Journal articles on the topic 'Medicare FFS'
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Hirsch, Joshua A., Ronil V. Chandra, Vidsysagar Pampati, John D. Barr, Allan L. Brook, and Laxmaiah Manchikanti. "Analysis of vertebral augmentation practice patterns: a 2016 update." Journal of NeuroInterventional Surgery 8, no. 12 (October 31, 2016): 1299–304. http://dx.doi.org/10.1136/neurintsurg-2016-012767.
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ObjectiveTo evaluate procedure utilization patterns for vertebroplasty and kyphoplasty in the US Medicare population from 2004 to 2014.MethodsThe analysis was performed using the Centers for Medicare and Medicaid Services database of specialty utilization files for the fee for service (FFS) Medicare population.ResultsThe FFS Medicare population increased by 28% with an annual increase of 2.5% from 2004 to 2014. Utilization of vertebroplasty procedures decreased by 63% with an average annual decrease of 9.5% from 2004 to 2014 per 100 000 FFS Medicare beneficiaries. During the same time period, kyphoplasty procedures decreased by a total of 10%, with an average annual decrease of 1.3%. For augmentation generally (combined vertebroplasty/kyphoplasty data) there was thus an overall decrease in the rate per 100 000 Medicare population of 32% from 2004 to 2014, with an average annual decrease of 4.8%. The majority of vertebroplasty procedures were performed by radiologists whereas the majority of kyphoplasties were performed by orthopedic surgeons and neurosurgeons.ConclusionsThere has been a significant decline in vertebroplasty and kyphoplasty procedures in the FFS Medicare population between 2004 and 2014.
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Fang, Hanming, and Qing Gong. "Detecting Potential Overbilling in Medicare Reimbursement via Hours Worked." American Economic Review 107, no. 2 (February 1, 2017): 562–91. http://dx.doi.org/10.1257/aer.20160349.
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We propose a novel and easy-to-implement approach to detect potential overbilling based on the hours worked implied by the service codes which physicians submit to Medicare. Using the Medicare Part B Fee-for-Service (FFS) Physician Utilization and Payment Data in 2012 and 2013 released by the Centers for Medicare and Medicaid Services, we construct estimates for physicians' hours spent on Medicare beneficiaries. We find that about 2,300 physicians, representing about 3 percent of those with 20 or more hours of Medicare Part B FFS services, have billed Medicare over 100 hours per week. We consider these implausibly long hours. (JEL H51, I13, I18, J22)
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Pollissard, Laurence, Anne Shah, Rajeshwari Punekar, Allison Petrilla, and Huy P. Pham. "Burden of Illness Among Medicare and Non-Medicare Populations with Acquired Thrombotic Thrombocytopenic Purpura, 2010-2018." Blood 136, Supplement 1 (November 5, 2020): 19–20. http://dx.doi.org/10.1182/blood-2020-140740.
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Background and Objective Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare hematologic disorder that causes microvascular thromboses and can lead to serious and life-threatening medical complications. The aim of this study was to describe aTTP-related resource utilization, cost, complications, and overall survival (OS) among US Medicare and non-Medicare populations following aTTP episodes. Methods This retrospective study utilized administrative claims data for Medicare Fee-for-Service (FFS) beneficiaries (100% sample) and a sample of commercial, managed Medicaid [MM], Medicare Advantage [MA] plan members from the Inovalon MORE2 Registry. Patients aged 18+ with aTTP were identified using a validated algorithm (Wahl et al, 2010): ≥1 hospitalization for thrombotic microangiopathy + therapeutic plasma exchange (TPE) between 2010 and 2018. Patients with hemolytic-uremic syndrome or other conditions mimicking aTTP during same hospitalization were excluded. Outcomes included characterization of index hospitalization (including length of stay), diagnosis-related group (DRG) payment amount (2019 US$ [Medicare payments also included outlier payments]), and risk of mortality. OS was compared for Medicare FFS patients with aTTP to a 1:1 matched cohort of Medicare FFS beneficiaries without aTTP (matched on age, gender, region, index year, socioeconomic status, disability insurance benefits, and Charlson comorbidity index score). Median survival time and 1-year/2-year survival rates were estimated using Kaplan Meier methodology and hazard ratio was obtained using Cox proportional hazard model. In a subgroup analysis of aTTP patients across payer channels with at least 6 months of baseline and 1 month of follow-up data, percentage of patients with readmission for TPE (exacerbation if <30 days post-discharge; relapse if >30 days post-discharge) and rate of post-discharge clinical complications per 100 person-years was calculated. Results During the 9-year period, 2,279 patients met the study criteria for aTTP; 65.2% (N=1,486) were enrolled in Medicare FFS: 13.6% (N=312) in commercial, 15.7% (N=358) in MM, and 5.4% (N=123) in MA. Mean (SD) age (in years) varied by payers as expected: Medicare FFS: 65.9 (13.9); MA: 63.8 (13.6); commercial: 45.0 (14.3); MM: 37.5 (14.0). Mean (SD) hospitalization for index event ranged from 12.4 (9.4) to 15.8 (11.8) days; majority of patients required intensive care (Medicare FFS: 61.4% [mean (SD) ICU days: 8.3 (8.2)]; MA: 61.8%; commercial: 62.2%; MM: 60.1%). Among Medicare FFS patients, 15.7% died during initial hospitalization and 21.0% died within first 30 days of the event (mean (SD) time to death: 11.7 (7.2) days). Among matched cohorts of Medicare patients with and without aTTP (N=833 in each cohort), OS was lower for patients with aTTP (Figure 1). Specifically, 1-year survival rates among aTTP patients was 71.8% (95% CI: 68.6%-74.8%) vs. 95.6% (94.0%-96.8%) for those without aTTP. Two-year survival rates among aTTP patients was 66.6% (63.2%-69.8%) vs. 91.1% (88.8%-92.9%) for those without aTTP. Risk of mortality was 2.9 times higher for patients with aTTP vs. without aTTP (95% CI: 2.4-3.4). Mean (SD) DRG payment for index hospitalization varied by payers: Medicare FFS: $29,024 ($32,565); MA: $12,860 ($6,981); commercial: $9,996 ($5,995); MM: $10,470 ($7,370). During follow-up, 18.4%-22.4% of patients experienced aTTP-related exacerbation [Medicare FFS: 18.4%; MA: 21.9%; commercial: 22.4% and MM: 22.2%]. Annual incidence rate of relapse per 100 person-years was 5.6 [Medicare FFS: 3.6; MA: 8.7; commercial: 10.4 and MM: 14.7] and annual incidence rate of complications per 100 person-years was 16.7 [Medicare FFS: 15.5; MA: 20.5; commercial: 21.7 and MM: 19.1]. Conclusions This is the first real-world study evaluating burden of illness among aTTP patients in the US across payer types. Despite being treated with TPE, patients with aTTP have high acute mortality and are nearly three times as likely to die compared with the general Medicare population without aTTP. During the initial hospitalization, many required intensive care. Following discharge, approximately 1 in 5 was readmitted within 30 days and had higher incidence for clinical complications associated with aTTP. The study findings highlight the need for more effective therapies to reduce disease burden for this population. Disclosures Pollissard: Sanofi: Current Employment, Current equity holder in publicly-traded company. Shah:Avalere Health: Current Employment. Punekar:Sanofi: Other: Employee of Sanofi at the time of study and may hold stock/stock options in Sanofi. Petrilla:Avalere Health: Current Employment. Pham:Sanofi: Consultancy; Alexion: Other: Speaker.
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Manchikanti, Laxmaiah. "Update on Reversal and Decline of Growth of Utilization of Interventional Techniques In Managing Chronic Pain in the Medicare Population from 2000 to 2018." November 2019 6, no. 22;6 (November 14, 2019): 521–36. http://dx.doi.org/10.36076/ppj/2019.22.521.
