Disaggregating the dementia monolith: An analysis of variation in Medicare costs and use by dementia subtype.

IMPORTANCE: With an aging population, it is necessary to systematically examine variation in costs and use of Medicare services by dementia subtype. We provide the first national estimates for dementia by subtype, and the respective Medicare costs and use. METHODS: We analyzed Medicare fee-for-service (FFS) claims from 2017 through 2019. The sample included 41 million beneficiaries: 727,700 beneficiaries with a new dementia diagnosis in 2017. We calculated descriptive statistics and conducted generalized linear regression models by subtype of dementia. RESULTS: Annual Medicare costs for beneficiaries with dementia ranged from $22,840 for frontotemporal dementia to $44,896 for vascular dementia compared to $9,034 for beneficiaries without dementia. Comparing beneficiaries across dementia subtypes, the greatest differences were in the use of home health and hospice care. CONCLUSIONS: These analyses demonstrate substantial heterogeneity across dementia subtypes, which will be important in developing models of care that improve value for people with dementia.

County-Level Variation in Emergency Department Admission Rates Among US Medicare Beneficiaries.

STUDY OBJECTIVE: Hospital-based emergency departments (EDs) are the gateway to hospital admissions for many Americans. Approximately half of all US hospital admissions originate from EDs, and more than 3 in 4 are among Medicare beneficiaries. Recent literature has demonstrated nearly 2-fold variation in both physician- and hospital-level ED admission rates. We study geographic variation at the county level in ED admission rates among Medicare fee-for-service beneficiaries. METHODS: Using the 100% population data from the Centers for Medicare & Medicaid Services (CMS), we analyzed beneficiaries continuously enrolled in Medicare fee-for-service Parts A and B who resided in the 50 states and the District of Columbia in 2012. The ED admission rate was aggregated to the county level. ED admission rates were adjusted with the CMS Hierarchical Condition Categories (HCC) risk score. The resulting HCC adjusted ED admission rate was mapped to display the variation by county. RESULTS: The average county HCC adjusted ED admission rate was 30.8% in the Medicare population. Counties in the lowest quintile had an ED admission rate of 19.9% or lower. By comparison, counties in the highest quintile had an ED admission rate of 40.3% or higher. CONCLUSION: Among Medicare beneficiaries, county-level ED admission rates varied 2-fold between counties in the lowest and highest quintiles. Future work should focus on exploring causes for this variation, such as racial ethnic composition, socioeconomic status, and health care delivery system characteristics and the research of effectiveness of policies that affect ED admission decisions.

Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes.

IMPORTANCE: Bundled Payments for Care Improvement (BPCI) is a voluntary initiative of the Centers for Medicare & Medicaid Services to test the effect of holding an entity accountable for all services provided during an episode of care on episode payments and quality of care. OBJECTIVE: To evaluate whether BPCI was associated with a greater reduction in Medicare payments without loss of quality of care for lower extremity joint (primarily hip and knee) replacement episodes initiated in BPCI-participating hospitals that are accountable for total episode payments (for the hospitalization and Medicare-covered services during the 90 days after discharge). DESIGN, SETTING, AND PARTICIPANTS: A difference-in-differences approach estimated the differential change in outcomes for Medicare fee-for-service beneficiaries who had a lower extremity joint replacement at a BPCI-participating hospital between the baseline (October 2011 through September 2012) and intervention (October 2013 through June 2015) periods and beneficiaries with the same surgical procedure at matched comparison hospitals. EXPOSURE: Lower extremity joint replacement at a BPCI-participating hospital. MAIN OUTCOMES AND MEASURES: Standardized Medicare-allowed payments (Medicare payments), utilization, and quality (unplanned readmissions, emergency department visits, and mortality) during hospitalization and the 90-day postdischarge period. RESULTS: There were 29 441 lower extremity joint replacement episodes in the baseline period and 31 700 in the intervention period (mean [SD] age, 74.1 [8.89] years; 65.2% women) at 176 BPCI-participating hospitals, compared with 29 440 episodes in the baseline period (768 hospitals) and 31 696 episodes in the intervention period (841 hospitals) (mean [SD] age, 74.1 [8.92] years; 64.9% women) at matched comparison hospitals. The BPCI mean Medicare episode payments were $30 551 (95% CI, $30 201 to $30 901) in the baseline period and declined by $3286 to $27 265 (95% CI, $26 838 to $27 692) in the intervention period. The comparison mean Medicare episode payments were $30 057 (95% CI, $29 765 to $30 350) in the baseline period and declined by $2119 to $27 938 (95% CI, $27 639 to $28 237). The mean Medicare episode payments declined by an estimated $1166 more (95% CI, -$1634 to -$699; P < .001) for BPCI episodes than for comparison episodes, primarily due to reduced use of institutional postacute care. There were no statistical differences in the claims-based quality measures, which included 30-day unplanned readmissions (-0.1%; 95% CI, -0.6% to 0.4%), 90-day unplanned readmissions (-0.4%; 95% CI, -1.1% to 0.3%), 30-day emergency department visits (-0.1%; 95% CI, -0.7% to 0.5%), 90-day emergency department visits (0.2%; 95% CI, -0.6% to 1.0%), 30-day postdischarge mortality (-0.1%; 95% CI, -0.3% to 0.2%), and 90-day postdischarge mortality (-0.0%; 95% CI, -0.3% to 0.3%). CONCLUSIONS AND RELEVANCE: In the first 21 months of the BPCI initiative, Medicare payments declined more for lower extremity joint replacement episodes provided in BPCI-participating hospitals than for those provided in comparison hospitals, without a significant change in quality outcomes. Further studies are needed to assess longer-term follow-up as well as patterns for other types of clinical care.

