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1.
Value Health ; 24(2): 196-205, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33518026

RESUMEN

OBJECTIVES: Little is known about relationships between opioid- and gabapentinoid-use patterns and healthcare expenditures that may be affected by pain management and risk of adverse outcomes. This study examined the association between patients' opioid and gabapentinoid prescription filling/refilling trajectories and direct medical expenditures in US Medicare. METHODS: This cross-sectional study included a 5% national sample (2011-2016) of fee-for-service beneficiaries with fibromyalgia, low back pain, neuropathy, or osteoarthritis newly initiating opioids or gabapentinoids. Using group-based multitrajectory modeling, this study identified patients' distinct opioid and gabapentinoid (OPI-GABA) dose and duration patterns, based on standardized daily doses, within a year of initiating opioids and/or gabapentinoids. Concurrent direct medical expenditures within the same year were estimated using inverse probability of treatment weighted multivariable generalized linear regression, adjusting for sociodemographic and health status factors. RESULTS: Among 67 827 eligible beneficiaries (mean age ± SD = 63.6 ± 14.8 years, female = 65.8%, white = 77.1%), 11 distinct trajectories were identified (3 opioid-only, 4 gabapentinoid-only, and 4 concurrent OPI-GABA trajectories). Compared with opioid-only early discontinuers ($13 830, 95% confidence interval = $13 643-14 019), gabapentinoid-only early discontinuers and consistent low-dose and moderate-dose gabapentinoid-only users were associated with 11% to 23% lower health expenditures (adjusted mean expenditure = $10 607-$11 713). Consistent low-dose opioid-only users, consistent high-dose opioid-only users, consistent low-dose OPI-GABA users, consistent low-dose opioid and high-dose gabapentinoid users, and consistent high-dose opioid and moderate-dose gabapentinoid users were associated with 14% to 106% higher healthcare expenditures (adjusted mean expenditure = $15 721-$28 464). CONCLUSIONS: Dose and duration patterns of concurrent OPI-GABA varied substantially among fee-for-service Medicare beneficiaries. Consistent opioid-only users and all concurrent OPI-GABA users were associated with higher healthcare expenditures compared to opioid-only discontinuers.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Analgésicos/uso terapéutico , Gabapentina/uso terapéutico , Medicare/economía , Dolor/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Analgésicos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Estudios Transversales , Utilización de Medicamentos , Planes de Aranceles por Servicios/economía , Femenino , Gabapentina/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos
2.
JAAPA ; 34(2): 50-53, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-33470723

RESUMEN

ABSTRACT: Despite extensive evidence-based guidelines, clinicians still face many barriers to reducing the incidence of obesity. Recognizing that obesity is a chronic disease will allow clinicians to properly treat patients and bill for reimbursement. With enhanced education, knowledge of reimbursement, and a push for legislation, physician assistants can pave the way to reducing rates of obesity in adults.


Asunto(s)
Manejo de la Obesidad/economía , Manejo de la Obesidad/métodos , Obesidad/prevención & control , Obesidad/terapia , Asistentes Médicos , Enfermedad Crónica , Práctica Clínica Basada en la Evidencia , Planes de Aranceles por Servicios/economía , Femenino , Humanos , Incidencia , Masculino , Obesidad/economía , Obesidad/epidemiología , Asistentes Médicos/economía , Asistentes Médicos/educación , Guías de Práctica Clínica como Asunto , Atención Primaria de Salud
3.
Cochrane Database Syst Rev ; 1: CD011865, 2021 Jan 20.
Artículo en Inglés | MEDLINE | ID: mdl-33469932

RESUMEN

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.


Asunto(s)
Instituciones de Atención Ambulatoria/economía , Personal de Salud/economía , Mecanismo de Reembolso/economía , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Capitación , Estudios Controlados Antes y Después/estadística & datos numéricos , Costos y Análisis de Costo , Atención a la Salud/economía , Atención a la Salud/normas , Atención a la Salud/estadística & datos numéricos , Planes de Aranceles por Servicios/economía , Planes de Aranceles por Servicios/normas , Planes de Aranceles por Servicios/estadística & datos numéricos , Humanos , Análisis de Series de Tiempo Interrumpido , Médicos de Atención Primaria/economía , Médicos de Atención Primaria/estadística & datos numéricos , Calidad de la Atención de Salud/economía , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Mecanismo de Reembolso/clasificación , Mecanismo de Reembolso/estadística & datos numéricos , Reembolso de Incentivo/economía , Reembolso de Incentivo/normas , Reembolso de Incentivo/estadística & datos numéricos , Salarios y Beneficios/economía , Resultado del Tratamiento
4.
J Am Acad Dermatol ; 84(1): 53-59, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32553682

