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2.
Plast Reconstr Surg ; 145(6): 1541-1551, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32459783

RESUMEN

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/economía , Seguro de Costos Compartidos/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Reembolso de Seguro de Salud/economía , Procedimientos Quirúrgicos Reconstructivos/economía , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Ahorro de Costo/economía , Ahorro de Costo/legislación & jurisprudencia , Seguro de Costos Compartidos/economía , Seguro de Costos Compartidos/legislación & jurisprudencia , Seguro de Costos Compartidos/tendencias , Bases de Datos Factuales/estadística & datos numéricos , Planes de Aranceles por Servicios/economía , Planes de Aranceles por Servicios/legislación & jurisprudencia , Planes de Aranceles por Servicios/estadística & datos numéricos , Planes de Aranceles por Servicios/tendencias , Femenino , Gastos en Salud/legislación & jurisprudencia , Gastos en Salud/tendencias , Precios de Hospital/estadística & datos numéricos , Precios de Hospital/tendencias , Humanos , Reembolso de Seguro de Salud/legislación & jurisprudencia , Reembolso de Seguro de Salud/tendencias , Masculino , Programas Controlados de Atención en Salud/economía , Programas Controlados de Atención en Salud/legislación & jurisprudencia , Programas Controlados de Atención en Salud/estadística & datos numéricos , Programas Controlados de Atención en Salud/tendencias , Medicare/economía , Medicare/legislación & jurisprudencia , Medicare/estadística & datos numéricos , Medicare/tendencias , Persona de Mediana Edad , Servicio Ambulatorio en Hospital/economía , Servicio Ambulatorio en Hospital/estadística & datos numéricos , Políticas , Procedimientos Quirúrgicos Reconstructivos/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos , Adulto Joven
3.
J Manag Care Spec Pharm ; 26(1): 30-34, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31880232

RESUMEN

BACKGROUND: Although several states recognize pharmacists as providers and allow credentialing, this practice is not recognized nationwide. Following adoption of Oregon House Bill 2028, pharmacists are recognized as providers, allowing "health insurers to provide payment or reimbursement for their services to patients." Before this law, and in several instances currently, pharmacist-run programs were financially justified through soft dollars saved by improving patient outcomes, reducing emergency department use, and decreasing readmission rates. OBJECTIVE: To determine if direct billing of third-party payers covers the direct cost of a comprehensive medication management (CMM) program in an ambulatory rural health adult population with uncontrolled diabetes or hypertension. METHODS: This study of a population derived from 2 Oregon rural health primary care clinics was a retrospective chart review of adults (aged ≥18 years) with a primary diagnosis of diabetes mellitus or hypertension who completed a CMM visit with a clinical pharmacist from March 2017 to June 2018. In determining the financial sustainability of a pharmacist-run CMM program, the following primary outcomes were evaluated: (a) percentage of visits completed per insurance type; (b) median reimbursement rate (dollars per visit) per insurance type; and (c) the estimated number of visits per day to cover 100% of the total CMM cost annually. The secondary outcome was the percentage of the major third-party payers that allowed credentialing of pharmacists. All outcomes were evaluated using descriptive statistics. RESULTS: 664 CMM visits were included. Visits per insurance type comprised Medicare Advantage (34%), traditional Medicare (25%), Oregon State Medicaid (20.9%), commercial (17.8%), and self-pay (cash; 1.4%). Median reimbursement rate (dollars per visit) was highest from Oregon Medicaid, followed by Medicare Advantage, and lowest among commercial, self-pay (cash), and traditional Medicare. Total reimbursement received throughout the duration of this pilot project covered 14.1% of the total CMM program cost. It was estimated that approximately 17 visits per day are needed to cover 100% of the total CMM cost annually per pharmacist relying solely on direct revenue within these clinics. Currently, of the 18 contracted insurance companies, only 50% recognize and allow credentialing of pharmacists as providers. CONCLUSIONS: Pharmacist-run services within the 2 rural health primary care clinics were not financially justifiable via direct billing of third-party payers alone. The lack of credentialing, recognition of pharmacists as providers, and reimbursement is inadequate for program expansion and sustainability without relying on additional revenue streams or benefits from improved patient outcomes. Currently, federal insurance significantly contributes to this lack of funding. DISCLOSURES: No outside funding provided support for this research; however, funding from Willamette Valley Community Health was given in the form of a grant to partially fund the comprehensive medication management pilot program. Pharmacists were paid from this grant, while Sublimity Pharmacy compensated pharmacists in the form of benefits. The authors have nothing to disclose. This work was presented in part as a poster at the ASHP Midyear Clinical Meeting; December 4, 2018; Anaheim, CA, and as a peer-reviewed podium presentation at the Northwestern States Residency Conference; May 4, 2019; Portland, OR.


