RESUMO
This Viewpoint discusses the proliferation of Medicare Advantage plans targeting specific groups of individuals and whether these plans will improve quality of care for beneficiaries.
Assuntos
Benefícios do Seguro , Medicare Part C , Qualidade da Assistência à Saúde , Planos de Pagamento por Serviço Prestado , Medicare Part C/economia , Medicare Part C/estatística & dados numéricos , Medicare Part C/tendências , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/normas , Estados Unidos/epidemiologia , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Cobertura do Seguro/tendências , Benefícios do Seguro/economia , Benefícios do Seguro/estatística & dados numéricos , Benefícios do Seguro/tendênciasRESUMO
Health benefits packages in Colombia-what is covered, by whom, and at what cost-have evolved over the past thirty years. Coverage changed from two explicit health benefits packages (with benefits linked to ability to contribute) to an implicit approach that covers, in theory, everything for everyone, excluding a narrow negative list of services and health technologies. This article explores the evolution of priority setting in Colombia during two periods of major reform. Each period had its own advantages and disadvantages associated with different institutional arrangements, processes, and methodologies. Colombia's evolution provides several lessons for other low- and middle-income countries interested in institutionalizing evidence-based priority-setting.
Assuntos
Reforma dos Serviços de Saúde , Colômbia , Humanos , Reforma dos Serviços de Saúde/tendências , Prioridades em Saúde/tendências , Benefícios do Seguro/tendências , Seguro Saúde/tendênciasAssuntos
Gastos em Saúde , Benefícios do Seguro , Medicare , Patient Protection and Affordable Care Act , Idoso , Humanos , Gastos em Saúde/legislação & jurisprudência , Medicare/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência , Estados Unidos , Inflação/legislação & jurisprudência , Benefícios do Seguro/legislação & jurisprudência , Benefícios do Seguro/tendênciasRESUMO
We estimated excess mortality in Medicare recipients in the United States with probable and confirmed Covid-19 infections in the general community and amongst residents of long-term care (LTC) facilities. We considered 28,389,098 Medicare and dual-eligible recipients from one year before February 29, 2020 through September 30, 2020, with mortality followed through November 30th, 2020. Probable and confirmed Covid-19 diagnoses, presumably mostly symptomatic, were determined from ICD-10 codes. We developed a Risk Stratification Index (RSI) mortality model which was applied prospectively to establish baseline mortality risk. Excess deaths attributable to Covid-19 were estimated by comparing actual-to-expected deaths based on historical (2017-2019) comparisons and in closely matched concurrent (2020) cohorts with and without Covid-19. Overall, 677,100 (2.4%) beneficiaries had confirmed Covid-19 and 2,917,604 (10.3%) had probable Covid-19. A total of 472,329 confirmed cases were community living and 204,771 were in LTC. Mortality following a probable or confirmed diagnosis in the community increased from an expected incidence of about 4.0% to actual incidence of 7.5%. In long-term care facilities, the corresponding increase was from 20.3% to 24.6%. The absolute increase was therefore similar at 3-4% in the community and in LTC residents. The percentage increase was far greater in the community (89.5%) than among patients in chronic care facilities (21.1%) who had higher baseline risk of mortality. The LTC population without probable or confirmed Covid-19 diagnoses experienced 38,932 excess deaths (34.8%) compared to historical estimates. Limitations in access to Covid-19 testing and disease under-reporting in LTC patients probably were important factors, although social isolation and disruption in usual care presumably also contributed. Remarkably, there were 31,360 (5.4%) fewer deaths than expected in community dwellers without probable or confirmed Covid-19 diagnoses. Disruptions to the healthcare system and avoided medical care were thus apparently offset by other factors, representing overall benefit. The Covid-19 pandemic had marked effects on mortality, but the effects were highly context-dependent.
