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1.
Am Surg ; 86(2): 140-145, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-32167057

RESUMO

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.


Assuntos
Gastrectomia/economia , Pessoal de Saúde/psicologia , Hepatectomia/economia , Reembolso de Seguro de Saúde/economia , Medicare/economia , Pancreaticoduodenectomia/economia , Institutos de Câncer , Honorários e Preços , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Corpo Clínico/economia , Corpo Clínico/estatística & dados numéricos , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem/economia , Recursos Humanos de Enfermagem/estatística & dados numéricos , Estados Unidos
3.
Lancet ; 395(10223): 524-533, 2020 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-32061298

RESUMO

Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68 000 lives and 1·73 million life-years every year compared with the status quo.


Assuntos
Assistência à Saúde/organização & administração , Redução de Custos/métodos , Assistência à Saúde/economia , Custos de Medicamentos/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/organização & administração , Humanos , Medicare/economia , Patient Protection and Affordable Care Act , Prognóstico , Estados Unidos
4.
World Neurosurg ; 135: e716-e722, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31899389

RESUMO

BACKGROUND: Anterior lumbar interbody fusion (ALIF) is a commonly performed surgical procedure for the management of degenerative lumbar spine pathologic entities. Despite an increasing number of ALIFs performed nationally, to the best of our knowledge, no study has evaluated the costs associated with the 90-day episode of care postoperatively. METHODS: The 2007-2016 Humana Administrative Claims data set, a national database of commercial and Medicare Advantage (MA) beneficiaries, was queried using Current Procedural Terminology code 22558 for patients who had undergone single-level ALIF. The 90-day costs were defined using the following categories: facility, surgeon, anesthesia, other hospitalization costs and services, radiology, office visits, physical therapy/rehabilitation, emergency department visits, and readmissions. RESULTS: A total of 365 ALIF procedures (MA, n = 244; commercial, n = 121) were included in the analysis. The average 90-day cost of single-level ALIF was $25,568 and $51,741 for the MA and commercial enrollees, respectively. The major proportion of 90-day costs was attributable to facility reimbursement (74%-76%), followed by surgeon costs (9%-11%). Postacute care (i.e., office visits and physical therapy/rehabilitation) was not a major driver of the 90-day costs, consisting of only 0.7%-1.3% of the total 90-day reimbursement. Of patients who had required readmission, the costs of the readmission increased the average 90-day costs by 65%-66%. CONCLUSIONS: Facility costs were the major drivers of a stipulated 90-day reimbursement for patients undergoing single-level ALIF. Health policy makers and providers can use these data to better understand the distribution of costs in a stipulated bundled-payment model for ALIFs and allow them to identify areas in which cost reduction strategies can be performed.


Assuntos
Degeneração do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Fusão Vertebral/métodos , Custos e Análise de Custo , Assistência à Saúde/economia , Cuidado Periódico , Instalações de Saúde/economia , Custos Hospitalares , Humanos , Degeneração do Disco Intervertebral/economia , Medicare/economia , Readmissão do Paciente/economia , Setor Privado/economia , Estudos Retrospectivos , Fusão Vertebral/economia , Cirurgiões/economia , Estados Unidos
5.
J Surg Res ; 246: 123-130, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31569034

RESUMO

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Fixação de Fratura/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/cirurgia , Organizações de Assistência Responsáveis/economia , Idoso , Idoso de 80 Anos ou mais , Grupos de Populações Continentais/estatística & dados numéricos , Redução de Custos/economia , Redução de Custos/estatística & dados numéricos , Grupos Étnicos , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/organização & administração , Mortalidade Hospitalar , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/estatística & dados numéricos , Fatores Socioeconômicos , Fraturas da Coluna Vertebral/economia , Estados Unidos/epidemiologia
6.
Support Care Cancer ; 28(1): 113-122, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30993450

