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1.
Med Care ; 60(1): 50-55, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34739412

RESUMO

BACKGROUND: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019. OBJECTIVE: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative. STUDY DESIGN: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample. SUBJECTS: A total of 761 PTN practices and 3451 non-PTN practices. MEASURES: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics. RESULTS: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541). CONCLUSIONS: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.


Assuntos
Medicina de Família e Comunidade/métodos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos de Coortes , Medicina de Família e Comunidade/normas , Medicina de Família e Comunidade/estatística & dados numéricos , Humanos , Estudos Longitudinais , Medicare/economia , Medicare/estatística & dados numéricos , Estados Unidos
2.
JAMA Netw Open ; 4(12): e2139169, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-34913978

RESUMO

Importance: Little is known about whether a clinician having multiple hospital affiliations (ie, 1 clinician working across multiple teams and organizations) is associated with clinician practice style and cost. The measurement of this association requires adjusting for selection into multihospital affiliations based on both observable and unobservable clinician characteristics. Objective: To evaluate the association of multiple hospital affiliations with clinician service use, breadth of procedures used, and costs. Design, Setting, and Participants: This cohort study used Medicare Part B data from 2016 through 2017 in a fixed-effects panel data design to compare service use, procedure breadth, and costs between clinicians with multiple affiliations (treatment group) and clinicians with a single affiliation (control group), with adjustment for volume, patients, and clinician characteristics. The study also controlled for unobserved (time-invariant) clinician characteristics using individual clinician fixed effects. Clinicians with Medicare claims, a reported National Provider Identifier, and affiliation data within Medicare Physician Compare were included for a total sample of 1 073 252 observations (633 552 unique clinicians) for medical services and 358 669 observations (210 260 unique clinicians) for drug prescribing. Statistical analyses were performed from February 1 to October 15, 2021. Main Outcomes and Measures: Service use is the total number of medical (or drug) services that clinicians render to their Medicare beneficiaries within a given year, procedure breadth is the total number of unique Healthcare Common Procedure Coding System codes that are associated with clinicians' medical (or drug) services within a given year, and costs represent the total standardized amount paid by Medicare for the medical (or drug) services. Additional measures were multiple-hospital affiliations, Accountable Care Organization affiliation, and controls across clinician and patient characteristics. Results: The medical service sample consisted of 633 552 clinicians (248 359 women [39.2%]; mean [SD] of 19.6 [12.5] years of experience), and the drug service sample consisted of 210 260 clinicians (74 875 women [35.6%]; mean [SD] of 21.6 [12.3] years of experience). For medical services, clinicians with multiple practice affiliations used a mean 8.2% (95% CI, 7.5%-8.9%; P < .001) more medical services per patient, drew on a mean 5.4% (95% CI, 5.1%-5.7%; P < .001) wider set of procedures within their medical care, and incurred a mean 8.6% (95% CI, 7.9%-9.2%; P < .001) more in medical costs. Pertaining to drug services, clinicians with multiple practice affiliations used a mean 2.9% (95% CI, 1.9%-3.9%; P < .001) more drug services per patient, drew on a mean 1.0% (95% CI, 0.5%-1.4%; P < .001) wider set of procedures within their medical care, and incurred a mean 2.7% (95% CI, 1.6%-3.7%; P < .001) more in drug costs. Significant results were also found across extensive and intensive margins of hospital affiliation, and supplemental analysis further indicated heterogenous treatment associations across clinician specialties. Conclusions and Relevance: This cohort study found that a clinician having multihospital affiliations was associated with greater service use, procedure breadth, and costs across both medical and drug services. These findings suggest that clinician affiliations ought to be considered as part of health care delivery design and potential cost-containment strategies.


Assuntos
Custos de Medicamentos/estatística & dados numéricos , Administração Hospitalar/economia , Custos Hospitalares/organização & administração , Medicare/economia , Afiliação Institucional/economia , Padrões de Prática Médica/organização & administração , Estudos Transversais , Feminino , Administração Hospitalar/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos
3.
PLoS One ; 16(12): e0261363, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34932592

RESUMO

Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare's Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals' 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.