Assuntos
COVID-19/mortalidade , Medicare/tendências , Idoso , Idoso de 80 Anos ou mais , COVID-19/economia , Feminino , Humanos , Incidência , Benefícios do Seguro/tendências , Assistência de Longa Duração/tendências , Masculino , Mortalidade , Fatores de Risco , SARS-CoV-2/patogenicidade , Instituições de Cuidados Especializados de Enfermagem/tendências , Estados UnidosRESUMO
BACKGROUND: Carotid revascularization for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial in the past few decades as the best medical therapy has improved. The aim of this study was to assess and define contemporary trends in the rate of carotid revascularization procedures for ACAS in the United States and to characterize outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers. METHODS: We used 100% Medicare fee-for-service claims to identify all patients who were newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic carotid artery stenosis, those with prior carotid revascularization, and surgeons who performed ≤10 CEAs during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with undergoing a carotid endarterectomy or carotid artery stent procedure within 3 months after the initial diagnosis of ACAS. We also assessed temporal trends in carotid revascularization rates over time using the Cochran-Armitage Trend Test. RESULTS: Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS during the study period, of which 23,481 (3.0%) underwent carotid revascularization within 3 months. There was a significant decline in overall carotid artery revascularization rates over time (2011: 3.2% vs. 2018: 2.1%; P < 0.001). The median and mean physician-specific carotid revascularization rates were 2.0% (IQR 0.0%-6.3%) and 4.7% ± 7.1%, respectively. Three-hundred and fifty physicians (5.2%) had carotid revascularization rates ≥19%, which was more than 2 standard deviations above the mean. After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for newly diagnosed ACAS included male sex (adjusted OR 1.59, 95% CI 1.35-1.89), more years in practice (≥31 vs. <10 years, aOR 1.64, 95% CI 1.32-2.04), rural practice location (aOR 1.34, 95% CI 1.18-1.52), Southern region practice location (versus Northeast, aOR 1.54, 95% CI 1.39-1.69), and lower volume of ACAS patients (lower versus upper tertile, aOR 2.62, 95% CI 2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of carotid revascularization compared to vascular surgeons (95% CI 1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P < 0.05). CONCLUSIONS: The current early revascularization rate for newly diagnosed ACAS is <5% among proceduralists in the United States, and has been decreasing steadily since 2014. There are particular physician-level characteristics that are associated with higher rates of carotid revascularization that cannot be fully contextualized without high-level contemporary outcomes data to guide decision making in ACAS.
Assuntos
Estenose das Carótidas/terapia , Endarterectomia das Carótidas/tendências , Procedimentos Endovasculares/tendências , Benefícios do Seguro/tendências , Medicare/tendências , Padrões de Prática Médica/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cardiologistas/tendências , Estenose das Carótidas/diagnóstico por imagem , Bases de Dados Factuais , Endarterectomia das Carótidas/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiologistas/tendências , Estudos Retrospectivos , Stents/tendências , Cirurgiões/tendências , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Neurosurgical spine specialists receive considerable amounts of industry support that may impact the cost of care. The aim of this study was to evaluate the association between industry payments received by spine surgeons and the total hospital and operating room (OR) costs of an anterior cervical discectomy and fusion (ACDF) procedure among Medicare beneficiaries. METHODS: All ACDF cases were identified among the Medicare carrier files from January 1, 2013, to December 31, 2014, and matched to the Medicare inpatient baseline file. The total hospital and OR charges were obtained for these cases. Charges were converted to cost using year-specific cost-to-charge ratios. Surgeons were identified among the Open Payments database, which is used to quantify industry support. Analyses were performed to examine the association between industry payments received and ACDF costs. RESULTS: Matching resulting in the inclusion of 2209 ACDF claims from 2013-2014. In 2013 and 2014, the mean total cost for an ACDF was $21,798 and $21,008, respectively; mean OR cost was $5878 and $6064, respectively. Mann-Whitney U test demonstrated no significant differences in the mean total or OR cost for an ACDF based on quartile of general industry payment received (P = 0.21 and P = 0.54), and linear regression found no association between industry general payments, research support, or investments on the total hospital cost (P = 0.41, P = 0.13, and P = 0.25, respectively), or OR cost for an ACDF (P = 0.35, P = 0.24, and P = 0.40, respectively). CONCLUSIONS: This study suggests that spine surgeons performing ACDF surgeries may receive industry support without impacting the cost of care.
