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1.
Bone Joint J ; 102-B(6_Supple_A): 19-23, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32475276

RESUMO

AIMS: The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018. METHODS: We examined our institutional database to identify all Medicare patients who underwent primary TKA from 2017 to 2018. Hospital inpatient or outpatient status was cross-referenced with Centers for Medicare & Medicaid Services (CMS) claims data. Demographics, comorbidities, and outcomes were compared between patients classified as 'outpatient' and 'inpatient' TKA. Episode-of-care BPCI costs were then compared from 2017 to 2018. RESULTS: Of the 2,135 primary TKA patients in 2018, 908 (43%) were classified as an outpatient and were excluded from BPCI. Inpatient classified patients had longer mean length of stay (1.9 (SD 1.4) vs 1.4 (SD 1.7) days, p < 0.001) and higher rates of discharge to rehabilitation (17% vs 3%, p < 0.001). Post-acute care costs increased when comparing the BPCI patients from 2017 to 2018, ($5,037 (SD $7,792) vs $5793 (SD $8,311), p = 0.010). The removal of TKA from the IPO list turned a net savings of $53,805 in 2017 into a loss of $219,747 in 2018 for our BPCI programme. CONCLUSIONS: Following the removal of TKA from the IPO list, nearly half of the patients at our institution were inappropriately classified as an outpatient. Our target price was increased and our institution realized a substantial loss in 2018 BPCI despite strong quality metrics. CMS should address its negative implications on bundled payment programmes. Cite this article: Bone Joint J 2020;102-B(6 Supple A):19-23.


Assuntos
Artroplastia do Joelho/economia , Remoção de Dispositivo/economia , Mecanismo de Reembolso , Adulto , Idoso , Feminino , Hospitalização , Humanos , Masculino , Medicare , Estudos Retrospectivos , Estados Unidos
2.
Arthroscopy ; 36(6): 1584-1586, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32503772

RESUMO

Hip arthroscopy is known to be a relatively safe procedure with a limited and unique set complications and low hospital readmission rates. Many patients, however, may seek emergency department evaluation after surgery for postoperative pain or complaints unrelated to the most commonly cited complications, such as traction neuropraxia. It is important to recognize and understand the reasons why patients seek medical care after surgery because many of these encounters may be preventable with optimization of perioperative multimodal pain control regimens and proper patient education regarding their expected postoperative course. Patients with barriers to health care access, such as Medicare and Medicaid patients, may be at higher risk for emergency department evaluation of their problems after surgery and clinicians should consider providing additional counseling to these patients regarding when and how to seek medical evaluation after surgery.


Assuntos
Artroscopia , Manejo da Dor , Serviço Hospitalar de Emergência , Humanos , Medicare , Readmissão do Paciente , Estados Unidos
5.
JAMA ; 323(18): 1813-1823, 2020 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-32396181

RESUMO

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge. Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015. Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge. Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality. Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01). Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.


Assuntos
Doença Pulmonar Obstrutiva Crônica/reabilitação , Idoso , Estudos de Coortes , Planos de Pagamento por Serviço Prestado , Feminino , Hospitalização , Humanos , Masculino , Medicare , Pontuação de Propensão , Doença Pulmonar Obstrutiva Crônica/mortalidade , Análise de Regressão , Estudos Retrospectivos , Análise de Sobrevida , Tempo para o Tratamento , Estados Unidos
9.
Sr Care Pharm ; 35(5): 237, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32340661

RESUMO

The decision of the Centers for Medicare & Medicaid Services to suspend routine surveys in favor of focused inspections targeted at infection control is the first signal that long-term care will be at the epicenter of federal oversight.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Assistência de Longa Duração , Medicare , Pandemias , Pneumonia Viral , Centers for Medicare and Medicaid Services, U.S. , Humanos , Medicaid , Estados Unidos
10.
Surgery ; 167(6): 978-984, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32253027

