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1.
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
2.
BMC Health Serv Res ; 19(1): 776, 2019 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-31666066

RESUMO

BACKGROUND: In 2002, a voluntary diagnosis-related groups (DRGs) payment system was introduced in South Korea for seven disease groups, and participation in the DRGs was mandated for all hospitals beginning in 2013. The primary aim of this study was to compare results reflective of patient care between voluntary participation hospitals (VPHs) and mandatory participation hospitals (MPHs) governed by either the DRGs or fee-for-service (FFS) payment system. METHODS: We collected DRGs and FFS inpatient records (n=3,038,006) from the Health Insurance Review and Assessment for the period of July 2011 to July 2014 and compared length-of-stay, total medical costs, shifting services to an outpatient setting, and readmission rates according to payment system, time of DRGs implementation, and hospital type. We analyzed the effects of mandatory introduction in DRGs payment system on results for patient care and used generalized estimating equations with difference-in-difference methodology. RESULTS: Most notably, patients at MPHs had significantly shorter LOS and lower readmission rates than VPH patients after mandatory introduction of the DRGs. Shifting services to an outpatient setting was similar between the groups. CONCLUSIONS: Our findings suggest that the DRGs payment policy in Korea has decreased LOS and readmission rates. These findings support the continued implementation and enlargement of the DRGs payment system for other diseases in South Korea, given its potential for curbing unnecessary resource usage encouraged by FFS. If the Korean government deliberates on expansion of the DRGs to include other diseases with higher rates of complications, policymakers need to monitor deterioration of health care quality caused by fixed pricing.


Assuntos
Grupos Diagnósticos Relacionados/economia , Hospitais , Programas Obrigatórios , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Revisão da Utilização de Seguros , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , República da Coreia , Adulto Jovem
3.
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
5.
Ann Intern Med ; 171(1): 27-36, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31207609

RESUMO

Background: Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs. Objective: To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit. Design: Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants. Setting: Fee-for-service Medicare, 2008 through 2014. Patients: A 20% sample (97 204 192 beneficiary-quarters). Measurements: Total spending, 4 quality indicators, and hospitalization for hip fracture. Results: In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile). Limitation: The study used an observational design and administrative data. Conclusion: After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP. Primary Funding Source: Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.


Assuntos
Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/normas , Redução de Custos , Medicare/economia , Medicare/normas , Idoso , Planos de Pagamento por Serviço Prestado/economia , Fraturas do Quadril/terapia , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Indicadores de Qualidade em Assistência à Saúde , Viés de Seleção , Estados Unidos
7.
JAMA Netw Open ; 2(5): e193290, 2019 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-31050779

RESUMO

Importance: The measured severity of illness of hospitalized Medicare beneficiaries has increased. Whether this change is associated with payment reforms, concentrated among hospitalizations with principal diagnoses targeted by payment reform, and reflective of true increases in severity of illness is unknown. Objectives: To assess whether the expansion of secondary diagnosis codes in January 2011 and the incentive payments for health information technology under the US Health Information Technology for Economic and Clinical Health Act were associated with changes in measured severity of illness and whether those changes are reflective of true increases in underlying patient severity. Design, Setting, and Participants: This cohort study of Medicare fee-for-service beneficiary discharges (N = 47 951 443) between January 1, 2008, and August 31, 2015, used a regression-discontinuity design to evaluate changes in measured severity of illness after the expansion of secondary diagnoses. Discharge-level linear regression model with hospital fixed effects was used to evaluate changes in measured severity of illness after hospitals' receipt of incentives for health information technology. The change in predictive accuracy of measured severity of illness on 30-day readmissions after the implementation of both policies was evaluated. Data analysis was performed from November 1, 2018, to March 5, 2019. Main Outcomes and Measures: The primary outcome was patients' measured severity of illness determined by the number of condition categories from secondary discharge diagnosis codes. Measured severity of illness for diagnoses commonly targeted by Medicare policies and untargeted diagnoses was assessed. Results: In total, 47 951 443 discharges at 2850 hospitals were included. In 2008, these beneficiaries included 3 882 672 women (58.5%) with a mean (SD) age of 78.5 (8.4) years. In 2014, the discharges included 3 377 137 women (57.8%) with the mean (SD) age of 78.4 (8.7) years. The Centers for Medicare & Medicaid Services expansion of secondary diagnoses was associated with a 0.348 (95% CI, 0.328-0.367; P < .001) change in condition categories for all diagnoses, 0.445 (95% CI, 0.419-0.470; P < .001) for targeted diagnoses, and 0.321 (95% CI, 0.302-0.341; P < .001) for untargeted diagnoses. Health information technology incentives were associated with a 0.013 (95% CI, 0.004-0.022; P = .005) change in condition categories for all diagnoses, 0.195 (95% CI, 0.184-0.207; P < .001) for targeted diagnoses, and -0.016 (95% CI, -0.025 to -0.007; P < .001) for untargeted diagnoses. Minimal improvements in predictive accuracy were observed. Conclusions and Relevance: Changes in Centers for Medicare & Medicaid Services policies appear to be associated with increases in measured severity of illness; these increases do not appear to reflect substantive changes in true patient severity.