RESUMEN

BACKGROUND: Skin biopsies are increasing at a rapid rate, and some may be unnecessary. Although skin cancer incidence is rising, there is varied biopsy accuracy between dermatologists and advanced practice professionals (APPs). A comparison of Current Procedural Terminology code (American Medical Association, Chicago, IL) use for skin biopsy and skin cancer treatment over 18 years and a comparison of provider types is needed. Excess skin biopsies increase health care costs and patient morbidity. OBJECTIVE: To examine changes in skin biopsy and skin cancer treatment utilization rates per year in the Medicare fee-for-service (FFS) population and to compare skin biopsy utilization rates between dermatologists and APPs. METHODS: Retrospective cross-sectional study of Medicare FFS paid claims using the Centers for Medicare and Medicaid Services Physician Claims databases. We calculated the number of skin biopsies and skin cancer treatments in the Medicare FFS population from 1993 to 2016, and percentage use by provider type from 2001 to 2016. Our primary outcome measurements were the number of skin biopsies and skin cancer treatments per 1000 Medicare FFS beneficiaries per year and the number of additional skin biopsies per 1000 Medicare FFS beneficiaries per year, or the difference in the number of skin biopsies and number of skin cancer treatments per 1000 Medicare FFS beneficiaries. Our secondary outcome measurements were the skin biopsy-to-skin cancer treatment ratio and the number of procedures per 1000 Medicare FFS beneficiaries per year by provider type. RESULTS: After adjusting for the number of enrollees in the Medicare FFS population from 1993 to 2016, skin biopsies per 1000 Medicare FFS beneficiaries increased 153% (from 39.31 to 99.33), and skin cancer treatments per 1000 Medicare FFS beneficiaries increased 39% (from 34.67 to 48.26). Between 1993 and 2016, the skin biopsy-to-skin cancer treatment ratio increased 81% (from 1.134 to 2.058), and the number of additional biopsies per 1000 Medicare FFS beneficiaries increased 1001% (from 4.638 to 51.072) between 1993 and 2016. Utilization data by provider type is available from 2001 to 2016. The number of skin biopsies per 1000 Medicare beneficiaries performed by APPs increased from 0.82 to 17.19 or 1996% (nurse practitioners, 2211%; physician assistants, 1916%) and the number of biopsies by dermatologists increased by 41% from 53.98 to 76.17. LIMITATIONS: Medicare claims data do not provide specific information regarding skin biopsy or skin cancer treatment use. CONCLUSION: The number of skin biopsies has risen 153% since 1993, while the number of skin cancer treatments has only increased 39%. Our data highlight the rise of biopsy use and the increase in biopsies that do not result in skin cancer diagnosis or treatment. This suggests APPs may be responsible for increasing the cost of skin cancer management by biopsying significantly more benign lesions than dermatologists.


Asunto(s)
Biopsia/tendencias , Planes de Aranceles por Servicios/economía , Medicare/economía , Neoplasias Cutáneas/diagnóstico , Neoplasias Cutáneas/cirugía , Anciano , Biopsia/estadística & datos numéricos , Estudios Transversales , Costos de la Atención en Salud , Humanos , Persona de Mediana Edad , Cirugía de Mohs , Utilización de Procedimientos y Técnicas , Estudios Retrospectivos , Estados Unidos , Procedimientos Innecesarios
6.
J Vasc Interv Radiol ; 31(8): 1302-1307.e1, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32741554

RESUMEN

PURPOSE: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. MATERIALS AND METHODS: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). RESULTS: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. CONCLUSIONS: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.


