Prescription Drug Spending in Fee-for-Service Medicare, 2008-2019.

Importance: Prescription drug spending is a topic of increased interest to the public and policymakers. However, prior assessments have been limited by focusing on retail spending (Part D-covered drugs), omitting clinician-administered (Part B-covered) drug spending, or focusing on all fee-for-service Medicare beneficiaries, regardless of their enrollment into prescription drug coverage. Objective: To estimate the proportion of health care spending contributed by prescription drugs and to assess spending for retail and clinician-administered prescriptions. Design, Setting, and Participants: Descriptive, serial, cross-sectional analysis of a 20% random sample of fee-for-service Medicare beneficiaries in the United States from 2008 to 2019 who were continuously enrolled in Parts A (hospital), B (medical), and D (prescription drug) benefits, and not in Medicare Advantage. Exposure: Calendar year. Main Outcomes and Measures: Net spending on retail (Part D-covered) and clinician-administered (Part B-covered) prescription drugs; prescription drug spending (spending on Part B-covered and Part D-covered drugs) as a percentage of total per-capita health care spending. Measures were adjusted for inflation and for postsale rebates (for Part D-covered drugs). Results: There were 3 201 284 beneficiaries enrolled in Parts A, B, and D in 2008 and 4 502 718 in 2019. In 2019, beneficiaries had a mean (SD) age of 71.7 (12.0) years, documented sex was female for 57.7%, and 69.5% had no low-income subsidies. Total per-capita spending was $16 345 in 2008 and $20 117 in 2019. Comparing 2008 with 2019, per-capita Part A spending was $7106 (95% CI, $7084-$7128) vs $7120 (95% CI, $7098-$7141), Part B drug spending was $720 (95% CI, $713-$728) vs $1641 (95% CI, $1629-$1653), Part B nondrug spending was $5113 (95% CI, $5105-$5122) vs $6702 (95% CI, $6692-$6712), and Part D net spending was $3122 (95% CI, $3117-$3127) vs $3477 (95% CI, $3466-$3489). The proportion of total annual spending attributed to prescription drugs increased from 24.0% in 2008 to 27.2% in 2019, net of estimated rebates and discounts. Conclusions and Relevance: In 2019, spending on prescription drugs represented approximately 27% of total spending among fee-for-service Medicare beneficiaries enrolled in Part D, even after accounting for postsale rebates.

Trends in Characteristics of Adults Enrolled in Traditional Fee-for-Service Medicare and Medicare Advantage, 2011-2019.

BACKGROUND: While overall Medicare Part C (Medicare Advantage) enrollment has grown more rapidly than fee-for-service Medicare enrollment, changes in the growth and characteristics of different enrollee populations have not been examined. OBJECTIVES: For 2011-2019, to compare changes in the growth and characteristics of younger (age younger than 65) and older (age 65 and older) Medicare beneficiaries enrolled in Medicare Part A only, Medicare Parts A & B, and Medicare Part C. RESEARCH DESIGN: This was a retrospective, observational study. SUBJECTS: Medicare beneficiaries who were alive and enrolled in Medicare Part A only, Medicare Parts A & B, or Medicare Part C on June 30 of each year and in no other plan that year. MEASURES: For each plan type and age group the numbers and mean ages of enrollees and the proportion of enrollees who were: black, female, concurrently enrolled in Medicaid, and (for older enrollees), whose initial reason for eligibility was old age and survivors' benefits. RESULTS: Between 2011 and 2019, Medicare Part C experienced rapid expansions of 85.0% among older and 109.5% among younger enrollees. Part C enrollees were increasingly likely to be dually enrolled in Medicaid, Black and, among younger enrollees, female. CONCLUSIONS: Trends in demographic characteristics and changes in policy and growth in employer group plan offerings will likely continue to impact health care service utilization and costs in the Medicare population. Particularly as Medicare expansion to younger age groups is considered, future research should explore disparities in risk scores and care equity, quality, and costs across different Medicare enrollment options.

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021.

Importance: Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective: To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants: In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures: Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures: Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results: More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance: Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

Predicting avoidable hospital events in Maryland.