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Background: The cost of US health care continues to increase, with treatments related to low back and neck pain and other musculoskeletal disorders accounting for the third highest amount of various disease categories. Interventional techniques for managing pain apart from conservative modalities and surgical interventions, have generally been thought to be growing rapidly. However, a recent analysis of utilization of interventional techniques from 2000 to 2016 has shown a modest decline from 2009 to 2016, compared to 2000 to 2009. Objectives: The objectives of this analysis include providing an update on utilization of interventional techniques in managing chronic pain in the Medicare population from 2009 to 2018 in the fee-for-service (FFS) Medicare population of the United States. Study Design: Utilization patterns and variables of interventional techniques in managing chronic pain were assessed from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population of the United States. Methods: The data for the analysis was obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. Results: The analysis of data showed that there was a decline in utilization of interventional techniques from 2009 to 2018 of 6.7%, with an annual decline of 0.8% per 100,000 FFS Medicare population, despite an increase of 0.7% per year of population growth (3.2% of those 65 years or older) and a 3% annual increase in Medicare participation from 2009 to 2018. Medicare data from 2000 to 2009 showed an increase of 11.8% per year per 100,000 individuals of the Medicare population. The 2009 to 2018 data also showed a 2.6% annual decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000 population of FFS Medicare, and a 1% decrease for disc procedures and other types of nerve blocks, while there was an increase of 0.9% annually for facet joint interventions and sacroiliac joint blocks. Limitations: Limitations of this analysis include: only the Medicare population was utilized, and among the Medicare population, only the FFS population was evaluated; utilization patterns in Medicare Advantage Plans, which constitutes almost 30% of the population were not considered. Further, the utilization data for individual states was sparse and may not be accurate. Conclusion: The decline in utilization of interventional techniques continued from 2009 to 2018 with 6.7% per 100,000 Medicare population, with an annual decline of 0.8%, despite an increase in the population rate and Medicare enrollees of 0.7% and 3% annually. Key words: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks
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Chuba, Paul J., Maria T. Vlachaki, Sean Koerner, William Stefani, and Jeffrey Falk. "Are there inequities in reconstruction after mastectomy in breast cancer patients related to race or insurance status?" Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): e12615-e12615. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.e12615.
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e12615 Background: Patients with invasive or in-situ breast cancers may increasingly be offered bilateral mastectomy with reconstruction with a view towards achieving symmetry and risk reduction. We investigated whether this treatment option was offered equally based on race and insurance status. Methods: Rates of mastectomy and reconstruction were studied among 4703 patients diagnosed or treated at Ascension St John Hospital, Ascension Macomb Oakland Hospital, and Ascension Providence Hospital between 2005 and 2015. Data collected included demographics, tumor characteristics, insurance (primary payer), first course of surgical treatment, vital status, and cause of death. Cases coded as contralateral mastectomy and reconstruction were considered as representative of “bilateral mastectomy” and reconstruction. Results: Insurance status could be definitively categorized as HMO/PPO, fee for service (FFS), Medicare, or Medicaid in 2375 breast cancer patients. Medicaid HMO was categorized as Medicaid and Medicare with or without supplemental insurance was categorized as Medicare. For simplicity, cases coded as uninsured, other, and NOS were not analyzed further. A total of 406 of 2375 (17.0%) were coded as contralateral mastectomy with reconstruction. Smaller numbers of Medicare cases had contralateral mastectomy and reconstruction (7.3%) compared to 23.3% for HMO/PPO, 26.3% for FFS, and 16% for Medicaid, presumably related to older age. Within each insurance category, similar proportions of Caucasian and African American women were treated with contralateral mastectomy (Table) compared to all patients (Table). Conclusions: Patients having Medicaid insurance had lower rates of contralateral mastectomy and reconstruction compared to HMO/PPO and FFS cases. African American race did not appear to be associated with lower rates of this surgery within the Ascension St John, Ascension Macomb Oakland, and Ascension Providence hospitals. [Table: see text]
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Maeda, Jared Lane K., and Lyle Nelson. "How Do the Hospital Prices Paid by Medicare Advantage Plans and Commercial Plans Compare With Medicare Fee-for-Service Prices?" INQUIRY: The Journal of Health Care Organization, Provision, and Financing 55 (January 1, 2018): 004695801877965. http://dx.doi.org/10.1177/0046958018779654.
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The prices that private insurers pay hospitals have received considerable attention in recent years, but most of that literature has focused on the commercially insured population. Although nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, little is known about the prices paid to hospitals by the private insurers that administer such plans. More information on the hospital prices paid by MA plans would provide additional insights into whether MA prices are more closely tied to Medicare fee-for-service (FFS) prices or commercial prices. Moreover, information on whether the hospital prices paid by MA plans vary with market characteristics or other factors would be useful for evaluating the performance of the MA program and analyzing proposals to modify it. In this study, we compared the hospital prices paid by MA plans and commercial plans with Medicare FFS prices using 2013 claims from the Health Care Cost Institute (HCCI) database. The HCCI claims were used to calculate hospital prices for private insurers, and Medicare’s payment rules were used to estimate Medicare FFS prices. We focused on stays at acute care hospitals in metropolitan statistical areas (MSAs). We found MA prices to be roughly equal to Medicare FFS prices, on average, but commercial prices were 89% higher than FFS prices. In addition, commercial prices varied greatly across and within MSAs, but MA prices varied much less.
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Manchikanti, Laxmaiah. "Utilization of Interventional Techniques in Managing Chronic Pain In Medicare Population from 2000 to 2014: An Analysis of Patterns of Utilization." Pain Physician 4;19, no. 4;5 (May 14, 2016): E531—E546. http://dx.doi.org/10.36076/ppj/2019.19.e531.
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Background: The increase in the utilization of various techniques in managing chronic pain, including interventional techniques, is a major concern for policy-makers and the public at large. Consequently, multiple regulations have been instituted to reduce health care expenditures in general and expenditures related to interventional techniques in particular. Previous investigations have shown significant increases of utilization of interventional techniques across the board with minor decreases noted in 2007, 2010, 2012 and 2013. Objective: To assess the patterns of utilization of interventional techniques in chronic pain management in the fee-for-service (FFS) Medicare population. Study Design: Analysis of utilization patterns of interventional techniques from 2000 to 2014 in Fee-for-Services (FFS) Medicare beneficiaries in managing chronic pain. Methods: The analyzed data was derived from the Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary Master Data from 2000 to 2014. Results: The analysis of data from 2000 to 2014 in FFS Medicare beneficiaries showed overall utilization of interventional techniques increasing at a rate of 153% and an annual average growth rate of 6.9% per 100,000 Medicare population with increase in services of 242%. This showed a 3% decrease per 100,000 Medicare population, compared to the data from 2000 through 2013, even though services increased by 6% due to the increase in the number of Medicare recipients in the FFS beneficiary group. The overall increases in epidural and adhesiolysis procedures were 165% with a rate of 96% per 100,000 Medicare population with an average annual increase of 4.9%. Facet joint interventions and sacroiliac joint blocks increased at a rate of 313% per 100,000 population with an annual average increase of 10.7%. Disc procedures and other types of nerve blocks increased at a much lesser pace than epidural and adhesiolysis procedures or facet joint interventions with an increase of 54% per 100,000 Medicare population and annual increase of 3.1%. A decrease in utilization was noted in 5 of 14 years ranging from 1.2% to 3.8%. Limitations: The limitations of this updated utilization patterns of interventional techniques in managing chronic pain are multiple with lack of inclusion of participants from Medicare Advantage Plans, lack of complete and accurate data for statewide utilization, and potential errors in coding, billing, and documentation. Conclusion: This overall analysis of patterns of utilization in managing chronic pain with interventional techniques showed a continued and significant increase in FFS Medicare beneficiaries from 2000 to 2014 with an increase of 153% per 100,000 Medicare population and at a rate of 6.9% on average per year. However, there were decreases of 2.9% in 2007, 3.8% in 2010, and 1.3%, 3.4%, and 1.2% from 2012 to 2014. Key words: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks
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Turbeville, Sean, Kevin M. Francis, Ilan Behm, Gretchen R. Chiu, Herman Sanchez, Blake A. Morrison, and Jacob M. Rowe. "Prevalence and Incidence of Acute Myeloid Leukemia May be Higher Than Currently Accepted Estimates Among the ≥65 Year-Old Population in the United States." Blood 124, no. 21 (December 6, 2014): 958. http://dx.doi.org/10.1182/blood.v124.21.958.958.