RESUMO

PURPOSE: Limited information is available regarding elderly patients experiencing febrile neutropenia (FN). This study evaluated FN-related care among elderly cancer patients who received high/intermediate FN-risk chemotherapy and experienced ≥ 1 FN episodes. METHODS: We used Medicare data to identify patients aged ≥ 66 years who initiated high/intermediate FN-risk chemotherapy between 1 January 2008 and 31 August 2015 to treat breast cancer (BC), lung cancer (LC), or non-Hodgkin lymphoma (NHL) and had ≥ 1 FN episodes. We identified within-cycle FN episodes for each chemotherapy cycle on Part A inpatient claims or outpatient or Part B claims. We described the FN-related care setting (inpatient hospital, outpatient emergency department [ED], or outpatient non-ED) and reported mean total cost of FN-related care per episode overall and by care setting (adjusted to 2015 US$). RESULTS: We identified 2138, 3521, and 2862 patients with BC, LC, and NHL, respectively, with ≥ 1 FN episodes (total episodes: 2407, 3840, 3587, respectively). Most FN episodes required inpatient care (BC, 88.1%; LC, 93.0%; NHL, 93.2%) with mean hospital length of stay (LOS) 6.2, 6.5, and 6.8 days, respectively. Intensive care unit admission was required for 20.4% of BC, 29.0% of LC, and 25.7% of NHL hospitalizations (mean LOS: 4.7, 4.7, 5.5 days, respectively). The mean total cost of FN care per episode was $11,959 BC, $14,388 LC, and $15,006 NHL, with inpatient admission the costliest care component ($11,826; $14,294; and $14,873; respectively). CONCLUSIONS: Among elderly patients with BC, LC, or NHL who experienced FN, most FN episodes required costly hospital care, highlighting the FN burden on healthcare systems.


Assuntos
Neoplasias da Mama/tratamento farmacológico , Neutropenia Febril Induzida por Quimioterapia/economia , Neutropenia Febril Induzida por Quimioterapia/terapia , Custos de Cuidados de Saúde , Neoplasias Pulmonares/tratamento farmacológico , Linfoma não Hodgkin/tratamento farmacológico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/economia , Neoplasias da Mama/epidemiologia , Neutropenia Febril Induzida por Quimioterapia/epidemiologia , Custos e Análise de Custo , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde para Idosos/economia , Serviços de Saúde para Idosos/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/epidemiologia , Linfoma não Hodgkin/economia , Linfoma não Hodgkin/epidemiologia , Masculino , Medicare/economia , Estudos Retrospectivos , Estados Unidos/epidemiologia
7.
Ann Vasc Surg ; 62: 148-158, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31610277

RESUMO

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


Assuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/economia , Planos de Pagamento por Serviço Prestado/economia , Custos Hospitalares , Medicare/economia , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/tendências , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Custos Hospitalares/tendências , Humanos , Masculino , Medicare/tendências , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
8.
BMC Health Serv Res ; 19(1): 921, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31791322

RESUMO

BACKGROUND: The Hospital Value Based Purchasing Program (HVBP) in the United States, announced in 2010 and implemented since 2013 by the Centers for Medicare and Medicaid Services (CMS), introduced payment penalties and bonuses based on hospital performance on patient 30-day mortality and other indicators. Evidence on the impact of this program is limited and reliant on the choice of program-exempt hospitals as controls. As program-exempt hospitals may have systematic differences with program-participating hospitals, in this study we used an alternative approach wherein program-participating hospitals are stratified by their financial exposure to penalty, and examined changes in hospital performance on 30-day mortality between hospitals with high vs. low financial exposure to penalty. METHODS: Our study examined all hospitals reimbursed through the Medicare Inpatient Prospective Payment System (IPPS) - which include most community and tertiary acute care hospitals - from 2009 to 2016. A hospital's financial exposure to HVBP penalties was measured by the share of its annual aggregate inpatient days provided to Medicare patients ("Medicare bed share"). The main outcome measures were annual hospital-level 30-day risk-adjusted mortality rates for acute myocardial infarction (AMI), heart failure (HF) and pneumonia patients. Using difference-in-differences models we estimated the change in the outcomes in high vs. low Medicare bed share hospitals following HVBP. RESULTS: In the study cohort of 1902 US hospitals, average Medicare bed share was 61 and 41% in high (n = 540) and low (n = 1362) Medicare bed share hospitals, respectively. High Medicare bed share hospitals were more likely to have smaller bed size and less likely to be teaching hospitals, but ownership type was similar among both Medicare bed share groups.. Among low Medicare bed share (control) hospitals, baseline (pre-HVBP) 30-day mortality was 16.0% (AMI), 10.9% (HF) and 11.4% (pneumonia). In both high and low Medicare bed share hospitals 30-day mortality experienced a secular decrease for AMI, increase for HF and pneumonia; differences in the pre-post change between the two hospital groups were small (< 0.12%) and not significant across all three conditions. CONCLUSIONS: HVBP was not associated with a meaningful change in 30-day mortality across hospitals with differential exposure to the program penalty.