Assuntos
Vértebras Cervicais/cirurgia , Discotomia/economia , Custos Hospitalares , Medicare/economia , Médicos/economia , Fusão Vertebral/economia , Idoso , Idoso de 80 Anos ou mais , Discotomia/tendências , Feminino , Custos Hospitalares/tendências , Humanos , Indústrias/economia , Indústrias/tendências , Benefícios do Seguro/economia , Benefícios do Seguro/tendências , Masculino , Medicare/tendências , Médicos/tendências , Fusão Vertebral/tendências , Estados UnidosRESUMO
BACKGROUND: Despite the proven efficacy of prescription regimens in reducing disease symptoms and preventing or minimizing complications, poor medication adherence remains a significant public health problem. Medicare beneficiaries have high rates of chronic illness and prescription medication use, making this population particularly vulnerable to nonadherence. Failure to fill prescribed medication is a key component of nonadherence. OBJECTIVES: To (1) determine the rates of self-reported failure to fill at least 1 prescription among a sample of Medicare beneficiaries in 2004, (2) identify the reasons for not filling prescribed medication, (3) examine the characteristics of Medicare beneficiaries who failed to fill their prescription(s), and (4) identify the types of medications that were not obtained. METHODS: The study is a secondary analysis of the 2004 Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey conducted by the Centers for Medicare & Medicaid Services (CMS). Medicare beneficiaries living in the community (N = 14,464) were asked: "During the current year [2004], were there any medicines prescribed for you that you did not get (please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a doctor)?" Those who responded "yes" to this question (n = 664) were asked to identify the specific medication(s) not obtained. Rates of failure to fill were compared by demographic and income categories and for respondents with versus without self-reported chronic conditions, identified by asking respondents if they had ever been told by a doctor that they had the condition. Weighted population estimates for nonadherence were calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN) to account for the MCBS multistage stratified cluster sampling process. Unweighted counts of the prescriptions not filled by therapeutic class were calculated using Statistical Analysis Software (SAS). RESULTS: In 2004, an estimated 1.6 million Medicare beneficiaries (4.4%) failed to fill or refill 1 or more prescriptions. The most common reasons cited for failure to fill were: "thought it would cost too much" (55.5%), followed by "medicine not covered by insurance" (20.2%), "didn't think medicine was necessary for the condition" (18.0%), and "was afraid of medicine reactions/contraindications" (11.8%). Rates of failure to fill were significantly higher among Medicare beneficiaries aged 18 to 64 years eligible through Social Security Disability Insurance (10.4%) than among beneficiaries aged 65 years or older (3.3%, P < 0.001). Rates were slightly higher for women than for men (5.0 vs. 3.6%, P = 0.001), for nonwhite than for white respondents (5.5% vs. 4.2%, P = 0.010), and for dually eligible Medicaid beneficiaries than for those who did not have Medicaid coverage (6.3% vs. 4.0% P = 0.001). Failure-to-fill rates were significantly higher among beneficiaries with psychiatric conditions (8.0%, P < 0.001); arthritis (5.2%, P < 0.001); cardiovascular disease (5.2%, P = 0.003); and emphysema, asthma, or chronic obstructive pulmonary disease (6.6%, P < 0.001) than among respondents who did not report those conditions, and the rate for respondents who reported no chronic conditions was 2.5%. Rates were higher for those with more self-reported chronic conditions (3.2%, 4.0%, 4.3%, and 5.9% for those with 1, 2, 3, and 4 or more conditions, respectively, P < 0.001). Among the prescriptions not filled (993 prescriptions indentified by 664 respondents), central nervous system agents, including nonsteroidal anti-inflammatory drugs, were most frequently identified (23.6%, n = 234), followed by cardiovascular agents (18.3%, n = 182) and endocrine/metabolic agents (6.5%, n = 65). Of the reported unfilled prescriptions, 8.1% were for antihyperlipidemic agents, 5.4% were for antidepressant drugs, 4.6% were for antibiotics, and 29.9% were for unidentified therapy classes. CONCLUSION: Most Medicare beneficiaries fill their prescriptions, but some subpopulations are at significantly higher risk for nonadherence associated with unfilled prescriptions, including working-age beneficiaries, dual-eligible beneficiaries, and beneficiaries with multiple chronic conditions. Self-reported unfilled prescriptions included critical medications for treatment of acute and chronic disease, including antihyperlipidemic agents, antidepressants, and antibiotics. DISCLOSURES: This study was funded by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research, Field Initiated Research Grant H133G070055. However, the analysis and the interpretation of these findings do not necessarily represent the policy of the Department of Education and are not endorsed by the federal government. All authors contributed approximately equally to the study concept and design. Tuleu performed the majority of the data collection, with assistance from Kennedy. Kennedy interpreted the data, with assistance from Tuleu and Mackay. Kennedy and Mackay wrote the majority of the manuscript, with assistance from Tuleu. Kennedy made the majority of the changes in revision of the manuscript.