Assuntos
Planos de Pagamento por Serviço Prestado/economia , Reforma dos Serviços de Saúde , Medicare/legislação & jurisprudência , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estados Unidos/epidemiologia
8.
Med Care ; 57(6): 417-424, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30994523

RESUMO

BACKGROUND: Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014. OBJECTIVES: To evaluate the effect of hospital global budgets on health care utilization and expenditures. RESEARCH DESIGN: Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group. SUBJECTS: Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas. MEASURES: Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses. RESULTS: Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group. CONCLUSIONS: This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.


Assuntos
Orçamentos , Economia Hospitalar , Medicare/economia , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde , Hospitalização/economia , Humanos , Maryland , Mecanismo de Reembolso , Estados Unidos , Revisão da Utilização de Recursos de Saúde
9.
JAMA Intern Med ; 179(5): 648-657, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30907922

RESUMO

Importance: Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective: To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants: This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions: Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures: Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results: Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance: This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.


Assuntos
Extração de Catarata/métodos , Catarata , Testes Diagnósticos de Rotina/métodos , Custos de Cuidados de Saúde , Cuidados Pré-Operatórios/métodos , Melhoria de Qualidade , Idoso , California , Capitação , Extração de Catarata/economia , Redução de Custos , Testes Diagnósticos de Rotina/economia , Eletrocardiografia/economia , Eletrocardiografia/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/economia , Radiografia Torácica/economia , Radiografia Torácica/estatística & dados numéricos , Provedores de Redes de Segurança/economia
10.
PLoS One ; 14(3): e0213647, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30908492

RESUMO

OBJECTIVES: To measure value in the delivery of inpatient care and to quantify its variation across U.S. regions. DATA SOURCES / STUDY SETTING: A random (20%) sample of 33,713 elderly fee-for-service Medicare beneficiaries treated in 2,232 hospitals for a heart attack in 2013. STUDY DESIGN: We estimate a production function for inpatient care, defining output as stays with favorable patient outcomes in terms of survival and readmission. The regression model includes hospital inputs measured by treatment costs, as well as patient characteristics. Region-level effects in the production function are used to estimate the productivity and value of the care delivered by hospitals within regions. DATA COLLECTION / EXTRACTION METHODS: Medicare claims and enrollment files, linked to the Dartmouth Atlas of Health Care and Inpatient Prospective Payment System Impact Files. PRINCIPAL FINDINGS: Hospitals in the hospital referral region at the 90th percentile of the value distribution delivered 54% more high-quality stays than hospitals at the 10th percentile could have delivered, after adjusting for treatment costs and patient severity. CONCLUSIONS: Variation in the delivery of high-value inpatient care points to opportunities for better quality and lower costs.


Assuntos
Custos de Cuidados de Saúde , Pesquisa sobre Serviços de Saúde , Hospitalização/economia , Pacientes Internados , Readmissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Economia Hospitalar , Planos de Pagamento por Serviço Prestado/economia , Feminino , Geografia , Hospitais/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Sistema de Pagamento Prospectivo/economia , Qualidade da Assistência à Saúde , Risco , Resultado do Tratamento , Estados Unidos
11.
Fam Med ; 51(2): 185-192, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30736045