RESUMO

BACKGROUND: The true cost of liver and pancreatic surgery may not be completely ascertained by examining costs associated solely with the index hospitalization. We sought to assess post-discharge costs related to liver and pancreatic surgery after the index hospitalization. METHODS: We identified Medicare beneficiaries who underwent liver and pancreatic resection between 2013 and 2015. To assess post-discharge costs, costs were assessed for the following: all inpatient readmissions associated with an operative complication, follow-up outpatient visits with their operating surgeon, and use of skilled nursing facilities, hospice, and home health care within 90 days of discharge. RESULTS: Among the 21,737 patients who underwent either pancreatic or liver resection, the median cost of the index admission was $20,500 (interquartile range: $16,100-$34,300) (pancreas median: $22,100; interquartile range: $16,800-$36,500 vs liver median: $19,100; interquartile range: $15,100-$29,000). Approximately 30% (n = 6,435) had an all-cause readmission; more than half of readmissions (55.8%; n = 3,589) were related to an operative complication. Skilled nursing facilities and home health care services were utilized by 18.5% (n = 4,016) and 42.6% (n = 9,259) of patients, respectively. In total, nearly 75% of patients had additional, post-discharge hidden costs associated with their operative episode of care (n = 15,733: 72.4%). Male sex (95% confidence interval: 1.15-1.30) and black/African American race (95% confidence interval: 1.02-1.34) were associated with greater odds of post-discharge costs (both <0.05). CONCLUSION: Nearly 3 out of 4 patients who underwent a liver or pancreatic resection had post-discharge costs. Male and black/African American patients had greater odds of incurring post-discharge costs. As payers move to more bundled care payment models, strategies aimed at bending the cost curve associated with both the in-hospital, as well as the post-discharge setting, are needed.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Hepatectomia/economia , Medicare/economia , Pancreatectomia/economia , Idoso , Feminino , Serviços Hospitalares de Assistência Domiciliar/economia , Hospitais para Doentes Terminais/economia , Hospitalização , Humanos , Masculino , Visita a Consultório Médico/economia , Alta do Paciente , Readmissão do Paciente/economia , Complicações Pós-Operatórias/economia , Fatores Raciais , Fatores Sexuais , Instituições de Cuidados Especializados de Enfermagem/economia , Estados Unidos
11.
Am J Otolaryngol ; 41(3): 102490, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32307192

RESUMO

The COVID-19 pandemic has quickly and radically altered how Otolaryngologists provide patient care in the outpatient setting. Continuity of care with established patients as well as establishment of a professional relationship with new patients is challenging during this Public Health Emergency (PHE). Many geographic areas are under "stay at home" or "shelter in place" directives from state and local governments to avoid COVID-19 exposure risks. Medicare has recently allowed "broad flexibilities to furnish services using remote communications technology to avoid exposure risks to health care providers, patients, and the community." [1] The implementation of telemedicine, or virtual, services, will help the Otolaryngologists provide needed care to patients while mitigating the clinical and financial impact of the pandemic. The significant coding and billing issues related to implementing telemedicine services are discussed to promote acceptance of this technology by the practicing Otolaryngologist. Of particular importance, outpatient visit Current Procedural Terminology® codes (99201-99215) may be used for telehealth visits performed in real-time audio and video.


Assuntos
Infecções por Coronavirus/epidemiologia , Medicare/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Padrões de Prática Médica/organização & administração , Telemedicina/organização & administração , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Medicare/economia , Otorrinolaringologistas/economia , Otorrinolaringologistas/estatística & dados numéricos , Otolaringologia/economia , Otolaringologia/métodos , Avaliação de Resultados em Cuidados de Saúde , Pandemias/economia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Consulta Remota/organização & administração , Estados Unidos
14.
JAMA ; 323(10): 961-969, 2020 03 10.
Artigo em Inglês | MEDLINE | ID: mdl-32154858

RESUMO

Importance: Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries). Objective: To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries. Design, Setting, and Participants: Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018. Exposures: Dual vs nondual enrollment status. Main Outcomes and Measures: Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates. Results: There were 71 017 608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11 697 900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P < .001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100 000 beneficiary-years declined from 49 888 in 2004 to 41 121 in 2017 among dually enrolled beneficiaries (P < .001) and from 29 000 in 2004 to 22 601 in 2017 among nondually enrolled beneficiaries (P < .001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P < .001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period. Conclusions and Relevance: Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.


Assuntos
Planos de Pagamento por Serviço Prestado , Hospitalização/estatística & dados numéricos , Medicaid , Medicare , Mortalidade , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Estados Unidos/epidemiologia
16.
Am J Surg ; 219(4): 571-577, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32147020

RESUMO

INTRODUCTION: Bariatric surgery is an effective treatment for obesity resulting in both sustained weight loss and reduction in obesity-related comorbidities. It is uncertain how sociodemographic factors affect postoperative outcomes. METHODS: The National Inpatient Sample was queried for patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2005 to 2014. Factors associated with selection of SG over RYGB, increased postoperative length of stay (LOS) greater than 3 days, and inpatient mortality were compared by race, insurance status, and other clinical and hospital factors. RESULTS: The database captured 781,413 patients, of which 525,986 had a RYGB and 255,428 had SG. There was an increase in the incidence of SG over RYGB over time. Among the self-pay/uninsured, the increased incidence began several years earlier than other groups. Black patients had greater odds of increased postoperative LOS (OR 1.40) and in-hospital mortality (OR 2.11). CONCLUSION: Sociodemographic factors are associated with differences in temporal trends in the adoption of SG versus RYGB for surgical weight loss.