Assuntos
Prescrições de Medicamentos , Benefícios do Seguro/tendências , Medicare/tendências , Adesão à Medicação , Medicamentos sob Prescrição/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Adesão à Medicação/psicologia , Pessoa de Meia-Idade , Prevalência , Estados Unidos/epidemiologia , Adulto JovemRESUMO
DISCLOSURES: No funding supported the writing of this commentary. The authors have nothing to disclose.
Assuntos
Benefícios do Seguro/legislação & jurisprudência , Medicare Part D/legislação & jurisprudência , Assistência Farmacêutica/legislação & jurisprudência , Humanos , Benefícios do Seguro/tendências , Medicare Part D/tendências , Adesão à Medicação , Assistência Farmacêutica/tendências , Estados UnidosAssuntos
Diabetes Mellitus/terapia , Medicare/tendências , Educação de Pacientes como Assunto/economia , Educação de Pacientes como Assunto/métodos , Autogestão/educação , Academias e Institutos , Idoso , Dietética , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/tendências , Medicare/economia , Medicare Part B , Defesa do Paciente , Mecanismo de Reembolso , Autogestão/economia , Resultado do Tratamento , Estados UnidosRESUMO
Objective: This article presents the results of a systematic review of the latest, state-of-the-art research on videogames designed for older adults (i.e., those aged 65 or older) and the health benefits derived from playing these games. Findings from each study that met the inclusion criteria were analyzed and summarized into emergent themes to determine the impact of digital games in promoting healthy behaviors and benefits among these older adults. Materials and Methods: Five databases (PubMed, ScienceDirect, IEEE Xplore, ACM Digital Library, and Google Scholar) were searched for studies that evaluated interventions of videogames for older adults aged 65 and older. The initial search yielded 806 articles. After evaluating them against the inclusion criteria, 23 studies remained. Results: Out of the 23 studies we reviewed, 20 reported the significant impact of videogame interventions on the elderly's physical health. In addition, 14 studies reported effects on the elderly's mental health. Exergame is the most popular type of game used in these videogame-based interventions. This review also includes the details of study design (e.g., type of intervention, length, frequency), population sample, and measurements used in the studies. Conclusions: This systematic review demonstrates that videogame-based interventions are helpful in promoting physical health (i.e., balance, mobility, strength, physical fitness, and walking performance/gait parameters) and mental health (i.e., balance confidence, executive functions, reaction time, and processing speed) among older adults. It can also be used by researchers in this field to inform their design decisions. We have listed guidelines that can be used to frame future research in the area and enhance its quality.