RESUMO

BACKGROUND AND OBJECTIVES: Fee for service (FFS), the dominant payment model for primary care in the United States, compensates physicians based on volume. There are many initiatives exploring alternative payment models that prioritize value over volume. The Family Medicine for America's Health (FMAHealth) Payment Team has developed a comprehensive primary care payment (CPCP) model to support the move from activity- and volume-based payment to performance-based payment for value. METHODS: In 2016-2017, the FMAHealth Payment Team performed a comprehensive study of the current state of primary care payment models in the United States. This study explored the features, motivations, successes, and failures of a wide variety of payment arrangements. RESULTS: The results of this work have informed a definition of comprehensive primary care payment (CPCP) as well as a CPCP calculator. This quantitative methodology calculates a base rate and includes modifiers that recognize the importance of infrastructure and resources that have been found to be successful in innovative models. The modifiers also incorporate adjustments for chronic disease burden, social determinants of health, quality, and utilization. CONCLUSIONS: The calculator and CPCP methodology offer a potential roadmap for transitioning from volume to value and details how to calculate such an adjustable comprehensive payment. This has impact and interest for all levels of the health care system and is intended for use by practices of all types as well as health systems, employers, and payers.


Assuntos
Assistência Integral à Saúde/economia , Medicina de Família e Comunidade/organização & administração , Modelos Econômicos , Atenção Primária à Saúde/economia , Assistência à Saúde , Planos de Pagamento por Serviço Prestado/economia , Humanos , Estados Unidos
13.
Health Serv Res ; 54(2): 484-491, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30790281

RESUMO

OBJECTIVE: The study's purpose was to describe the cumulative duration of 19 chronic conditions among Medicare fee-for-service (FFS) beneficiaries and examine variation in total expenditures explained by cumulative duration and condition counts. DESIGN, SETTING, STUDY DESIGN, AND DATA EXTRACTION: In a retrospective cohort of FFS beneficiaries age ≥68, 2015 Medicare enrollment and claims data (N = 20 124 230) were used to identify the presence or absence of 19 diagnosed chronic conditions, and to construct MCC categories (0-1, 2-3, 4-5, 6+) and cumulative duration of each of 19 conditions from the date of first possible occurrence in claims (1/1/1999) to the end of follow-up (date of death or 12/31/2015). Total Medicare expenditures were estimated using linear models adjusted for demographic characteristics. PRINCIPAL FINDINGS: Multimorbidity was common (71.7 percent with 2+ conditions). The mean cumulative duration of all 19 conditions was 23.6 person-years, which varied greatly by age and number of conditions. Condition counts were more predictive of Medicare expenditures than cumulative duration (R-squared for continuous measures = 0.461 vs 0.272; R-squared for quartiles = 0.408 vs 0.266). CONCLUSIONS: The cumulative duration of chronic conditions varied widely for Medicare beneficiaries, especially for those with 6+ conditions, but was less predictive of total expenditures than condition counts.


Assuntos
Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Múltiplas Afecções Crônicas/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Medicare/economia , Modelos Econômicos , Múltiplas Afecções Crônicas/economia , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos
14.
Phys Ther ; 99(5): 526-539, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30801639

RESUMO

BACKGROUND: Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood. OBJECTIVE: The objectives of this study were to examine variations in annual outpatient physical therapy expenditures of Medicare fee-for-service beneficiaries by primary diagnosis and baseline functional mobility, and to assess whether case mix groups based on primary diagnosis and functional mobility scores would be useful for expenditure differentiation. DESIGN: This was an observational, longitudinal study. METHODS: Volunteer providers in community settings participated in data collection with Continuity Assessment Record and Evaluation-Community (CARE-C) assessments for Medicare fee-for-service beneficiaries. Annual outpatient physical therapy expenditures were calculated using allowed charges on Medicare claims; primary diagnosis and baseline functional mobility were obtained from CARE-C assessments. Whether annual expenditures varied significantly across primary diagnosis groups and within diagnosis groups by functional mobility was examined. RESULTS: Data for 4210 patients (mean [SD] age = 72.9 [9.9] years; 64.6% women) from 127 providers were included. Mean expenditures differed significantly across 12 primary diagnosis groups created from CARE-C clinician-reported diagnoses (F = 12.73; df = 11). Twenty-five pairwise differences in 66 pairwise diagnosis group comparisons were statistically significant. Within 8 diagnosis groups, expenditures were significantly higher for low-mobility subgroups than for high-mobility subgroups; borderline significance was achieved for 1 diagnosis group. LIMITATIONS: The small convenience sample limited the statistical power and the generalizability of the results. CONCLUSIONS: Significant variations in physical therapy expenditures based on primary diagnosis and baseline functional mobility support the use of these variables in predicting outpatient physical therapy expenditures. Although Medicare's annual therapy spending cap was repealed effective January 2018, the data from this study provide an initial foundation to inform any future policy efforts, such as targeted medical review, risk-adjusted therapy payments, or case mix groups as potential payment alternatives. Additional research with larger samples is needed to further develop and test case mix groups and improve generalizability to the national population. Refined case mix groups could also help providers prognosticate physical therapy expenditures based on patient profiles.