Asunto(s)
Antihipertensivos/economía , Servicios Comunitarios de Farmacia/economía , Costos de los Medicamentos , Planes de Aranceles por Servicios/economía , Hipoglucemiantes/economía , Seguro de Salud/economía , Administración del Tratamiento Farmacológico/economía , Farmacéuticos/economía , Atención Primaria de Salud/economía , Servicios de Salud Rural/economía , Antihipertensivos/uso terapéutico , Servicios Comunitarios de Farmacia/organización & administración , Análisis Costo-Beneficio , Habilitación Profesional/economía , Planes de Aranceles por Servicios/organización & administración , Humanos , Hipoglucemiantes/uso terapéutico , Seguro de Salud/organización & administración , Administración del Tratamiento Farmacológico/organización & administración , Visita a Consultorio Médico/economía , Oregon , Farmacéuticos/organización & administración , Atención Primaria de Salud/organización & administración , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Servicios de Salud Rural/organización & administración
4.
Ann Vasc Surg ; 62: 148-158, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31610277

RESUMEN

BACKGROUND: Endovascular aortic aneurysm repair (EVR) has a major financial impact on health care systems. We characterized reimbursement for index EVR hospitalizations among Medicare beneficiaries having surgery at Vascular Quality Initiative (VQI) centers. METHODS: We linked Medicare claims to VQI clinical registry data for patients undergoing EVR from 2003 to 2015. Analysis was limited to patients fully covered by fee-for-service Medicare parts A and B in the year of their operation and assigned a corresponding diagnosis-related group for EVR. The primary outcome was Medicare's reimbursement for inpatient hospital and professional services, adjusted to 2015 dollars. We performed descriptive analysis of reimbursement over time and univariate analysis to evaluate patient demographics, clinical characteristics, procedural variables, and postoperative events associated with reimbursement. This informed a multilevel regression model used to identify factors independently associated with EVR reimbursement and quantify VQI center-level variation in reimbursement. RESULTS: We studied 9,403 Medicare patients who underwent EVR at VQI centers during the study period. Reimbursements declined from $37,450 ± $9,350 (mean ± standard deviation) in 2003 to $27,723 ± $10,613 in 2015 (test for trend, P < 0.001). For patients experiencing a complication (n = 773; 8.2%), mean reimbursement for EVR was $44,858 ± $23,825 versus $28,857 ± $9,258 for those without complications (P < 0.001). Intestinal ischemia, new dialysis requirement, and respiratory compromise each doubled Medicare's average reimbursement for EVR. After adjusting for diagnosis-related group, several patient-level factors were independently associated with higher Medicare reimbursement; these included ruptured abdominal aortic aneurysm (+$2,372), additional day in length of stay (+$1,275), and being unfit for open repair (+$501). Controlling for patient-level factors, 4-fold variation in average reimbursement was seen across VQI centers. CONCLUSIONS: Reimbursement for EVR declined between 2003 and 2015. We identified preoperative clinical factors independently associated with reimbursement and quantified the impact of different postoperative complications on reimbursement. More work is needed to better understand the substantial variation observed in reimbursement at the center level.


