Drivers of Medicare Spending: A 15-Year Review of Radiation Oncology Charges Allowed by the Medicare Physician/Supplier Fee-for-Service Program Compared With Other Specialties.

PURPOSE: In 2019, the Centers for Medicare and Medicaid Services proposed a new radiation oncology alternative payment model aimed at reducing expenditures. We examined changes in aggregate physician Medicare charges allowed per specialty to provide contemporary context to proposed changes and hypothesize that radiation oncology charges remained stable through 2017. METHODS AND MATERIALS: Medicare physician/supplier utilization, program payments, and balance billing for original Medicare beneficiaries, by physician specialty, were analyzed from 2002 to 2017. Total allowed charges under the physician/supplier fee-for-service program, inflation-adjusted charges, and percent of total charges billed per specialty were examined. We adjusted for inflation using the consumer price index for medical care from the US Bureau of Labor Statistics. RESULTS: Total allowed charges increased from $83 billion in 2002 to $138 billion in 2017. The specialties accounting for the most charges billed to Medicare were internal medicine and ophthalmology. Radiation oncology charges accounted for 1.2%, 1.6%, and 1.4% of total charges allowed by Medicare in 2002, 2012, and 2017, respectively. Radiation oncology charges allowed increased 44% from 2002 to 2012 ($987.6 million to $1.42 billion) but decreased by 19% from 2012 to 2017 ($1.15 billion), adjusted for inflation. Total charges allowed by internal medicine decreased 2% from 2002 to 2012 ($8.53 to $8.36 billion), adjusted for inflation, and decreased 16% from 2012 to 2017 ($7.05 billion). When adjusting for inflation, ophthalmology charges increased 18% from 2002 to 2012 ($4.53 to $5.36 billion) and increased 3% from 2012 to 2017 ($5.5 billion). CONCLUSIONS: Radiation oncology physician charges represent a small fraction of total Medicare expenses and are not a driver for Medicare spending. Aggregate inflation-adjusted charges by radiation oncology have dramatically declined in the past 5 years and represent a stable fraction of total Medicare charges. The need to target radiation oncology with cost-cutting measures may be overstated.

Comparison of Resident, Advanced Practice Clinician, and Hospitalist Teams in an Academic Medical Center: Association With Clinical Outcomes and Resource Utilization.

BACKGROUND: Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures. OBJECTIVE: Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams. DESIGN: Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization. SUBJECTS: Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716). MAIN MEASURES: Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization. KEY RESULTS: Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams. CONCLUSION: We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.

High-cost, high-need patients: the impact of reported penicillin allergy.

OBJECTIVES: More than 90% of patients who report a penicillin allergy have the allergy disproved when tested. Unnecessary use of alternative (non-beta-lactam) antibiotics can result in more treatment failures and adverse reactions. We described the prevalence and impact of a reported penicillin allergy in high-cost, high-need (HCHN) patients. STUDY DESIGN: Retrospective cohort. METHODS: We identified HCHN patients in a care management program of an urban academic medical center (January 1, 2014, to December 31, 2016). We used multivariable logistic regression models to determine the association between a reported penicillin allergy and antibiotic use. We used multivariable Poisson regression models to determine the association between a reported penicillin allergy, with or without multiple drug intolerance syndrome (MDIS; ≥3 reported drug allergies), and healthcare resource utilization (HRU). RESULTS: Of 1870 HCHN patients, 383 (20%) reported penicillin allergy, 835 (45%) had MDIS, and 290 (16%) had both. HCHN patients reporting penicillin allergy had an increased odds of beta-lactam alternative antibiotic use (adjusted odds ratio, 3.84; 95% CI, 2.17-6.80). HRU was significantly higher for patients reporting a penicillin allergy alone (adjusted relative risk [aRR], 1.13; 95% CI, 1.03-1.25) and with concurrent MDIS (aRR, 1.20; 95% CI, 1.08-1.34). CONCLUSIONS: HCHN patients had a high burden of reported drug allergy. A reported penicillin allergy conferred a 4-fold increased odds of beta-lactam alternative antibiotic use. Reporting penicillin allergy, with and without MDIS, was associated with significantly more HRU. HCHN care management programs should consider systematic drug allergy evaluations to optimize antibiotic use in these fragile patients.

Data linkage analysis of giant cell arteritis in Italy: Healthcare burden and cost of illness in the Italian region of Friuli Venezia Giulia (2001-2017).