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Abstract Introduction: Population-based cancer registries, such as the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) program and the North American Association of Central Cancer Registries (NAACCR) are the largest sources of information for cancer epidemiology and statistics. The most recent acute myeloid leukemia incidence estimate from SEER (2011) is 17.5 per 100,000 (N=7,245) among the US ≥65 year-old population; however, recent studies suggest these registries may underreport cancer rates due to reasons including sequencing of diagnoses and inpatient reporting requirements. For cancers such as myelodysplastic syndrome (MDS) and acute and chronic myeloid leukemia (AML & CML), this is concerning as they are more likely to occur after initial diagnosis of other cancers. A recent study independently calculated MDS, AML and CML cases from 2000-2005 using a Medicare claims-based algorithm and concluded that SEER and NAACCR failed to capture a substantial number of cases and the true incidence was 50-75% greater than reported (Cogle, et al., 2012). Updated AML epidemiology statistics outside of SEER and NAACCR have not been published. Objective: To employ a Medicare claims-based algorithm to estimate gender- and age-specific AML incidence and prevalence among the 2012 US Medicare fee-for-service (FFS) population. Methods: A retrospective analysis of claims using 2012 Centers for Medicare and Medicaid Services (CMS) data included an Institutional sample (100%) and random Non-Institutional Carrier samples (5%) which together represented the healthcare utilization of Medicare Part A & B (Medicare FFS) beneficiaries. AML diagnoses were identified using ICD-9 codes and AML treatments identified using HCPCS J Codes and ICD-9 infusion codes. Prevalent AML patients were defined as having ≥2 AML diagnoses associated with medical claims OR 1 AML medical claim and 1 AML treatment. A sub-population of all prevalent AML patients without historical AML diagnoses or treatments during the prior 2 years were identified as new (incident) AML patients.Analyses were computed by gender and two age-cohorts (<65 and ≥65 years old). Patients in the Institutional 100% dataset were considered census and no weighting was required but appropriate weights were used to project the 5% random carrier sample (<9% of AML patients) to the Medicare FFS population. Results: Of 34.2 million Medicare FFS beneficiaries, 15,976 had AML, a prevalence rate of 0.05% (Table). Most were ≥65 years old (N=11,936; 75%) and prevalence did not vary between age groups; however, women ≥65 years old had a significantly lower prevalence than men ≥65 years old (0.03% vs. 0.06%; z=31.2, p<.001) as men were nearly twice as likely to be diagnosed with AML (RR=1.86, 95% CI: 1.78, 1.95). There were no gender differences in incidence among younger patients (18.6 per 100,000 for men vs. 18.4 per 100,000 for women). A high proportion of AML patients were newly diagnosed (N=9,074; 57%). Conclusions : Our AML incidence estimate for the ≥65 year Medicare FFS cohort of 29.0 per 100,000 (N=7,582) is substantially higher than incidence estimate reported by SEER for this age group. As only 70-80% of the ≥65 year-old population is covered under Medicare FFS, the total number of ≥65 incident patients is likely higher than reported by SEER. Registries may be underreporting AML due to methodological differences. Furthermore, the 15,976 prevalent patients in Medicare FFS alone may be much higher than previously known. Claim-based algorithms may provide higher AML estimates than current SEER methodology. Further research should investigate claims data in the remaining ≥65 year-old population covered under Medicare Advantage and a younger, non-Medicare FFS population sample more representative of persons <65 years of age. Table One-year Prevalence and Incidence Rates of AML in the Medicare FFS Population, 2012 Population, N 1-year AML Incident per 100,000, n (%) 1-Year AML Prevalence, n (%) Overall 34,216,076 9,074 (26.5) 15,976 (0.05) <65 years 8,064,566 1,492 (18.5) 4,040 (0.05) ≥65 years 26,151,510 7,582 (29.0) 11,936 (0.05) Male 15,329,040 5,181 (33.8) 8,854 (0.06) Female 18,887,036 3,893 (20.6) 7,121 (0.04) Male, <65 years 4,137,155 770 (18.6) 2,061 (0.05) Male, ≥65 years 11,191,885 4,410 (39.4) 6,793 (0.06) Female, <65 years 3,927,411 722 (18.4) 1,978 (0.05) Female, ≥65 years 14,959,625 3,171 (21.2) 5,143 (0.03) Disclosures Turbeville: Sunesis Pharmaceuticals, Inc.: Employment. Morrison:Sunesis Pharmaceuticals, Inc.: Employment.
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Kent, Erin, Lisa M. Lines, Sarah Gaillot, Nicola C. Schussler, Michael Halpern, Michelle Mollica, Maria Rincon, and Ashley Wilder Smith. "Measuring experiences of patients with cancer with care: The SEER-CAHPS linked data resource." Journal of Clinical Oncology 35, no. 8_suppl (March 10, 2017): 238. http://dx.doi.org/10.1200/jco.2017.35.8_suppl.238.
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238 Background: Care experience ratings are recognized as measures of quality. We introduce a new resource, SEER-CAHPS, linking cancer registry data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program with Medicare claims and the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Methods: The SEER-CAHPS data resource includes registry data from 1973-2011 (diagnosis, incidence, mortality, and sociodemographic data), Medicare CAHPS survey data from 1998-2013 (sociodemographic, health status, and care experience ratings), and Medicare fee-for-service (FFS) claims data from 2002-2013. SEER-CAHPS includes global ratings of overall care, personal doctor, specialist, health plan, and prescription drug plan and composite ratings of doctor communication, care coordination, getting needed care, and getting care quickly. The data also contain optional survey weights to account for the Medicare CAHPS sampling design. Results: Currently, SEER-CAHPS includes 205,339 individuals with a history of cancer documented in SEER (FFS: 26,802 with a survey before cancer diagnosis, and 55,231 with a survey after cancer diagnosis; Medicare Advantage [MA]: 57,227 with a survey before cancer diagnosis and 71,436 with a survey after cancer diagnosis). The database also includes 724,965 MCAHPS respondents without cancer in SEER regions (FFS: 282,592; MA: 447,358). The data provide insights on topics including experiences of cancer patients in their last year of life; experiences of cancer survivors; experiences of dually eligible (Medicare-Medicaid) cancer patients; and the associations of guideline-concordant follow-up care with patient experiences among people with colorectal cancer. We will demonstrate project sample-size estimation and present instructions for submitting data access applications. Conclusions: SEER-CAHPS provides population-based, cancer-specific data on patient experiences and associations with both health outcomes and healthcare utilization.
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Reichard, Amanda, Elsa Haile, and Andrew Morris. "Characteristics of Medicare Beneficiaries With Intellectual or Developmental Disabilities." Intellectual and Developmental Disabilities 57, no. 5 (October 2019): 405–20. http://dx.doi.org/10.1352/1934-9556-57.5.405.
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Gaps in knowledge and systematic tracking of the prevalence of intellectual and developmental disabilities (IDD) and characteristics that may affect the health of this disability group limits our ability to address the health disparities they experience in comparison to people without disability. The purpose of this study is to begin to fill one relevant critical gap in knowledge: understanding the demographics and health outcomes of adults with IDD who receive services under Medicare Fee-for-Service (FFS), many of who are also eligible for Medicaid. Using 2016 Medicare administrative claims, we examined the prevalence and characteristics of five diagnosis groups of IDD, in those under 65 and those 65 and over, as well as their health outcomes. We found that the IDD Medicare FFS group had high prevalence rates for chronic physical and mental health conditions, overuse of emergency departments, and high rate of 30-day readmission. These findings highlight the need for evidence-based health care coordination, improved and increased public health interventions, and continued surveillance.