Asunto(s)
Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/economía , Planes de Aranceles por Servicios/economía , Costos de Hospital , Medicare/economía , Reclamos Administrativos en el Cuidado de la Salud , Anciano , Anciano de 80 o más Años , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/tendencias , Planes de Aranceles por Servicios/tendencias , Femenino , Costos de Hospital/tendencias , Humanos , Masculino , Medicare/tendencias , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/terapia , Sistema de Registros , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
5.
Health Policy Plan ; 34(Supplement_2): ii56-ii66, 2019 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-31723970

RESUMEN

Integration of health services has been pursued worldwide. Diversity in integration approaches and in the contexts in which integrated programmes operate, however, hinders comparative analysis of care integration in both high-income countries (HICs) and low- and middle-income countries (LMICs). This study evaluates an HIC programme implemented in a delivery system resembling those of LMICs, especially its weak primary care system. The programme, Taiwan's Family Doctor Plan (FDP), targets high-cost and chronic patients, incorporating key elements of integrated care, viz., case management, multidisciplinary teams and care pathways. This study estimates the effects of shifting from usual to integrated care and locates contextual factors that may distort programme implementation. To estimate programme effects, difference-in-differences analysis is applied to a balanced panel comprising >160 000 patients over 2009-13. Because physician participation is voluntary, a propensity score matching method is used to match providers. The research findings reveal that introduction of the FDP has not reoriented the model of care from fragmented towards integrated health services. It reduces continuity of care and has no effect on co-ordination of care. Regarding quality of care, the FDP is shown to have no effect on avoidable admissions and increases drug injections and emergency department visits. Several contextual factors may serve as barriers that impede elements of FDP from generating desirable outcomes. These include absence of registration and gatekeeping systems; limited capacities of clinics; and preponderance of fee-for-service remuneration. These findings suggest that HIC design elements may not be directly transferrable to settings with weak primary care systems, as is typical of LMIC healthcare. Changes at the system level, such as establishing regular sources of care, may be necessary before elements of integrated care are introduced to a weaker primary care system.


Asunto(s)
Continuidad de la Atención al Paciente , Prestación Integrada de Atención de Salud/organización & administración , Atención Primaria de Salud/organización & administración , Planes de Aranceles por Servicios/economía , Control de Acceso , Humanos , Persona de Mediana Edad , Calidad de la Atención de Salud , Taiwán
6.
BMC Health Serv Res ; 19(1): 776, 2019 Oct 30.
Artículo en Inglés | MEDLINE | ID: mdl-31666066

RESUMEN

BACKGROUND: In 2002, a voluntary diagnosis-related groups (DRGs) payment system was introduced in South Korea for seven disease groups, and participation in the DRGs was mandated for all hospitals beginning in 2013. The primary aim of this study was to compare results reflective of patient care between voluntary participation hospitals (VPHs) and mandatory participation hospitals (MPHs) governed by either the DRGs or fee-for-service (FFS) payment system. METHODS: We collected DRGs and FFS inpatient records (n=3,038,006) from the Health Insurance Review and Assessment for the period of July 2011 to July 2014 and compared length-of-stay, total medical costs, shifting services to an outpatient setting, and readmission rates according to payment system, time of DRGs implementation, and hospital type. We analyzed the effects of mandatory introduction in DRGs payment system on results for patient care and used generalized estimating equations with difference-in-difference methodology. RESULTS: Most notably, patients at MPHs had significantly shorter LOS and lower readmission rates than VPH patients after mandatory introduction of the DRGs. Shifting services to an outpatient setting was similar between the groups. CONCLUSIONS: Our findings suggest that the DRGs payment policy in Korea has decreased LOS and readmission rates. These findings support the continued implementation and enlargement of the DRGs payment system for other diseases in South Korea, given its potential for curbing unnecessary resource usage encouraged by FFS. If the Korean government deliberates on expansion of the DRGs to include other diseases with higher rates of complications, policymakers need to monitor deterioration of health care quality caused by fixed pricing.


Asunto(s)
Grupos Diagnósticos Relacionados/economía , Hospitales , Programas Obligatorios , Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Anciano , Planes de Aranceles por Servicios/economía , Femenino , Humanos , Revisión de Utilización de Seguros , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , República de Corea , Adulto Joven
7.
Health Serv Res ; 54(6): 1214-1222, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31742688

RESUMEN

IMPORTANCE: It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES: Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES: The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent). STUDY DESIGN: Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS: ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION: ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.