Assuntos
Grupos Diagnósticos Relacionados/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Modalidades de Fisioterapia/economia , Idoso , Grupos Diagnósticos Relacionados/economia , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Estudos Longitudinais , Masculino , Medicare/economia , Limitação da Mobilidade , Pacientes Ambulatoriais/estatística & dados numéricos , Estados Unidos
15.
Clin Orthop Relat Res ; 477(2): 334-341, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30794221

RESUMO

BACKGROUND: The advent of value-based care, in which surgeons and hospitals accept more responsibility for clinical and financial results, has increased the focus on surgeon- and hospital-specific outcomes. However, methods to identify high-quality, low-cost surgeons are not well developed. QUESTIONS/PURPOSES: (1) Is there an association between surgeon THA volume and 90-day Centers for Medicare & Medicaid Services (CMS) Part A payments, readmissions, or mortality? (2) What proportion of THAs in the United States is performed by low- and high-volume surgeons? METHODS: We performed a retrospective analysis of the CMS Limited Data Set on all primary elective THAs performed in the United States (except Maryland) between January 2013 and June 2016 on patients insured by Medicare. This represented 409,844 THAs totaling more than USD 7.7 billion in direct CMS expenditures. Surgeons were divided into five groups based on annualized volume of CMS elective THAs over the study period. Using linear and logistic regression, we calculated and compared 90-day CMS Part A payments, readmissions, and mortality among the groups. For each episode, demographic information (age, sex, and race), geographic location, and Elixhauser comorbidities were calculated to control for major confounding factors in the regression. RESULTS: When compared with the highest volume group, each lower volume group had increased payments, increased readmission rates, and increased mortality rates in a stepwise fashion when controlling for patient-specific variables including Elixhauser comorbidity index, demographic information, region, and background trend. The lowest volume group resulted in 27.2% more CMS payments per case (p < 0.001; 95% confidence interval [CI], 26.6%-27.8%), had an increased readmission odds ratio (OR) of 1.8 (p < 0.001; 95% CI, 1.7-1.9), and an increased mortality OR of 4.7 (p < 0.001; 95% CI, 4.0-5.5) when compared with the highest volume group. There was also variation within volume groups: some lower volume surgeons had lower payments, readmissions, and mortality than some higher volume surgeons despite the general trend. In terms of CMS volume, surgeons who were at least moderate volume (11+ annual cases) performed 78% of THAs and represented 26% of operating surgeons. The low- and lowest volume surgeons (10 or fewer annual cases) performed only 22% of THAs in the United States while representing 74% of unique operating surgeons. CONCLUSIONS: There is a strong association between a surgeon's Medicare volume and lower CMS payments, readmissions, and mortality. Furthermore, the majority of Medicare THAs in the United States are performed by surgeons who perform > 10 CMS operations annually. Compared with previous work, these results suggest a trend toward higher volume surgeons in the Medicare population. The results also suggest a benefit to the shift toward higher volume surgeons in reducing payments, readmissions, and mortality for elective THA in the United States. However, given that payments, readmission, and mortality of surgeons varied widely, it is important to note that available individual CMS data can be used to directly evaluate each individual surgeon based on their actual results well as through association with volume. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Artroplastia de Quadril/economia , Planos de Pagamento por Serviço Prestado/economia , Custos Hospitalares , Hospitais com Alto Volume de Atendimentos , Medicare/economia , Readmissão do Paciente/economia , Seguro de Saúde Baseado em Valor/economia , Aquisição Baseada em Valor/economia , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/mortalidade , Competência Clínica/economia , Análise Custo-Benefício , Bases de Dados Factuais , Humanos , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
16.
Clin Orthop Relat Res ; 477(2): 271-280, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30664603