Assuntos
Economia Hospitalar/normas , Hospitais/normas , Medicare/economia , Readmissão do Paciente/economia , Qualidade da Assistência à Saúde , Reembolso de Incentivo/normas , Provedores de Redes de Segurança/normas , Idoso , Humanos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estados Unidos
4.
JAMA ; 326(18): 1829-1839, 2021 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-34751709

RESUMO

Importance: In 2016, the US Centers for Medicare & Medicaid Services initiated the Oncology Care Model (OCM), an alternative payment model designed to improve the value of care delivered to Medicare beneficiaries with cancer. Objective: To assess the association of the OCM with changes in Medicare spending, utilization, quality, and patient experience during the OCM's first 3 years. Design, Setting, and Participants: Exploratory difference-in-differences study comparing care during 6-month chemotherapy episodes in OCM participating practices and propensity-matched comparison practices initiated before (January 2014 through June 2015) and after (July 2016 through December 2018) the start of the OCM. Participants included Medicare fee-for-service beneficiaries with cancer treated at these practices through June 2019. Exposures: OCM participation. Main Outcomes and Measures: Total episode payments (Medicare spending for Parts A, B, and D, not including monthly payments for enhanced oncology services); utilization and payments for hospitalizations, emergency department (ED) visits, office visits, chemotherapy, supportive care, and imaging; quality (chemotherapy-associated hospitalizations and ED visits, timely chemotherapy, end-of-life care, and survival); and patient experiences. Results: Among Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy, 483 319 beneficiaries (mean age, 73.0 [SD, 8.7] years; 60.1% women; 987 332 episodes) were treated at 201 OCM participating practices, and 557 354 beneficiaries (mean age, 72.9 [SD, 9.0] years; 57.4% women; 1 122 597 episodes) were treated at 534 comparison practices. From the baseline period, total episode payments increased from $28 681 for OCM episodes and $28 421 for comparison episodes to $33 211 for OCM episodes and $33 249 for comparison episodes during the intervention period (difference in differences, -$297; 90% CI, -$504 to -$91), less than the mean $704 Monthly Enhanced Oncology Services payments. Relative decreases in total episode payments were primarily for Part B nonchemotherapy drug payments (difference in differences, -$145; 90% CI, -$218 to -$72), especially supportive care drugs (difference in differences, -$150; 90% CI, -$216 to -$84). The OCM was associated with statistically significant relative reductions in total episode payments among higher-risk episodes (difference in differences, -$503; 90% CI, -$802 to -$204) and statistically significant relative increases in total episode payments among lower-risk episodes (difference in differences, $151; 90% CI, $39-$264). The OCM was not significantly associated with differences in hospitalizations, ED visits, or survival. Of 22 measures of utilization, 10 measures of quality, and 7 measures of care experiences, only 5 were significantly different. Conclusions and Relevance: In this exploratory analysis, the OCM was significantly associated with modest payment reductions during 6-month episodes for Medicare beneficiaries receiving chemotherapy for cancer in the first 3 years of the OCM that did not offset the monthly payments for enhanced oncology services. There were no statistically significant differences for most utilization, quality, and patient experience outcomes.


Assuntos
Gastos em Saúde , Medicare/economia , Neoplasias/tratamento farmacológico , Qualidade da Assistência à Saúde , Mecanismo de Reembolso , Idoso , Centers for Medicare and Medicaid Services, U.S. , Redução de Custos , Atenção à Saúde , Cuidado Periódico , Planos de Pagamento por Serviço Prestado , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Oncologia , Neoplasias/economia , Estados Unidos
5.
J Manag Care Spec Pharm ; 27(10): 1457-1468, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34595957