OBJECTIVE: To develop and validate a prediction model of avoidable hospital events among Medicare fee-for-service (FFS) beneficiaries in Maryland. DATA SOURCES: Medicare FFS claims from Maryland from 2017 to 2020 and other publicly available ZIP code-level data sets. STUDY DESIGN: Multivariable logistic regression models were used to estimate the relationship between a variety of risk factors and future avoidable hospital events. The predictive power of the resulting risk scores was gauged using a concentration curve. DATA COLLECTION/EXTRACTION METHODS: One hundred and ninety-eight individual- and ZIP code-level risk factors were used to create an analytic person-month data set of over 11.6 million person-month observations. PRINCIPAL FINDINGS: We included 198 risk factors for the model based on the results of a targeted literature review, both at the individual and neighborhood levels. These risk factors span six domains as follows: diagnoses, pharmacy utilization, procedure history, prior utilization, social determinants of health, and demographic information. Feature selection retained 73 highly statistically significant risk factors (p < 0.0012) in the primary model. Risk scores were estimated for each individual in the cohort, and, for scores released in April 2020, the top 10% riskiest individuals in the cohort account for 48.7% of avoidable hospital events in the following month. These scores significantly outperform the Centers for Medicare & Medicaid Services hierarchical condition category risk scores in terms of predictive power. CONCLUSIONS: A risk prediction model based on standard administrative claims data can identify individuals at risk of incurring a future avoidable hospital event with good accuracy.

Plastic Surgeon Financial Compensation-Incentivization Models in Surgical Care Delivery: The Past, Present, and Future.

BACKGROUND: Surgeons are critical for the success of any health care enterprise. However, few studies have examined the potential impact of value-based care on surgeon compensation. METHODS: This review presents value-based financial incentive models that will shape the future of surgeon compensation. The following incentivization models will be discussed: pay-for-reporting, pay-for-performance, pay-for-patient-safety, bundled payments, and pay-for-academic-productivity. Moreover, the authors suggest the application of the congruence model-a model developed to help business leaders understand the interplay of forces that shape the performance of their organizations-to determine surgeon compensation methods applicable in value-based care-centric environments. RESULTS: The application of research in organizational behavior can assist health care leaders in developing surgeon compensation models optimized for value-based care. Health care leaders can utilize the congruence model to determine total surgeon compensation, proportion of compensation that is short term versus long term, proportion of compensation that is fixed versus variable, and proportion of compensation based on seniority versus performance. CONCLUSION: This review provides a framework extensively studied by researchers in organizational behavior that can be utilized when designing surgeon financial compensation plans for any health care entity shifting toward value-based care.

Association of a Medicare Outpatient Payment Reform With Hospital-Primary Care Integration: Heterogeneity Across Markets and Physicians.

BACKGROUND: Hospital-physician integration increased rapidly in the past decade, threatening the affordability of care with minimal gains in quality. Medicare recently reformed its facility fee payments to hospitals for office consultations delivered by hospital-integrated physicians. This policy reform, affecting 200 million office visits annually, may have inadvertently encouraged hospitals to integrate with certain primary care physicians. OBJECTIVE: The objective of this study was to determine whether the policy reform was associated with hospital-primary care integration. RESEARCH DESIGN: I used a large sample of primary care physicians (n=98,884) drawn from Medicare claims data. I estimated cross-sectional multivariable linear probability models to measure whether the change in physicians' value-to-hospitals was associated with integration. RESULTS: The reform created heterogenous results: some physicians' value-to-hospitals decreased, while others increased (first percentile to 99th percentile, -$16,000 to $47,000). This change in value had a small association with integration: for every $10,000 increase, a physician was about 0.34 percentage points (95% confidence interval: 0.16-0.52) more likely to become integrated. Among high-volume physicians, the reform had larger effects: physicians whose value-to-hospitals grew by $20,000 or more were nearly 3 percentage points more likely to become integrated. Changes in value had no effect in concentrated hospital markets and rural areas. CONCLUSIONS: Effects of Medicare's site-based payments on hospital-primary care integration were concentrated among a small subset of physicians. Reforms to Medicare payment policy could influence integration among this group.

Progression of Changes in Vascular Surgery Practices during the Novel Corona Virus SARS-CoV-2 Pandemic.

