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1.
Value Health ; 24(2): 196-205, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33518026

RESUMO

OBJECTIVES: Little is known about relationships between opioid- and gabapentinoid-use patterns and healthcare expenditures that may be affected by pain management and risk of adverse outcomes. This study examined the association between patients' opioid and gabapentinoid prescription filling/refilling trajectories and direct medical expenditures in US Medicare. METHODS: This cross-sectional study included a 5% national sample (2011-2016) of fee-for-service beneficiaries with fibromyalgia, low back pain, neuropathy, or osteoarthritis newly initiating opioids or gabapentinoids. Using group-based multitrajectory modeling, this study identified patients' distinct opioid and gabapentinoid (OPI-GABA) dose and duration patterns, based on standardized daily doses, within a year of initiating opioids and/or gabapentinoids. Concurrent direct medical expenditures within the same year were estimated using inverse probability of treatment weighted multivariable generalized linear regression, adjusting for sociodemographic and health status factors. RESULTS: Among 67 827 eligible beneficiaries (mean age ± SD = 63.6 ± 14.8 years, female = 65.8%, white = 77.1%), 11 distinct trajectories were identified (3 opioid-only, 4 gabapentinoid-only, and 4 concurrent OPI-GABA trajectories). Compared with opioid-only early discontinuers ($13 830, 95% confidence interval = $13 643-14 019), gabapentinoid-only early discontinuers and consistent low-dose and moderate-dose gabapentinoid-only users were associated with 11% to 23% lower health expenditures (adjusted mean expenditure = $10 607-$11 713). Consistent low-dose opioid-only users, consistent high-dose opioid-only users, consistent low-dose OPI-GABA users, consistent low-dose opioid and high-dose gabapentinoid users, and consistent high-dose opioid and moderate-dose gabapentinoid users were associated with 14% to 106% higher healthcare expenditures (adjusted mean expenditure = $15 721-$28 464). CONCLUSIONS: Dose and duration patterns of concurrent OPI-GABA varied substantially among fee-for-service Medicare beneficiaries. Consistent opioid-only users and all concurrent OPI-GABA users were associated with higher healthcare expenditures compared to opioid-only discontinuers.


Assuntos
Analgésicos Opioides/uso terapêutico , Analgésicos/uso terapêutico , Gabapentina/uso terapêutico , Medicare/economia , Dor/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Analgésicos/administração & dosagem , Analgésicos Opioides/administração & dosagem , Estudos Transversais , Uso de Medicamentos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Gabapentina/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
2.
Cochrane Database Syst Rev ; 1: CD011865, 2021 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-33469932

RESUMO

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.


Assuntos
Instituições de Assistência Ambulatorial/economia , Pessoal de Saúde/economia , Mecanismo de Reembolso/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Capitação , Estudos Controlados Antes e Depois/estatística & dados numéricos , Custos e Análise de Custo , Assistência à Saúde/economia , Assistência à Saúde/normas , Assistência à Saúde/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/normas , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Humanos , Análise de Séries Temporais Interrompida , Médicos de Atenção Primária/economia , Médicos de Atenção Primária/estatística & dados numéricos , Qualidade da Assistência à Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Mecanismo de Reembolso/classificação , Mecanismo de Reembolso/estatística & dados numéricos , Reembolso de Incentivo/economia , Reembolso de Incentivo/normas , Reembolso de Incentivo/estatística & dados numéricos , Salários e Benefícios/economia , Resultado do Tratamento
4.
J Vasc Interv Radiol ; 31(8): 1302-1307.e1, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32741554

RESUMO

PURPOSE: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. MATERIALS AND METHODS: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). RESULTS: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. CONCLUSIONS: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.


Assuntos
Sedação Consciente/economia , Planos de Pagamento por Serviço Prestado/economia , Custos de Cuidados de Saúde , Pacotes de Assistência ao Paciente/economia , Radiografia Intervencionista/economia , Terminologia como Assunto , Sedação Consciente/classificação , Sedação Consciente/tendências , Planos de Pagamento por Serviço Prestado/tendências , Custos de Cuidados de Saúde/tendências , Custos Hospitalares , Humanos , Medicare/economia , Pacotes de Assistência ao Paciente/classificação , Pacotes de Assistência ao Paciente/tendências , Prática Privada/economia , Radiografia Intervencionista/classificação , Radiografia Intervencionista/tendências , Provedores de Redes de Segurança/economia , Estados Unidos
5.
J Ment Health Policy Econ ; 23(3): 81-91, 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32853157

RESUMO

BACKGROUND: Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY: In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS: We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS: We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION: These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES: Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.


