New CMS Nursing Home Ownership Data: Major Gaps And Discrepancies.

Nursing home ownership has become increasingly complicated, partly because of the growth of facilities owned by institutional investors such as private equity (PE) firms and real estate investment trusts (REITs). Although the ownership transparency and accountability of nursing homes have historically been poor, the Biden administration's nursing home reform plans released in 2022 included a series of data releases on ownership. However, our evaluation of the newly released data identified several gaps: One-third of PE and fewer than one-fifth of REIT investments identified in the proprietary Irving Levin Associates and S&P Capital IQ investment data were present in Centers for Medicare and Medicaid Services (CMS) publicly available ownership data. Similarly, we obtained different results when searching for the ten top common owners of nursing homes using CMS data and facility survey reports of chain ownership. Finally, ownership percentages were missing in the CMS data for 82.40 percent of owners in the top ten chains and 55.21 percent of owners across all US facilities. Although the new data represent an important step forward, we highlight additional steps to ensure that the data are timely, accurate, and responsive. Transparent ownership data are fundamental to understanding the adequacy of public payments to provide patient care, enable policy makers to make timely decisions, and evaluate nursing home quality.

Comparing the Centers for Medicare and Medicaid Services (CMS) enrollment data death dates to the National Death Index (NDI).

PURPOSE: In the United States, the National Death Index (NDI) is the most complete source of death information, while epidemiologic studies with mortality outcomes often rely on U.S. Medicare data for outcome ascertainment. The purpose of this study was to assess the agreement of death information between the Centers for Medicare & Medicaid Services (CMS) Medicare enrolment data and NDI. METHODS: Using Medicare and NDI data from 1999 through 2016, we identified Medicare beneficiaries who were reported dead in the CMS Medicare enrolment database (EDB) and Common Medicare Environment (CME), linked these beneficiaries to the NDI using CMS Health Insurance Claim number, and compared death dates between the two data sources. To assess agreement between our data sources, we calculated kappa scores; where a kappa of 1 indicates perfect agreement and a kappa of 0 indicates agreement equivalent to chance. We also examined CMS to NDI linkage and death date matching for stability over time. RESULTS: Of the 36 785 640, Medicare beneficiaries reported dead in CMS enrollment data from 1999 to 2016, 97.5% were linked to the NDI. A kappa score of 0.98 showed a near perfect agreement between NDI and CMS reported deaths. The percentage of linked cases exactly matching on death dates increased from 94.8% in 1999 to 99.4% in 2016. CONCLUSIONS: Our findings suggest strong concordance between death dates as recorded by CMS enrollment data and the NDI in the entire Medicare population.

Missed opportunities in hospital quality measurement during the COVID-19 pandemic: a retrospective investigation of US hospitals' CMS Star Ratings and 30-day mortality during the early pandemic.

OBJECTIVES: In the USA and UK, pandemic-era outcome data have been excluded from hospital rankings and pay-for-performance programmes. We assessed the relationship between US hospitals' pre-pandemic Centers for Medicare and Medicaid Services (CMS) Overall Hospital Star ratings and early pandemic 30-day mortality among both patients with COVID and non-COVID to understand whether pre-existing structures, processes and outcomes related to quality enabled greater pandemic resiliency. DESIGN AND DATA SOURCE: A retrospective, claim-based data study using the 100% Inpatient Standard Analytic File and Medicare Beneficiary Summary File including all US Medicare Fee-for-Service inpatient encounters from 1 April 2020 to 30 November 2020 linked with the CMS Hospital Star Ratings using six-digit CMS provider IDs. OUTCOME MEASURE: The outcome was risk-adjusted 30-day mortality. We used multivariate logistic regression adjusting for age, sex, Elixhauser mortality index, US Census Region, month, hospital-specific January 2020 CMS Star rating (1-5 stars), COVID diagnosis (U07.1) and COVID diagnosis×CMS Star Rating interaction. RESULTS: We included 4 473 390 Medicare encounters from 2533 hospitals, with 92 896 (28.2%) mortalities among COVID-19 encounters and 387 029 (9.3%) mortalities among non-COVID encounters. There was significantly greater odds of mortality as CMS Star Ratings decreased, with 18% (95% CI 15% to 22%; p<0.0001), 33% (95% CI 30% to 37%; p<0.0001), 38% (95% CI 34% to 42%; p<0.0001) and 60% (95% CI 55% to 66%; p<0.0001), greater odds of COVID mortality comparing 4-star, 3-star, 2-star and 1-star hospitals (respectively) to 5-star hospitals. Among non-COVID encounters, there were 17% (95% CI 16% to 19%; p<0.0001), 24% (95% CI 23% to 26%; p<0.0001), 32% (95% CI 30% to 33%; p<0.0001) and 40% (95% CI 38% to 42%; p<0.0001) greater odds of mortality at 4-star, 3-star, 2-star and 1-star hospitals (respectively) as compared with 5-star hospitals. CONCLUSION: Our results support a need to further understand how quality outcomes were maintained during the pandemic. Valuable insights can be gained by including the reporting of risk-adjusted pandemic era hospital quality outcomes for high and low performing hospitals.