RESUMO

BACKGROUND: Few studies have examined oral anticancer treatment utilization patterns among Medicare beneficiaries. OBJECTIVE: To assess treatment utilization patterns of newly initiated oral anticancer agents across national samples of Medicare beneficiaries for 5 cancer types: chronic myeloid leukemia (CML), multiple myeloma (MM), metastatic prostate cancer (mPC), metastatic renal cell carcinoma (mRCC), and metastatic breast cancer (mBC). METHODS: This retrospective claims analysis used 100% Medicare Chronic Condition Data Warehouse (CCW) Parts A, B, and D files from 2011 to 2014 (for CML, MM, mPC, and mRCC patients) and a 5% random fee-for-service sample from 2011 to 2013 (for mBC patients). Outcomes of interest were the number of 30-day supply prescriptions, adherence, and discontinuation of newly initiated (ie, index) oral anticancer agents indicated for each of the cancers. Adherence was calculated with both the "traditional" proportion of days covered (PDC) approach, measured over a fixed 1-year period or until hospice/death, and a "modified" PDC approach, measured over the time between the first and last fill of the index oral anticancer agent. Patients with PDC of at least 0.80 were deemed as being adherent. Discontinuation was defined as the presence of a continuous 90-day gap in the availability of days supply of the index oral anticancer agent. RESULTS: Our study included 1,650, 7,461, 6,998, 2,553, and 79 patients for CML, MM, mPC, mRCC, and mBC, respectively. Patients with mRCC had the highest proportion of patients with only 1 fill of their index anticancer agent (28%) followed by mBC (17%), MM (17%), mPC (12%), and CML (12%). Patients with CML had the highest mean (SD) number of 30-day supply equivalent prescriptions (8.3 [4.6]), followed by patients with mPC (6.5 [4.2]), MM (5.7 [4.1]), mBC (4.7 [3.2]), and mRCC (4.5 [3.9]). Using the modified PDC measured between the first and last fills, approximately three-quarters of patients with CML (74%), mRCC (71%), and mBC (70%) were adherent to the index oral anticancer agent. Adherence was highest for patients with mPC (87%) and lowest for patients with MM (58%). The percentage of patients defined as adherent to the index oral anticancer agent decreased for all cancers when using the traditional PDC measure over a fixed 1-year period: CML (54%), MM (35%), mPC (48%), mRCC (37%), and mBC (22%). Rates of discontinuation for patients in our sample were 32% (CML), 38% (mPC), 42% (mRCC), 48% (MM), and 58% (mBC). CONCLUSIONS: Between 13% and 42% of Medicare patients were nonadherent between the first and last fill of their newly initiated oral anticancer therapies across a range of cancers. This study provides a valuable benchmark for stakeholders seeking to measure and improve adherence to oral anticancer agents in Medicare patients. DISCLOSURES: This study was supported by Humana, Inc. (Louisville, KY). The sponsor played a role in the development of the study protocol, interpretation of results, and revisions of the manuscript. The sponsor was not involved in data analysis. Brown is employed by Humana, Inc., and Ward was employed by Humana, Inc., from research inception through initial drafts. Doshi has served as an advisory board member or consultant for Allergan, Ironwood Pharmaceuticals, Janssen, Kite Pharma, Merck, Otsuka, Regeneron, Sarepta, Sage Therapeutics, Sanofi, and Vertex and has received research funding from AbbVie, Biogen, Humana, Janssen, Novartis, PhRMA, Regeneron, Sanofi, and Valeant. Her spouse holds stock in Merck and Pfizer. All other authors have no financial conflicts of interest to report.


Assuntos
Antineoplásicos/administração & dosagem , Medicare , Padrões de Prática Médica , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/tratamento farmacológico , Bases de Dados Factuais , Feminino , Humanos , Masculino , Medicare/economia , Adesão à Medicação , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos
6.
PLoS One ; 16(10): e0257796, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34705847

RESUMO

Sickle cell disease is a progressively debilitating genetic condition that affects red blood cells and can result in a variety of serious medical complications, reduced life expectancy, and diminished quality of life. Medicaid nationwide covered 66 percent of sickle cell disease hospitalizations in 2004 and 58 percent of emergency department visits for the disease between 1999 and 2007. Using Medicaid data from four states with large populations that account for more than one-third of Medicaid program enrollment, we examined the characteristics of those with sickle cell disease. We found instances of mortality rates more than nine times the age-adjusted population average (in Texas, a mortality rate for Medicaid enrollees with SCD of 1.11 percent compared to 0.12 percent overall); rates of disability-related eligibility-which is associated with long-term Medicaid enrollment-of up to 69 percent; and half or more of affected enrollees having (all-cause) hospital stays, emergency department visits, and opioid prescription fills. With gene therapies on the horizon that will spur discussions of treatment coverage, costs, and outcomes for people with sickle cell disease, it is important for relevant stakeholders to understand the affected populations.