Asunto(s)
Organizaciones Responsables por la Atención/economía , Organizaciones Responsables por la Atención/estadística & datos numéricos , Compensación y Reparación , Planes de Aranceles por Servicios/economía , Planes de Aranceles por Servicios/estadística & datos numéricos , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Humanos , Medicare/economía , Medicare/estadística & datos numéricos , Estados Unidos
8.
J Manag Care Spec Pharm ; 25(11): 1236-1242, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31663464

RESUMEN

BACKGROUND: New hepatitis C virus (HCV) drugs-direct-acting antivirals (DAAs)-are highly effective but costly, which raises a concern about limited access to DAAs by vulnerable populations. Previous studies of disparities in DAA use across patient groups showed mixed results, but their generalizability was limited due to using data from commercial insurers or from 2014 only-the first year DAAs were available. Disparities in DAA use in a national cohort in the years when more DAAs were available is unknown. OBJECTIVE: To examine whether disparities in DAA use by patient race/ethnicity and socioeconomic status in Medicare changed between 2014 and 2016. METHODS: The study population was made up of chronic hepatitis C patients in fee-for-service Medicare with Part D between 2014 and 2016. We used multinomial logistic regression to estimate adjusted odds ratios (aOR) of using DAAs by patient race/ethnicity and socioeconomic status. We estimated the model separately for 2014 and 2014-2016. RESULTS: Of 281,810 Medicare patients who were followed to the end of 2016, a total of 90,419 (32.1%) filled prescriptions for DAAs. In the 2014 analysis, blacks were less likely to use DAAs than whites (aOR = 0.95; 95% CI = 0.91-0.99). However, in the 2014-2016 analysis, blacks had higher odds of using DAAs than whites (aOR = 1.24; 95% CI = 1.22-1.27). No significant Hispanic-white gap existed during the study period. Income was positively associated with DAA use in both periods. Between 2014 and 2016, patients who received a Part D low-income subsidy had lower odds of using DAAs than patients who did not (aOR = 0.90; 95% CI = 0.88-0.92), and patients in areas with the higher income tertiles were more likely to initiate DAAs than those in areas with the lowest income tertile. CONCLUSIONS: DAA use among Medicare patients remained far below the level needed to eradicate HCV. The black-white gap in HCV treatment was closed by 2016, but disparities by patient socioeconomic status remained. DAA use also varied by patient age and health risk, as well as across geographic regions. Continued efforts to improve DAA uptake in all HCV patients are needed to eradicate HCV. DISCLOSURES: This study was supported by the National Institute on Aging (1 R01 AG055636-01A1) and National Institute of Child Health & Human Development (R24 HD04025). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Feldman owns stock in Gilead Sciences and Abbvie. No other potential competing interest exists.


Asunto(s)
Antivirales/uso terapéutico , Planes de Aranceles por Servicios/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Hepatitis C Crónica/tratamiento farmacológico , Medicare Part D/estadística & datos numéricos , Afroamericanos/estadística & datos numéricos , Anciano , Antivirales/economía , Estudios de Cohortes , Costos de los Medicamentos , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Planes de Aranceles por Servicios/economía , Femenino , Hispanoamericanos/estadística & datos numéricos , Humanos , Masculino , Medicare Part D/economía , Persona de Mediana Edad , Factores Socioeconómicos , Estados Unidos
9.
PLoS One ; 14(10): e0223672, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31589655

RESUMEN

We aim to determine whether a game-theoretic model between an insurer and a healthcare practice yields a predictive equilibrium that incentivizes either player to deviate from a fee-for-service to capitation payment system. Using United States data from various primary care surveys, we find that non-extreme equilibria (i.e., shares of patients, or shares of patient visits, seen under a fee-for-service payment system) can be derived from a Stackelberg game if insurers award a non-linear bonus to practices based on performance. Overall, both insurers and practices can be incentivized to embrace capitation payments somewhat, but potentially at the expense of practice performance.


Asunto(s)
Capitación , Planes de Aranceles por Servicios/economía , Juegos Experimentales , Modelos Económicos , Humanos
10.
Ann Thorac Surg ; 108(6): 1710-1716, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31400321

