Incorporating Medicare Advantage Admissions Into the CMS Hospital-Wide Readmission Measure.

Importance: Medicare Advantage (MA) enrollment is rapidly expanding, yet Centers for Medicare & Medicaid Services (CMS) claims-based hospital outcome measures, including readmission rates, have historically included only fee-for-service (FFS) beneficiaries. Objective: To assess the outcomes of incorporating MA data into the CMS claims-based FFS Hospital-Wide All-Cause Unplanned Readmission (HWR) measure. Design, Setting, and Participants: This cohort study assessed differences in 30-day unadjusted readmission rates and demographic and risk adjustment variables for MA vs FFS admissions. Inpatient FFS and MA administrative claims data were extracted from the Integrated Data Repository for all admissions for Medicare beneficiaries from July 1, 2018, to June 30, 2019. Measure reliability and risk-standardized readmission rates were calculated for the FFS and MA cohort vs the FFS-only cohort, overall and within specialty subgroups (cardiorespiratory, cardiovascular, medicine, surgery, neurology), then changes in hospital performance quintiles were assessed after adding MA admissions. Main Outcome and Measure: Risk-standardized readmission rates. Results: The cohort included 11 029 470 admissions (4 077 633 [37.0%] MA; 6 044 060 [54.8%] female; mean [SD] age, 77.7 [8.2] years). Unadjusted readmission rates were slightly higher for MA vs FFS admissions (15.7% vs 15.4%), yet comorbidities were generally lower among MA beneficiaries. Test-retest reliability for the FFS and MA cohort was higher than for the FFS-only cohort (0.78 vs 0.73) and signal-to-noise reliability increased in each specialty subgroup. Mean hospital risk-standardized readmission rates were similar for the FFS and MA cohort and FFS-only cohorts (15.5% vs 15.3%); this trend was consistent across the 5 specialty subgroups. After adding MA admissions to the FFS-only HWR measure, 1489 hospitals (33.1%) had their performance quintile ranking changed. As their proportion of MA admissions increased, more hospitals experienced a change in their performance quintile ranking (147 hospitals [16.3%] in the lowest quintile of percentage MA admissions; 408 [45.3%] in the highest). The combined cohort added 63 hospitals eligible for public reporting and more than 4 million admissions to the measure. Conclusions and Relevance: In this cohort study, adding MA admissions to the HWR measure was associated with improved measure reliability and precision and enabled the inclusion of more hospitals and beneficiaries. After MA admissions were included, 1 in 3 hospitals had their performance quintile changed, with the greatest shifts among hospitals with a high percentage of MA admissions.

Gaps in standardized postoperative pain management quality measures: A systematic review.

BACKGROUND: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery. METHODS: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020. RESULTS: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain. CONCLUSION: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

A Guide to Industry Payments and an Algorithm for Their Management.

BACKGROUND: The Open Payments database was created to increase transparency of industry payment relationships within medicine. The current literature often examines only 1 year of the database. In this study, the authors use 5 years of data to show trends among industry payments to plastic surgeons from 2014 to 2018. In addition, the authors lay out the basics of conflict-of-interest reporting for the new plastic surgeon. Finally, the authors suggest an algorithm for the responsible management of industry relationships. METHODS: This study analyzed nonresearch payments made to plastic surgeons from January 1, 2014, to December 31, 2018. Descriptive statistics were calculated using R Statistical Software and visualized using Tableau. RESULTS: A total of 304,663 payments totaling $140,889,747 were made to 8148 plastic surgeons; 41 percent ($58.28 million) was paid to 50 plastic surgeons in the form of royalty or license payments. With royalties excluded, average and median payments were $276 and $25. The average yearly total per physician was $2028. Of the 14 payment categories, 95 percent of the total amount paid was attributable payments in one of six categories. Seven hundred thirty companies reported payments to plastic surgeons from 2014 to 2018; 15 companies (2 percent) were responsible for 80 percent ($66.34 million) of the total sum paid. Allergan was responsible for $24.45 million (29.6 percent) of this amount. CONCLUSIONS: Although discussions on the proper management of industry relationships continue to evolve, the data in this study illustrate the importance of managing industry relationships. The simple guidelines suggested create a basis for managing industry relationships in the career of the everyday plastic surgeon.