Federal efforts to define and advance telehealth--a work in progress.

BACKGROUND: The integration of telecommunications and information systems in healthcare is not new or novel; indeed, it is the current practice of medicine and has been an integral part of medicine in remote locations for several decades. The U.S. Government has made a significant investment, measured in hundreds of millions of dollars, and therefore has a strong presence in the integration of telehealth/telemedicine in healthcare. However, the terminologies and definitions in the lexicon vary across agencies and departments of the U.S. Government. The objective of our survey was to identify and evaluate the definitions of telehealth/telemedicine across the U.S. Government to provide a better understanding of what each agency or department means when it uses these terms. METHODOLOGY: The U.S. Government, under the leadership of the Health Resources and Services Administration in the U.S. Department of Health and Human Services, established the Federal Telemedicine (FedTel) Working Group, through which all members responded to a survey on each agency or department's definition and use of terms associated with telehealth. RESULTS AND CONCLUSIONS: Twenty-six agencies represented by more than 100 individuals participating in the FedTel Working Group identified seven unique definitions of telehealth in current use across the U.S. Government. Although many definitions are similar, there are nuanced differences that reflect each organization's legislative intent and the population they serve. These definitions affect how telemedicine has been or is being applied across the healthcare landscape, reflecting the U.S. Government's widespread and influential role in healthcare access and service delivery. The evidence base suggests that a common nomenclature for defining telemedicine may benefit efforts to advance the use of this technology to address the changing nature of healthcare and new demands for services expected as a result of health reform.

Hospice Coding and Data Conventions Contribute to Oversimplify the Presence of Dementia in Hospice.

OBJECTIVES: To document how dementia diagnoses appear in hospice claims, and how these different presentations reflect different hospice utilization. The reliance in the hospice literature on primary diagnosis, in addition to the focus on decedents, may underestimate the true presence of dementia in hospice, and little is known about the health care utilization of hospice patients with dementia as a secondary or not present diagnosis. DESIGN: Secondary data analysis of Medicare claims. SETTING AND PARTICIPANTS: Medicare beneficiaries with 2 or more dementia diagnoses from 2016 to 2018 electing hospice in 2018. METHODS: Beneficiaries were classified based on the presence and position of dementia on their subset of hospice claims: primary diagnosis, secondary diagnosis, and not present. We then compared the demographics and utilization of the 3 claim-based categories of dementia beneficiaries in hospice in 2018. RESULTS: Fewer than half of beneficiaries with a dementia diagnosis in all of their Medicare claims have dementia indicated as the primary diagnosis associated with their hospice claims, and 30% of beneficiaries did not have their diagnosed dementia appear at all on their hospice claims. Hospice length of stay and other utilization characteristics varied markedly across the 3 claim-based categories of dementia beneficiaries in hospice in 2018. CONCLUSIONS AND IMPLICATIONS: Collectively, International Classification of Diseases, Tenth Revision (ICD-10) coding and sequencing conventions, coding practices, and research methods related to hospice claim diagnoses may unintentionally underestimate and oversimplify how dementia manifests in hospice utilization.

A Horizon Scan to Support Chemical Pollution-Related Policymaking for Sustainable and Climate-Resilient Economies.

While chemicals are vital to modern society through materials, agriculture, textiles, new technology, medicines, and consumer goods, their use is not without risks. Unfortunately, our resources seem inadequate to address the breadth of chemical challenges to the environment and human health. Therefore, it is important we use our intelligence and knowledge wisely to prepare for what lies ahead. The present study used a Delphi-style approach to horizon-scan future chemical threats that need to be considered in the setting of chemicals and environmental policy, which involved a multidisciplinary, multisectoral, and multinational panel of 25 scientists and practitioners (mainly from the United Kingdom, Europe, and other industrialized nations) in a three-stage process. Fifteen issues were shortlisted (from a nominated list of 48), considered by the panel to hold global relevance. The issues span from the need for new chemical manufacturing (including transitioning to non-fossil-fuel feedstocks); challenges from novel materials, food imports, landfills, and tire wear; and opportunities from artificial intelligence, greater data transparency, and the weight-of-evidence approach. The 15 issues can be divided into three classes: new perspectives on historic but insufficiently appreciated chemicals/issues, new or relatively new products and their associated industries, and thinking through approaches we can use to meet these challenges. Chemicals are one threat among many that influence the environment and human health, and interlinkages with wider issues such as climate change and how we mitigate these were clear in this exercise. The horizon scan highlights the value of thinking broadly and consulting widely, considering systems approaches to ensure that interventions appreciate synergies and avoid harmful trade-offs in other areas. We recommend further collaboration between researchers, industry, regulators, and policymakers to perform horizon scanning to inform policymaking, to develop our ability to meet these challenges, and especially to extend the approach to consider also concerns from countries with developing economies. Environ Toxicol Chem 2023;42:1212-1228. © 2023 Crown copyright and The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.