RESUMO

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) initiative in 2013 to create incentives to improve outcomes and reduce costs in various clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for THA and to determine the optimal party (for example, hospital versus physician group practice [PGP]) to manage the program. QUESTIONS/PURPOSES: (1) Is BPCI associated with lower 90-day payments, readmissions, or mortality for elective THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by PGPs and episodes initiated by hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index or age for elective THA? METHODS: We performed a retrospective analysis on the CMS Limited Data Set on all Medicare primary elective THAs without a major comorbidity performed in the United States (except Maryland) between January 2013 and March 2016, totaling more than USD 7.1 billion in expenditures. Episodes were grouped into hospital-run BPCI (n = 42,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n = 284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and Elixhauser comorbidities were determined to control for major confounding variables. Total payments, readmissions, and mortality were compared among the groups with logistic regression. RESULTS: When controlling for demographics, background trend, geographic variation, and total Elixhauser comorbidities in elective Diagnosis-Related Group 470 THA episodes, BPCI was associated with a 4.44% (95% confidence interval [CI], -4.58% to -4.30%; p < 0.001) payment decrease for all participants (USD 1244 decrease from a baseline of USD 18,802); additionally, odds ratios (ORs) for 90-day mortality and readmissions were unchanged. PGP groups showed a 4.81% decrease in payments (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI (USD 1335 decrease from a baseline of USD 17,841). Hospital groups showed a 4.04% decrease in payments (95% CI, -4.24% to 3.84%; p < 0.01) after enrolling in BPCI (USD 1138 decrease from a baseline of USD 19,799). The decrease in payments of PGP-run episodes was greater compared with hospital-run episodes. ORs for 90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs. Patient age and mean Elixhauser comorbidity index did not change after BPCI for PGP-run, hospital-run, or overall BPCI episodes. CONCLUSIONS: Even when controlling for decreasing costs in traditional fee-for-service care, BPCI is associated with payment reduction with no change in adverse events, and this is not because of the selection of younger patients or those with fewer comorbidities. Furthermore, physician group practices were associated with greater payment reduction than hospital programs with no difference in readmission or mortality from baseline for either. Physicians may be a more logical group than hospitals to manage payment reduction in future healthcare reform. LEVEL OF EVIDENCE: Level II, economic and decision analysis.


Assuntos
Artroplastia de Quadril/economia , Planos de Pagamento por Serviço Prestado/economia , Prática de Grupo/economia , Custos Hospitalares , Pacotes de Assistência ao Paciente/economia , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/mortalidade , Distinções e Prêmios , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Humanos , Pacotes de Assistência ao Paciente/efeitos adversos , Readmissão do Paciente/economia , Diretores Médicos , Complicações Pós-Operatórias/economia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
17.
Health Aff (Millwood) ; 38(1): 107-114, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30615516

RESUMO

One strategy for reducing health care spending is to target the Medicare beneficiaries who remain persistently high cost over time. Using a 20 percent sample of Medicare fee-for-service beneficiaries in the period 2012-14, we sought to identify the proportion of patients who remained persistently high cost (that is, in the top 10 percent of spending each year) and determine the characteristics and spending patterns that differentiated them from other patients. We found that 28.1 percent of patients who were high cost in 2012 remained persistently high cost over the subsequent two years. On average, persistently high-cost patients were younger, more likely to be members of racial/ethnic minority groups, eligible for Medicare based on having end-stage renal disease, and dually eligible for Medicaid, compared to transiently and never high-cost patients. Persistently high-cost patients had greater relative spending on outpatient care and medications, while very little of their spending was related to preventable hospitalizations. Health care systems and policy makers can use this information to better target spending reductions and care improvements over time.


Assuntos
Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Medicare/economia , Idoso , Doença Crônica/economia , Doença Crônica/etnologia , Grupos Étnicos/estatística & dados numéricos , Feminino , Hospitalização/economia , Humanos , Masculino , Medicare/estatística & dados numéricos , Estados Unidos
18.
Orv Hetil ; 160(2): 50-56, 2019 Jan.
Artigo em Húngaro | MEDLINE | ID: mdl-30616370

RESUMO

There is no nation in the developed world without dysfunctions of its health care system. The cause behind is universal since it goes back to the historic conflict of private and public financing of services. Phenomena on the surface are multi-faceted, in Hungary they are concentrated in the doctors' informal payment the original pattern of which was emerging three centuries ago. While neglecting our series of mismanagement, all our new initiatives will disable any real solution. The world's best health system models in Germany and the United Kingdom function without informal payment. Their substantial models compromise private and public financing. Instead of questionable ideas, Hungary needs to find its own relevant solution based on a new deal with the society but it must have a firm base of scientific evidences. Orv Hetil. 2019; 160(2): 50-56.