Assuntos
Envelhecimento/psicologia , Benefícios do Seguro/tendências , Jogos de Vídeo/normas , Humanos , Saúde Mental , Aptidão Física/fisiologia , Aptidão Física/psicologia , Jogos de Vídeo/psicologia , Jogos de Vídeo/tendênciasAssuntos
Política Ambiental/legislação & jurisprudência , União Europeia/organização & administração , Gases de Efeito Estufa/efeitos adversos , Saúde/legislação & jurisprudência , Benefícios do Seguro/tendências , Mudança Climática/estatística & dados numéricos , Saúde/estatística & dados numéricos , Humanos , Benefícios do Seguro/estatística & dados numéricos , Comportamento SedentárioRESUMO
OBJECTIVE: This study used Social Security Administration program data to identify population-level trends in Supplemental Security Income (SSI) program participation and payments to adult recipients with autism spectrum disorder (ASD) relative to recipients with intellectual disability and other mental disorders. METHODS: The authors examined SSI program data from 2005 to 2015. Variables included caseload size, number of new adult awardees per year, total annual SSI payments per disability group, and average annual SSI payment per recipient. RESULTS: Adults with ASD represented a growing share of the total first-time SSI awards given to adults with mental disorders, with percentages increasing from 1.3% in 2005 to 5.0% in 2015. In 2015, 158,105 adults with ASD received SSI benefits, a 326.8% increase since 2005. Federal SSI payments to adults with ASD increased by 383.2% during the same period (totaling roughly $1.0 billion in 2015). The annual average payment for adults with ASD was $6,527.40 in 2015. CONCLUSIONS: The purpose of the SSI program is to reduce the extent of poverty by providing monthly payments to eligible individuals with disabilities. The authors found that a large and growing number of adults with autism receive SSI benefits. This finding underscores the importance of future research related to the economic security of adults on the autism spectrum.
Assuntos
Transtorno do Espectro Autista , Pessoas com Deficiência , Benefícios do Seguro/tendências , Previdência Social/tendências , Adolescente , Adulto , Feminino , Humanos , Benefícios do Seguro/estatística & dados numéricos , Masculino , Pobreza , Previdência Social/estatística & dados numéricos , Estados Unidos , United States Social Security Administration , Adulto JovemRESUMO
Importance: Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage was extended to benzodiazepines in 2013. Objective: To examine whether the expansion of benzodiazepine coverage among Medicare Advantage (MA) beneficiaries was associated with increases in fall-related injuries or overdoses among older adults. Design, Setting, and Participants: This ecological study used interrupted time-series with comparison-series analyses of MA claims data from 4â¯635â¯312 age-eligible MA beneficiaries and 940â¯629 commercially insured individuals (comparison group) stratified by age (65-69, 70-74, 75-79, and ≥80 years) to separately compare trends in fall-related injury and overdose before (January 1, 2010, to December 31, 2012) and after (January 1, 2013, to December 31, 2015) coverage expansion for benzodiazepines. Data analysis was performed from September 1, 2018, to August 31, 2019. Exposures: Expansion of benzodiazepine coverage in Medicare Part D in 2013. Main Outcomes and Measures: Monthly rate of fall-related injury and overdose. Results: In 2012 (the year before the policy change), women constituted 57.5% of the MA group and 47.4% of the comparison group. A total of 25.8% of individuals in the MA group were aged 65 to 69 years, and 29.3% were 80 years or older (mean [SD], 75.1 [6.4] years); 56.7% of individuals in the comparison group were aged 65 to 69 years, and 15.1% were 80 years or older (mean [SD] age, 70.9 [6.5] years). In the MA group, 4â¯635â¯312 individuals contributed 156â¯754â¯749 person-months from 2010 through 2015; in the comparison group, 940â¯629 individuals contributed 25â¯104â¯534 person-months. After coverage of benzodiazepines began, the rate (ie, slope) of fall-related injury among MA beneficiaries increased from before to after coverage among all age groups. Compared with the comparison group, the increase in rate was statistically significant for those 80 years or older (rate changes for the MA vs comparison groups: 0.12 [95% CI, 0.07 to 0.17] vs -0.01 [95% CI, -0.11 to 0.10]; P = .04 for interaction). The overdose trend changed from decreasing