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Hall, Anne E. "Estimating Regression-Based Medical Care Expenditure Indexes for Medicare Advantage Enrollees." Forum for Health Economics and Policy 19, no. 2 (December 1, 2016): 261–97. http://dx.doi.org/10.1515/fhep-2015-0031.
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Abstract I construct a disease-based medical expenditure index for Medicare Advantage (private plan) enrollees using data from the Medicare Current Beneficiary Survey from 2001 to 2009. I create the indexes by modeling total health-care expenditure as a function of each respondent’s diagnoses. Total medical inflation for this population is found to be 5.7 percent annually. By comparison, medical inflation in the Medicare fee-for-service (FFS) population is 4.5 percent annually. The difference is partly due to differential reporting of drug and nondrug spending in the MCBS for FFS beneficiaries; once this is corrected for, inflation among FFS beneficiaries is 5.0 percent. The remaining difference results from drug spending increasingly more rapidly among Medicare Advantage enrollees. I show that the introduction of Part D accounts for much of, and possibly all the remaining gap in inflation.
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Manchikanti, Laxmaiah. "Trends of Expenditures and Utilization of Facet Joint Interventions in Fee-For-Service (FFS) Medicare Population from 2009-2018." Pain Physician 3S;23, no. 5;3S (May 14, 2020): S129—S147. http://dx.doi.org/10.36076/ppj.2020/23/s129.
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Background: The trends of the expenditures of facet joint interventions have not been specifically assessed in the fee-for-service (FFS) Medicare population since 2009 Objectives: The objective of this investigation is to assess trends of expenditures and utilization of facet joint interventions in FFS Medicare population from 2009 to 2018. Study Design: The study was designed to analyze trends of expenditures and utilization of facet joint interventions in FFS Medicare population from 2009-2018 in the United States. In this manuscript: • A patient was considered as undergoing facet joint interventions throughout the year. • A visit included all regions treated during the visit. • An episode was considered as one per region utilizing primary codes only. • Services or procedures were considered all procedures (multiple levels). Data for the analysis was obtained from the standard 5% national sample of the Centers for Medicare & Medicaid Services (CMS) physician outpatient billing claims for those enrolled in the FFS Medicare program from 2009 to 2018. All the expenditures were presented with allowed costs and also were inflation adjusted to 2018 US dollars. Results: This analysis showed expenditures increased by 79% from 2009 to 2018 in the form of total cost for facet joint interventions, at an annual rate of 6.7%. Cervical and lumbar radiofrequency neurotomy procedures increased 185% and 169%. However, inflation-adjusted expenditures with 2018 US dollars showed an overall increase of 53% with an annual increase of 4.9%. In addition, using inflation-adjusted expenditures per procedures increased, the overall 6% with an annual increase of 0.7%. Overall, per patient costs, with inflation adjustment, decreased from $1,925 to $1,785 with a decline of 7% and an annual decline of 0.8%. Allowed charges per visit also declined after inflation adjustment from $951.76 to $849.86 with an overall decline of 11% and an annual decline of 1.3%. Staged episodes of radiofrequency neurotomy were performed in 23.9% of patients and more than 2 episodes for radiofrequency neurotomy in 6.9%, in lumbar spine and 19.6% staged and 5.1% more than 2 episodes in cervical spine of patients in 2018. Limitations: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. Conclusions: Even after adjusting for inflation, there was a significant increase for the expenditures of facet joint interventions with an overall 53% increase. Costs per patient and cost per visit declined. Inflation-adjusted cost per year declined 7% overall and 0.8% annually from $1,925 to $1,785, and inflation-adjusted cost per visit also declined 11% annually and 1.3% per year from $952 in 2009 to $850 in 2018. Key words: Facet joint interventions, facet joint nerve blocks, facet joint neurolysis, facet joint injections, Medicare expenditures
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Kumar, Amit, Maricruz Rivera-Hernandez, Lin-Na Chou, Amol Karmarkar, Yong-Fang Kuo, and Kenneth J. Ottenbacher. "ROLE OF SOCIAL DETERMINANTS IN ENROLLMENT AND DISENROLLMENT IN MEDICARE INSURANCE PLANS IN OLDER MEXICAN AMERICANS." Innovation in Aging 3, Supplement_1 (November 2019): S563. http://dx.doi.org/10.1093/geroni/igz038.2081.
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Abstract Objective: The objective of this study is to examine the association between social-medical risk factor with disenrollment from Medicare Fee-for-Service (FFS) and enrollment in a Medicare Advantage (MA) plan in Older Mexican Americans. Methods: The sample included older adults participating in the Hispanic Established Populations for the Epidemiologic Study of the Elderly linked with Medicare data. We used logistic regression to estimate odds ratios (OR) for the association of each sociodemographic and clinical factor with insurance plan switching. Results: FFS enrollees were more likely to speak Spanish, less educated, lower income, disability, and be dual eligible compared to MA enrollees. At 2-year follow up, older adults with social support had higher odds of switching from FFS to MA after controlling for all covariates (OR; 1.73, 95% CI: 1.11-2.69). Conclusion: Having social support from family and the community was strongly associated with disenrollment from FFS and transition to an MA plan.
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Cohen, Kenneth, Omid Ameli, Christine E. Chaisson, Kierstin Catlett, Jonathan Chiang, Amy Kwong, Samira Kamrudin, and Boris Vabson. "Comparison of Care Quality Metrics in 2-Sided Risk Medicare Advantage vs Fee-for-Service Medicare Programs." JAMA Network Open 5, no. 12 (December 12, 2022): e2246064. http://dx.doi.org/10.1001/jamanetworkopen.2022.46064.
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ImportanceMedicare Advantage is associated with improved health outcomes, increased care efficiency, and lower out-of-pocket costs compared with fee-for-service (FFS) Medicare. When engaged in 2-sided risk arrangements, physicians are incented to offer high value for patients; however, no studies have explored the quality and efficiency outcomes in 2-sided risk Medicare Advantage models compared with FFS Medicare.ObjectiveTo compare quality and efficiency of care between physicians using a Medicare Advantage 2-sided risk model and FFS Medicare.Design, Setting, and ParticipantsThis retrospective cohort analysis with exact and propensity score–matched design used claims data from January 1, 2018, to December 31, 2019. Participants included beneficiaries enrolled in a Medicare Advantage 2-sided risk model (ie, physicians assumed the financial risk of total costs of care) and those in an FFS Medicare program in a 5% limited data set with part A and B coverage residing in 6 states (Arizona, California, Florida, Nevada, Texas, and Utah). Data were analyzed from February 1 to June 15, 2022.ExposuresMedicare Advantage 2-sided risk model seen in practices that are part of a nationwide health care delivery organization compared with traditional FFS Medicare.Main Outcomes and MeasuresComparative analysis of 8 quality and efficiency metrics in populations enrolled in a 2-sided risk-model Medicare Advantage program and 5% FFS Medicare.ResultsIn this analytic cohort of 316 312 individuals (158 156 in each group), 46.11% were men and 53.89% were women; 32.72% were aged 65-69 years, 29.44% were aged 70-74 years, 19.05% were aged 75-79 years, 10.84% were aged 80-85 years, and 7.95% were 85 years or older. The Medicare Advantage model was associated with care of higher quality and efficiency in all 8 metrics compared with the FFS model. This included lower odds of inpatient admission (−18%; odds ratio [OR], 0.82 [95% CI, 0.79-0.84]), inpatient admission through the emergency department (ED) (−6%; OR, 0.94 [95% CI, 0.91-0.97]), ED visits (−11%; OR, 0.89 [95% CI, 0.86-0.91]), avoidable ED visits (−14%; OR, 0.86 [95% CI, 0.82-0.89]), 30-day inpatient readmission (−9%; rate ratio, 0.91 [95% CI, 0.86-0.98]), admission for stroke or myocardial infarction (−10%; OR, 0.90 [95% CI, 0.83-0.98]), and hospitalization for chronic obstructive pulmonary disease or asthma exacerbation (−44%; OR, 0.56 [95% CI, 0.50-0.62]).Conclusions and RelevanceThe improvements observed in this study may be partly or fully attributed to the Medicare Advantage model. The Medicare Advantage risk adjustment system appears to be meeting its intended goal by aligning the capitation payments to the health care burden of the individual beneficiary and aggregate population served, thus providing revenue to develop infrastructure that supports improvements in quality and efficiency for the patients enrolled in Medicare Advantage models with 2-sided risk.