RESUMEN

BACKGROUND: As cancer payment models transition from fee for service toward payment "bundles" based on episodes of care, a deeper understanding of the costs associated with stage I lung cancer treatment becomes increasingly relevant. To better understand costs in early lung cancer care, we sought to characterize hospital-level variation in Medicare expenditure after lobectomy for stage I non-small cell lung carcinoma. METHODS: Patients who were diagnosed with stage I non-small cell lung carcinoma from 2006 through 2011 and undergoing lobectomy were selected from the Surveillance, Epidemiology and End Results-Medicare linked database. We used Medicare claims to estimate costs of care in the 90 days after initial surgical hospitalization. Hospitals were grouped into quintiles of mean excess cost, calculated as the mean difference between observed costs and risk-adjusted predicted costs. The association between hospital factors and mean excess cost were compared across hospitals, including complication rates and hospital volume. RESULTS: A total of 3530 patients underwent lobectomy at 156 hospitals. Hospitals in the lowest cost quintile had index hospitalizations $6226 less costly than predicted. Conversely, the most expensive hospital quintile had index hospital costs that were $6151 costlier than predicted. Increased costs were positively associated with the number of complications per patient (P < .001), but not hospital volume (P = .85). CONCLUSIONS: Among Medicare beneficiaries undergoing lobectomy for stage I non-small cell lung carcinoma, the cost of perioperative care varied substantially across hospitals and was strongly associated with complication rate, but not hospital volume.


Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Gastos en Salud/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Neoplasias Pulmonares/cirugía , Medicare/economía , Neumonectomía/economía , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Pulmón de Células no Pequeñas/economía , Costos y Análisis de Costo , Planes de Aranceles por Servicios/economía , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/economía , Masculino , Estadificación de Neoplasias , Estudios Retrospectivos , Programa de VERF , Estados Unidos
12.
Ann Intern Med ; 171(1): 27-36, 2019 07 02.
Artículo en Inglés | MEDLINE | ID: mdl-31207609

RESUMEN

Background: Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs. Objective: To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit. Design: Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants. Setting: Fee-for-service Medicare, 2008 through 2014. Patients: A 20% sample (97 204 192 beneficiary-quarters). Measurements: Total spending, 4 quality indicators, and hospitalization for hip fracture. Results: In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile). Limitation: The study used an observational design and administrative data. Conclusion: After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP. Primary Funding Source: Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.


Asunto(s)
Organizaciones Responsables por la Atención/economía , Organizaciones Responsables por la Atención/normas , Ahorro de Costo , Medicare/economía , Medicare/normas , Anciano , Planes de Aranceles por Servicios/economía , Fracturas de Cadera/terapia , Hospitalización/estadística & datos numéricos , Humanos , Estudios Longitudinales , Indicadores de Calidad de la Atención de Salud , Sesgo de Selección , Estados Unidos
13.
PLoS One ; 14(6): e0218154, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31181131

RESUMEN

BACKGROUND: Understanding how doctors respond to occupational and monetary incentives in health care payment systems is important for determining the effectiveness of such systems. This study examined changes in doctors' behaviors in response to monetary incentives within health care payment systems in a ceteris paribus setting. METHODS: An online experiment was developed to analyze the effect of monetary incentives similar to fee-for-service (FFS) and capitation (CAP) on doctors' prescription patterns. In the first session, no monetary values were presented. In the second session conducted 1 week later, doctors were randomly assigned to one of two monetary incentive groups (FFS group: n = 25, CAP group: n = 25). In all sessions, doctors were presented with 10 cases and asked to determine the type and number of treatments. RESULTS: In the first session with no monetary incentives, there was no significant difference between the FFS and CAP groups in the number of treatments. When monetary incentives were provided, doctors in the CAP group prescribed fewer treatments than the FFS group. The perceived severity of the cases did not change significantly between sessions and between groups. linear mixed-effects regression model indicated the treatment choices were influenced by monetary incentives, but not by the perceived severity of the patient's symptoms. CONCLUSION: The monetary values incentivized the doctors' treatment choices, but not their professional evaluation of patients. Monetary values designed within health care systems influence the doctor's decisions in the form of external rewards, in addition to occupational values, and can thus be adjusted by more effective incentives.