Asunto(s)
Sedación Consciente/economía , Planes de Aranceles por Servicios/economía , Costos de la Atención en Salud , Paquetes de Atención al Paciente/economía , Radiografía Intervencional/economía , Terminología como Asunto , Sedación Consciente/clasificación , Sedación Consciente/tendencias , Planes de Aranceles por Servicios/tendencias , Costos de la Atención en Salud/tendencias , Costos de Hospital , Humanos , Medicare/economía , Paquetes de Atención al Paciente/clasificación , Paquetes de Atención al Paciente/tendencias , Práctica Privada/economía , Radiografía Intervencional/clasificación , Radiografía Intervencional/tendencias , Proveedores de Redes de Seguridad/economía , Estados Unidos
7.
J Ment Health Policy Econ ; 23(3): 81-91, 2020 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-32853157

RESUMEN

BACKGROUND: Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY: In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS: We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS: We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION: These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES: Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.


Asunto(s)
Organizaciones Responsables por la Atención , Capitación/estadística & datos numéricos , Planes de Aranceles por Servicios/economía , Motivación , Atención Primaria de Salud/economía , Análisis Costo-Beneficio/estadística & datos numéricos , Planes de Aranceles por Servicios/estadística & datos numéricos , Gastos en Salud , Humanos , Modelos Económicos , Modelos Teóricos , Sector Público
8.
Tex Med ; 116(6): 34-36, 2020 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-32645179

RESUMEN

Texas physicians who deal with Medicare's substandard payments and world-class administrative hassles are feeling underappreciated. The latest report from the committee that advises Congress on Medicare payment policy may exacerbate that feeling. In March, the Medicare Payment Advisory Committee (MedPAC) released its annual report assessing payments to physicians, among other sectors. MedPAC recommended no changes to the 2021 Medicare physician fee schedule, meaning no increase in physician payments.


Asunto(s)
Tabla de Aranceles , Planes de Aranceles por Servicios/economía , Medicare/economía , Médicos/economía , Sistema de Pago Prospectivo/economía , Mecanismo de Reembolso/economía , Humanos , Texas , Estados Unidos
9.
Tex Med ; 116(6): 30-32, 2020 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-32645180

RESUMEN

Comptroller delays medical billing tax until October 2021, giving TMA a chance to work out a legislative fix.


Asunto(s)
Planes de Aranceles por Servicios/economía , Revisión de Utilización de Seguros/economía , Servicios Externos/economía , Impuestos/economía , Renta , Texas , Factores de Tiempo
10.
Tex Med ; 116(5): 37-39, 2020 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-32645188

RESUMEN

From electronic health records to quality reporting, today's physicians deal with plenty of distractions from patient care. Starting in 2021, hospital-employed physicians may find themselves adding another one: explaining to patients the difference between their hospital's multiple published prices for the same service.


Asunto(s)
Economía Hospitalaria/legislación & jurisprudencia , Planes de Aranceles por Servicios/economía , Planes de Aranceles por Servicios/legislación & jurisprudencia , Costos de la Atención en Salud/legislación & jurisprudencia , Sistema de Pago Prospectivo/legislación & jurisprudencia , Registros Electrónicos de Salud , Humanos , Cobertura del Seguro/economía
12.
Value Health ; 23(6): 812-823, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32540239

RESUMEN

OBJECTIVES: Implementation of value-based initiatives depends on cost-assessment methods that can provide high-quality cost information. Time-driven activity-based costing (TDABC) is increasingly being used to solve the cost-information gap. This study aimed to review the use of the TDABC methodology in real-world settings and to estimate its impact on the value-based healthcare concept for inpatient management. METHODS: This systematic review was conducted by screening PubMed/MEDLINE and Scopus databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all studies up to August 2019. The use of TDABC for inpatient management was the main eligibility criterion. A qualitative approach was used to analyze the different methodological aspects of TDABC and its effective contribution to the implementation of value-based initiatives. RESULTS: A total of 1066 studies were retrieved, and 26 full-text articles were selected for review. Only studies focused on surgical inpatient conditions were identified. Most of the studies reported the types of activities on a macrolevel. Professional and structural cost variables were usually assessed. Eighteen studies reported that TDABC contributed to value-based initiatives, especially cost-saving findings. TDABC was satisfactorily applied to achieve value-based contributions in all the studies that used the method for this purpose. CONCLUSIONS: TDABC could be a strategy for increasing cost accuracy in real-world settings, and the method could help in the transition from fee-for-service to value-based systems. The results could provide a clearer idea of the costs, help with resource allocation and waste reduction, and might support clinicians and managers in increasing value in a more accurate and transparent way.