Assuntos
Economia Hospitalar , Mortalidade Hospitalar/tendências , Medicare/economia , Aquisição Baseada em Valor/estatística & dados numéricos , Insuficiência Cardíaca/mortalidade , Humanos , Infarto do Miocárdio/mortalidade , Pneumonia/mortalidade , Avaliação de Programas e Projetos de Saúde , Sistema de Pagamento Prospectivo , Reembolso de Incentivo , Estados Unidos/epidemiologia
9.
PLoS Med ; 16(12): e1002981, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31846453

RESUMO

BACKGROUND: Poor diet is a leading risk factor for cardiometabolic disease (CMD) in the United States, but its economic costs are unknown. We sought to estimate the cost associated with suboptimal diet in the US. METHODS AND FINDINGS: A validated microsimulation model (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends [CVD PREDICT]) was used to estimate annual cardiovascular disease (fatal and nonfatal myocardial infarction, angina, and stroke) and type 2 diabetes costs associated with suboptimal intake of 10 food groups (fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, sodium). A representative US population sample of individuals aged 35-85 years was created using weighted sampling from National Health And Nutrition Examination Surveys (NHANES) 2009-2012 cycles. Estimates were stratified by cost type (acute, chronic, drug), sex, age, race, education, BMI, and health insurance. Annual diet-related CMD costs were $301/person (95% CI $287-$316). This translates to $50.4 billion in CMD costs (18.2% of total) for the whole population, of which 84.3% are attributed to acute care ($42.6 billion). The largest annual per capita costs are attributed to low consumption of nuts/seeds ($81; 95% CI $74-$86) and seafood omega-3 fats ($76; 95% CI $70-$83), and the lowest are attributed to high consumption of red meat ($3; 95% CI $2.8-$3.5) and polyunsaturated fats ($20; 95% CI $19-$22). Individual costs are highest for men ($380), those aged ≥65 years ($408), blacks ($320), the less educated ($392), and those with Medicare ($481) or dual-eligible ($536) insurance coverage. A limitation of our study is that dietary intake data were assessed from 24-hour dietary recall, which may not fully capture a diet over a person's life span and is subject to measurement errors. CONCLUSIONS: Suboptimal diet of 10 dietary factors accounts for 18.2% of all ischemic heart disease, stroke, and type 2 diabetes costs in the US, highlighting that timely implementation of diet policies could address these health and economic burdens.


Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Dieta/economia , Medicare/economia , Inquéritos Nutricionais/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Efeitos Psicossociais da Doença , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
12.
Health Serv Res ; 54(6): 1214-1222, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31742688

RESUMO

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


Assuntos
Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/estatística & dados numéricos , Compensação e Reparação , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Humanos , Medicare/economia , Medicare/estatística & dados numéricos , Estados Unidos
13.
BMC Health Serv Res ; 19(1): 837, 2019 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-31727168

RESUMO

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score. METHODS: Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics. RESULTS: There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients. CONCLUSIONS: The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Humanos , Medicare/economia , Patient Protection and Affordable Care Act , Readmissão do Paciente/economia , Avaliação de Programas e Projetos de Saúde , Estados Unidos
14.
Med Care ; 57(11): 869-874, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31634268

RESUMO

INTRODUCTION: Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high-cost patients. To study the effects of surgeon and hospital characteristics on surgical expenditures, a way to adjust for patient characteristics is essential. DESIGN: Using 100% Medicare claims data, we identified patients aged 66-99 undergoing elective inpatient surgery (coronary artery bypass grafting, colectomy, and total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). On the basis of predictor variables from 2013, that is, Elixhauser comorbidities, hierarchical condition categories, Medicare's Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014. RESULTS: All sources of comorbidity data performed well in predicting the costliest cases (Spearman correlation 0.86-0.98). Models on the basis of hierarchical condition categories had slightly superior performance. The costliest quintile of patients as predicted by the model captured 35%-45% of the patients in each procedure's actual costliest quintile. For example, in hip replacement, 44% of the costliest quintile was predicted by the model's costliest quintile. CONCLUSIONS: A significant proportion of surgical spending can be predicted using patient factors on the basis of readily available claims data. By adjusting for patient factors, this will facilitate future research on unwarranted variation in episode payments driven by surgeons, hospitals, or other market forces.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Medicare/economia , Procedimentos Cirúrgicos Operatórios/economia , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/economia , Colectomia/economia , Ponte de Artéria Coronária/economia , Cuidado Periódico , Feminino , Humanos , Masculino , Estados Unidos
15.
Health Serv Res ; 54(6): 1184-1192, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31657002

RESUMO

OBJECTIVE: To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. DATA SOURCES AND STUDY SETTING: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries. STUDY DESIGN: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. PRINCIPAL FINDINGS: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay. CONCLUSIONS: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Hospitalização/economia , Tempo de Internação/economia , Medicare/economia , Alta do Paciente/economia , Instituições de Cuidados Especializados de Enfermagem/economia , Cuidados Semi-Intensivos/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Cuidados Semi-Intensivos/estatística & dados numéricos , Estados Unidos
18.
BMC Health Serv Res ; 19(1): 703, 2019 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619229