Giant cell arteritis (GCA) is the most common vasculitis in adults. However, comprehensive analyses of the healthcare burden are still scarce. The aim of the study is to report the healthcare burden and cost of illness of GCA in the Friuli Venezia Giulia (FVG) region of Italy, based on a data linkage analysis. To this end, a retrospective study was conducted through the integration of many administrative health databases of the FVG region as the source of information. Cases were identified from two verified, partially overlapping sources (the rare disease registry and medical exemption database). From 2001 to 2017, 208 patients with GCA were registered. The prevalence of GCA in the population aged ⩾ 45 years as of December 31, 2017 was 27.2/100,000 inhabitants (95% CI 23.5-31.4). The mean time of observation was 4.5 ± 3.6 years. A total of 3182 visits (338 per 100 patient-years) was recorded. The most frequent specialty visits were rheumatology (n = 610, 19.2%), followed by internal medicine (n = 564, 17.7%). A total of 287 hospitalizations (30 per 100 patient-years) were reported. A total of 13,043 prescriptions (1386 per 100 patient-years) were registered. More than half of the patients were prescribed an immunosuppressive agent. The overall estimated direct healthcare cost was €2,234,070, corresponding to €2374 per patient-year. Overall, GCA is a rare disease which implies a high healthcare cost.

Physician Perceptions of Step Therapy Prescribing Requirements.

BACKGROUND: Step therapy policies that require prescribers to follow an ordered protocol for drug choices are widely used by public and private insurers to manage medication costs; however, the perceptions of prescribing physicians regarding these policies have not been studied. OBJECTIVE: To determine physician attitudes toward step therapy policies and the correlation of these beliefs with physician characteristics. METHODS: A sample of clinically active physicians specializing in internal medicine, cardiology, or endocrinology received a survey administered online or via mail. Five-point Likert scale questions assessed physicians' opinions of clinical, economic, and implementation elements of prior authorization policies; physician demographic characteristics; and the extent of their interactions with the pharmaceutical industry. RESULTS: 686 physicians (48%) responded to the survey, which was evenly divided among primary care physicians, endocrinologists, and cardiologists. Many respondents (70%) had interactions with industry, including receipt of meals or gifts and use of medication samples. Physicians reported that step therapy policies could improve the affordability of medication use (55% agree vs. 26% disagree) and its clinical appropriateness (59% agree vs. 19% disagree). By similar margins, however, physicians stated that step therapy policies were implemented inefficiently and inflexibly and often did not incorporate relevant patient-specific information. Physicians in subspecialties, especially endocrinology, and those who had interactions with the pharmaceutical industry were more likely to hold negative views of step therapy policies. CONCLUSIONS: Most physicians recognize the potential of step therapy to improve the quality and cost-effectiveness of prescribing, although interactions with industry may affect these opinions. Physician perception of ineffective implementation of these policies, however, undermines their acceptability. DISCLOSURES: The American Board of Internal Medicine (ABIM) funded the survey used in this study. The ABIM had no role in the design and conduct of the study or development and preparation of the manuscript. Survey honoraria was provided by the Consumers Union. Kesselheim and Avorn's work is funded by the Laura and John Arnold Foundation. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science, Arnold Ventures, and the Engelberg Foundation. Ross is employed by the ABIM. Fischer, Lu, and Tessema have nothing to disclose.

Analysis of the profitability of adult vaccination in 13 private provider practices in the United States.

Vaccination coverage among adults remains low in the United States. Understanding the barriers to provision of adult vaccination is an important step to increasing vaccination coverage and improving public health. To better understand financial factors that may affect practice decisions about adult vaccination, this study sought to understand how costs compared with payments for adult vaccinations in a sample of U.S. physician practices. We recruited a convenience sample of 19 practices in nine states in 2017. We conducted a time-motion study to assess the time costs of vaccination activities and conducted a survey of practice managers to assess materials, management, and dose costs and payments for vaccination. We received complete cost and payment data from 13 of the 19 practices. We calculated annual income from vaccination services by comparing estimated costs with payments received for vaccine doses and vaccine administration. Median annual total income from vaccination services was $90,343 at family medicine practices (range: $3968-$249,628), $28,267 at internal medicine practices (-$32,659-$141,034) and $2886 at obstetrics and gynecology practices (-$73,451-$23,820). Adult vaccination was profitable at the median of our sample, but there is wide variation in profitability due to differences in costs and payment rates across practices. This study provides evidence on the financial viability of adult vaccination and supports actions for improving financial viability. These results can help inform practices' decisions whether to provide adult vaccines and contribute to keeping adults up-to-date with the recommended vaccination schedule.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics.

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

U.S. Internists' Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey.