Asunto(s)
Terapia por Acupuntura/psicología , Prestación de Atención de Salud/economía , Seguro de Salud/economía , Planes de Incentivos para los Médicos/economía , Adulto , Planes de Aranceles por Servicios/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Motivación/fisiología , Recompensa , Adulto Joven
14.
JAMA Netw Open ; 2(5): e193290, 2019 05 03.
Artículo en Inglés | MEDLINE | ID: mdl-31050779

RESUMEN

Importance: The measured severity of illness of hospitalized Medicare beneficiaries has increased. Whether this change is associated with payment reforms, concentrated among hospitalizations with principal diagnoses targeted by payment reform, and reflective of true increases in severity of illness is unknown. Objectives: To assess whether the expansion of secondary diagnosis codes in January 2011 and the incentive payments for health information technology under the US Health Information Technology for Economic and Clinical Health Act were associated with changes in measured severity of illness and whether those changes are reflective of true increases in underlying patient severity. Design, Setting, and Participants: This cohort study of Medicare fee-for-service beneficiary discharges (N = 47 951 443) between January 1, 2008, and August 31, 2015, used a regression-discontinuity design to evaluate changes in measured severity of illness after the expansion of secondary diagnoses. Discharge-level linear regression model with hospital fixed effects was used to evaluate changes in measured severity of illness after hospitals' receipt of incentives for health information technology. The change in predictive accuracy of measured severity of illness on 30-day readmissions after the implementation of both policies was evaluated. Data analysis was performed from November 1, 2018, to March 5, 2019. Main Outcomes and Measures: The primary outcome was patients' measured severity of illness determined by the number of condition categories from secondary discharge diagnosis codes. Measured severity of illness for diagnoses commonly targeted by Medicare policies and untargeted diagnoses was assessed. Results: In total, 47 951 443 discharges at 2850 hospitals were included. In 2008, these beneficiaries included 3 882 672 women (58.5%) with a mean (SD) age of 78.5 (8.4) years. In 2014, the discharges included 3 377 137 women (57.8%) with the mean (SD) age of 78.4 (8.7) years. The Centers for Medicare & Medicaid Services expansion of secondary diagnoses was associated with a 0.348 (95% CI, 0.328-0.367; P < .001) change in condition categories for all diagnoses, 0.445 (95% CI, 0.419-0.470; P < .001) for targeted diagnoses, and 0.321 (95% CI, 0.302-0.341; P < .001) for untargeted diagnoses. Health information technology incentives were associated with a 0.013 (95% CI, 0.004-0.022; P = .005) change in condition categories for all diagnoses, 0.195 (95% CI, 0.184-0.207; P < .001) for targeted diagnoses, and -0.016 (95% CI, -0.025 to -0.007; P < .001) for untargeted diagnoses. Minimal improvements in predictive accuracy were observed. Conclusions and Relevance: Changes in Centers for Medicare & Medicaid Services policies appear to be associated with increases in measured severity of illness; these increases do not appear to reflect substantive changes in true patient severity.


Asunto(s)
Planes de Aranceles por Servicios/economía , Reforma de la Atención de Salud , Medicare/legislación & jurisprudencia , Índice de Severidad de la Enfermedad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Hospitales/estadística & datos numéricos , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Estados Unidos/epidemiología
16.
Med Care ; 57(6): 417-424, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30994523

RESUMEN

BACKGROUND: Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014. OBJECTIVES: To evaluate the effect of hospital global budgets on health care utilization and expenditures. RESEARCH DESIGN: Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group. SUBJECTS: Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas. MEASURES: Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses. RESULTS: Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group. CONCLUSIONS: This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.


Asunto(s)
Presupuestos , Economía Hospitalaria , Medicare/economía , Planes de Aranceles por Servicios/economía , Gastos en Salud , Hospitalización/economía , Humanos , Maryland , Mecanismo de Reembolso , Estados Unidos , Revisión de Utilización de Recursos
17.
JAMA Intern Med ; 179(5): 648-657, 2019 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-30907922

RESUMEN

Importance: Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective: To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants: This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions: Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures: Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results: Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance: This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.


Asunto(s)
Extracción de Catarata/métodos , Catarata , Pruebas Diagnósticas de Rutina/métodos , Costos de la Atención en Salud , Cuidados Preoperatorios/métodos , Mejoramiento de la Calidad , Anciano , California , Capitación , Extracción de Catarata/economía , Ahorro de Costo , Pruebas Diagnósticas de Rutina/economía , Electrocardiografía/economía , Electrocardiografía/estadística & datos numéricos , Planes de Aranceles por Servicios/economía , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios/economía , Radiografía Torácica/economía , Radiografía Torácica/estadística & datos numéricos , Proveedores de Redes de Seguridad/economía
18.
PLoS One ; 14(3): e0213647, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30908492