RESUMO

BACKGROUND: In the United States, there is well-documented regional variation in prescription drug spending. However, the specific role of physician adoption of brand name drugs on the variation in patient-level prescription drug spending is still being investigated across a multitude of drug classes. Our study aims to add to the literature by determining the association between physician adoption of a first-in-class anti-diabetic (AD) drug, sitagliptin, and AD drug spending in the Medicare and Medicaid populations in Pennsylvania. METHODS: We obtained physician-level data from QuintilesIMS Xponent™ database for Pennsylvania and constructed county-level measures of time to adoption and share of physicians adopting sitagliptin in its first year post-introduction. We additionally measured total AD drug spending for all Medicare fee-for-service and Part D enrollees (N = 125,264) and all Medicaid (N = 50,836) enrollees with type II diabetes in Pennsylvania for 2011. Finite mixture model regression, adjusting for patient socio-demographic/clinical characteristics, was used to examine the association between physician adoption of sitagliptin and AD drug spending. RESULTS: Physician adoption of sitagliptin varied from 44 to 99% across the state's 67 counties. Average per capita AD spending was $1340 (SD $1764) in Medicare and $1291 (SD $1881) in Medicaid. A 10% increase in the share of physicians adopting sitagliptin in a county was associated with a 3.5% (95% CI: 2.0-4.9) and 5.3% (95% CI: 0.3-10.3) increase in drug spending for the Medicare and Medicaid populations, respectively. CONCLUSIONS: In a medication market with many choices, county-level adoption of sitagliptin was positively associated with AD spending in Medicare and Medicaid, two programs with different approaches to formulary management.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/economia , Medicaid/economia , Medicare/economia , Padrões de Prática Médica/economia , Fosfato de Sitagliptina/economia , Administração Oral , Idoso , Diabetes Mellitus Tipo 2/economia , Planos de Pagamento por Serviço Prestado , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Hipoglicemiantes/administração & dosagem , Masculino , Pessoa de Meia-Idade , Pennsylvania , Fosfato de Sitagliptina/administração & dosagem , Estados Unidos
19.
Curr Pain Headache Rep ; 23(10): 73, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31388874

RESUMO

PURPOSE OF REVIEW: To assess patterns of utilization and variables of facet joint interventions in managing chronic spinal pain in a fee-for-service (FFS) Medicare population from 2009 to 2016, with a comparative analysis from 2000 to 2009 and 2009 to 2016. RECENT FINDINGS: From 2009 to 2016, facet joint interventions increased at an annual rate of 2% per 100,000 Medicare population compared to 10.2% annual rate of increase from 2000 to 2009. Lumbosacral facet joint nerve block episodes decreased at an annual rate of 0.1% from 2009 to 2016, with an increase of 16.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis episodes increased at an annual rate of 7.6% from 2009 to 2016 and the utilization rate also increased at an annual rate of 26% from 2000 to 2009. The ratio of lumbar facet joint block episodes to lumbosacral facet joint neurolysis episodes changed from 6.7 in 2000 to 2.2 in 2016. From 2009 to 2016, cervical and thoracic facet joint injections increased at an annual rate of 0.6% compared to cervicothoracic facet neurolysis episodes of 9.2%. During 2000 to 2009, annual increase of cervical facet joint injections was 18% compared to neurolysis procedures of 26%. The ratio of cervical facet joint injections episodes to neurolysis episodes changed from 8.85 in 2000 to 2.8 in 2016. In summary, based on available data, utilization patterns of facet joint interventions demonstrated an increase of 2% per 100,000 Medicare population from 2009 to 2016, with an annual decline of lumbar facet joint injection episodes.


Assuntos
Dor Crônica/cirurgia , Medicare/economia , Procedimentos Neurocirúrgicos , Articulação Zigapofisária/cirurgia , Dor nas Costas/cirurgia , Dor Crônica/epidemiologia , Humanos , Manejo da Dor/métodos , Estados Unidos
20.
Inquiry ; 56: 46958019867612, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31382843

RESUMO

The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of delivering better care at lower cost. Policymakers must reverse this trend and ensure parity between traditional Medicare and MA rather than encourage it through legislation that only benefits MA. Furthermore, as discussions of expanding health insurance coverage through Medicare intensify, policymakers should explore what version of Medicare they wish to expand.


Assuntos
Medicare Part C/tendências , Medicare/tendências , Privatização/tendências , Humanos , Medicare/economia , Medicare/organização & administração , Medicare Part C/economia , Medicare Part C/organização & administração , Estados Unidos
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