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1.
Am Surg ; 85(10): 1079-1082, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657298

RESUMO

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


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

RESUMO

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


Assuntos
Adesão à Medicação , Médicos/normas , Indicadores de Qualidade em Assistência à Saúde , Idoso , Feminino , Humanos , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Medicare Part D/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
3.
Am Heart J ; 207: 19-26, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30404047

RESUMO

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


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Admissão do Paciente/estatística & dados numéricos , Organizações de Assistência Responsáveis/classificação , Organizações de Assistência Responsáveis/normas , Idoso , Algoritmos , Análise de Variância , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Feminino , Insuficiência Cardíaca/diagnóstico , Hospitalização/estatística & dados numéricos , Humanos , Classificação Internacional de Doenças , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/normas , Assistência Centrada no Paciente/estatística & dados numéricos , Distribuição por Sexo , Fatores de Tempo , Estados Unidos
4.
Issue Brief (Commonw Fund) ; 2018: 1-15, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30211508

RESUMO

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


Assuntos
Política de Saúde/economia , Acesso aos Serviços de Saúde/economia , Medicare Part A/economia , Medicare Part B/economia , Medicare/economia , Custo Compartilhado de Seguro/economia , Humanos , Múltiplas Afecções Crônicas/economia , Pobreza , Estados Unidos
5.
Health Serv Res ; 53 Suppl 3: 5181-5200, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29896771

RESUMO

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


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

RESUMO

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


Assuntos
Medicare/normas , Profissionais de Enfermagem/organização & administração , Padrões de Prática em Enfermagem/organização & administração , Padrões de Prática Médica/organização & administração , Atenção Primária à Saúde/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Humanos , Medicare Part A , Medicare Part B , Médicos de Atenção Primária/organização & administração , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Estados Unidos
7.
Health Serv Res ; 53(5): 3507-3527, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29512154

RESUMO

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


Assuntos
Gastos em Saúde/tendências , Medicare Part A/economia , Medicare Part B/economia , Idoso , Feminino , Humanos , Masculino , Modelos Econômicos , Estados Unidos
8.
Fed Regist ; 83(249): 67816-8082, 2018 12 31.
Artigo em Inglês | MEDLINE | ID: mdl-30596411

RESUMO

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


Assuntos
Organizações de Assistência Responsáveis/economia , Redução de Custos/economia , Planos de Pagamento por Serviço Prestado/economia , Medicare Part A/economia , Medicare Part B/economia , Medicare/economia , Organizações de Assistência Responsáveis/legislação & jurisprudência , Benchmarking , Redução de Custos/legislação & jurisprudência , Desastres , Planos de Pagamento por Serviço Prestado/tendências , Previsões , Política de Saúde , Humanos , Medicare/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Estados Unidos
9.
Health Serv Res ; 53(2): 711-729, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28295261

RESUMO

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


Assuntos
Custo Compartilhado de Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Custo Compartilhado de Seguro/economia , Feminino , Financiamento Pessoal/economia , Financiamento Pessoal/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Medicare Part A/economia , Medicare Part A/estatística & dados numéricos , Readmissão do Paciente/economia , Análise de Regressão , Características de Residência , Fatores Socioeconômicos , Estados Unidos
10.
Geriatr Nurs ; 39(4): 371-375, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29275990

RESUMO

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


Assuntos
Assistência ao Convalescente/organização & administração , Valvas Cardíacas/cirurgia , Alta do Paciente , Reabilitação/organização & administração , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Humanos , Medicare Part A/estatística & dados numéricos , Estados Unidos
12.
World Neurosurg ; 104: 68-73, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28502681

RESUMO

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


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Tempo de Internação/economia , Complicações Pós-Operatórias/economia , Reoperação/economia , Escoliose/economia , Escoliose/cirurgia , Fusão Vertebral/economia , Distribuição por Idade , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare Part A/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Prevalência , Reoperação/estatística & dados numéricos , Fatores de Risco , Escoliose/epidemiologia , Distribuição por Sexo , Fusão Vertebral/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia
14.
Biostatistics ; 18(4): 695-710, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-28419189

RESUMO

Propensity score methods are widely used in comparative effectiveness research using claims data. In this context, the inaccuracy of procedural or billing codes in claims data frequently misclassifies patients into treatment groups, that is, the treatment assignment ($T$) is often measured with error. In the context of a validation data where treatment assignment is accurate, we show that misclassification of treatment assignment can impact three distinct stages of a propensity score analysis: (i) propensity score estimation; (ii) propensity score implementation; and (iii) outcome analysis conducted conditional on the estimated propensity score and its implementation. We examine how the error in $T$ impacts each stage in the context of three common propensity score implementations: subclassification, matching, and inverse probability of treatment weighting (IPTW). Using validation data, we propose a two-step likelihood-based approach which fully adjusts for treatment misclassification bias under subclassification. This approach relies on two common measurement error-assumptions; non-differential measurement error and transportability of the measurement error model. We use simulation studies to assess the performance of the adjustment under subclassification, and also investigate the method's performance under matching or IPTW. We apply the methods to Medicare Part A hospital claims data to estimate the effect of resection versus biopsy on 1-year mortality among $10\,284$ Medicare beneficiaries diagnosed with brain tumors. The ICD9 billing codes from Medicare Part A inaccurately reflect surgical treatment, but SEER-Medicare validation data are available with more accurate information.