Assuntos
Analgésicos Opioides/uso terapêutico , Anemia Falciforme/epidemiologia , Serviço Hospitalar de Emergência/economia , Medicaid/economia , Adulto , Idoso , Analgésicos Opioides/economia , Anemia Falciforme/economia , Anemia Falciforme/terapia , Pessoas com Deficiência , Feminino , Hospitalização/economia , Humanos , Pacientes Internados , Masculino , Medicare/economia , Pessoa de Meia-Idade , Mortalidade , Pacientes Ambulatoriais , Prescrições/economia , Qualidade de Vida , Texas/epidemiologia , Estados Unidos/epidemiologia
8.
BMJ Health Care Inform ; 28(1)2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34535447

RESUMO

OBJECTIVE: To identify undercompensated groups in plan payment risk adjustment that are defined by multiple attributes with a systematic new approach, improving on the arbitrary and inconsistent nature of existing evaluations. METHODS: Extending the concept of variable importance for single attributes, we construct a measure of 'group importance' in the random forests algorithm to identify groups with multiple attributes that are undercompensated by current risk adjustment formulas. Using 2016-2018 IBM MarketScan and 2015-2018 Medicare claims and enrolment data, we evaluate two risk adjustment scenarios: the risk adjustment formula used in the individual health insurance Marketplaces and the risk adjustment formula used in Medicare. RESULTS: A number of previously unidentified groups with multiple chronic conditions are undercompensated in the Marketplaces risk adjustment formula, while groups without chronic conditions tend to be overcompensated in the Marketplaces. The magnitude of undercompensation when defining groups with multiple attributes is many times larger than with single attributes. No complex groups were found to be consistently undercompensated or overcompensated in the Medicare risk adjustment formula. CONCLUSIONS: Our method is effective at identifying complex undercompensated groups in health plan payment risk adjustment where undercompensation creates incentives for insurers to discriminate against these groups. This work provides policy-makers with new information on potential targets of discrimination in the healthcare system and a path towards more equitable health coverage.


Assuntos
Trocas de Seguro de Saúde , Medicare , Modelos Econômicos , Risco Ajustado , Idoso , Algoritmos , Feminino , Trocas de Seguro de Saúde/economia , Humanos , Seguradoras/economia , Masculino , Medicare/economia , Estados Unidos
9.
Am J Obstet Gynecol ; 225(5): 566.e1-566.e5, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34473964

RESUMO

BACKGROUND: Gender disparities in medicine have been demonstrated in the past, including differences in the attainment of roles in administration and in physician income. OBJECTIVE: Our objective was to determine the differences in Medicare payments based on the provider gender and training track among female pelvic medicine and reconstructive surgeons. STUDY DESIGN: Medicare payments from the Provider Utilization Aggregate Files were used to determine the payments made by Medicare to urogynecologists. This database was merged with the National Provider Identifier registry with information on subspecialty training, years since graduation, and the geographic pricing cost index used for Medicare payment adjustments. Physicians with <90% female patients and those who graduated medical school <7 years ago in obstetrics and gynecology or <8 years ago in urology were excluded. The effects of gender, specialty of training, number of services provided, years of practice, and geographic pricing cost index on physician reimbursement were evaluated using linear mixed modeling. RESULTS: A total of 578 surgeons with female pelvic medicine and reconstructive surgery subspecialty training met the inclusion criteria. Of those, 517 (89%) were trained as gynecologists, whereas 61 (11%) were trained as urologists. Furthermore, 265 (51%) of the gynecology-trained surgeons and 39 (80%) of the urology-trained surgeons were women. Among the urology-trained surgeons, the median female surgeon was paid $85,962 and their male counterparts were paid $121,531 (41% payment difference). In addition, urology-trained female pelvic medicine and reconstructive surgery surgeons performed a median of 1135 services and their male counterparts performed a median of 1793 services (57% volume difference). Similarly, among gynecology-trained surgeons, the median female payment was $59,277 with 880 services performed, whereas male gynecology-trained surgeons received a median of $66,880 with 791 services performed, representing a difference of 12% in payments and 11% in services. With linear mixed modeling, male physicians were paid more than female physicians while controlling for specialty training, number of services performed, years of practice, and geographic pricing cost index (P<.001). CONCLUSION: Although Medicare payments are based on an equation, differences in reimbursement by physician gender exist in female pelvic medicine and reconstructive surgery with female surgeons receiving lower payments from Medicare. The differences in reimbursement could not be solely explained by differences in patient volume, area of practice, or years of experience alone, suggesting that, similar to other fields in medicine, female surgeons in female pelvic medicine and reconstructive surgery are not paid as much as their male counterparts.