Background: Rising out-of-pocket costs are creating a need for cost conversations between patients and physicians. Objective: To understand the factors that influence physicians to discuss and consider cost during a patient encounter. Design: Mixed-methods study using semistructured interviews and a survey. Setting: United States. Participants: 20 internal medicine physicians were interviewed; 621 internal medicine physician members of the American College of Physicians completed the survey. Measurements: Interviews were analyzed by using thematic analysis, and surveys were analyzed by using descriptive statistics. Results: From the interviews, 4 themes were identified: Physicians are 1) aware that patients are struggling to afford medical care; 2) relying on clues from patients that hint at their cost sensitivity; 3) relying on experience to anticipate potentially high-cost treatments; and 4) aware that patients are making financial trade-offs to afford their care. Three quarters (n = 466) of survey respondents stated that they consider out-of-pocket costs when making most clinical decisions. For 31% (n = 191) of participants, there were times in the past year that they wanted to discuss out-of-pocket prescription drug costs with patients but did not. The most influential factors for ordering a test are the desire to be as thorough as possible (71% [n = 422]) and insurance coverage for the test (68% [n = 422]). Limitation: Findings are self-reported, the sample is limited to a single specialty, the survey response rate was low, information on the patient population was limited, and the survey instrument is not validated. Conclusion: Physicians are attuned to the burden of health care costs and are willing to consider alternative options based on a patient's cost sensitivity. Primary Funding Source: Robert Wood Johnson Foundation.

Improving Opioid Management and Resource Utilization in an Internal Medicine Residency Clinic: A Before-After Study over Two Plan-Do-Study-Act Cycles.

Objective Chronic pain and opioid management are challenging in primary care, especially for trainees with discontinuous ambulatory schedules and less practice experience. The study objective was to improve adherence to quality metrics and office visit utilization in a resident clinic. Design Before-after quality improvement intervention over two Plan-Do-Study-Act cycles. Setting Suburban, university-affiliated Internal Medicine resident clinic. Methods During the 2015-2017 academic years, two sequential interventions were implemented: 1) use of electronic pain and opioid management templates and workflow redesign routing opioid renewals through a registered nurse (RN); 2) RN previsit planning and daily nurse-physician huddles before patient visits. Outcomes included adherence to annual toxicology screening, risk assessment and opioid agreements, opioid dose prescribed, and office visit utilization. Results The template and workflow redesign intervention increased annual toxicology from 53% to 81% (P < 0.0015), annual opioid agreement from 13.8% to 53.5% (P < 0.0001), and risk assessment from 0% to 75.9% (P < 0.0001). Average daily morphine milligram equivalents (MME) decreased from 96.6 MME to 67.7 MME (P < 0.0001), and annual office visits decreased from 11.1 to 8.9 (P = 0.0004). Previsit planning and huddles did not show incremental increases in adherence to quality measures but did improve clinic utilization and maintained high levels of adherence to quality measures. Conclusions Quality improvement interventions can improve adherence to quality measures and clinic utilization. A critical role is served by midlevel nursing providers to provide continuity to patients and trainees. Teaching clinics need to develop sustainable systems of care to moderate quality assurance in opioid prescribing.

Prevalence and Costs of Discharge Diagnoses in Inpatient General Internal Medicine: a Multi-center Cross-sectional Study.

BACKGROUND: Understanding the most common and costly conditions treated by inpatient general medical services is important for implementing quality improvement, developing health policy, conducting research, and designing medical education. OBJECTIVE: To determine the prevalence and cost of conditions treated on general internal medicine (GIM) inpatient services. DESIGN: Retrospective cross-sectional study involving 7 hospital sites in Toronto, Canada. PARTICIPANTS: All patients discharged between April 1, 2010 and March 31, 2015 who were admitted to or discharged from an inpatient GIM service. MAIN MEASURES: Hospital administrative data were used to identify diagnoses and costs associated with admissions. The primary discharge diagnosis was identified for each admission and categorized into clinically relevant and mutually exclusive categories using the Clinical Classifications Software (CCS) tool. KEY RESULTS: Among 148,442 admissions, the most common primary discharge diagnoses were heart failure (5.1%), pneumonia (5.0%), urinary tract infection (4.6%), chronic obstructive pulmonary disease (4.5%), and stroke (4.4%). The prevalence of the 20 most common conditions was significantly correlated across hospitals (correlation coefficients ranging from 0.55 to 0.95, p ≤ 0.01 for all comparisons). No single condition represented more than 5.1% of all admissions or more than 7.9% of admissions at any hospital site. The costliest conditions were stroke (median cost $7122, interquartile range 5587-12,354, total cost $94,199,422, representing 6.0% of all costs) and the group of delirium, dementia, and cognitive disorders (median cost $12,831, IQR 9539-17,509, total cost $77,372,541, representing 4.9% of all costs). The 10 most common conditions accounted for only 36.2% of hospitalizations and 36.8% of total costs. The remaining hospitalizations included 223 different CCS conditions. CONCLUSIONS: GIM services care for a markedly heterogeneous population but the most common conditions were similar across 7 hospitals. The diversity of conditions cared for in GIM may be challenging for healthcare delivery and quality improvement. Initiatives that cut across individual diseases to address processes of care, patient experience, and functional outcomes may be more relevant to a greater proportion of the GIM population than disease-specific efforts.