The association of nursing home quality ratings and spread of COVID-19.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing home residents. Given the continued high incidence of COVID-19, and the likelihood that new variants and other infectious agents may cause future outbreaks, we sought to understand the relationship of nursing home quality ratings and measures of COVID-19 outbreak severity and persistence. DESIGN: We analyzed nursing home facility-level data on COVID-19 cases and deaths, county-level COVID-19 rates, and nursing home data from the Centers for Medicare & Medicaid Services (CMS), including ratings from the CMS Nursing Home Five-Star Quality Rating System. We used regression analysis to examine the association between star ratings and cumulative COVID-19 incidence and mortality as well as persistent high resident incidence. SETTING: All nursing homes in the CMS COVID-19 Nursing Home Dataset reporting data that passed quality assurance checks for at least 20 weeks and that were included in the January 2021 Nursing Home Care Compare update. PARTICIPANTS: Residents of the included nursing homes. MEASUREMENTS: Cumulative resident COVID-19 incidence and mortality through January 10, 2021; number of weeks with weekly resident incidence of COVID-19 in the top decile nationally. RESULTS: As of January 10, 2021, nearly all nursing homes (93.6%) had reported at least one case of COVID-19 among their residents, more than three-quarters (76.9%) had reported at least one resident death, and most (83.5%) had experienced at least 1 week in the top decile of weekly incidence. In analyses adjusted for facility and county-level characteristics, we found generally consistent relationships between higher nursing home quality ratings and lower COVID-19 incidence and mortality, as well as with fewer high-incidence weeks. CONCLUSION: Nursing home quality ratings are associated with COVID-19 incidence, mortality, and persistence. Nursing homes receiving five-star ratings, for overall quality as well as for each domain, had lower COVID-19 rates among their residents.

Mandated Copayment Reductions in Medicare Advantage: Effects on Skilled Nursing Care, Hospitalizations, and Plan Exit.

OBJECTIVES: To address concerns that postacute cost-sharing may deter high-need beneficiaries from participating in Medicare Advantage (MA) plans, the Centers for Medicare and Medicaid Services have capped cost-sharing for skilled nursing facility (SNF) services in MA plans since 2011. This study examines whether SNF use, inpatient use, and plan disenrollment changed following stricter regulations in 2015 that required most MA plans to eliminate or substantially reduce cost-sharing for SNF care. DESIGN: Difference-in-differences retrospective analysis from 2013 to 2016. SETTING: MA plans. PARTICIPANTS: Thirty-one million MA members in 320 plans with mandatory cost-sharing reductions and 261 plans without such reductions. MEASUREMENTS: Mean monthly number of SNF admissions, SNF days, hospitalizations, and plan disenrollees per 1000 members. RESULTS: Mean total cost-sharing for the first 20 days of SNF services decreased from $911 to $104 in affected plans. Relative to concurrent changes in plans without mandated cost-sharing reductions, plans with mandatory cost-sharing reductions experienced no significant differences in the number of SNF days per 1000 members (adjusted between-group difference: 0.4 days per 1000 members [95% confidence interval (95% CI), -5.2 to 6.0, P=0.89], small decreases in the number of hospitalizations per 1000 members [adjusted between-group difference: 0.6 admissions per 1000 members (95% CI, -1.0 to -0.1; P=0.03)], and small decreases in the number of SNF users who disenrolled at year-end [adjusted between-group difference: -16.8 disenrollees per 1000 members (95% CI, -31.9 to -1.8; P=0.03)]. CONCLUSIONS: Mandated reductions in SNF cost-sharing may have curbed selective disenrollment from MA plans without significantly increasing use of SNF services.

Nursing home oversight during the COVID-19 pandemic.