INTRODUCTION: The novel coronavirus SARS-CoV-2 (COVID-19) has spread rapidly since it was identified. We sought to understand its effects on vascular surgery practices stratified by VASCON surgical readiness level and determine how these effects have changed during the course of the pandemic. METHODS: All members of the Vascular and Endovascular Surgery Society were sent electronic surveys questioning the effects of COVID-19 on their practices in the early pandemic in April (EP) and four months later in the pandemic in August (LP) 2020. RESULTS: Response rates were 206/731 (28%) in the EP group and 108/731 (15%) in the LP group (P < 0.0001). Most EP respondents reported VASCON levels less than 3 (168/206,82%), indicating increased hospital limitations while 6/108 (6%) in the LP group reported this level (P < 0.0001). The EP group was more likely to report a lower VASCON level (increased resource limitations), and decreased clinic, hospital and emergency room consults. Despite an increase of average cases/week to pre-COVID-19 levels, 46/108 (43%) of LP report continued decreased compensation, with 57% reporting more than 10% decrease. Respondents in the decreased compensation group were more likely to have reported a VASCON level 3 or lower earlier in the pandemic (P = 0.018). 91/108(84%) of LP group have treated COVID-19 patients for thromboembolic events, most commonly acute limb ischemia (76/108) and acute DVT (76/108). While the majority of respondents are no longer delaying the vascular surgery cases, 76/108 (70%) feel that vascular patient care has suffered due to earlier delays, and 36/108 (33%) report a backlog of cases caused by the pandemic. CONCLUSIONS: COVID-19 had a profound effect on vascular surgery practices earlier in the pandemic, resulting in continued detrimental effects on the provision of vascular care as well as compensation received by vascular surgeons.

Assessment of Racial/Ethnic Disparities in Timeliness and Comprehensiveness of Dementia Diagnosis in California.

Importance: The US aging population is rapidly becoming more racially and ethnically diverse. Early diagnosis of dementia is a health care priority. Objective: To examine the associations between race/ethnicity and timeliness of dementia diagnosis and comprehensiveness of diagnostic evaluation. Design, Setting, and Participants: This retrospective cross-sectional study used 2013-2015 California Medicare fee-for-service data to examine the associations of race/ethnicity, individual factors, and contextual factors with the timeliness and comprehensiveness of dementia diagnosis. Data from 10 472 unique beneficiaries were analyzed. The sample was selected on the basis of the following criteria: presence of 1 or more claims; no diagnoses of dementia or mild cognitive impairment in 2013 to 2014; continuous enrollment in Medicare Parts A and B; Asian, Black, Hispanic, or White race/ethnicity; and incident diagnoses of dementia or mild cognitive impairment in January through June 2015. Data analyses were conducted from November 1, 2019, through November 10, 2020. Main Outcomes and Measures: Timeliness of diagnosis, defined as incident diagnosis of mild cognitive impairment vs dementia, and comprehensiveness of diagnostic evaluation, defined as presence of the following services in claims within 6 months before or after the incident diagnosis date: specialist evaluation, laboratory testing, and neuroimaging studies. Results: The sample comprised 10 472 unique Medicare beneficiaries with incident diagnoses of dementia or mild cognitive impairment (6504 women [62.1%]; mean [SD] age, 82.9 [8.0] years) and included 993 individuals who identified as Asian (9.5%), 407 as Black (3.9%), 1255 as Hispanic (12.0%), and 7817 as White (74.6%). Compared with White beneficiaries, those who identified as Asian (odds ratio, 0.46; 95% CI, 0.38-0.56), Black (odds ratio, 0.73; 95% CI, 0.56-0.94), or Hispanic (odds ratio, 0.62; 95% CI, 0.52-0.72) were less likely to receive a timely diagnosis. Asian beneficiaries (incidence rate ratio, 0.81; 95% CI, 0.74-0.87) also received fewer diagnostic evaluation elements. These associations remained significant after adjusting for age, sex, comorbidity burden, neighborhood disadvantage, and rurality. Conclusions and Relevance: These findings highlight substantial disparities in the timeliness and comprehensiveness of dementia diagnosis. Public health interventions are needed to achieve equitable care for people living with dementia across all racial/ethnic groups.

Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage.