to increasing among MA beneficiaries after coverage for all age groups, with a statistically significant increase compared with the comparison group among those aged 65 to 69 years (rate changes for the MA vs comparison groups: 0.23 [95% CI, 0.17 to 0.30] vs 0.02 [95% CI, -0.06 to 0.11]; P < .001 for interaction) and among those 80 years or older (rate changes for the MA vs comparison groups: 0.07 [95% CI, 0.00 to 0.14] vs -0.20 [95% CI, -0.35 to -0.05]; P = .002 for interaction). Results among MA beneficiaries were consistent when stratified by sex and when limited to those prescribed opioids. Conclusions and Relevance: Medicare's expansion of benzodiazepine coverage may have been associated with increases in the rates of overdose among adults ages 65 to 69 years and in the rates of overdose and fall-related injury among those 80 years or older.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Benzodiazepinas/efeitos adversos , Benefícios do Seguro/tendências , Cobertura do Seguro/estatística & dados numéricos , Medicare Part D/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Benzodiazepinas/uso terapêutico , Estudos de Casos e Controles , Overdose de Drogas/epidemiologia , Feminino , Humanos , Benefícios do Seguro/economia , Análise de Séries Temporais Interrompida , Masculino , Medicare Part C , Medicare Part D/economia , Segurança do Paciente , Medicamentos sob Prescrição/efeitos adversos , Medicamentos sob Prescrição/provisão & distribuição , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions. OBJECTIVE: We tested the association between structural factors of the health care delivery system and regional differences systemic overuse. RESEARCH DESIGN: We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time. RESULTS: The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse. CONCLUSIONS: Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.
Assuntos
Geografia , Mau Uso de Serviços de Saúde , Benefícios do Seguro , Setor Privado , Adulto , Atenção à Saúde/economia , Atenção à Saúde/tendências , Feminino , Mau Uso de Serviços de Saúde/economia , Mau Uso de Serviços de Saúde/tendências , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/tendências , Masculino , Medicare/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. METHODS AND RESULTS: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. CONCLUSIONS: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.
Assuntos
Reabilitação Cardíaca/tendências , Cardiopatias/reabilitação , Benefícios do Seguro/tendências , Medicare/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Cooperação do Paciente , Participação do Paciente/tendências , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Definição da Elegibilidade/tendências , Feminino , Disparidades em Assistência à Saúde/tendências , Cardiopatias/diagnóstico , Cardiopatias/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: This study aimed to examine the temporal trend of 30-day and 1-year mortality among U.S. Medicare beneficiaries who were hospitalized for ischemic stroke, with special focus on the mortality among subgroup of patients in relation to acute reperfusion therapies including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). METHODS: We evaluated Medicare fee-for-service beneficiaries age 65 years or older who were hospitalized for ischemic stroke between 2009 and 2013. Multivariable Cox proportional hazards models were generated to analyze the trend of adjusted mortality. RESULTS: A total of 1,070,574 patients were included in the study. The 30-day mortality did not change among patients who were not treated with IVT or EVT. It decreased by 13% among patients treated with IVT but not EVT (HRâ¯=â¯.87, 95% CI .82-.92), 25% among patients treated with EVT but not IVT (HRâ¯=â¯.75, 95% CI .59-.95), and 37% among patients treated with both IVT and EVT (HRâ¯=â¯.63, 95% CI .52-.77). One-year mortality decreased by 19% among patients who were not treated with IVT nor EVT (HRâ¯=â¯.81, 95% CI .80-.83), 22% among those treated with IVT but not EVT (HRâ¯=â¯.78, 95% CI .75-.81), 33% among those treated with EVT but not IVT (HRâ¯=â¯.67, 95% CI .55-.81), and 38% among those treated with both IVT and EVT (HRâ¯=â¯.62, 95% CI .53-.73). CONCLUSIONS: From 2009 to 2013, the 30-day stroke case fatality decreased only among the patients received reperfusion therapy. The 1-year mortality declined among all the stroke patients, with the greatest decline among those treated with both IVT and EVT.