BACKGROUND/OBJECTIVES: Regulatory oversight has been a central strategy to assure nursing home quality of care for decades. In response to COVID-19, traditional elements of oversight that relate to resident care have been curtailed in favor of implementing limited infection control surveys and targeted complaint investigations. We seek to describe the state of nursing home oversight during the pandemic to facilitate a discussion of whether and how these activities should be altered going forward. DESIGN AND SETTING: In a retrospective study, we describe national oversight activities in January-June 2020 and compare these activities to the same time period from 2019. We also examine state-level oversight activities during the peak months of the pandemic. PARTICIPANTS: United States nursing homes. DATA: Publicly available Quality, Certification, and Oversight Reports (QCOR) data from the Centers for Medicare and Medicaid Services (CMS). MEASUREMENTS: Number of standard, complaint, and onsite infection surveys, number of deficiencies from standard and complaint surveys, number of citations by deficiency tag, and number and amount of civil monetary penalties. RESULTS: The number of standard and complaint surveys declined considerably in the second quarter of 2020 relative to the same time frame in 2019. Deficiency citations generally decreased to near zero by April 2020 with the exception of infection prevention and control deficiencies and citations for failure to report COVID-19 data to the national health safety network. Related enforcement actions were down considerably in 2020, relative to 2019. CONCLUSION: In the months since COVID-19 first impacted nursing homes, regulatory oversight efforts have fallen off considerably. While CMS implemented universal infection control surveys and targeted complaint investigations, other routine aspects of oversight dropped in light of justifiable limits on nursing home entry. Going forward, we must develop policies that allow regulators to balance the demands of the pandemic while fulfilling their responsibilities effectively.

Paclitaxel-coated devices in the treatment of femoropopliteal stenosis among patients ≥65 years old: An ACC PVI Registry Analysis.

BACKGROUND: The connection between paclitaxel-coated devices (PCD) use during peripheral vascular interventions (PVI) and mortality is debated. We aimed to analyze patterns of PCD use and the safety and effectiveness of PCD use in the superficial femoral and/or popliteal arteries. METHODS: Patients undergoing PVI of femoropopliteal lesions with and without PCD between January 1, 2015 and June 30, 2017 were compared using the American College of Cardiology's National Cardiovascular Data Registry PVI Registry. Outcomes were derived from Centers for Medicare & Medicaid claims data. The primary outcome was all-cause mortality at 6-, 12-, and 24-months following PVI. Inverse probability weighting and frailty models were used to assess the differences between groups. The analysis was IRB-approved. RESULTS: In the overall cohort consisting of 6,302 femoropopliteal PVIs, PCD-PVI patients were more likely to be treated for claudication (63.5% vs 51.3%, P< .001), less likely to have a chronic total occlusion (24.6% vs 34.7%, P < .001), and more likely to be treated in certain geographic and practice settings. In the analytic cohort consisting of 1,666 femoropopliteal PVIs with linked claims outcomes (888 PCD-PVI, 53.3%), unadjusted rates of all outcomes were lower in PCD-PVI patients. After adjustment, there were no significant differences in mortality following PCD-PVI versus non-PCD PVI at 1 year (adjusted RR 0.78, 95% CI 0.60-1.01, P= .055) or 2 years (aRR 0.98, 95% CI 0.77-1.24, P= .844). CONCLUSION: There were significant differences between the patients in whom and settings in which PCD-PVI was versus was not used. PCD-PVI was not associated with an increased risk of 2-year mortality in real-world use.

Financial Transactions from Manufacturers to Otolaryngologists in 2018.

OBJECTIVE: To characterize in depth non-research and research payments from industry to otolaryngologists in 2018 with an emphasis on product types. METHODS: Centers for Medicare and Medicaid Services Open Payments program was used for data collection: payment amount, the nature of payments, products associated with the payments, date of the payments, and companies making the payments were studied. Products associated with the payments were classified by categorical type. Descriptive statistics were used to analyze the data. RESULTS: There were 70,172 payments for a total of $11,001,875 made to otolaryngologists in 2018 with a median payment of $19. Food and beverage had the highest number of payments made (89.96%). Consulting fees (33.46%) composed the highest total payment amount. The two companies that contributed the highest amount were Stryker Corporation and Intersect ENT Inc. Sinus conditions had the most products within the top 25 products associated with payments. The top five products with the highest payments received were for balloon sinus dilation, nasal spray, sinus implant, Botox, and cochlear implant. There was a bimodal payment distribution demonstrating a higher number of payments made in the spring and fall. CONCLUSION: Our study is the first to review payments to otolaryngologists in 2018 and classify these payments into product types. The products and companies that contributed the highest payments were associated with sinus conditions. The products that dominated in each subspecialty of otolaryngology coincide with clinical practice trends and emerging technologies. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E388-E394, 2021.

Price transparency implementation: Accessibility of hospital chargemasters and variation in hospital pricing after CMS mandate.