Assuntos
Ginecologia , Medicare/economia , Mecanismo de Reembolso/economia , Cirurgiões/economia , Urologia , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Humanos , Masculino , Fatores Sexuais , Cirurgiões/estatística & dados numéricos , Estados Unidos , Procedimentos Cirúrgicos Urológicos/economia
12.
J Am Heart Assoc ; 10(16): e020528, 2021 08 17.
Artigo em Inglês | MEDLINE | ID: mdl-34387132

RESUMO

Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95-1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89-0.96), Western states (aOR, 0.89; 95% CI, 0.84-0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86-0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11-1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.


Assuntos
Hemorragia Cerebral/reabilitação , Reforma dos Serviços de Saúde , Medicare , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Alta do Paciente/tendências , Sistema de Pagamento Prospectivo , Centros de Reabilitação/tendências , Instituições de Cuidados Especializados de Enfermagem/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/tendências , Humanos , Pacientes Internados , Masculino , Medicare/economia , Medicare/legislação & jurisprudência , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/legislação & jurisprudência , Alta do Paciente/economia , Alta do Paciente/legislação & jurisprudência , Formulação de Políticas , Sistema de Pagamento Prospectivo/economia , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Sistema de Registros , Centros de Reabilitação/economia , Centros de Reabilitação/legislação & jurisprudência , Instituições de Cuidados Especializados de Enfermagem/economia , Instituições de Cuidados Especializados de Enfermagem/legislação & jurisprudência , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
14.
N Engl J Med ; 385(7): 618-627, 2021 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-34379923

RESUMO

BACKGROUND: The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments. METHODS: We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals). The primary outcomes were the differences in changes in quarterly trends in 90-day per-episode Medicare payments and the percentage of patients with readmission within 90 days after discharge. Secondary outcomes were mortality, volume, and case mix. RESULTS: A total of 826 BPCI-A participant hospitals were compared with 2016 nonjoining hospitals and 334 late-joining hospitals. Among BPCI-A hospitals, the mean baseline 90-day per-episode Medicare payment was $27,315; the change in the quarterly trends in the intervention period as compared with baseline was -$78 per quarter. Among nonjoining hospitals, the mean baseline 90-day per-episode Medicare payment was $25,994; the change in quarterly trends as compared with baseline was -$26 per quarter (difference between nonjoining hospitals and BPCI-A hospitals, $52 [95% confidence interval {CI}, 34 to 70] per quarter; P<0.001; 0.2% of the baseline payment). Among late-joining hospitals, the mean baseline 90-day per-episode Medicare payment was $26,807; the change in the quarterly trends as compared with baseline was $4 per quarter (difference between late-joining hospitals and BPCI-A hospitals, $82 [95% CI, 41 to 122] per quarter; P<0.001; 0.3% of the baseline payment). There were no meaningful differences in the changes with regard to readmission, mortality, volume, or case mix. CONCLUSIONS: The BPCI-A program was associated with small reductions in Medicare payments among participating hospitals as compared with control hospitals. (Funded by the National Heart, Lung, and Blood Institute.).


Assuntos
Economia Hospitalar , Medicare/economia , Pacotes de Assistência ao Paciente/economia , Melhoria de Qualidade/economia , Mecanismo de Reembolso , Idoso , Idoso de 80 Anos ou mais , Grupos Diagnósticos Relacionados , Cuidado Periódico , Feminino , Insuficiência Cardíaca/terapia , Hospitais/normas , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Análise de Regressão , Estados Unidos
15.
J Trauma Acute Care Surg ; 91(4): 728-735, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34252061