Assuntos
Organizações de Assistência Responsáveis , Capitação/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Motivação , Atenção Primária à Saúde/economia , Análise Custo-Benefício/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Gastos em Saúde , Humanos , Modelos Econômicos , Modelos Teóricos , Setor Público
6.
Tex Med ; 116(6): 34-36, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32645179

RESUMO

Texas physicians who deal with Medicare's substandard payments and world-class administrative hassles are feeling underappreciated. The latest report from the committee that advises Congress on Medicare payment policy may exacerbate that feeling. In March, the Medicare Payment Advisory Committee (MedPAC) released its annual report assessing payments to physicians, among other sectors. MedPAC recommended no changes to the 2021 Medicare physician fee schedule, meaning no increase in physician payments.


Assuntos
Tabela de Remuneração de Serviços , Planos de Pagamento por Serviço Prestado/economia , Medicare/economia , Médicos/economia , Sistema de Pagamento Prospectivo/economia , Mecanismo de Reembolso/economia , Humanos , Texas , Estados Unidos
7.
Tex Med ; 116(6): 30-32, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32645180

RESUMO

Comptroller delays medical billing tax until October 2021, giving TMA a chance to work out a legislative fix.


Assuntos
Planos de Pagamento por Serviço Prestado/economia , Revisão da Utilização de Seguros/economia , Serviços Terceirizados/economia , Impostos/economia , Renda , Texas , Fatores de Tempo
8.
Tex Med ; 116(5): 37-39, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32645188

RESUMO

From electronic health records to quality reporting, today's physicians deal with plenty of distractions from patient care. Starting in 2021, hospital-employed physicians may find themselves adding another one: explaining to patients the difference between their hospital's multiple published prices for the same service.


Assuntos
Economia Hospitalar/legislação & jurisprudência , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/legislação & jurisprudência , Custos de Cuidados de Saúde/legislação & jurisprudência , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Registros Eletrônicos de Saúde , Humanos , Cobertura do Seguro/economia
10.
Value Health ; 23(6): 812-823, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32540239

RESUMO

OBJECTIVES: Implementation of value-based initiatives depends on cost-assessment methods that can provide high-quality cost information. Time-driven activity-based costing (TDABC) is increasingly being used to solve the cost-information gap. This study aimed to review the use of the TDABC methodology in real-world settings and to estimate its impact on the value-based healthcare concept for inpatient management. METHODS: This systematic review was conducted by screening PubMed/MEDLINE and Scopus databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all studies up to August 2019. The use of TDABC for inpatient management was the main eligibility criterion. A qualitative approach was used to analyze the different methodological aspects of TDABC and its effective contribution to the implementation of value-based initiatives. RESULTS: A total of 1066 studies were retrieved, and 26 full-text articles were selected for review. Only studies focused on surgical inpatient conditions were identified. Most of the studies reported the types of activities on a macrolevel. Professional and structural cost variables were usually assessed. Eighteen studies reported that TDABC contributed to value-based initiatives, especially cost-saving findings. TDABC was satisfactorily applied to achieve value-based contributions in all the studies that used the method for this purpose. CONCLUSIONS: TDABC could be a strategy for increasing cost accuracy in real-world settings, and the method could help in the transition from fee-for-service to value-based systems. The results could provide a clearer idea of the costs, help with resource allocation and waste reduction, and might support clinicians and managers in increasing value in a more accurate and transparent way.


Assuntos
Custos e Análise de Custo/métodos , Assistência à Saúde/economia , Custos de Cuidados de Saúde , Redução de Custos , Planos de Pagamento por Serviço Prestado/economia , Humanos , Pacientes Internados , Alocação de Recursos/economia , Fatores de Tempo
13.
Plast Reconstr Surg ; 145(6): 1541-1551, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459783

