 ± $1069 (P < 0.001). The 30-day and 90-day adjusted difference in cost of care when sustaining any of the major medical complications in primary surgery versus revision surgery was insignificant. CONCLUSIONS: Patients undergoing primary and revision corrective procedures for ASD have similar readmission rates, lengths of stays, and complication rates. Our data showed a higher cost of primary surgery compared with revision surgery, although costs of sustaining postoperative complications were similar. This finding supports the decision to perform revision procedures in patients with ASD when indicated because neither outcomes nor costs are a hindrance to correction.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Tempo de Internação/economia , Complicações Pós-Operatórias/economia , Reoperação/economia , Escoliose/economia , Escoliose/cirurgia , Fusão Vertebral/economia , Distribuição por Idade , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare Part A/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Prevalência , Reoperação/estatística & dados numéricos , Fatores de Risco , Escoliose/epidemiologia , Distribuição por Sexo , Fusão Vertebral/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...