BACKGROUND: National regulations have increasingly focused on transparency in hospital billing and pricing practices. A January 2019 federal mandate required hospitals to publicize lists of billable procedures and items known as chargemasters. METHODS: We identified the 500 top self-pay/uninsured revenue grossing hospitals nationally and searched each hospital's website for a chargemaster. Corresponding items were matched across chargemasters. Intrahospital and interhospital price variation were calculated. To investigate variation in item naming, a name variant and fuzzy matching search was conducted for fifteen common chargemaster items. RESULTS: Of 500 hospitals in this study, 69 (13.8%) had chargemasters that were inaccessible and 30 (6.0%) had chargemasters that did not meet mandated requirements. Among the remaining 431 hospitals, the mean interhospital and intrahospital variation in pricing for identical items was 18% (SD 28%) and 28% (SD 29%), respectively. 388 hospitals listed multiple prices for the same item, with a mean of 687.3 duplicated items (SD 1157.7). Among fifteen common chargemaster items, each item was associated with an average of 275 (SD 213) unique name variants. Interhospital price variation of these items ranged from 53% (transthoracic echocardiogram) to 243% (furosemide 40 mg). CONCLUSIONS: Many chargemasters have barriers to access, and item naming is inconsistent across chargemasters. There is significant interhospital price variation for similar items. IMPLICATIONS: Chargemasters are uninterpretable for the purpose of patient price comparison in their current form. Further regulatory efforts are necessary to increase price transparency and enhance the ability of patients to compare hospital prices.

Medicare Diabetes Prevention Program: where are the suppliers?

OBJECTIVES: The Medicare Diabetes Prevention Program (MDPP) launched in April 2018, offering an unprecedented opportunity to reach the estimated 48.3% of older adults with prediabetes. Success of the innovative policy is likely to depend on adequate supplier availability. We examined supplier data from CMS to assess beneficiaries' potential access to MDPP services. STUDY DESIGN: We conducted a descriptive analysis of MDPP suppliers using data extracted from the CMS registry of suppliers as of July 2019 and data about beneficiary populations. METHODS: Identifying the location, type, and number of MDPP suppliers and their respective sites, including within states, US territories, and the District of Columbia (hereafter, states), we mapped geographic coverage of MDPP access. RESULTS: There are 126 unique supplier organizations that offer the MDPP across 601 sites, equating to only 1 site per 100,000 Medicare beneficiaries. Seventy-five percent of states have no MDPP sites, fewer than 1 site per 100,000 beneficiaries, and/or availability limited to a single municipality. Although only 10.3% of MDPP suppliers are community-based organizations, they represent more than half (55.7%) of sites where beneficiaries can access the program. CONCLUSIONS: Findings show inadequate MDPP access, with relatively few suppliers and locations where beneficiaries can receive services. Insufficient reimbursement relative to costs for suppliers may largely account for limited availability. Strategies to facilitate access are urgently needed, which may include partnering with large organizations for greater per capita reach and rural organizations for broader geographic coverage, along with setting fiscally sustainable rates based on refined program implementation and cost analysis.

Mapping colocation: Using national provider identified data to assess primary care and behavioral health colocation.

INTRODUCTION: Evidence supports that integrated behavioral health care improves patient outcomes. Colocation, where health and behavioral health providers work in the same physical space, is a key element of integration, but national rates of colocation are unknown. We established national colocation rates and analyzed variation by primary care provider (PCP) type, practice size, rural/urban setting, Health and Human Services region, and state. METHOD: Data were from the Centers for Medicare & Medicaid Services' 2018 National Plan and Provider Enumeration System data set. Practice addresses of PCPs (family medicine, general practitioners, internal medicine, pediatrics, and obstetrician/gynecologists), social workers, and psychologists were geocoded to latitude and longitude coordinates. Distances were calculated; those < 0.01 miles apart were considered colocated. Bivariate and multivariate analyses were conducted, and maps were generated. RESULTS: Of the 380,690 PCPs, > 44% were colocated with a behavioral health provider. PCPs in urban settings were significantly more likely to be colocated than rural providers (46% vs. 26%). Family medicine and general practitioners were least likely to be colocated. Only 12% of PCPs who were the sole PCP at an address were colocated compared with 48% at medium-size practices (11-25 PCPs). DISCUSSION: Although colocation is modestly expanding in the United States, it is most often occurring in large urban health centers. Efforts to expand integrated behavioral health care should focus on rural and smaller practices, which may require greater assistance achieving integration. Increased colocation can improve access to behavioral health care for rural, underserved populations. This work provides a baseline to assist policymakers and practices reach behavioral health integration. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Preparing for a value-driven future.