Assuntos
Isquemia Encefálica/mortalidade , Benefícios do Seguro/tendências , Medicare/tendências , Acidente Vascular Cerebral/mortalidade , Trombectomia/mortalidade , Terapia Trombolítica/mortalidade , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Terapia Combinada , Feminino , Humanos , Masculino , Mortalidade/tendências , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Despite widespread adoption of Medicare accountable care organizations (ACOs), healthcare spending reductions have been modest. This may relate to variable participation in ACOs by specialist physicians, who disproportionately drive spending. To examine whether specialist participation in Medicare ACOs was associated with changes in healthcare spending and clinical quality, we analyzed national Medicare data. METHODS AND RESULTS: Working with a 20% random sample of Medicare beneficiaries (2008 to 2015), we identified those with cardiovascular disease. We estimated linear regression models at the beneficiary-quarter level to evaluate changes in healthcare spending and clinical quality after the start of the Shared Savings Program in 2012. We then examined whether changes in spending and quality across ACOs were conditional on cardiologist participation. Our study included ≈1.6 million beneficiaries per year. Although the number of ACOs increased over the study period (from 114 in 2012 to 392 in 2015), the proportion with any cardiologist participation remained stable (from 80% in 2012 to 83% in 2015). Compared with unaligned beneficiaries, those cared for by ACOs without cardiologist participation were associated with a spending reduction (per quarter) of -$75 (95% CI, -$105 to -$46; P<0.001). Care receipt in an ACO with cardiologist participation was associated with an additional difference in spending of -$56 (95% CI, -$87 to -$25; P<0.001), driven by lower spending for skilled nursing facilities, evaluation and management services, procedural care, and testing. While heart failure admission rates were similar among aligned and unaligned beneficiaries, ACO care was associated with fewer all-cause readmissions (P<0.001) and emergency department visits (P<0.001). Rates of these outcomes did not vary by cardiologist participation. CONCLUSIONS: Annual spending for beneficiaries with cardiovascular disease was ≈$200 lower when cared for by ACOs with cardiologist participation (compared with those without). These spending reductions did not come at the expense of clinical quality.
Assuntos
Organizações de Assistência Responsáveis/economia , Cardiologistas/economia , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/terapia , Custos de Cuidados de Saúde , Benefícios do Seguro/economia , Medicare/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Papel do Médico , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Organizações de Assistência Responsáveis/tendências , Idoso , Idoso de 80 Anos ou mais , Cardiologistas/tendências , Doenças Cardiovasculares/diagnóstico , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Custos de Cuidados de Saúde/tendências , Humanos , Benefícios do Seguro/tendências , Masculino , Medicare/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Estudos Retrospectivos , Fatores de Tempo , Estados UnidosAssuntos
Custos de Medicamentos/ética , Acessibilidade aos Serviços de Saúde , Insulina/economia , Insulina/uso terapêutico , Benefícios do Seguro , Adulto , África/epidemiologia , Fatores Etários , Canadá/epidemiologia , Indústria Farmacêutica/economia , Indústria Farmacêutica/ética , Indústria Farmacêutica/organização & administração , Feminino , Saúde Global/economia , Saúde Global/normas , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/normas , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/ética , Disparidades em Assistência à Saúde/organização & administração , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Benefícios do Seguro/estatística & dados numéricos , Benefícios do Seguro/tendências , Masculino , Relações Pais-Filho , Estados Unidos/epidemiologia , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/organização & administração , Cobertura Universal do Seguro de Saúde/normas , Organização Mundial da Saúde/economia , Organização Mundial da Saúde/organização & administraçãoRESUMO
PURPOSE: To evaluate the statewide variability in the role of different specialties in lower extremity endovascular revascularization (LEER) and associated submitted charges of care and actual reimbursement for Medicare beneficiaries. METHODS: The 2015 "Medicare Provider Utilization and Payment Data: Physician and Other Supplier" data includes provider-specific information regarding the type of service, submitted average charges of care, and actual average Medicare reimbursements per Healthcare Common Procedure Coding System (HCPCS) code per provider. All HCPCS codes related to LEER were identified. The role of vascular surgery (VS), interventional cardiology (IC), and interventional radiology (IR) in each HCPCS-specific intervention was investigated. RESULTS: In 2015, 4113 providers submitted claims for iliac (n = 13,659), femoropopliteal (n = 52,344), and tibioperoneal (n = 32,688) endovascular revascularizations. In the facility setting, VS performed most of these procedures (52%), followed by IC (32%) and IR (8%). In the outpatient-based lab setting, the proportions were 46%, 36%, and 13%, respectively. Substantial statewide variability in the role of different specialties in LEER was noted. In Maine, Vermont, and Hawaii, all facility claims were submitted by VS, while more than 70% of the claims in Arizona and Utah were submitted by IC. The highest share of LEER for IR was observed in Montana and North Dakota (50%). There was substantial statewide variability in the submitted charges. CONCLUSION: Currently, less than 10% of LEER procedures are being performed by IR. The statewide variability in the submitted charges of care by providers and actual reimbursement for Medicare beneficiaries were investigated in this study.