Asunto(s)
Costos y Análisis de Costo/métodos , Atención a la Salud/economía , Costos de la Atención en Salud , Ahorro de Costo , Planes de Aranceles por Servicios/economía , Humanos , Pacientes Internos , Asignación de Recursos/economía , Factores de Tiempo
15.
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
16.
Circ Arrhythm Electrophysiol ; 13(5): e008280, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32281393

RESUMEN

BACKGROUND: Current understanding of the impact of cardiac implantable electronic device (CIED) infection is based on retrospective analyses from medical records or administrative claims data. The WRAP-IT (Worldwide Randomized Antibiotic Envelope Infection Prevention Trial) offers an opportunity to evaluate the clinical and economic impacts of CIED infection from the hospital, payer, and patient perspectives in the US healthcare system. METHODS: This was a prespecified, as-treated analysis evaluating outcomes related to major CIED infections: mortality, quality of life, disruption of CIED therapy, healthcare utilization, and costs. Payer costs were assigned using medicare fee for service national payments, while medicare advantage, hospital, and patient costs were derived from similar hospital admissions in administrative datasets. RESULTS: Major CIED infection was associated with increased all-cause mortality (12-month risk-adjusted hazard ratio, 3.41 [95% CI, 1.81-6.41]; P<0.001), an effect that sustained beyond 12 months (hazard ratio through all follow-up, 2.30 [95% CI, 1.29-4.07]; P=0.004). Quality of life was reduced (P=0.004) and did not normalize for 6 months. Disruptions in CIED therapy were experienced in 36% of infections for a median duration of 184 days. Mean costs were $55 547±$45 802 for the hospital, $26 867±$14 893, for medicare fee for service and $57 978±$29 431 for Medicare Advantage (mean hospital margin of -$30 828±$39 757 for medicare fee for service and -$6055±$45 033 for medicare advantage). Mean out-of-pocket costs for patients were $2156±$1999 for medicare fee for service, and $1658±$1250 for medicare advantage. CONCLUSIONS: This large, prospective analysis corroborates and extends understanding of the impact of CIED infections as seen in real-world datasets. CIED infections severely impact mortality, quality of life, healthcare utilization, and cost in the US healthcare system. Registration: URL: https://www.clinicaltrials.gov Unique Identifier: NCT02277990.


Asunto(s)
Antibacterianos/economía , Antibacterianos/uso terapéutico , Profilaxis Antibiótica/economía , Desfibriladores Implantables/economía , Costos de la Atención en Salud , Recursos en Salud/economía , Marcapaso Artificial/economía , Infecciones Relacionadas con Prótesis/economía , Infecciones Relacionadas con Prótesis/prevención & control , Anciano , Anciano de 80 o más Años , Antibacterianos/efectos adversos , Profilaxis Antibiótica/efectos adversos , Causas de Muerte , Desfibriladores Implantables/efectos adversos , Remoción de Dispositivos/economía , Costos de los Medicamentos , Planes de Aranceles por Servicios/economía , Femenino , Gastos en Salud , Costos de Hospital , Humanos , Tiempo de Internación/economía , Masculino , Medicare/economía , Persona de Mediana Edad , Marcapaso Artificial/efectos adversos , Readmisión del Paciente/economía , Estudios Prospectivos , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/mortalidad , Calidad de Vida , Método Simple Ciego , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
17.
Value Health ; 23(4): 481-486, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32327165

RESUMEN

OBJECTIVES: To examine the uptake of filgrastim-sndz (Zarxio), the first biosimilar to launch in the United States, in the Medicare Part B fee-for-service program from its launch in September 2015 to December 2017 and compare characteristics of patients and facilities that used filgrastim-sndz or originator filgrastim (Neupogen). METHODS: The 20% sample of Medicare Part B fee-for-service administrative claims data was used to extract information on claims for any filgrastim product between January 1, 2015 and December 31, 2017. RESULTS: The utilization of filgrastim-sndz in Medicare Part B increased sharply between January and August 2016, surpassing filgrastim by November 2017, contributing to a 30% decrease in overall spending on this drug since 2015. Uptake was faster and larger in physician practices compared with hospital outpatient departments. About 77% of patients receiving filgrastim-sndz were new users. Utilization patterns indicated that product selection occurred at the facility level, rather than being at the discretion of the prescribing physician or driven by patient characteristics. CONCLUSION: Uptake of biosimilar filgrastim in the Medicare Part B program occurred despite multiple challenges to the adoption of biosimilars in the US market, suggesting that substantial potential savings could be generated by improving biosimilar uptake. Our findings indicated that physician practices and hospital outpatient departments have distinctive biosimilar uptake patterns. Thus policy makers aiming to contain Medicare Part B spending might consider focusing on incentivizing biosimilar uptake among hospital outpatient departments.