RESUMO

BACKGROUND: Nearly 1-in-10 trauma patients in the United States are readmitted within 30 days of discharge, with a median hospital cost of more than $8,000 per readmission. There are national efforts to reduce readmissions in trauma care, but we do not yet understand which are potentially preventable. Our study aims to quantify the potentially preventable readmissions (PPRs) in trauma care to serve as the anchor point for ongoing efforts to curb hospital readmissions and ultimately, bring preventable readmissions to zero. METHODS: We identified inpatient hospitalizations after trauma and readmissions within 90 days in the 2017 National Readmissions Database (NRD). Potentially preventable readmissions were defined as the Agency for Healthcare Research and Quality-defined Ambulatory Care Sensitive Conditions, in addition to superficial surgical site infection, acute kidney injury/acute renal failure, and aspiration pneumonitis. Mean costs for these admissions were calculated using the NRD. A multivariable logistic regression model was used to characterize the relationship between patient characteristics and PPR. RESULTS: A total of 1,320,083 patients were admitted for trauma care in the 2017 NRD, and 137,854 (10.4%) were readmitted within 90 days of discharge. Of these readmissions, 22.7% were potentially preventable. The mean cost was $10,001/PPR, resulting in $313,802,278 in cost to the US health care system. Of readmitted trauma patients younger than 65 years, Medicaid or Medicare patients had 2.7-fold increased odds of PPRs compared with privately insured patients. Patients of any age with congestive heart failure had 2.9 times increased odds of PPR, those with chronic obstructive pulmonary disease or complicated diabetes mellitus had 1.8 times increased odds, and those with chronic kidney disease had 1.7 times increased odds. Furthermore, as the days from discharge increased, the proportion of readmissions due to PPRs increased. CONCLUSION: One-in-five trauma readmissions are potentially preventable, which account for more than $300 million annually in health care costs. Improved access to postdischarge ambulatory care may be key to minimizing PPRs, especially for those with certain comorbidities. LEVEL OF EVIDENCE: Economic and value-based evaluations, level II.


Assuntos
Assistência ao Convalescente/organização & administração , Assistência Ambulatorial/organização & administração , Custos Hospitalares/estatística & dados numéricos , Readmissão do Paciente/economia , Ferimentos e Lesões/terapia , Idoso , Comorbidade , Redução de Custos , Bases de Dados Factuais/estatística & dados numéricos , Humanos , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , Ferimentos e Lesões/economia , Ferimentos e Lesões/epidemiologia
17.
PLoS One ; 16(7): e0254039, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34283840

RESUMO

OBJECTIVES: We sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery. SUMMARY BACKGROUND DATA: The majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients' hospital visits after surgery since patients may present to a different hospital. METHODS: We used state-level, administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures. RESULTS: Among a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001). CONCLUSIONS: The overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Assistência Ambulatorial/economia , Procedimentos Cirúrgicos Ambulatórios/economia , Serviço Hospitalar de Emergência , Feminino , Custos de Cuidados de Saúde , Hospitais , Humanos , Masculino , Medicare/economia , Pessoa de Meia-Idade , Pacientes Ambulatoriais/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Qualidade da Assistência à Saúde/economia , Estados Unidos/epidemiologia
18.
Clin Pharmacol Ther ; 110(4): 1050-1056, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34145566

RESUMO

Launched in 2002, originator adalimumab (Humira) is the top revenue-generating drug in the United States. Between 2016 and 2019, the US Food and Drug Administration approved 5 adalimumab biosimilars, yet none have been marketed owing to patent dispute settlements. We sought to calculate the cost of this delayed entry to Medicare over this period by estimating the difference between reported spending on originator adalimumab and estimated spending on originator and biosimilar adalimumab products assuming timely biosimilar market entry. Estimates of potential biosimilar spending were calculated based on the following evidence-based projections: (i) market capture of 15% for the first biosimilar and 5.5% for successive biosimilars in their first year on the market, and 5% annually thereafter; (ii) price reductions of 3.5% per year and 2.4% per additional biosimilar entry for originator adalimumab; and (iii) price discounts of 25% at launch, 3.4% per year, and 1.7% per additional biosimilar entry for biosimilar adalimumab. Based on these assumptions, had adalimumab biosimilars launched upon approval, estimated non-rebate spending on them would have been $18.3 million in 2016, $225.7 million in 2017, $436.2 million in 2018, and $727.7 million in 2019, whereas estimated non-rebate spending on originator adalimumab would have been $2.33 billion, $2.04 billion, $1.78 billion, and $1.42 billion. Cumulative spending on adalimumab would have thus been $8.98 billion instead of an observed $12.11 billion. Accounting for estimated rebates, total predicted savings would have been $2.19 billion. Reforms for timely biosimilar availability will be critical in ensuring optimal savings for Medicare after biosimilar approval.