RESUMO

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Custo Compartilhado de Seguro/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/economia , Procedimentos Cirúrgicos Reconstrutivos/economia , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Redução de Custos/economia , Redução de Custos/legislação & jurisprudência , Custo Compartilhado de Seguro/economia , Custo Compartilhado de Seguro/legislação & jurisprudência , Custo Compartilhado de Seguro/tendências , Bases de Dados Factuais/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/legislação & jurisprudência , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Gastos em Saúde/legislação & jurisprudência , Gastos em Saúde/tendências , Preços Hospitalares/estatística & dados numéricos , Preços Hospitalares/tendências , Humanos , Reembolso de Seguro de Saúde/legislação & jurisprudência , Reembolso de Seguro de Saúde/tendências , Masculino , Programas de Assistência Gerenciada/economia , Programas de Assistência Gerenciada/legislação & jurisprudência , Programas de Assistência Gerenciada/estatística & dados numéricos , Programas de Assistência Gerenciada/tendências , Medicare/economia , Medicare/legislação & jurisprudência , Medicare/estatística & dados numéricos , Medicare/tendências , Pessoa de Meia-Idade , Ambulatório Hospitalar/economia , Ambulatório Hospitalar/estatística & dados numéricos , Políticas , Procedimentos Cirúrgicos Reconstrutivos/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
14.
Circ Arrhythm Electrophysiol ; 13(5): e008280, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32281393

RESUMO

BACKGROUND: Current understanding of the impact of cardiac implantable electronic device (CIED) infection is based on retrospective analyses from medical records or administrative claims data. The WRAP-IT (Worldwide Randomized Antibiotic Envelope Infection Prevention Trial) offers an opportunity to evaluate the clinical and economic impacts of CIED infection from the hospital, payer, and patient perspectives in the US healthcare system. METHODS: This was a prespecified, as-treated analysis evaluating outcomes related to major CIED infections: mortality, quality of life, disruption of CIED therapy, healthcare utilization, and costs. Payer costs were assigned using medicare fee for service national payments, while medicare advantage, hospital, and patient costs were derived from similar hospital admissions in administrative datasets. RESULTS: Major CIED infection was associated with increased all-cause mortality (12-month risk-adjusted hazard ratio, 3.41 [95% CI, 1.81-6.41]; P<0.001), an effect that sustained beyond 12 months (hazard ratio through all follow-up, 2.30 [95% CI, 1.29-4.07]; P=0.004). Quality of life was reduced (P=0.004) and did not normalize for 6 months. Disruptions in CIED therapy were experienced in 36% of infections for a median duration of 184 days. Mean costs were $55 547±$45 802 for the hospital, $26 867±$14 893, for medicare fee for service and $57 978±$29 431 for Medicare Advantage (mean hospital margin of -$30 828±$39 757 for medicare fee for service and -$6055±$45 033 for medicare advantage). Mean out-of-pocket costs for patients were $2156±$1999 for medicare fee for service, and $1658±$1250 for medicare advantage. CONCLUSIONS: This large, prospective analysis corroborates and extends understanding of the impact of CIED infections as seen in real-world datasets. CIED infections severely impact mortality, quality of life, healthcare utilization, and cost in the US healthcare system. Registration: URL: https://www.clinicaltrials.gov Unique Identifier: NCT02277990.


Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/economia , Desfibriladores Implantáveis/economia , Custos de Cuidados de Saúde , Recursos em Saúde/economia , Marca-Passo Artificial/economia , Infecções Relacionadas à Prótese/economia , Infecções Relacionadas à Prótese/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/efeitos adversos , Antibioticoprofilaxia/efeitos adversos , Causas de Morte , Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/economia , Custos de Medicamentos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Gastos em Saúde , Custos Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Medicare/economia , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversos , Readmissão do Paciente/economia , Estudos Prospectivos , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Qualidade de Vida , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
Value Health ; 23(4): 481-486, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32327165

RESUMO

OBJECTIVES: To examine the uptake of filgrastim-sndz (Zarxio), the first biosimilar to launch in the United States, in the Medicare Part B fee-for-service program from its launch in September 2015 to December 2017 and compare characteristics of patients and facilities that used filgrastim-sndz or originator filgrastim (Neupogen). METHODS: The 20% sample of Medicare Part B fee-for-service administrative claims data was used to extract information on claims for any filgrastim product between January 1, 2015 and December 31, 2017. RESULTS: The utilization of filgrastim-sndz in Medicare Part B increased sharply between January and August 2016, surpassing filgrastim by November 2017, contributing to a 30% decrease in overall spending on this drug since 2015. Uptake was faster and larger in physician practices compared with hospital outpatient departments. About 77% of patients receiving filgrastim-sndz were new users. Utilization patterns indicated that product selection occurred at the facility level, rather than being at the discretion of the prescribing physician or driven by patient characteristics. CONCLUSION: Uptake of biosimilar filgrastim in the Medicare Part B program occurred despite multiple challenges to the adoption of biosimilars in the US market, suggesting that substantial potential savings could be generated by improving biosimilar uptake. Our findings indicated that physician practices and hospital outpatient departments have distinctive biosimilar uptake patterns. Thus policy makers aiming to contain Medicare Part B spending might consider focusing on incentivizing biosimilar uptake among hospital outpatient departments.