Assuntos
Procedimentos Endovasculares/tendências , Disparidades em Assistência à Saúde/tendências , Benefícios do Seguro/tendências , Extremidade Inferior/irrigação sanguínea , Medicare/tendências , Doença Arterial Periférica/cirurgia , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Especialização/tendências , Cardiologistas/tendências , Procedimentos Endovasculares/economia , Disparidades em Assistência à Saúde/economia , Humanos , Benefícios do Seguro/economia , Reembolso de Seguro de Saúde/tendências , Medicare/economia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/economia , Padrões de Prática Médica/economia , Avaliação de Processos em Cuidados de Saúde/economia , Radiologistas/tendências , Especialização/economia , Cirurgiões/tendências , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Medicaid expansion among previously uninsured individuals has led to improved healthcare access. However, considerably lower reimbursement rates of Medicaid have raised concerns on the unintended consequence of lower utilization of life-saving therapies and inferior outcomes compared with private insurance. We examined the rates of revascularization and in-hospital mortality among Medicaid beneficiaries versus privately insured individuals hospitalized with ST-segment-elevation myocardial infarction (STEMI). METHODS AND RESULTS: We queried the National Inpatient Sample from 2012 to 2015 for STEMI hospitalizations with Medicaid or private insurance as primary payer. Hospitalizations with the following criteria were excluded: (1) age <18 or ≥65 years, (2) transfer to another acute care facility, and (3) left against medical advice. Outcomes were compared in propensity score-matched cohort based on demographics, socioeconomic status (income based), clinical comorbidities, including drug and alcohol use, STEMI acuity (cardiac arrest and cardiogenic shock), and hospital characteristics. A total of 42 645 and 171 545 STEMI hospitalizations were identified as having Medicaid and private insurance, respectively. In unadjusted analyses, Medicaid beneficiaries with STEMI had lower rates of coronary revascularization (88.9% versus 92.3%; odds ratio, 0.67; 95% CI, 0.65-0.70) and higher rates of in-hospital mortality (4.9% versus 2.8%; odds ratio, 1.81; 95% CI, 1.72-1.91) compared with privately insured individuals ( P<0.001 for both). In propensity-matched cohort of 40 870 hospitalizations per group, similar results for lower rates of revascularization (89.1% versus 91.1%; odds ratio, 0.80; 95% CI, 0.76-0.84) and higher in-hospital mortality (4.9% versus 3.7%; odds ratio, 1.35; 95% CI, 1.26-1.45) were observed in Medicaid compared with private insurance, despite extensive matching ( P<0.001 for both). CONCLUSIONS: Medicaid beneficiaries with STEMI had lower rates of revascularization, although small absolute difference, and higher in-hospital mortality compared with privately insured individuals. Further studies are needed to identify and understand the variation in STEMI outcomes by insurance status.