Assuntos
Medicina de Família e Comunidade/economia , Planos de Pagamento por Serviço Prestado/economia , Planos de Incentivos Médicos/economia , Salários e Benefícios/economia , Financiamento Pessoal/estatística & dados numéricos , Reforma dos Serviços de Saúde , Acesso aos Serviços de Saúde/economia , Humanos , Hungria , Sociologia Médica
19.
Med Care ; 57(3): 218-224, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30676355

RESUMO

BACKGROUND: Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level. OBJECTIVE: The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions. RESEARCH DESIGN: Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries. SUBJECTS: A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013. MEASURES: Avoidable health care costs and hospital use from medication nonadherence. RESULTS: Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted. CONCLUSION: Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.


Assuntos
Doença Crônica/economia , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Medicare Part D/economia , Adesão à Medicação/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/terapia , Redução de Custos/economia , Serviço Hospitalar de Emergência , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Humanos , Medicare Part D/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
20.
J Vasc Surg ; 69(1): 210-218, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29937283

RESUMO

OBJECTIVE: Previous cost analyses have found small to negative margins between hospitalization cost and reimbursement for endovascular aneurysm repair (EVAR). Hospitals obtain reimbursement on the basis of Medicare Severity Diagnosis Related Group (MS-DRG) coding to distinguish patient encounters with or without major comorbidity or complication (MCC). This study's objective was to evaluate coding accuracy and its effect on hospital cost for patients undergoing EVAR. METHODS: A retrospective, single university hospital review of all elective, infrarenal EVARs performed from 2010 to 2015 was completed. Index procedure hospitalizations were reviewed for MS-DRG classification, comorbidities, complications, length of stay (LOS), and hospitalization cost. Patients' comorbidities and postoperative complications were tabulated to verify accuracy of MS-DRG classification. Misclassified patients were audited and reclassified as "standard" or "complex" on the basis of a corrected MS-DRG: standard for 238 (major cardiovascular procedure without MCC) and complex for 237 (major cardiovascular procedure with MCC). RESULTS: There were 104 EVARs identified, including 91 standard (original MS-DRG 238, n = 85; MS-DRG 254, n = 6) and 13 complex hospitalizations (original MS-DRG 237, n = 9; MS-DRG 238, n = 3; MS-DRG 253, n = 1). On review, 3% (n = 3) of the originally assigned MS-DRG 238 patients were undercoded while actually meeting MCC criteria for a 237 designation. Hospitalizations coded with MS-DRG 253 and 254 were considered billing errors because MS-DRG 237 and 238 are more appropriate and specific classifications as major cardiovascular procedures. Overall, there was a 9.6% miscoding rate (n = 10), representing a total lost billing opportunity of $587,799. Mean LOS for standard and complex hospitalizations was 3.0 ± 1.5 days vs 7.8 ± 6.0 days (P < .001), with respective intensive care unit LOS of 0.4 ± 0.7 day vs 2.6 ± 3.1 days (P < .001). Postoperative complications occurred in 23% of patients; however, not all met the Centers for Medicare and Medicaid Services criteria as MCC. Miscoded complexity was found to be due to postoperative events in all patients rather than to missed comorbidities. Mean hospitalization cost for standard and complex patients was $28,833 ± $5597 vs $41,543 ± $12,943 (P < .001). Based on institutional reimbursement data, this translates to a mean loss of $5407 per correctly coded patient. Miscoded patients represent an additional overall reimbursement loss of $140,102. CONCLUSIONS: Our study reveals a large lost billing opportunity with miscoding of elective EVARs from 2010 to 2015, with errors in categorization of the procedure as well as miscoding of complexity. The revenue impact is potentially significant in this population, and additional reviews of coding practices should be considered.


Assuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/economia , Procedimentos Endovasculares/economia , Planos de Pagamento por Serviço Prestado/economia , Custos Hospitalares , Hospitais Universitários/economia , Classificação Internacional de Doenças/economia , Aneurisma da Aorta Abdominal/classificação , Prótese Vascular/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/classificação , Implante de Prótese Vascular/instrumentação , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/classificação , Procedimentos Endovasculares/instrumentação , Humanos , Tempo de Internação/economia , Medicare/economia , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
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