Assuntos
Funções Verossimilhança , Medicare Part A/estatística & dados numéricos , Modelos Estatísticos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Pontuação de Propensão , Neoplasias Encefálicas/mortalidade , Neoplasias Encefálicas/cirurgia , Humanos , Estados Unidos
15.
J Hosp Med ; 12(4): 251-255, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28411297

RESUMO

Hospitalists and other providers must classify hospitalized patients as inpatient or outpatient, the latter of which includes all observation stays. These orders direct hospital billing and payment, as well as patient out-of-pocket expenses. The Centers for Medicare & Medicaid Services (CMS) audits hospital billing for Medicare beneficiaries, historically through the Recovery Audit program. A recent U.S. Government Accountability Office (GAO) report identified problems in the hospital appeals process of Recovery Audit program audits to which CMS proposed reforms. In the context of the GAO report and CMS's proposed improvements, we conducted a study to describe the time course and process of complex Medicare Part A audits and appeals reaching Level 3 of the 5-level appeals process as of May 1, 2016 at 3 academic medical centers. Of 219 appeals reaching Level 3, 135 had a decision--96 (71.1%) successful for the hospitals. Mean total time since date of service was 1663.3 days, which includes mean days between date of service and audit (560.4) and total days in appeals (891.3). Government contractors were responsible for 70.7% of total appeals time. Overall, government contractors and judges met legislative timeliness deadlines less than half the time (47.7%), with declining compliance at successive levels (discussion, 92.5%; Level 1, 85.4%; Level 2, 38.8%; Level 3, 0%). Most Level 1 and Level 2 decision letters (95.2%) cited time-based (24-hour) criteria for determining inpatient status, despite 70.3% of denied appeals meeting the 24-hour benchmark. These findings suggest that the Medicare appeals system merits process improvement beyond current proposed reforms. Journal of Hospital Medicine 2017;12:251-255.


Assuntos
Centros Médicos Acadêmicos , Hospitalização/economia , Hospitalização/legislação & jurisprudência , Revisão da Utilização de Seguros/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Fraude/prevenção & controle , Gastos em Saúde , Auditoria Médica/métodos , Medicare Part A/normas , Estados Unidos
16.
J Am Geriatr Soc ; 65(2): 340-347, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28198561

RESUMO

OBJECTIVES: To evaluate the incidence and characteristics of nursing home (NH) use after implantable cardioverter-defibrillator (ICD) implantation. DESIGN: Cohort study. SETTING: Medicare beneficiaries in the National Cardiovascular Data Registry-ICD Registry. PARTICIPANTS: Individuals aged 65 and older receiving ICDs between January 1, 2006, and March 31, 2010 (N = 192,483). MEASUREMENTS: Proportion of ICD recipients discharged to NHs directly after device placement, cumulative incidence of long-term NH admission, and factors associated with immediate discharge to a NH and time to long-term NH admission. RESULTS: Over 4 years, 40.6% of the cohort died, and 35,939 (18.7%) experienced at least one NH admission, including 4.0% directly discharged to a NH after ICD implantation and 2.8% admitted to long-term NH care during follow-up. The cumulative incidence of long-term NH admission, accounting for the competing risk of death, was 1.7% at 1 year, 3.8% at 3 years, and 4.6% at 4 years; 20.1% of individuals admitted to a NH died there. Factors most strongly associated with direct NH discharge and time to long-term NH care were older age (adjusted odds ratio (AOR) = 2.09, 95% confidence interval (CI) = 2.01-2.17 per 10-year increment; adjusted hazard ratio (AHR) = 1.88, 95% CI = 1.80-1.97, respectively), dementia (AOR = 2.60, 95% CI = 2.25-3.01; AHR = 2.50, 95% CI = 2.14-2.93, respectively), and Medicare Part A claim for NH stay in prior 6 months (AOR = 3.96, 95% CI = 3.70-4.25; AHR = 2.88, 95% CI = 2.65-3.14, respectively). CONCLUSION: Nearly one in five individuals are admitted to NHs over a median of 1.6 years of follow-up after ICD implantation. Understanding these outcomes may help inform the clinical care of these individuals.