Factors Influencing Selection of Infectious Diseases Training for Military Internal Medicine Residents.

Background: Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort. Methods: An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest. Result: The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02). Conclusions: Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

[Representation of Internal Medicine in G-DRG System - Analysis of Reasons for Prolonged Length of Stay]. / Innere Medizin im G-DRG-System.

Background There is an ongoing discussion within the German Society of Internal Medicine (DGIM) and the Professional Association of German Internists (BDI) about the appropriate depiction and remuneration of internal medicine in the G-DRG. Method Therefore, cases with a significantly prolonged length of stay were analyzed in a multicenter study. 124 cases from 6 hospitals were collected for evaluation. Results The results show that the observed prolongation of hospitalization was mainly due to medical reasons. Discussion Thus, patients with unclear symptoms and consequently need for a thorough workup could not be identified to cause longer inpatient stay. Instead, treatment complications and comorbidities led to extended hospitalization. The results also reveal prolonged hospitalization as a consequence of unsettled or delayed postdischarge care e. g. in rehabilitation facilities.

Variation in Emergency Department vs Internal Medicine Excess Charges in the United States.

Importance: Uninsured and insured but out-of-network emergency department (ED) patients are often billed hospital chargemaster prices, which exceed amounts typically paid by insurers. Objective: To examine the variation in excess charges for services provided by emergency medicine and internal medicine physicians. Design, Setting, and Participants: Retrospective analysis was conducted of professional fee payment claims made by the Centers for Medicare & Medicaid Services for all services provided to Medicare Part B fee-for-service beneficiaries in calendar year 2013. Data analysis was conducted from January 1 to July 31, 2016. Main Outcomes and Measures: Markup ratios for ED and internal medicine professional services, defined as the charges submitted by the hospital divided by the Medicare allowable amount. Results: Our analysis included 12 337 emergency medicine physicians from 2707 hospitals and 57 607 internal medicine physicians from 3669 hospitals in all 50 states. Services provided by emergency medicine physicians had an overall markup ratio of 4.4 (340% excess charges), which was greater than the markup ratio of 2.1 (110% excess charges) for all services performed by internal medicine physicians. Markup ratios for all ED services ranged by hospital from 1.0 to 12.6 (median, 4.2; interquartile range [IQR], 3.3-5.8); markup ratios for all internal medicine services ranged by hospital from 1.0 to 14.1 (median, 2.0; IQR, 1.7-2.5). The median markup ratio by hospital for ED evaluation and management procedure codes varied between 4.0 and 5.0. Among the most common ED services, laceration repair had the highest median markup ratio (7.0); emergency medicine physician review of a head computed tomographic scan had the greatest interhospital variation (range, 1.6-27.7). Across hospitals, markups in the ED were often substantially higher than those in the internal medicine department for the same services. Higher ED markup ratios were associated with hospital for-profit ownership (median, 5.7; IQR, 4.0-7.1), a greater percentage of uninsured patients seen (median, 5.0; IQR, 3.5-6.7 for ≥20% uninsured), and location (median, 5.3; IQR, 3.8-6.8 for the southeastern United States). Conclusions and Relevance: Across hospitals, there is wide variation in excess charges on ED services, which are often priced higher than internal medicine services. Our results inform policy efforts to protect uninsured and out-of-network patients from highly variable pricing.

Using Quality Improvement in Resident Education to Improve Transition Care.

The importance of a specific transition process is recognized by many health organizations. Got Transition, a cooperative endeavor aimed at improving the transition from pediatric to adult health care, developed Six Core Elements defining the basic components of health care transition support. In this article, we review the Six Core Elements by presenting a model that combines resident quality improvement and transition care training. In this Internal Medicine-Pediatrics residency program, ambulatory training for residents takes place in a combined adult and pediatric clinic. Aligned with the Six Core Elements, the program has crafted and disseminated a transition policy for the practice, designed a portable health summary template for the electronic medical record (EMR), created EMR tools for assessing transition readiness and setting transition goals, formed a registry of patients, and audited charts. [Pediatr Ann. 2017;46(5):e203-e206.].