New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting.

This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) - the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.

Impact of Centers for Medicare and Medicaid Services Final Rule on Organ Procurement Organization Metrics and Procedural Trends in the Procurement of Pancreata for Research.

OBJECTIVE: Pancreata recovered for research are included as a success (or positive) in the Centers for Medicare and Medicaid Services' (CMS) donation and organ transplantation rate metrics for recertification of organ procurement organizations (OPOs). MATERIALS AND METHODS: Given these metrics directly incentivize recovery of pancreata for research, this study tracks trends in recovery of pancreata for research across the implementation of the CMS metrics. RESULTS: In the 26 months before the December 2, 2020, publication of the CMS metrics, research pancreata as a percent of organs transplanted, including research pancreata, was 1.7% nationally, including as much as 10.8% of organs transplanted within any OPO. In the 26 months after the CMS metrics were published, research pancreata increased to 5.1% of organs counted as transplants nationally, including as much as 20.3% within any OPO. If research pancreata were excluded from the CMS metrics, 6 OPOs would change their CMS evaluation status for recertification purposes: 2 would move up a tier and 4 would move down a tier. CONCLUSIONS: Procurement of research pancreata has increased since the publication of the CMS performance metrics, OPOs vary in their recovery of pancreata for research, and recovery of pancreata for research can affect recertification of OPOs.

The mechanics of risk adjustment and incentives for coding intensity in Medicare.

OBJECTIVE: To study diagnosis coding intensity across Medicare programs, and to examine the impacts of changes in the risk model adopted by the Centers for Medicare and Medicaid Services (CMS) for 2024. DATA SOURCES AND STUDY SETTING: Claims and encounter data from the CMS data warehouse for Traditional Medicare (TM) beneficiaries and Medicare Advantage (MA) enrollees. STUDY DESIGN: We created cohorts of MA enrollees, TM beneficiaries attributed to Accountable Care Organizations (ACOs), and TM non-ACO beneficiaries. Using the 2019 Hierarchical Condition Category (HCC) software from CMS, we computed HCC prevalence and scores from base records, then computed incremental prevalence and scores from health risk assessments (HRA) and chart review (CR) records. DATA COLLECTION/EXTRACTION METHODS: We used CMS's 2019 random 20% sample of individuals and their 2018 diagnosis history, retaining those with 12 months of Parts A/B/D coverage in 2018. PRINCIPAL FINDINGS: Measured health risks for MA and TM ACO individuals were comparable in base records for propensity-score matched cohorts, while TM non-ACO beneficiaries had lower risk. Incremental health risk due to diagnoses in HRA records increased across coverage cohorts in line with incentives to maximize risk scores: +0.9% for TM non-ACO, +1.2% for TM ACO, and + 3.6% for MA. Including HRA and CR records, the MA risk scores increased by 9.8% in the matched cohort. We identify the HCC groups with the greatest sensitivity to these sources of coding intensity among MA enrollees, comparing those groups to the new model's areas of targeted change. CONCLUSIONS: Consistent with previous literature, we find increased health risk in MA associated with HRA and CR records. We also demonstrate the meaningful impacts of HRAs on health risk measurement for TM coverage cohorts. CMS's model changes have the potential to reduce coding intensity, but they do not target the full scope of hierarchies sensitive to coding intensity.