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Hayford, Tamara Beth, and Alice Levy Burns. "Medicare Advantage Enrollment and Beneficiary Risk Scores: Difference-in-Differences Analyses Show Increases for All Enrollees On Account of Market-Wide Changes." INQUIRY: The Journal of Health Care Organization, Provision, and Financing 55 (January 1, 2018): 004695801878864. http://dx.doi.org/10.1177/0046958018788640.
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Medicare adjusts payments to Medicare Advantage (MA) insurers using risk scores that summarize the relationship between fee-for-service (FFS) Medicare spending and beneficiaries’ demographic characteristics and documented health conditions. Research shows that MA insurers have increasingly documented conditions more thoroughly than traditional Medicare—resulting in higher payments to insurers—but little is known about what factors contribute to diverging risk scores. We apportion that divergence between market-wide increases and increases that vary with length of MA enrollment. We also examine whether effects vary across plan types and whether the enrollment duration effect is contingent upon remaining with the same insurer. Using Medicare administrative data from 2008 to 2013, we employ a difference-in-differences model to compare the growth in risk scores of Medicare beneficiaries who switch from FFS to MA to that of beneficiaries who remain in FFS. We find that the effect of MA enrollment on risk scores increased from 5% in 2009 to 8% in 2012 and that continuous enrollment in MA was associated with an additional 1.2% increase per year, regardless of continuous enrollment with an insurer. Thus, even among those who switched to MA in 2009, enrollment duration comprised less than one-third of the coding intensity difference in 2012. We also find that risk scores grew faster in areas with greater MA penetration and among Health Maintenance Organization enrollees. Overall, our findings suggest that market-wide factors contributed most to the increasing divergence between FFS and MA risk scores.
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Beveridge, Roy A., Sean M. Mendes, Arial Caplan, Teresa L. Rogstad, Vanessa Olson, Meredith C. Williams, Jacquelyn M. McRae, and Stefan Vargas. "Mortality Differences Between Traditional Medicare and Medicare Advantage: A Risk-Adjusted Assessment Using Claims Data." INQUIRY: The Journal of Health Care Organization, Provision, and Financing 54 (January 1, 2017): 004695801770910. http://dx.doi.org/10.1177/0046958017709103.
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Medicare Advantage (MA) has grown rapidly since the Affordable Care Act; nearly one-third of Medicare beneficiaries now choose MA. An assessment of the comparative value of the 2 options is confounded by an apparent selection bias favoring MA, as reflected in mortality differences. Previous assessments have been hampered by lack of access to claims diagnosis data for the MA population. An indirect comparison of mortality as an outcome variable was conducted by modeling mortality on a traditional fee-for-service (FFS) Medicare data set, applying the model to an MA data set, and then evaluating the ratio of actual-to-predicted mortality in the MA data set. The mortality model adjusted for clinical conditions and demographic factors. Model development considered the effect of potentially greater coding intensity in the MA population. Further analysis calculated ratios for subpopulations. Predicted, risk-adjusted mortality was lower in the MA population than in FFS Medicare. However, the ratio of actual-to-predicted mortality (0.80) suggested that the individuals in the MA data set were less likely to die than would be predicted had those individuals been enrolled in FFS Medicare. Differences between actual and predicted mortality were particularly pronounced in low income (dual eligibility), nonwhite race, high morbidity, and Health Maintenance Organization (HMO) subgroups. After controlling for baseline clinical risk as represented by claims diagnosis data, mortality differences favoring MA over FFS Medicare persisted, particularly in vulnerable subgroups and HMO plans. These findings suggest that differences in morbidity do not fully explain differences in mortality between the 2 programs.
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Lissenden, Brett. "The Relationship between Health Insurance and Mortality for Cancer Patients: Medicare Advantage versus Fee-For-Service Medicare." Journal of Economics and Public Finance 5, no. 3 (July 17, 2019): p293. http://dx.doi.org/10.22158/jepf.v5n3p293.
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Compared to traditional fee-for-service Medicare (FFS), private Medicare Advantage (MA) plans offer additional health insurance coverage but restrict access to medical providers. This study measured how MA enrollment, relative to FFS enrollment, may influence mortality for cancer patients. The study used linked data from the Surveillance, Epidemiology, and End Results Program and Medicare administration (SEER-Medicare) including diagnoses between 2006 and 2011 at all four major cancer sites (breast, colorectal, lung, prostate). The key innovation of the study was to measure and account for variation in prescription drug coverage between MA and FFS cancer patients. Among cancer patients with Part D coverage, MA enrollment was associated with modestly increased mortality. The estimated relationships were statistically distinguishable from zero for lung cancer and (in most model specifications) colorectal cancer. The findings are consistent with a hypothesis that restricted provider access may reduce health outcomes for patients who already have a serious illness.
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Chen, Elizabeth Edmiston, and Edward Alan Miller. "A Longitudinal Analysis of Site of Death: The Effects of Continuous Enrollment in Medicare Advantage Versus Conventional Medicare." Research on Aging 39, no. 8 (May 4, 2016): 960–86. http://dx.doi.org/10.1177/0164027516645843.
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This study assessed the odds of dying in hospital associated with enrollment in Medicare Advantage (M-A) versus conventional Medicare Fee-for-Service (M-FFS). Data were derived from the 2008 and 2010 waves of the Health and Retirement Study ( n = 1,030). The sample consisted of elderly Medicare beneficiaries who died in 2008–2010 (34% died in hospital, and 66% died at home, in long-term senior care, a hospice facility, or other setting). Logistic regression estimated the odds of dying in hospital for those continuously enrolled in M-A from 2008 until death compared to those continuously enrolled in M-FFS and those switching between the two plans. Results indicate that decedents continuously enrolled in M-A had 43% lower odds of dying in hospital compared to those continuously enrolled in M-FFS. Financial incentives in M-A contracts may reduce the odds of dying in hospital.
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Belanger, Emma, Nicole Rosendaal, Xiao (Joyce) Wang, Joan Teno, Pedro Gozalo, David Dosa, and Kali Thomas. "PROFILE OF DECEDENTS FROM A NATIONAL COHORT OF ASSISTED LIVING RESIDENTS." Innovation in Aging 6, Supplement_1 (November 1, 2022): 189–90. http://dx.doi.org/10.1093/geroni/igac059.757.
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Abstract An increasing number of older adults reside in assisted living (AL) toward the end of life, and it remains unclear if this trend represents an additional place of care and end-of-life transition before eventual nursing home admission. Our objective was to examine the characteristics and healthcare utilization of AL residents who died during a two-year follow-up. We conducted a prospective cohort study of Medicare beneficiaries residing in large AL communities (25+ beds) in January 2017, and followed them until the end of 2018 using a variety of administrative healthcare claims data. The national population of Medicare beneficiaries in AL included 273,722 fee-for-service (FFS) beneficiaries, and 143,258 Medicare Advantage beneficiaries. From 2017 to the end of 2018, 23.7% of residents died. Of the 66,605 FFS Medicare beneficiaries who died during follow-up, 77.0% were 85 years old or older, 72.2% were diagnosed with Alzheimer’s disease and related dementia (ADRD) and 80.8% were diagnosed with heart failure or chronic obstructive pulmonary disease. Most FFS decedents (97.3%) resided in AL during their last 12 months of life, with 23.0% leaving AL before the last month of life. Half of FFS decedents died in AL, while another 24.1% died in a nursing home. AL communities represent an increasingly common place of end-of-life care for dying Medicare beneficiaries. These findings point to the need for state and federal policies to protect a growing population of frail and vulnerable AL residents.