Assuntos
Adalimumab/economia , Antirreumáticos/economia , Medicamentos Biossimilares/economia , Custos de Medicamentos , Gastos em Saúde , Medicare Part D/economia , Aprovação de Drogas , Humanos , Medicare/economia , Patentes como Assunto , Fatores de Tempo , Estados Unidos
19.
Medicine (Baltimore) ; 100(19): e25902, 2021 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-34106650

RESUMO

RATIONALE: The purpose of this research is to determine and develop a valid analytical method that can be easily implemented by providers to evaluate whether they should join the bundled payments for care improvement (BPCI) advanced bundled payment program, and analyze the projected impacts of BPCI advanced payment on their margins. METHODS: We have developed a decision tree model that incorporates the types of sepsis encountered and the resultant typical complications and associated costs. RESULTS: The initial cost of a sepsis episode was $30,386. Since Medicare requires that there is a 3% cost reduction under BPCI, we applied the model with a 3% cost reduction across the board. Since the model considers probabilities of the complications and readmission, there was actually a 3.36% reduction in costs when the 3% reduction was added to the model. We applied 2-way sensitivity analysis to the intensive care unit (ICU) long and short costs. We used the unbundled cost at the high end, and a 10% reduction at the low end. Per patient episode cost varied between $28,117 and $29,658. This is a 5.2% difference between low and high end. Next, we looked at varying the hospital bed (non-ICU) costs. Here the resultant cost varied between $28,708 and $29,099. This is only a 1.34% difference between low and high ends. Finally, we applied a sensitivity analysis varying the attending physician and the intensivist reimbursement fees. The result was a cost that varied between $29,191 and $29,366 which is a difference of only 0.595%. CONCLUSION: This is the precise environment where decision tree analysis modeling is essential. This analysis can guide the hospital in just how to allocate resources in light of the new BPCI advanced payment model.


Assuntos
Árvores de Decisões , Medicare/organização & administração , Pacotes de Assistência ao Paciente/economia , Sepse/economia , Sepse/terapia , Custos Hospitalares , Humanos , Unidades de Terapia Intensiva/economia , Medicare/economia , Modelos Econométricos , Readmissão do Paciente/economia , Sepse/complicações , Estados Unidos
20.
Surgery ; 170(5): 1376-1382, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34127301

RESUMO

BACKGROUND: Few studies assess use of parathyroidectomy among older adults with symptomatic primary hyperparathyroidism. Our objective was to determine national usage and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism among insured older adults. METHODS: We identified older adult patients with symptomatic primary hyperparathyroidism using Medicare claims (2006-2017). Primary study variables were race/ethnicity, rurality, and zip-code socioeconomic status. We calculated cumulative incidence of parathyroidectomy and used multivariable Cox proportional hazards regression models to assess the adjusted association of our study variables with parathyroidectomy. RESULTS: We included 94,803 patients. The median age at primary hyperparathyroidism diagnosis was 76 years (interquartile range 71-82). The majority of patients were female (72%), non-Hispanic White (82%), from metropolitan areas (82%), and had a Charlson Comorbidity score ≥3 (62%). Nine percent of patients (n = 8,251) underwent parathyroidectomy during follow-up. After adjustment, non-Hispanic Black patients, compared to non-Hispanic White (hazard ratio 0.80; 95% confidence interval 0.74, 0.87), and living in a low socioeconomic status neighborhood (low socioeconomic status vs highest socioeconomic status hazard ratio 0.89; 95% confidence interval 0.83, 0.95) were both associated with lower incidences of parathyroidectomy. Patients from non-metropolitan areas were more likely to undergo parathyroidectomy. CONCLUSION: Parathyroidectomy is underused for symptomatic primary hyperparathyroidism in older adults. Quality improvement efforts, rooted in equitable care, should be undertaken to increase access to parathyroidectomy for this disease.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Hiperparatireoidismo Primário/cirurgia , Medicare/economia , Paratireoidectomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Hiperparatireoidismo Primário/etnologia , Incidência , Masculino , Estudos Retrospectivos , Classe Social , Estados Unidos/epidemiologia
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