Assuntos
Medicamentos Biossimilares/administração & dosagem , Filgrastim/administração & dosagem , Fármacos Hematológicos/administração & dosagem , Medicare Part B/economia , Medicamentos Biossimilares/economia , Redução de Custos , Planos de Pagamento por Serviço Prestado/economia , Filgrastim/economia , Fármacos Hematológicos/economia , Humanos , Medicare Part B/estatística & dados numéricos , Ambulatório Hospitalar/estatística & dados numéricos , Pacientes Ambulatoriais , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos
17.
Spine Deform ; 8(3): 421-426, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32096128

RESUMO

STUDY DESIGN: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE: III.


Assuntos
Custos e Análise de Custo/métodos , Planos de Pagamento por Serviço Prestado/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Escoliose/economia , Escoliose/cirurgia , Fusão Vertebral/economia , Fusão Vertebral/métodos , Adolescente , Parafusos Ósseos/economia , Redução de Custos , Feminino , Humanos , Inflação , Tempo de Internação/economia , Masculino , Estudos Retrospectivos
18.
Crit Care Med ; 48(3): 276-288, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32058366

RESUMO

OBJECTIVES: To provide contemporary estimates of the burdens (costs and mortality) associated with acute inpatient Medicare beneficiary admissions for sepsis. DESIGN: Analysis of paid Medicare claims via the Centers for Medicare & Medicaid Services DataLink Project. SETTING: All U.S. acute care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency). PATIENTS: All Medicare beneficiaries, 2012-2018, with an inpatient admission including one or more explicit sepsis codes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total inpatient hospital and skilled nursing facility admission counts, costs, and mortality over time. From calendar year (CY)2012-CY2018, the total number of Medicare Part A/B (fee-for-service) beneficiaries with an inpatient hospital admission associated with an explicit sepsis code rose from 811,644 to 1,136,889. The total cost of inpatient hospital admission including an explicit sepsis code for those beneficiaries in those calendar years rose from $17,792,657,303 to $22,439,794,212. The total cost of skilled nursing facility care in the 90 days subsequent to an inpatient hospital discharge that included an explicit sepsis code for Medicare Part A/B rose from $3,931,616,160 to $5,623,862,486 over that same interval. Precise costs are not available for Medicare Part C (Medicare Advantage) patients. Using available federal data sources, we estimated the aggregate cost of inpatient admissions and skilled nursing facility admissions for Medicare Advantage patients to have risen from $6.0 to $13.4 billion over the CY2012-CY2018 interval. Combining data for fee-for-service beneficiaries and estimates for Medicare Advantage beneficiaries, we estimate the total inpatient admission sepsis cost and any subsequent skilled nursing facility admission for all (fee-for-service and Medicare Advantage) Medicare patients to have risen from $27.7 to $41.5 billion. Contemporary 6-month mortality rates for Medicare fee-for-service beneficiaries with a sepsis inpatient admission remain high: for septic shock, approximately 60%; for severe sepsis, approximately 36%; for sepsis attributed to a specific organism, approximately 31%; and for unspecified sepsis, approximately 27%. CONCLUSION: Sepsis remains common, costly to treat, and presages significant mortality for Medicare beneficiaries.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Hospitalização/economia , Medicare/economia , Sepse/economia , Sepse/mortalidade , Idoso , Idoso de 80 Anos ou mais , Centers for Medicare and Medicaid Services, U.S. , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Masculino , Medicare Part B/economia , Medicare Part C/economia , Qualidade de Vida , Índice de Gravidade de Doença , Choque Séptico/economia , Choque Séptico/mortalidade , Estados Unidos/epidemiologia
19.
Crit Care Med ; 48(3): 289-301, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32058367