Assuntos
Gastrectomia/tendências , Derivação Gástrica/tendências , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Comorbidade , Grupos de Populações Continentais/estatística & dados numéricos , Conjuntos de Dados como Assunto , Feminino , Financiamento Pessoal/estatística & dados numéricos , Humanos , Renda/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Setor Privado , Fatores Raciais , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto Jovem
17.
Value Health ; 23(2): 209-216, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32113626

RESUMO

OBJECTIVES: Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is)-innovative yet costly cholesterol-lowering agents-have been subject to substantial prior authorization (PA) requirements and low approval rates. We aimed to investigate trends in insurer approval and reasons for rejection for PCSK9i prescriptions as well as associations between patients' demographic, clinical, pharmacy, payer, and PCSK9i-specific plan/coverage factors and approval. METHODS: We examined trends in PCSK9i approval rates and reasons for rejection using medical and prescription claims from 2015 to 2017 for individuals who received a PCSK9i prescription. We used multinomial logistic regression to estimate quarterly risk-adjusted approval rates for initial PCSK9i prescriptions and approval for any PCSK9i prescription within 30, 90, and 180 days of the initial PCSK9i prescription. For a 2016 subsample for whom we had PCSK9i-specific plan policy data, we examined factors associated with approval including PCSK9i-specific plan formulary coverage, step therapy requirements, and number of PA criteria. RESULTS: The main sample included 12 309 patients (mean age 64.8 years [SD = 10.8], 52.1% female, 51.5% receiving Medicare) and was similar in characteristics to the 2016 subsample (n = 6091). Approval rates varied across quarters but remained low (initial prescription, 13%-23%; within 90 days, 28%-44%). Over time, rejections owing to a lack of formulary coverage decreased and rejections owing to PA requirements increased. Lack of formulary coverage and having ≥11 PA criteria in the plan policy were associated with lower odds of PCSK9i prescription approval. CONCLUSIONS: These findings confirm ongoing PCSK9i access issues and offer a baseline for comparison in future studies examining the impact of recent efforts to improve PCSK9i access.


Assuntos
Anticolesterolemiantes/uso terapêutico , Definição da Elegibilidade/tendências , Alocação de Recursos para a Atenção à Saúde/tendências , Cobertura do Seguro/tendências , Seguro de Serviços Farmacêuticos/tendências , Autorização Prévia/tendências , Pró-Proteína Convertase 9/antagonistas & inibidores , Inibidores de Serino Proteinase/uso terapêutico , Idoso , Anticolesterolemiantes/efeitos adversos , Anticolesterolemiantes/economia , Estudos Transversais , Bases de Dados Factuais , Custos de Medicamentos , Prescrições de Medicamentos , Definição da Elegibilidade/economia , Feminino , Formulários Farmacêuticos como Assunto , Alocação de Recursos para a Atenção à Saúde/economia , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/tendências , Humanos , Cobertura do Seguro/economia , Seguro de Serviços Farmacêuticos/economia , Masculino , Medicare/economia , Medicare/tendências , Pessoa de Meia-Idade , Autorização Prévia/economia , Inibidores de Serino Proteinase/efeitos adversos , Inibidores de Serino Proteinase/economia , Fatores de Tempo , Estados Unidos
18.
Am Surg ; 86(2): 140-145, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-32167057

RESUMO

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.


Assuntos
Gastrectomia/economia , Pessoal de Saúde/psicologia , Hepatectomia/economia , Reembolso de Seguro de Saúde/economia , Medicare/economia , Pancreaticoduodenectomia/economia , Institutos de Câncer , Honorários e Preços , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Corpo Clínico/economia , Corpo Clínico/estatística & dados numéricos , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem/economia , Recursos Humanos de Enfermagem/estatística & dados numéricos , Estados Unidos
20.
Lancet ; 395(10225): 660, 2020 02 29.
Artigo em Inglês | MEDLINE | ID: mdl-32113489
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