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Chakravarthy, Rohini, Gail R. Wilensky, and Brian J. Miller. "Implementing Competitive Bidding in the Medicare Program: An Expressway to Solvency." INQUIRY: The Journal of Health Care Organization, Provision, and Financing 59 (January 2022): 004695802211417. http://dx.doi.org/10.1177/00469580221141776.
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The Medicare program faces increasing budgetary pressures, with recent estimates suggesting that the Medicare Hospital Insurance Trust will be insolvent as soon as 2028. Simultaneously, the Medicare Advantage (MA) program, a managed competition model, continues to grow its market penetration as beneficiaries increasingly choose private plans over traditional fee for service (FFS) Medicare. With the relative cost of the 2 forms of Medicare a subject of debate, policy experts have proposed a variety of policy options to address the program’s budgetary pressures and place it on a firmer fiscal footing. This paper explores the implementation of one of these proposals in greater detail: fully transitioning the entire Medicare program to a competitive bidding model in order to reduce overall program costs and improve price competition. Current MA plan bidding methodology is explored, followed by a description of prior proposed competitive bidding models. Implementation challenges are addressed, along with specific policy considerations to protect beneficiaries who wish to remain in FFS Medicare.
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Manchikanti, Laxmaiah. "Utilization and Expenditures of Vertebral Augmentation Continue to Decline: An Analysis in Fee-For-Service (FFS) Recipients from 2009 to 2018." Pain Physician 24, no. 6 (September 17, 2021): 401–15. http://dx.doi.org/10.36076/ppj.2021.24.401.
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BACKGROUND: Despite the high prevalence of vertebral compression fractures (VCFs) associated with refractory pain, deformity, or progressive neurological symptoms, minimally invasive vertebral augmentation procedures, including vertebroplasty and kyphoplasty, have been declining in their relative utilization, along with expenditures. OBJECTIVES: This investigation was undertaken to assess utilization and expenditures for vertebral augmentation procedures, including vertebroplasty and kyphoplasty, in the fee-for-service (FFS) Medicare population from 2009 to 2018. STUDY DESIGN: The present study was designed to assess utilization and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving vertebral augmentation over the course of the year. • An episode was considered as one treatment per region per day utilizing primary codes only. • Services or procedures were considered to be procedures including multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted for inflation to 2018 US dollars. RESULTS: In 2009, there were 76,860 episodes of vertebral augmentation with a rate of 168 per 100,000 Medicare population, which declined to 58,760, or 99 per 100,000 population for a total decline of 41%, or an annual rate of decline of 5.7% per 100,000 Medicare population. Vertebroplasty interventions declined more dramatically than kyphoplasty from 2009. Total episodes of vertebroplasty were 27,380 with an annual rate of 60 per 100,000 Medicare population, decreasing to 9,240, or 16 per 100,000 Medicare population, a 66% decline in episodes and a 74% decline in overall rate with an annual decline of 11.4% and 13.9%. In contrast, kyphoplasty interventions were 49,480, for a rate per 100,000 population of 108 in 2009 compared to 49,520 in 2018 with a rate of 83, for a decrease of 23% and 2.9% annual decrease. Evaluation of expenditures showed a net decrease of $30,102,809, or 8%, from $378,758,311 in 2009 to $348,655,502 in 2018. However, inflation-adjusted expenditures decreased overall by 21% and 3% annually from $443,147,324 in 2009 to $345,655,502 in 2018. In addition, inflation-adjusted total expenditures per 100,000 Medicare population decreased from $967,549 to $584,992, for an overall decrease of 40%, or an annual decrease of 5%. Per patient expenditures decreased 2% overall with 0% decrease per year. LIMITATIONS: Vertebral augmentation procedures were assessed only in the FFS Medicare service population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. CONCLUSIONS: This study shows a significant decline in relative utilization patterns of vertebroplasty and kyphoplasty procedures, along with reductions in overall expenditures. The inflation-adjusted total expenditures of kyphoplasty and vertebroplasty decreased 21% with an annual decline of 3%. The inflation-adjusted expenditures per 100,000 of Medicare population decreased 40% overall and 5% per year. In addition, vertebroplasty has seen substantial declines in utilization and expenditure patterns compared to kyphoplasty procedures, which showed trends of decline. KEY WORDS: Osteoporosis, osteoporotic compression fracture, vertebroplasty, kyphoplasty, vertebral augmentation, expenditures, inflation-adjusted, utilization
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Manchikanti, Laxmaiah. "Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population." Pain Physician 2;23, no. 4;2 (April 14, 2020): E133—E149. http://dx.doi.org/10.36076/ppj.2020/23/e133.
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Background: Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. Objectives: The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. Study Design: The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States. Methods: Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. Results: Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. Limitations: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. Conclusions: Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. Key words: Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis
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Manchikanti, Laxmaiah. "Percutaneous Adhesiolysis Procedures in the Medicare Population: Analysis of Utilization and Growth Patterns from 2000 to 2011." Pain Physician 2;17, no. 2;3 (March 14, 2014): E129—E139. http://dx.doi.org/10.36076/ppj.2014/17/e129.
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Background: Multiple reviews have shown that interventional techniques for chronic pain have increased dramatically over the years. Of these interventional techniques, both sacroiliac joint injections and facet joint interventions showed explosive growth, followed by epidural procedures. Percutaneous adhesiolysis procedures have not been assessed for their utilization patterns separately from epidural injections. Study Design: An analysis of the utilization patterns of percutaneous adhesiolysis procedures in managing chronic low back pain in the Medicare population from 2000 to 2011. Objective: To assess the utilization and growth patterns of percutaneous adhesiolysis in managing chronic low back pain. Methods: The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master of Fee-For-Service (FFS) Data from 2000 to 2011. Results: Percutaneous adhesiolysis procedures increased 47% with an annual growth rate of 3.6% in the FFS Medicare population from 2000 to 2011. These growth rates are significantly lower than the growth rates for sacroiliac joint injections (331%), facet joint interventions (308%), and epidural injections (130%), but substantially lower than lumbar transforaminal injections (665%) and lumbar facet joint neurolysis (544%). Limitations: Study limitations include lack of inclusion of Medicare Advantage patients. In addition, the statewide data is based on claims which may include the contiguous or other states. Conclusion: Percutaneous adhesiolysis utilization increased moderately in Medicare beneficiaries from 2000 to 2011. Overall, there was an increase of 47% in the utilization of adhesiolysis procedures per 100,000 Medicare beneficiaries, with an annual geometric average increase of 3.6%. Key words: Interventional techniques, chronic spinal pain, epidural steroid injections, percutaneous adhesiolysis, post surgery syndrome, spinal stenosis
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Essien, Utibe R., Yuanyuan Tang, Jose F. Figueroa, Terrence Michael A. Litam, Fengming Tang, Philip G. Jones, Ravi Patel, et al. "Diabetes Care Among Older Adults Enrolled in Medicare Advantage Versus Traditional Medicare Fee-For-Service Plans: The Diabetes Collaborative Registry." Diabetes Care 45, no. 7 (July 6, 2022): 1549–57. http://dx.doi.org/10.2337/dc21-1178.