Importance: Decreasing use of low-value care is a major goal for Medicare given the potential to decrease costs and harms. Compared with traditional fee-for-service Medicare (TM), Medicare Advantage (MA) is more strongly financially incentivized to decrease use of low-value care. Objectives: To compare use of low-value care among individuals enrolled in TM and those enrolled in MA overall and to examine trends in use of low-value care in both programs from 2006 to 2015. Design, Setting, and Participants: This cross-sectional study analyzed individuals enrolled in TM and MA using data from the 2006 to 2015 Medical Expenditure Panel Survey. To account for differences in characteristics between individuals enrolled in TM and those enrolled in MA, a propensity score-based approach was used. Data were analyzed from August 2020 through January 2021. Exposures: Being enrolled in MA or TM. Main Outcomes and Measures: Binary measures of use were collected for 13 low-value services in 4 categories (ie, [1] cancer screening: cervical, colorectal, and prostate cancer screening in older adults; [2] antibiotic use: antibiotic for acute upper respiratory infection and antibiotic for influenza; [3] medication: anxiolytic, sedative, or hypnotic in an adult older than 65 years; benzodiazepine for depression; opioid for headache; opioid for back pain; and nonsteroidal anti-inflammatory drug [NSAID] for hypertension, heart failure, or chronic kidney disease; and [4] imaging: magnetic resonance imaging [MRI] or computed tomography [CT] for back pain, radiograph for back pain, and MRI or CT for headache) and 4 low-value composites corresponding to the categories (ie, cancer screening composite, antibiotic use composite, medication composite, and imaging composite). Results: Among 11 677 individuals enrolled in TM and 5164 individuals enrolled in MA, 9429 (56.0%) were women and the mean (SD) age was 74.5 (6.3) years. Of 13 low-value services and 4 low-value composites, statistically significant differences were found in 2 measures. For the low-value medication composite, 2054 of 11 636 eligible individuals enrolled in TM (adjusted mean, 17.6%; 95% CI, 16.8%-18.3%) received the care, and 981 of 5141 eligible individuals enrolled in MA (adjusted mean, 19.7%; 95% CI, 18.3%-21.2%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.2 percentage points (95% CI, 0.5-3.8 percentage points; P = .02). For the NSAID use for hypertension, heart failure, or kidney disease metric, 807 of 7832 individuals enrolled in TM (adjusted mean, 10.0%; 95% CI, 9.2%-10.8%) received the care, and 447 of 3566 individuals enrolled in MA (adjusted mean, 12.9%; 95% CI, 19.7%-27.1%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.9 percentage points (95% CI, 1.3-4.6 percentage points; P = .001). Overall, there were no decreases in use of low-value care in TM or MA over time. Conclusions and Relevance: This cross-sectional study found that use of low-value care was similarly prevalent in MA and TM, suggesting that MA enrollment was not associated with decreased provision of low-value care compared with TM.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers.

BACKGROUND: As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS: This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS: A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS: This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

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.

Differences in High- and Low-Value Cardiovascular Testing by Health Insurance Provider.

Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline-concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee-for-service patients ≥65 years. Methods and Results Using data from the Colorado All-Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high-value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low-value test that provides minimal patient benefit: stress testing prior to low-risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee-for-service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high-value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73-0.98]; P=0.03) and heart failure (OR, 0.59 [0.51-0.70]; P<0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high-value testing for acute myocardial infarction (OR, 1.35 [1.15-1.59]; P<0.01) and less likely to receive low-value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55-0.72]; P<0.01) compared with Medicare fee-for-service patients. Conclusions Guideline-concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee-for-service Medicare. Insurance plan features may provide valuable targets to improve guideline-concordant testing.

Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020.

PURPOSE: To investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020. MATERIALS AND METHODS: Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020. RESULTS: From 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by -6.9% (95% confidence interval [CI], -13.5% to -0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of -18.7% (95% CI, -24.4% to -12.9%) during the study period, with a mean yearly decline of -2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R2 = 0.97), indicating a steady decline in reimbursement over time. CONCLUSIONS: In just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.

Contemporary Trends in Physician Utilization Rates of CEA and CAS for Asymptomatic Carotid Stenosis among Medicare Beneficiaries.

BACKGROUND: Carotid revascularization for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial in the past few decades as the best medical therapy has improved. The aim of this study was to assess and define contemporary trends in the rate of carotid revascularization procedures for ACAS in the United States and to characterize outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers. METHODS: We used 100% Medicare fee-for-service claims to identify all patients who were newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic carotid artery stenosis, those with prior carotid revascularization, and surgeons who performed ≤10 CEAs during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with undergoing a carotid endarterectomy or carotid artery stent procedure within 3 months after the initial diagnosis of ACAS. We also assessed temporal trends in carotid revascularization rates over time using the Cochran-Armitage Trend Test. RESULTS: Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS during the study period, of which 23,481 (3.0%) underwent carotid revascularization within 3 months. There was a significant decline in overall carotid artery revascularization rates over time (2011: 3.2% vs. 2018: 2.1%; P < 0.001). The median and mean physician-specific carotid revascularization rates were 2.0% (IQR 0.0%-6.3%) and 4.7% ± 7.1%, respectively. Three-hundred and fifty physicians (5.2%) had carotid revascularization rates ≥19%, which was more than 2 standard deviations above the mean. After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for newly diagnosed ACAS included male sex (adjusted OR 1.59, 95% CI 1.35-1.89), more years in practice (≥31 vs. <10 years, aOR 1.64, 95% CI 1.32-2.04), rural practice location (aOR 1.34, 95% CI 1.18-1.52), Southern region practice location (versus Northeast, aOR 1.54, 95% CI 1.39-1.69), and lower volume of ACAS patients (lower versus upper tertile, aOR 2.62, 95% CI 2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of carotid revascularization compared to vascular surgeons (95% CI 1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P < 0.05). CONCLUSIONS: The current early revascularization rate for newly diagnosed ACAS is <5% among proceduralists in the United States, and has been decreasing steadily since 2014. There are particular physician-level characteristics that are associated with higher rates of carotid revascularization that cannot be fully contextualized without high-level contemporary outcomes data to guide decision making in ACAS.