Updated Overview of the SEER-Medicare Data: Enhanced Content and Applications.

BACKGROUND: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was first created almost 30 years ago. Over time, additional data have been added to the SEER-Medicare database, allowing for expanded insights into the delivery of health care across the cancer continuum from screening to end of life. METHODS: This article includes an overview of the current SEER-Medicare database, presenting potential users with an introduction to how the data can facilitate innovative epidemiologic and health services research studies. With a focus on the population 65 years and older, this article presents descriptive data on beneficiary demographics, cancer characteristics, service settings, Medicare coverage (eg, Parts A, B, C, and D), and use (number of services or bills) from 2011 to 2015. RESULTS: From 2011 to 2015, 857 056 cancer patients and 601 470 population-based noncancer controls were added to the database. The database includes detailed tumor characteristics and clinical assessments for cancer cases, and demographics and health-care use (eg, hospitals, outpatient facilities, individual providers, hospice, home health-care providers, and pharmacies) for both cases and controls. Although characteristics varied overall between cases and controls, sufficient cancer-specific matched controls are available. Roughly 60% of cases were enrolled in fee for service at cancer diagnosis. The annual average number of claims per case was 60.7 and 92.3 during the year before and after cancer diagnosis, respectively, and 127.5 during the year before death. CONCLUSIONS: The large sample size and diverse array of data on cancer patients and noncancer controls in the SEER-Medicare database make it a unique resource for conducting cancer health services research.

Creator scientists.

Early this year a group of UK scientists set out to develop a programme of research to build matter to a design - did they succeed?

New York's statistical model accurately predicts mortality risk for veterans who obtain private sector CABG.

OBJECTIVE: To determine whether patients' use of the Veterans Health Administration health care system (VHA) is an independent risk factor for mortality following coronary artery bypass grafting (CABG) in the private sector in New York. DATA SOURCES: VHA administrative and New York Department of Health Cardiac Surgery Reporting System (CSRS) databases for surgeries performed in 1999 and 2000. STUDY DESIGN: Prospective cohort study comparing observed, expected, and risk-adjusted mortality rates following private sector CABG for 2,326 male New York State residents aged 45 years and older who used the VHA (VHA users) and 21,607 who did not (non-VHA users). DATA COLLECTION METHODS: We linked VHA administrative databases to New York's CSRS to identify VHA users who obtained CABG in the private sector in New York in 1999 and 2000. Using CSRS risk factors and previously validated risk-adjustment model, we compared patient characteristics and expected and risk-adjusted mortality rates of VHA users to non-VHA users. PRINCIPAL FINDINGS: Compared with non-VHA users, patients undergoing private sector CABG who had used the VHA were older, had more severe cardiac disease, and were more likely to have the following comorbidities associated with increased risk of mortality: diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, and history of stroke (p<.001 for all); a calcified aorta (p=.009); and a high creatinine level (p=.003). Observed (2.28 versus 1.80 percent) and expected (2.48 versus 1.78 percent) mortality rates were higher for VHA users than for non-VHA users. The risk-adjusted mortality rate for VHA users (1.70 percent; 95 percent confidence interval [CI]: 1.27-2.22) was not statistically different than that for the non-VHA users (1.87 percent; 95 percent CI: 1.69-2.06). Use of the VHA was not an independent risk factor for mortality in the risk-adjustment model. CONCLUSIONS: Although VHA users had a greater illness burden, use of the VHA was not found to be an independent risk factor for mortality following private sector CABG in New York. The New York Department of Health risk adjustment model adequately applies to veterans who obtain CABG in the private sector in New York.

Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans.

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVE: To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. DATA SOURCE/STUDY SETTING: The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). STUDY DESIGN: A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. DATA COLLECTION/EXTRACTION METHODS: Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. PRINCIPAL FINDINGS: The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. CONCLUSIONS: Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.

Disease management for chronically ill beneficiaries in traditional Medicare.

We summarize the Centers for Medicare and Medicaid Services' (CMS's) experience with disease management (DM) in fee-for-service Medicare. Since 1999, the CMS has conducted seven DM demonstrations involving some 300,000 beneficiaries in thirty-five programs. Programs include provider-based, third-party, and hybrid models. Reducing costs sufficient to cover program fees has proved particularly challenging. Final evaluations on twenty programs found three with evidence of quality improvement at or near budget-neutrality, net of fees. Interim monitoring covering at least twenty-one months on the remaining fifteen programs suggests that four are close to covering their fees. Characteristics of the traditional Medicare program present a challenge to these DM models.

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.