Central Line-Associated Bloodstream Infection Misclassifications-Rethinking the Centers for Disease Control and Prevention's Central Line-Associated Bloodstream Infection Definition and Its Implications.

Centers for Medicare and Medicaid Services imparts financial penalties for central line-associated bloodstream infections (CLABSIs) and other healthcare-acquired infections. Data for this purpose is obtained from the Centers for Disease Control and Prevention (CDC)'s National Health Safety Network. We present examples of misclassification of bloodstream infections into CLABSI by the CDC's definition and present the financial implications of such misclassification and potential long-term implications.

Medicare drug price negotiation: The complexities of selecting therapeutic alternatives for estimating comparative effectiveness.

Under the 2022 Inflation Reduction Act, the Centers for Medicare and Medicaid Services (CMS) are able to negotiate prices for topselling drugs in the Medicare Part B and D programs. In determining initial price offers, CMS will compare the prices and clinical benefits of the drugs subject to negotiation to the prices and clinical benefits of therapeutic alternatives. Despite the central role that the selection of therapeutic alternatives will play in the price negotiations, the available guidance published by CMS provides few details about how the organization will undertake this process, which will be particularly complex for drugs approved for more than one indication. To better inform the selection process, we identified all US Food and Drug Administration-approved indications for the first 10 drugs subject to negotiation. Using 2020-2021 Medicare claims data, we identified Medicare Part D beneficiaries using each of the 10 drugs. We extracted medical claims with diagnosis codes for each of the approved indications to report the relative treated prevalence of use by indication for each drug. We reviewed published clinical guidelines to identify relevant therapeutic alternatives for each of the indications. We integrated the evidence on the relative treated prevalence of indications and clinical guidelines to propose therapeutic alternatives for each of the 10 drugs. We describe challenges that CMS may face in selecting therapeutic alternatives.

Uptake and outcomes of supervised exercise therapy for peripheral artery disease: The importance of vascular medicine specialists at a large midwestern health care system during the first 5 years of CMS reimbursement.

BACKGROUND: Supervised exercise therapy (SET) is the cornerstone of medical therapy for symptomatic peripheral artery disease (PAD). Despite the efficacy of SET, initial reports following the 2017 Centers for Medicare and Medicaid Services (CMS) reimbursement decision indicate low SET uptake, referral, and completion. Vascular medicine specialists are key to the success of such programs. We examined rates of SET referral, completion, and outcomes in a health system with a robust SET program during the first 5 years of CMS reimbursement. METHODS: A retrospective chart review of patients with PAD referred to SET between October 1, 2017 and December 31, 2022 was conducted. Patient demographic and medical characteristics, SET indication, referring provider specialty, SET participation (e.g., exercise modality, number of sessions, treadmill prescription), and outcomes were abstracted. Descriptive statistics, t-tests, and multiple linear regression were used to examine the sample, evaluate outcomes, and explore outcomes by relevant covariates (i.e., age, sex, referring provider specialty). RESULTS: Of 5320 patients with PAD, N = 773 were referred to SET; N = 415 enrolled and were included in the present study. Vascular medicine and vascular surgery specialists were the two primary sources of referrals (30.6% and 51.6%, respectively). A total of 207 patients (49.9%) completed SET. Statistically significant and clinically meaningful improvements were observed in all outcomes. CONCLUSION: SET referral and completion rates are low in the 5 years following CMS reimbursement, despite the advocacy of vascular medicine specialists. SET is effective in improving patient functional capacity and quality of life. Additional efforts are needed to increase both SET availability and referrals as part of comprehensive treatment of PAD.

Assessing the Impact of the Center for Medicare and Medicaid Services Policy Guidance on Part D Prescriptions Among Hospice Patients.