RESUMEN

OBJECTIVES: To measure value in the delivery of inpatient care and to quantify its variation across U.S. regions. DATA SOURCES / STUDY SETTING: A random (20%) sample of 33,713 elderly fee-for-service Medicare beneficiaries treated in 2,232 hospitals for a heart attack in 2013. STUDY DESIGN: We estimate a production function for inpatient care, defining output as stays with favorable patient outcomes in terms of survival and readmission. The regression model includes hospital inputs measured by treatment costs, as well as patient characteristics. Region-level effects in the production function are used to estimate the productivity and value of the care delivered by hospitals within regions. DATA COLLECTION / EXTRACTION METHODS: Medicare claims and enrollment files, linked to the Dartmouth Atlas of Health Care and Inpatient Prospective Payment System Impact Files. PRINCIPAL FINDINGS: Hospitals in the hospital referral region at the 90th percentile of the value distribution delivered 54% more high-quality stays than hospitals at the 10th percentile could have delivered, after adjusting for treatment costs and patient severity. CONCLUSIONS: Variation in the delivery of high-value inpatient care points to opportunities for better quality and lower costs.


Asunto(s)
Costos de la Atención en Salud , Investigación sobre Servicios de Salud , Hospitalización/economía , Pacientes Internos , Readmisión del Paciente , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Economía Hospitalaria , Planes de Aranceles por Servicios/economía , Femenino , Geografía , Hospitales/estadística & datos numéricos , Humanos , Masculino , Medicare/estadística & datos numéricos , Mortalidad , Sistema de Pago Prospectivo/economía , Calidad de la Atención de Salud , Riesgo , Resultado del Tratamiento , Estados Unidos
20.
Phys Ther ; 99(5): 526-539, 2019 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-30801639

RESUMEN

BACKGROUND: Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood. OBJECTIVE: The objectives of this study were to examine variations in annual outpatient physical therapy expenditures of Medicare fee-for-service beneficiaries by primary diagnosis and baseline functional mobility, and to assess whether case mix groups based on primary diagnosis and functional mobility scores would be useful for expenditure differentiation. DESIGN: This was an observational, longitudinal study. METHODS: Volunteer providers in community settings participated in data collection with Continuity Assessment Record and Evaluation-Community (CARE-C) assessments for Medicare fee-for-service beneficiaries. Annual outpatient physical therapy expenditures were calculated using allowed charges on Medicare claims; primary diagnosis and baseline functional mobility were obtained from CARE-C assessments. Whether annual expenditures varied significantly across primary diagnosis groups and within diagnosis groups by functional mobility was examined. RESULTS: Data for 4210 patients (mean [SD] age = 72.9 [9.9] years; 64.6% women) from 127 providers were included. Mean expenditures differed significantly across 12 primary diagnosis groups created from CARE-C clinician-reported diagnoses (F = 12.73; df = 11). Twenty-five pairwise differences in 66 pairwise diagnosis group comparisons were statistically significant. Within 8 diagnosis groups, expenditures were significantly higher for low-mobility subgroups than for high-mobility subgroups; borderline significance was achieved for 1 diagnosis group. LIMITATIONS: The small convenience sample limited the statistical power and the generalizability of the results. CONCLUSIONS: Significant variations in physical therapy expenditures based on primary diagnosis and baseline functional mobility support the use of these variables in predicting outpatient physical therapy expenditures. Although Medicare's annual therapy spending cap was repealed effective January 2018, the data from this study provide an initial foundation to inform any future policy efforts, such as targeted medical review, risk-adjusted therapy payments, or case mix groups as potential payment alternatives. Additional research with larger samples is needed to further develop and test case mix groups and improve generalizability to the national population. Refined case mix groups could also help providers prognosticate physical therapy expenditures based on patient profiles.


Asunto(s)
Grupos Diagnósticos Relacionados/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Medicare/estadística & datos numéricos , Modalidades de Fisioterapia/economía , Anciano , Grupos Diagnósticos Relacionados/economía , Planes de Aranceles por Servicios/economía , Femenino , Humanos , Estudios Longitudinales , Masculino , Medicare/economía , Limitación de la Movilidad , Pacientes Ambulatorios/estadística & datos numéricos , Estados Unidos
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