Association of Neurosurgical Work Relative Value Units with Objective Markers of Operative Complexity.

OBJECTIVE: Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align with objective measures of procedural complexity within neurosurgery. METHODS: The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures. RESULTS: Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R2 = 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU = 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU = 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU = -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU = -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU = -11.29) were associated with lower than predicted RVU. CONCLUSIONS: Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions.

Benzodiazepine Use among Medicare, Commercially Insured, and Veteran Older Adults, 2013-2017.

BACKGROUND/OBJECTIVES: Benzodiazepines (BZDs) are widely prescribed to older adults. Although prescribing has declined in the U.S. Department of Veterans Affairs (VA), Medicare introduced BZD coverage in 2013. It is unknown whether declines in the VA have been widespread among older adults in the United States. DESIGN: Observational study in traditional fee-for-service Medicare, commercial insurance, and the VA. SETTING: United States, 2013-2017. PARTICIPANTS: Adults aged 55 and older in traditional Medicare (234,290,693 person-months), commercial insurance (337,827,125 person-months), and the VA (256,590,369 person-months). MEASUREMENTS: (1) Change in BZD and BZD-opioid co-prescribing modeled by Poisson regression over time; and (2) standardized ratios of BZD and BZD-opioid co-prescribing, using Medicare as the reference. RESULTS: From April 2013 to December 2017, the monthly percentage of adults aged 55 and older who received BZDs fell from 10.4% to 9.3% in Medicare, 6.6% to 6.5% in commercial insurance, and 5.7% to 3.0% in the VA. Monthly BZD-opioid co-prescribing over the same time fell from 4.0% to 3.0% in Medicare, 2.3% to 2.0% in commercial, and 2.2% to .6% for the VA. Age- and sex-adjusted rates of decline for BZD and BZD-opioid co-prescribing were statistically significant for all systems. Annual BZD rate reductions were .98 (Medicare), .99 (commercial), and .87 (VA; P < .001 for all); co-prescribing rate reductions were .95, .99, and .75 (P < .001 for all). Using standardized ratios accounting for demographic and clinical characteristics, both prescribing and co-prescribing were lowest for the VA relative to Medicare (standardized BZD ratio = .40; 95% confidence interval [CI] = .39-.40; standardized BZD-opioid co-prescribing ratio = .35; 95% CI = .35-.35). Prescribing in commercial insurance was also lower (BZD = .65; 95% CI = .65-.65; BZD-opioid co-prescribing = .65; 95% CI = .65-.65). CONCLUSION: BZD prescribing has declined much more to older adults receiving care through the VA than Medicare or commercial insurance. Other systems may learn from strategies implemented in the VA.

Who provides what care? An analysis of clinical focus among the national emergency care workforce.

OBJECTIVE: Clinician expertise has been associated with improved patient outcomes, yet ED clinicians often work in various clinical settings beyond the ED and, therefore, may risk expertise by having less clinical focus. We sought to describe clinical focus among the emergency care workforce nationally. METHODS: Using the 2017 Medicare Public Use Files (PUF), we performed a cross-sectional analysis of clinicians receiving reimbursement for emergency care Evaluation & Management (E/M) services from Medicare fee-for-service Part B. Clinicians were categorized by type as EM physicians, non-EM physicians, and advanced practice providers (APPs). The primary outcome was the clinical focus of the individual clinician, defined as the proportion of E/M services within the ED setting relative to a clinician's total E/M services across all practice settings. RESULTS: Of 65,710 unique clinicians providing care to Medicare fee-for-service beneficiaries in the ED setting, 39,016 (59.4%) were classified as EM physicians, 8123 (12.4%) as non-EM physicians, and 18,571 (28.5%) as APPs. The individual clinician median focus was 92.8% (interquartile range [IQR]: 87.0, 100.0) for EM physicians, 45.2% (IQR: 5.1, 97.0) for non-EM physicians, and 100.0% (IQR: 96.3, 100.0) for APPs. CONCLUSION: EM physicians have twice as much clinical focus in comparison to non-EM physicians providing emergency care to Medicare fee-for-service beneficiaries. These findings underscore the importance of diverse training and certification programs to ensure access to clinically focused ED clinicians.