At this month's staff meeting of your integrated primary care practice, the medical director makes an announcement: Your health system just signed a contract that includes a value-based payment (VBP) arrangement with a local managed care organization (MCO). The medical director suggests that this will lead to big changes in your practice because you will now focus on producing patient outcomes rather than on volume of care delivered. You wonder: What is a VBP arrangement? What kinds of patient outcomes? What does this mean for integrated care? and How do I help our organization succeed? Value-based care is the future, and it will impact the way that all of us practice. In value-based arrangements, the delivery of care fundamentally changes because payment for care shifts from our current fee-for-service model, in which provider productivity is key to financial survival, to payment for positive clinical outcomes where quality of care rules. And this change is happening now. In 2015, the U.S. Department of Health and Human Services announced aggressive national VBP targets, with a goal of tying 50% of all Medicare payments to alternative payment models by the end of 2018 (New York State Department of Health, 2015). Since then, many states have adopted similar targets for their Medicaid programs in light of ongoing state budget challenges and unsustainable cost growth trends. As these changes take hold, health care providers are increasingly expected to make fundamental changes to service delivery, financial, and organizational operations. As health care providers, VBP will require us and our health centers to develop new skills, capacities, and systems for managing clinical, financial, and operational performance and risk. We must all make sure we understand and are ready to play our part in the transition to VBP. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Social media: How hospital facebook activity may influence patient satisfaction.

Some hospitals use social media to promote accurate health-related education, information, and engage consumers. We performed multiple linear regression analyses to determine the associations between hospital Facebook activity and patient satisfaction for 390 hospitals. Hospitals that had a Facebook page were active on Facebook in the past 30 days and had more "likes," had more patients willing to definitely recommend the hospital, and had a higher overall satisfaction score. Practitioners can use the results when considering whether a minimal financial investment in social media may be worth customer loyalty and Centers for Medicare and Medicaid Systems (CMS) reimbursement benefits.

Prescribing Patterns and Costs Associated with Postoperative Eye Drop Use in Medicare Beneficiaries Undergoing Cataract Surgery.

PURPOSE: To determine costs and prescribing patterns of postoperative eye drops for cataract surgery and estimate potential savings of generic or therapeutic drug substitutions. DESIGN: Retrospective, cross-sectional analysis. PARTICIPANTS: Medicare beneficiaries aged ≥65 years with Part D coverage who underwent cataract surgery in 2016. METHODS: Medicare Part D claims were used to extract information on eye drop prescriptions that were filled during the postoperative period of cataract surgery. Savings from generic or therapeutic drug substitutions were estimated for brand medications. MAIN OUTCOME MEASURES: Total cost of postoperative eye drops for cataract surgery and physician and patient factors associated with medication cost. RESULTS: Postoperative eye drops were prescribed in 2016 to 88% of 591 733 Medicare beneficiaries who underwent cataract surgery during that calendar year, with brand medications accounting for 57.5% of prescription volume. The overall cost totaled more than $167 million, 76.5% of which was attributable to use of brand medications. The mean costs of medications were $228 and $324 for those undergoing 1 and 2 surgeries, respectively. Topical antibiotics (89%) were the most commonly prescribed drug class by volume, followed by topical steroids (86%) and nonsteroidal anti-inflammatory drugs (66%), and accounted for 26%, 37%, and 36% of the total cataract surgery eye drop cost, respectively. Use of therapeutic and generic alternatives could have resulted in cost savings of as much as $118 million, or 70% of the total cost of postoperative eye drops. In adjusted analysis, patient factors associated with increased eye drop cost included older age, female gender, and race or ethnicity. Physician characteristics associated with increased eye drop cost included female gender, greater number of years in practice, practicing in metropolitan versus nonmetropolitan areas, and practicing in the Northeast versus the South and in the South versus the Midwest. CONCLUSIONS: The cost to the Centers for Medicare and Medicaid Services for eye drops prescribed for postoperative use after cataract surgery in 2016 was approximately $170 million. In the absence of evidence of clinical superiority of expensive versus less costly options, substantial opportunity exists to improve the value of care delivered to Medicare beneficiaries.