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OBJECTIVE Medicare Advantage (MA), Medicare’s managed care program, is quickly expanding, yet little is known about diabetes care quality delivered under MA compared with traditional fee-for-service (FFS) Medicare. RESEARCH DESIGN AND METHODS This was a retrospective cohort study of Medicare beneficiaries ≥65 years old enrolled in the Diabetes Collaborative Registry from 2014 to 2019 with type 2 diabetes treated with one or more antihyperglycemic therapies. Quality measures, cardiometabolic risk factor control, and antihyperglycemic prescription patterns were compared between Medicare plan groups, adjusted for sociodemographic and clinical factors. RESULTS Among 345,911 Medicare beneficiaries, 229,598 (66%) were enrolled in FFS and 116,313 (34%) in MA plans (for ≥1 month). MA beneficiaries were more likely to receive ACE inhibitors/angiotensin receptor blockers for coronary artery disease, tobacco cessation counseling, and screening for retinopathy, foot care, and kidney disease (adjusted P ≤ 0.001 for all). MA beneficiaries had modestly but significantly higher systolic blood pressure (+0.2 mmHg), LDL cholesterol (+2.6 mg/dL), and HbA1c (+0.1%) (adjusted P < 0.01 for all). MA beneficiaries were independently less likely to receive glucagon-like peptide 1 receptor agonists (6.9% vs. 9.0%; adjusted odds ratio 0.80, 95% CI 0.77–0.84) and sodium–glucose cotransporter 2 inhibitors (5.4% vs. 6.7%; adjusted odds ratio 0.91, 95% CI 0.87–0.95). When integrating Centers for Medicare and Medicaid Services-linked data from 2014 to 2017 and more recent unlinked data from the Diabetes Collaborative Registry through 2019 (total N = 411,465), these therapeutic differences persisted, including among subgroups with established cardiovascular and kidney disease. CONCLUSIONS While MA plans enable greater access to preventive care, this may not translate to improved intermediate health outcomes. MA beneficiaries are also less likely to receive newer antihyperglycemic therapies with proven outcome benefits in high-risk individuals. Long-term health outcomes under various Medicare plans requires surveillance.
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Lodise, Thomas P., Michael Nowak, and Mauricio Rodriguez. "The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community." Antibiotics 11, no. 5 (April 26, 2022): 578. http://dx.doi.org/10.3390/antibiotics11050578.
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Introduction: Scant data are available on the 30-day financial burden associated with incident complicated urinary tract infections (cUTIs) in a cohort of predominately elderly patients. This study sought to examine total and cUTI-related 30-day Medicare spending (MS), a proxy for healthcare costs, among Medicare fee-for-service (FFS) beneficiaries who resided in the community with newly diagnosed cUTIs. Methods: A retrospective multicenter cohort study of adult beneficiaries in the Medicare FFS database with a cUTI between 2017 and 2018 was performed. Patients were included if they were enrolled in Medicare FFS and Medicare Part D from 2016 to 2019, had a cUTI first diagnosis in 2017–2018, no evidence of any UTI diagnoses in 2016, and residence in the community between 2016 and 2018. Results: During the study period, 723,324 cases occurred in Medicare beneficiaries who met the study criteria. Overall and cUTI-related 30-day MS were $7.6 and $4.5 billion, respectively. The average overall and cUTI-related 30-day MS per beneficiary were $10,527 and $6181, respectively. The major driver of cUTI-related 30-day MS was acute care hospitalizations ($3.2 billion) and the average overall and cUTI-related 30-day MS per hospitalizations were $16,431 and $15,438, respectively. Conclusion: Overall 30-day MS for Medicare FSS patients who resided in the community with incident cUTIs was substantial, with cUTI-related MS accounting for 59%. As the major driver of cUTI-related 30-day MS was acute care hospitalizations, healthcare systems should develop well-defined criteria for hospital admissions that aim to avert hospitalizations in clinically stable patients and expedite the transition of patients to the outpatient setting to complete their care.
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Lodise, Thomas P., Michael Nowak, and Mauricio Rodriguez. "The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community." Antibiotics 11, no. 5 (April 26, 2022): 578. http://dx.doi.org/10.3390/antibiotics11050578.
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Introduction: Scant data are available on the 30-day financial burden associated with incident complicated urinary tract infections (cUTIs) in a cohort of predominately elderly patients. This study sought to examine total and cUTI-related 30-day Medicare spending (MS), a proxy for healthcare costs, among Medicare fee-for-service (FFS) beneficiaries who resided in the community with newly diagnosed cUTIs. Methods: A retrospective multicenter cohort study of adult beneficiaries in the Medicare FFS database with a cUTI between 2017 and 2018 was performed. Patients were included if they were enrolled in Medicare FFS and Medicare Part D from 2016 to 2019, had a cUTI first diagnosis in 2017–2018, no evidence of any UTI diagnoses in 2016, and residence in the community between 2016 and 2018. Results: During the study period, 723,324 cases occurred in Medicare beneficiaries who met the study criteria. Overall and cUTI-related 30-day MS were $7.6 and $4.5 billion, respectively. The average overall and cUTI-related 30-day MS per beneficiary were $10,527 and $6181, respectively. The major driver of cUTI-related 30-day MS was acute care hospitalizations ($3.2 billion) and the average overall and cUTI-related 30-day MS per hospitalizations were $16,431 and $15,438, respectively. Conclusion: Overall 30-day MS for Medicare FSS patients who resided in the community with incident cUTIs was substantial, with cUTI-related MS accounting for 59%. As the major driver of cUTI-related 30-day MS was acute care hospitalizations, healthcare systems should develop well-defined criteria for hospital admissions that aim to avert hospitalizations in clinically stable patients and expedite the transition of patients to the outpatient setting to complete their care.
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Plotzke, Michael, Betty Fout, and Thomas Christian. "Impacts of COVID-19 on the Utilization of the Medicare Hospice Benefit." Innovation in Aging 5, Supplement_1 (December 1, 2021): 63. http://dx.doi.org/10.1093/geroni/igab046.241.
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Abstract The Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE) has had a substantial impact on the provision and utilization of healthcare services. Given the high mortality rate associated with COVID-19 amongst older adults, COVID-19 is likely to have a profound impact on all hospice users due to disruptions in providing services. Our work describes how Medicare beneficiaries have utilized the Medicare Hospice Benefit (MHB) during the PHE and how that compares to utilization of the MHB prior to the PHE. We conducted a retrospective analysis of 100% Part A and Part B Fee-for-Service (FFS) Medicare claims from January 1, 2019 – December 31, 2020. We identified approximately 42.3 million unique Medicare FFS beneficiaries from January 2019 through December 2020. Of these, 1.6 million (3.8%) had at least one hospice claim and 1.7 million (4.0%) had at least one Medicare Part A or Part B claim with a COVID-19 diagnosis during the same time period. The rate of COVID-19 amongst FFS Medicare patients who utilized hospice was 8.3%. Average per-beneficiary per-month hospice visits fell by 28.2% for aides and 15.4% for nurses from December 2019 (7.1 aide visits, 6.5 skilled nursing visits) through December 2020 (5.1 aide visits, 5.5 skilled nursing visits). CMS should continue to monitor the prevalence of COVID-19 amongst hospice users and measures of hospice utilization amongst all hospice users in order to better understand how the PHE impacts the provision of the MHB and ensure beneficiaries continue to have access to needed services.
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Virnig, Beth A., Nancy A. Persily, Robert O. Morgan, and Carolee A. DeVito. "Do Medicare HMOs and Medicare FFS Differ in Their Use of the Medicare Hospice Benefit?" Hospice Journal 14, no. 1 (March 1999): 1–12. http://dx.doi.org/10.1080/0742-969x.1999.11882910.
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Daddato, Andrea E., Edward A. Miller, Pamela Nadash, Denise Tyler, and Rebecca S. Boxer. "READMISSION RISK BY INSURANCE TYPE FOR PATIENTS WITH HEART FAILURE IN SKILLED NURSING FACILITIES." Innovation in Aging 3, Supplement_1 (November 2019): S645. http://dx.doi.org/10.1093/geroni/igz038.2395.