Asunto(s)
Biosimilares Farmacéuticos/administración & dosificación , Filgrastim/administración & dosificación , Fármacos Hematológicos/administración & dosificación , Medicare Part B/economía , Biosimilares Farmacéuticos/economía , Ahorro de Costo , Planes de Aranceles por Servicios/economía , Filgrastim/economía , Fármacos Hematológicos/economía , Humanos , Medicare Part B/estadística & datos numéricos , Servicio Ambulatorio en Hospital/estadística & datos numéricos , Pacientes Ambulatorios , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estados Unidos
19.
Spine Deform ; 8(3): 421-426, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32096128

RESUMEN

STUDY DESIGN: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE: III.


Asunto(s)
Costos y Análisis de Costo/métodos , Planes de Aranceles por Servicios/economía , Costos de la Atención en Salud , Hospitalización/economía , Escoliosis/economía , Escoliosis/cirugía , Fusión Vertebral/economía , Fusión Vertebral/métodos , Adolescente , Tornillos Óseos/economía , Ahorro de Costo , Femenino , Humanos , Inflación Económica , Tiempo de Internación/economía , Masculino , Estudios Retrospectivos
20.
Crit Care Med ; 48(3): 276-288, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-32058366

RESUMEN

OBJECTIVES: To provide contemporary estimates of the burdens (costs and mortality) associated with acute inpatient Medicare beneficiary admissions for sepsis. DESIGN: Analysis of paid Medicare claims via the Centers for Medicare & Medicaid Services DataLink Project. SETTING: All U.S. acute care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency). PATIENTS: All Medicare beneficiaries, 2012-2018, with an inpatient admission including one or more explicit sepsis codes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total inpatient hospital and skilled nursing facility admission counts, costs, and mortality over time. From calendar year (CY)2012-CY2018, the total number of Medicare Part A/B (fee-for-service) beneficiaries with an inpatient hospital admission associated with an explicit sepsis code rose from 811,644 to 1,136,889. The total cost of inpatient hospital admission including an explicit sepsis code for those beneficiaries in those calendar years rose from $17,792,657,303 to $22,439,794,212. The total cost of skilled nursing facility care in the 90 days subsequent to an inpatient hospital discharge that included an explicit sepsis code for Medicare Part A/B rose from $3,931,616,160 to $5,623,862,486 over that same interval. Precise costs are not available for Medicare Part C (Medicare Advantage) patients. Using available federal data sources, we estimated the aggregate cost of inpatient admissions and skilled nursing facility admissions for Medicare Advantage patients to have risen from $6.0 to $13.4 billion over the CY2012-CY2018 interval. Combining data for fee-for-service beneficiaries and estimates for Medicare Advantage beneficiaries, we estimate the total inpatient admission sepsis cost and any subsequent skilled nursing facility admission for all (fee-for-service and Medicare Advantage) Medicare patients to have risen from $27.7 to $41.5 billion. Contemporary 6-month mortality rates for Medicare fee-for-service beneficiaries with a sepsis inpatient admission remain high: for septic shock, approximately 60%; for severe sepsis, approximately 36%; for sepsis attributed to a specific organism, approximately 31%; and for unspecified sepsis, approximately 27%. CONCLUSION: Sepsis remains common, costly to treat, and presages significant mortality for Medicare beneficiaries.


Asunto(s)
Gastos en Salud/estadística & datos numéricos , Hospitalización/economía , Medicare/economía , Sepsis/economía , Sepsis/mortalidad , Anciano , Anciano de 80 o más Años , Centers for Medicare and Medicaid Services, U.S. , Planes de Aranceles por Servicios/economía , Femenino , Humanos , Masculino , Medicare Part B/economía , Medicare Part C/economía , Calidad de Vida , Índice de Severidad de la Enfermedad , Choque Séptico/economía , Choque Séptico/mortalidad , Estados Unidos/epidemiología
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