Assuntos
Desfibriladores Implantáveis , Casas de Saúde/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Fatores Etários , Idoso , Estudos de Coortes , Demência/epidemiologia , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Masculino , Medicare Part A , Sistema de Registros , Fatores Sexuais , Estados Unidos/epidemiologia
17.
Artigo em Inglês | MEDLINE | ID: mdl-28203071

RESUMO

BACKGROUND: The ability of a long-acting muscarinic antagonist (LAMA) and long-acting beta 2 agonists (LABAs; long-acting bronchodilators, LABDs) with or without inhaled corticosteroids (ICSs) to reduce early readmission in hospitalized patients with COPD is unknown. METHODS: We studied a 5% sample of Medicare beneficiaries enrolled in Medicare parts A, B and D and hospitalized for COPD in 2011. We examined prescriptions filled for LABDs with or without ICSs (LABDs±ICSs) within 90 days prior to and 30 days after hospitalization. Primary outcome was the 30-day readmission rate between "users" and "nonusers" of LABDs±ICSs. Propensity score matching and sensitivity analysis were performed by limiting analysis to patients hospitalized for acute exacerbation of COPD (AECOPD). Among 6,066 patients hospitalized for COPD, 3,747 (61.8%) used LABDs±ICSs during the specified period. The "user" and "nonuser" groups had similar rates of all-cause emergency room (ER) visits and readmissions within 30 days of discharge date (22.4% vs 20.7%, P-value 0.11; 18.0% vs 17.8%, P-value 0.85, respectively). However, the "users" had higher rates of COPD-related ER visits (5.3% vs 3.4%, P-value 0.0006), higher adjusted odds ratio (aOR) 1.47 (95% CI, 1.11-1.93) and readmission (7.8% vs 5.0%, P-value <0.0001 and aOR 1.48 [95% CI, 1.18-1.86]) than "nonusers". After propensity score matching, the aOR of COPD-related ER visits was 1.45 (95% CI, 1.07-1.96) and that of readmission was 1.34 (95% CI, 1.04-1.73). The results were similar when restricted to patients hospitalized for AECOPD. CONCLUSION: Use of LABDs±ICSs did not reduce 30-day readmissions in patients hospitalized for COPD.


Assuntos
Corticosteroides/administração & dosagem , Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Broncodilatadores/administração & dosagem , Pulmão/efeitos dos fármacos , Antagonistas Muscarínicos/administração & dosagem , Readmissão do Paciente , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Corticosteroides/efeitos adversos , Agonistas de Receptores Adrenérgicos beta 2/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Broncodilatadores/efeitos adversos , Distribuição de Qui-Quadrado , Progressão da Doença , Prescrições de Medicamentos , Serviço Hospitalar de Emergência , Feminino , Humanos , Modelos Logísticos , Pulmão/fisiopatologia , Masculino , Medicare Part A , Medicare Part B , Medicare Part D , Antagonistas Muscarínicos/efeitos adversos , Razão de Chances , Pontuação de Propensão , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
18.
J Health Econ ; 51: 84-97, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28129637

RESUMO

Does tort reform reduce defensive medicine and thus healthcare spending? Several (though not all) prior studies, using a difference-in-differences (DiD) approach, find lower Medicare spending for hospital care after states adopt caps on non-economic or total damages ("damage caps"), during the "second" reform wave of the mid-1980s. We re-examine this issue in several ways. We study the nine states that adopted caps during the "third reform wave," from 2002 to 2005. We find that damage caps have no significant impact on Medicare Part A spending, but predict roughly 4% higher Medicare Part B spending. We then revisit the 1980s caps, and find no evidence of a post-adoption drop (or rise) in spending for these caps.


Assuntos
Medicina Defensiva/economia , Responsabilidade Legal , Imperícia/legislação & jurisprudência , Medicina Defensiva/organização & administração , Gastos em Saúde/estatística & dados numéricos , Humanos , Responsabilidade Legal/economia , Imperícia/economia , Medicare Part A/economia , Medicare Part A/estatística & dados numéricos , Medicare Part B/economia , Medicare Part B/estatística & dados numéricos , Estados Unidos
19.
Fed Regist ; 82(1): 180-651, 2017 01 03.
Artigo em Inglês | MEDLINE | ID: mdl-28071874

RESUMO

This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.


Assuntos
Artroplastia de Quadril/economia , Reabilitação Cardíaca/economia , Assistência Integral à Saúde/economia , Cuidado Periódico , Reembolso de Seguro de Saúde/economia , Medicare Part A/economia , Medicare Part B/economia , Pacotes de Assistência ao Paciente/economia , Reembolso de Incentivo/legislação & jurisprudência , Assistência Integral à Saúde/legislação & jurisprudência , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/reabilitação , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Medicare Part A/legislação & jurisprudência , Medicare Part B/legislação & jurisprudência , Modelos Econômicos , Infarto do Miocárdio/economia , Infarto do Miocárdio/reabilitação , Estados Unidos
20.
Health Serv Res ; 52(2): 676-696, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27060973

RESUMO

OBJECTIVE: To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. DATA SOURCES/STUDY SETTING: Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. STUDY DESIGN: We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. DATA COLLECTION/EXTRACTION METHODS: Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. PRINCIPAL FINDINGS: In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. CONCLUSIONS: Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Sistema de Pagamento Prospectivo/estatística & dados numéricos , Economia Hospitalar/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Medicare/economia , Medicare Part A/economia , Medicare Part A/estatística & dados numéricos , Sistema de Pagamento Prospectivo/economia , Estados Unidos
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