Hospice care facilities are required to provide prescription drugs related to a hospice patient's terminal illness. From October 2010 to present, the Center for Medicare and Medicaid Services (CMS) has issued a series of communications regarding Medicare paying for hospice patients' prescription drugs under Part D that should be covered under the hospice Medicare Part A benefit. On April 4, 2011, CMS issued specific policy guidance to providers aimed at preventing inappropriate billing. While CMS has documented Part D prescription decreases in hospice patients, no research exists that connects these decreases and the policy guidance. This study aims to evaluate the effect of the April 4, 2011, policy guidance on hospice patients' Part D prescriptions. This study employed generalized estimating equations to assess (1) total monthly average prescriptions of all medications and (2) four categories of commonly prescribed hospice medications in pre-and-post policy guidance. This research used the Medicare claims of 113,260 Part D-enrolled Medicare male patients aged 66 and older between April 2009 and March 2013, including 110,547 non-hospice patients and 2713 hospice patients. Hospice patients' monthly average total Part D prescriptions decreased from 7.3 pre-policy guidance to 6.5 medications following the issuing of the guidance, while the four categories of hospice-specific medications decreased from .57 to .49. The findings of this study show that CMS's guidance issued to providers to prevent the inappropriate billing of hospice patients' prescriptions to the Part D benefit may lead to Part D prescription decreases as observed in this sample.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list.

BACKGROUND: In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. METHODS: Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. RESULTS: Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001). CONCLUSIONS: There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

Cheating the Rules of Admission With "Observation".

When physicians admit patients to a hospital, their decisions about where-and to whose professional stewardship and services-those patients belong are influenced by federal policies, of which many clinicians are not aware. The distinction between observation and admission has clinical and ethical implications for patients and practices. The evolution of "observation status" from a clinical tool to a catchall of vague and imprecise meaning has been driven by changes to physician payment and compensation structures, particularly Current Procedural Terminology codes and Centers for Medicare and Medicaid Services regulations, and its current value to clinicians and patients is questionable. This article contextualizes clinicians' admission and observation practices and considers how metrics influence patient costs and how clinicians and organizations are compensated.

Compliance and Documentation for Evaluation and Management Services in Interventional Pain Management Practice.

Evaluation of new and established patients is an integral part of interventional pain management. Over the last 3 decades, there has been significant confusion over the proper documentation for evaluation and management (E/M) services in general and for interventional pain management in particular. Interventional pain physicians have learned how to evaluate patients presenting with pain on the basis of their specialty training. Although modern training programs are introducing residents and fellows to the intricacies of E/M services and federal regulations, this has not always been the case. Multiple textbooks about pain management, physiatry, and neurology, and numerous journal articles have described the evaluation of pain patients, but they have not been specific to chronic pain patients and may not meet the regulatory perspective.A multitude of these issues led to the development of guidelines in 1995 and 1997, which were highly complicated and difficult to follow. These also led to significant criticism from clinicians. Consequently, further guidance was developed to be effective January 2021.The crucial concept in the present system of coding for E/M services is medical decision making, which includes 3 elements since 2021: 1.The number and complexity of problems addressed. 2. Amount or complexity of data to be reviewed and analyzed. 3. Risk of complications and/or morbidity or mortality of patient management. In order to select a level of E/M service, 2 of the 3 elements of medical decision making (MDM) must be met or exceeded. This is in contrast to prior guidelines wherein for new patients, all 3 elements with history, physical examination and MDM , and for established patients have been met. For ease of appreciation, an algorithmic approach created by the American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS) approved a new MDM table outlining all of the appropriate criteria.This review systematically describes the changes and provides an algorithmic approach for application in interventional pain management practices.

Industry Payments Comparison Between Female and Male Mohs Surgeons From 2015 to 2021.

BACKGROUND: There are limited data on female Mohs surgeon industry relationships. OBJECTIVE: To evaluate industry payment activity between female and male Mohs surgeons. MATERIALS AND METHODS: A retrospective review of the U.S. Centers for Medicare and Medicaid Services open payments data was performed between 2015 and 2021 for Mohs surgeons in the United States. Gender, academic affiliation, practice region, annual total payment, cumulative payment, and industry payment type was collected. RESULTS: Male Mohs surgeons received higher mean total payments than female Mohs surgeons ( p = .04), which persisted when data were stratified based on industry payment type and practice region. Both genders had similar median total payments ( p = .4). Females in academic practice received higher mean total payments than those in private practice. Females experienced a significant lower mean total payment compared with males in the South ( p = .03). CONCLUSION: High total payments received by male Mohs surgeons skewed the data, which is supported by a significant mean total payment difference despite a similar median total payment distribution. Female Mohs surgeons receiving the top payments may address this mean payment difference. Females seem to have higher payments if they practice in the Northeast and are in academics. Further studies are needed to evaluate this payment gap.