RESUMO

OBJECTIVES: To distinguish characteristics of Medicare beneficiaries who will have an acute inpatient admission for sepsis from those who have an inpatient admission without sepsis, and to describe their further trajectories during and subsequent to those inpatient admissions. DESIGN: Analysis of paid Medicare claims via the Centers for Medicare and Medicaid Services DataLink Project. SETTING: All U.S. acute care hospitals, excepting federal hospitals (Veterans Administration and Defense Health Agency). PATIENTS: Medicare beneficiaries, 2012-2018, with an inpatient hospital admission including one or more explicit sepsis codes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Prevalent diagnoses in the year prior to the inpatient admission; healthcare contacts in the week prior to the inpatient admission; discharges, transfers, readmissions, and deaths (trajectories) for 6 months following discharge from the inpatient admission. Beneficiaries with no sepsis inpatient hospital admission for a year prior to an index hospital admission for sepsis were nearly indistinguishable by accumulated diagnostic codes from beneficiaries who had an index hospital admission without sepsis. Although the timing of healthcare services in the week prior to inpatient hospital admission was similar among beneficiaries who would be admitted for sepsis versus those whose inpatient admission did not include a sepsis code, the setting differed: beneficiaries destined for a sepsis admission were more likely to have received skilled nursing or unskilled nursing (e.g., nursing aide for activities of daily living) care. In contrast, comparing beneficiaries who had been free of any inpatient admission for an entire year and then required an inpatient admission, acute inpatient stays that included a sepsis code led to more than three times as many deaths within 1 week of discharge, with more admissions to skilled nursing facilities and fewer discharges to home. Comparing all beneficiaries who were admitted to a skilled nursing facility after an inpatient hospital admission, those who had sepsis coded during the index admission were more likely to die in the skilled nursing facility; more likely to be readmitted to an acute inpatient hospital and subsequently die in that setting; or if they survive to discharge from the skilled nursing facility, they are more likely to go next to a custodial nursing home. CONCLUSIONS: Although Medicare beneficiaries destined for an inpatient hospital admission with a sepsis code are nearly indistinguishable by other diagnostic codes from those whose admissions will not have a sepsis code, their healthcare trajectories following the admission are worse. This suggests that an inpatient stay that included a sepsis code not only identifies beneficiaries who were less resilient to infection but also signals increased risk for worsening health, for mortality, and for increased use of advanced healthcare services during and postdischarge along with an increased likelihood of an inpatient hospital readmission.


Assuntos
Medicare/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Sepse/epidemiologia , Sepse/terapia , Idoso , Idoso de 80 Anos ou mais , Centers for Medicare and Medicaid Services, U.S. , Comorbidade , Planos de Pagamento por Serviço Prestado/economia , Feminino , Gastos em Saúde/estatística & dados numéricos , Serviços de Assistência Domiciliar/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Metaloproteínas , Qualidade de Vida , Sepse/mortalidade , Índice de Gravidade de Doença , Choque Séptico/epidemiologia , Choque Séptico/mortalidade , Choque Séptico/terapia , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Succinatos , Estados Unidos/epidemiologia
20.
J Am Acad Orthop Surg ; 28(22): e995-e1000, 2020 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-32011546

RESUMO

INTRODUCTION: There has been a burgeoning interest for implementing bundled payments for hip fractures being treated with hemiarthroplasty, percutaneous pinning, and/or open reduction and internal fixation. Concerns exist about how hip fracture bundles may impede access to care for patients who require more resources, such as those with pathologic/neoplastic fractures. METHODS: The 2011 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database was queried to identify patients undergoing percutaneous pinning, hemiarthroplasty, plate/screw, and intramedullary nail for hip fractures. Multivariate regression analyses were used to identify notable differences in 30-day complications, readmissions, reoperations, mortality, length of stay, and nonhome discharges between native and pathologic/neoplastic hip fractures. RESULTS: A total of 67,548 patients were included-of which 378 (0.6%) had a pathologic/neoplastic hip fracture. Pathologic fractures (versus native hip fractures) had significantly higher odds of experiencing a prolonged length of stay >5 days (odds ratio [OR] 1.57), pulmonary embolism (OR 3.67), deep vein thrombosis (OR 2.03), 30-day readmissions (OR 1.43), and 30-day mortality (OR 2.66). DISCUSSION: Patients sustaining a pathologic/neoplastic hip fracture have a worse adverse event profile. Risk adjustment based on facture etiology will be necessary to ensure that providers taking care of pathologic/neoplastic fractures are appropriately reimbursed to minimize barriers to access of care for this vulnerable cohort.


Assuntos
Planos de Pagamento por Serviço Prestado/economia , Fraturas do Quadril/economia , Fraturas do Quadril/cirurgia , Reembolso de Seguro de Saúde , Pacotes de Assistência ao Paciente/economia , Idoso , Pinos Ortopédicos , Bases de Dados Factuais , Feminino , Fixação Interna de Fraturas , Fraturas Espontâneas , Acesso aos Serviços de Saúde/economia , Hemiartroplastia , Fraturas do Quadril/etiologia , Fraturas do Quadril/mortalidade , Humanos , Tempo de Internação , Masculino , Redução Aberta , Qualidade da Assistência à Saúde/economia , Resultado do Tratamento
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