Vascular Surgeons Are Not Adequately Valued by Traditional Productivity Metrics.

BACKGROUND: Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVUs) and professional reimbursement has decreased for some of the most common procedures performed. Hospital reimbursements, however, often remain stable or increases. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVUs and professional reimbursements decrease, hospital reimbursements for these services increased over the same time period. METHODS: Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015 and 2018 using current procedural terminology codes. Reimbursements were classified into 3 categories: medical center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based laboratory (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare's Physician Fee Schedule was used to calculate wRVU and professional reimbursement. Medicare's Hospital Outpatient Prospective Payment System-Ambulatory Payment Classification was used to calculate hospital outpatient reimbursement. RESULTS: From 2015 to 2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared with 2015, total professional reimbursements from 2017 to 2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, medical center reimbursement increased by 6.6% (+$14.1 million). CONCLUSIONS: Vascular surgeons' contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of fistulagram procedures while experiencing marked reductions in wRVU and reimbursement. Medical centers, on the other hand, experienced an overall increase in reimbursement during the same time period. This study highlights that professional reimbursements, taken in isolation and without consideration of medical center reimbursement, undervalues the services and contributions provided by vascular surgeons.

Practice Patterns of Vascular Surgery's "1%".

BACKGROUND: Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce. METHODS: 2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n = 31) were compared with the remainder of the workforce (n = 3,104). RESULTS: In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P < 0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting. CONCLUSIONS: One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.

Use of Data-Driven Methods to Predict Long-term Patterns of Health Care Spending for Medicare Patients.

Importance: Current approaches to predicting health care costs generally rely on a single composite value of spending and focus on short time horizons. By contrast, examining patients' spending patterns using dynamic measures applied over longer periods may better identify patients with different spending and help target interventions to those with the greatest need. Objective: To classify patients by their long-term, dynamic health care spending patterns using a data-driven approach and assess the ability to predict spending patterns, particularly using characteristics that are potentially modifiable through intervention. Design, Setting, and Participants: This cohort study used a retrospective cohort design from a random nationwide sample of Medicare fee-for-service administrative claims data to identify beneficiaries aged 65 years or older with continuous eligibility from 2011 to 2013. Statistical analysis was performed from August 2018 to December 2019. Main Outcomes and Measures: Group-based trajectory modeling was applied to the claims data to classify the Medicare beneficiaries by their total health care spending patterns over a 2-year period. The ability to predict membership in each trajectory spending group was assessed using generalized boosted regression, a data mining approach to model building and prediction, with split-sample validation. Models were estimated using (1) prior-year predictors and (2) prior-year predictors potentially modifiable through intervention measured in the claims data. These models were evaluated using validated C-statistics. The relative influence of individual predictors in the models was evaluated. Results: Among the 329 476 beneficiaries, the mean (SD) age was 76.0 (7.2) years and 190 346 (57.8%) were female. This final 5-group model included a minimal-user group (group 1, 37 572 individuals [11.4%]), a low-cost group (group 2, 48 575 individuals [14.7%]), a rising-cost group (group 3, 24 736 individuals [7.5%]), a moderate-cost group (group 4, 83 338 individuals [25.3%]), and a high-cost group (group 5, 135 255 individuals [41.2%]). Potentially modifiable characteristics strongly predicted these patterns (C-statistics range: 0.68-0.94). For groups with progressively increasing spending in particular, the most influential factors were number of medications (relative influence: 29.2), number of office visits (relative influence: 30.3), and mean medication adherence (relative influence: 33.6). Conclusions and Relevance: Using a data-driven approach, distinct spending patterns were identified with high accuracy. The potentially modifiable predictors of membership in the rising-cost group represent important levers for early interventions that may prevent later spending increases. This approach could be adapted by organizations to target quality improvement interventions, particularly because numerous health care organizations are increasingly using these routinely collected data.