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Abstract Heart failure (HF) is a leading cause of potentially preventable hospital readmissions for Medicare beneficiaries from skilled nursing facilities (SNFs). This research seeks to determine if a HF patient’s insurance type (Medicare Fee-for-Service (FFS) vs. Medicare Advantage (MA)) influences their risk for readmission within 30 days of hospital discharge to a SNF. MA beneficiaries receive benefits through managed care plans with restricted networks, but typically expanded benefits. This research is particularly timely in light of CMS’ new penalties under the Protecting Access to Medicare Act (PAMA) directed at SNFs for 30-day rehospitalizations. Outcomes data on readmissions from a randomized controlled trial of HF Disease Management in SNFs conducted from 2014-2017 were used to evaluate the risk of readmission. Patients with HF receiving SNF care were enrolled and followed for 30 days from SNF admission. Patients were recruited from 29 primarily for-profit (93%) SNFs that contracted with an average of 4.07 (±5.48) MA plans. Of the 340 study participants followed, 62% had FFS Medicare coverage (n=212) and 38% had MA (n=128). In total, 23% (n=79) of patients experienced at least one readmission within 30 days of hospital discharge. FFS patients had a higher risk of rehospitalization within 30 days of hospital discharge than MA patients (25% vs. 20%), but the association between insurance type and rehospitalization was not statistically significant (p-value=0.177). Findings suggest that insurance type may be an important risk factor for rehospitalizations for patients with HF from SNF; however, a larger sample will need to confirm this relationship.
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Pelech, Daria M. "Prices for Physicians’ Services in Medicare Advantage and Commercial Plans." Medical Care Research and Review 77, no. 3 (June 25, 2018): 236–48. http://dx.doi.org/10.1177/1077558718780604.
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The prices that insurers pay physicians ultimately affect beneficiaries’ health insurance premiums. Using 2014 claims data from three major insurers, we analyzed the prices insurers paid in their Medicare Advantage (MA) and commercial plans for 20 physician services, in and out of network, and compared those prices with estimated amounts that Medicare’s fee-for-service (FFS) program would pay for the same service. MA prices paid by those insurers were close to Medicare FFS prices, varied minimally, and were similar in and out of network. In contrast, commercial prices paid by the same insurers were substantially higher than FFS, varied widely, and were up to three times higher out of network than in network. Those results suggest that insurers can use statutory limits on out-of-network charges in MA to negotiate lower in-network prices in those plans. In contrast, without those limits on out-of-network prices, in-network prices in commercial plans are much higher.
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Schmeida, Mary, and Ronald A. Savrin. "Heart Failure Rehospitalization of the Medicare FFS Patient." Professional Case Management 17, no. 4 (2012): 155–61. http://dx.doi.org/10.1097/ncm.0b013e31824c5fca.
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&NA;. "Heart Failure Rehospitalization of the Medicare FFS Patient." Professional Case Management 17, no. 4 (2012): 162–63. http://dx.doi.org/10.1097/ncm.0b013e31825d7183.
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Thomas, Christian A., and Jeffrey C. Ward. "The Oncology Care Model: A Critique." American Society of Clinical Oncology Educational Book, no. 36 (May 2016): e109-e114. http://dx.doi.org/10.1200/edbk_156883.
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Rapidly increasing national health care expenditures are a major area of concern as threats to the integrity of the health care system. Significant increases in the cost of care for patients with cancer are driven by numerous factors, most importantly the cost of hospital care and escalating pharmaceutical costs. The current fee-for-service system (FFS) has been identified as a potential driver of the increasing cost of care, and multiple stakeholders are interested in replacing FFS with a system that improves the quality of care while at the same time reducing cost. Several models have been piloted, including a Center for Medicare & Medicaid Innovation (CMMI)–sponsored medical home model (COME HOME) for patients with solid tumors that was able to generate savings by integrating a phone triage system, pathways, and seamless patient care 7 days a week to reduce overall cost of care, mostly by decreasing patient admissions to hospitals and referrals to emergency departments. CMMI is now launching a new pilot model, the Oncology Care Model (OCM), which differs from COME HOME in several important ways. It does not abolish FFS but provides an additional payment in 6-month increments for each patient on active cancer treatment. It also allows practices to participate in savings if they can decrease the overall cost of care, to include all chemotherapy and supportive care drugs, and fulfill certain quality metrics. A critical discussion of the proposed model, which is scheduled to start in 2016, will be provided at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting with practicing oncologists and a Centers for Medicare & Medicaid Services (CMS) representative.
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Rincon, Maria Andrea, Erin Kent, Lisa M. Lines, Sarah Gaillot, Nicola C. Schussler, Michael T. Halpern, Michelle Mollica, and Ashley Wilder Smith. "Measuring cancer care experiences: Introducing SEER-CAHPS." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): 6595. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.6595.
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6595 Background: Care experience ratings are recognized as measures of healthcare quality. Here we introduce a new, public data resource, SEER-CAHPS, which links cancer registry data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program with Medicare claims and the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey. Methods: The SEER-CAHPS resource includes cancer registry data from 1973-2011 (diagnosis, incidence, mortality, and sociodemographic data), Medicare CAHPS survey data from 1998-2013 (sociodemographic, health status, and care experience ratings), and Medicare fee-for-service (FFS) claims data from 2002-2013. The survey includes global ratings of overall care, personal doctor, specialist, health plan, and prescription drug plans, and composite ratings of doctor communication, care coordination, getting needed care, and getting care quickly. Data also contain survey weights to account for the Medicare CAHPS sampling design. Cross-sectional and longitudinal analyses are possible. Results: Currently, SEER-CAHPS includes 205,339 individuals with a history of cancer documented in SEER (FFS: 26,802 with a survey before cancer diagnosis, and 55,231 with a survey after cancer diagnosis; Medicare Advantage [MA]: 57,227 with a survey before cancer diagnosis and 71,436 with a survey after cancer diagnosis). The data resource also includes 724,965 MCAHPS respondents without cancer in SEER regions (FFS: 282,592; MA: 447,358). The data provide insights on topics including experiences of cancer patients in their last year of life; experiences of cancer survivors; and the associations of guideline-concordant follow-up care with patient experiences among cancer survivors. We will demonstrate project sample-size estimation and present instructions for submitting data access applications. Conclusions: SEER-CAHPS, a new, publicly available resource, provides population-based, cancer-specific data on patient experiences, health outcomes and healthcare utilization.
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Daddato, Andrea E., Cynthia Drake, Edward A. Miller, Pamela Nadash, Denise Tyler, and Rebecca S. Boxer. "MANAGING MANAGED CARE: PERSPECTIVES FROM KEY STAKEHOLDERS IN SKILLED NURSING FACILITIES." Innovation in Aging 3, Supplement_1 (November 2019): S498—S499. http://dx.doi.org/10.1093/geroni/igz038.1846.
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Abstract In recent years, Medicare Advantage (MA) plan enrollment has increased, a trend that is expected to continue. Many skilled nursing facilities (SNFs) rely on MA managed care insurer referrals to maintain their census in a market with high competition for post-acute care patients. This study used semi-structured interviews to describe the relationship between MA plans and SNFs from the perspective of key decision-makers in SNFs. Twenty-three interviews were conducted with key stakeholders from 11 Denver Metropolitan area SNFs. A combined purposive-snowball sampling approach was used to identify and recruit select staff from the participating facilities. Interviews focused on the relationship between MA plans and SNFs, including mechanisms of control, power dynamics, and preferences for MA versus Fee-for-Service (FFS) Medicare patients. Key findings included: 1) challenges SNF staff had navigating MA plans’ case management processes, a key mechanism used by MA plans to influence the behavior of SNF decision-makers; 2) MA plans exercising power over beneficiaries’ length of stay, potentially leading to early discharge and heightened risk for rehospitalization; 3) SNF preference for admitting Medicare FFS over MA patients due to higher rates of Medicare FFS reimbursement and greater control over patient care. SNFs are increasingly reliant on MA plans for patient referrals and revenue. The themes suggest that this growing reliance may place SNFs at odds with MA plans on how best to manage overall patient care. It is therefore important that future research investigate how MA plans’ influence over care affects patient outcomes in SNFs and other post-acute settings.
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Muldoon, L. Daniel, Jared Hirsch, Gabriela Dieguez, and Paul Cockrum. "Treatment patterns, survival rate, and Parts A and B costs by line of therapy for FDA-approved/NCCN Category 1 treatments for patients with metastatic pancreatic cancer." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): e18357-e18357. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.e18357.
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e18357 Background: There is currently limited real-world evidence regarding metastatic pancreatic cancer (m-PANC) FDA-approved/NCCN Category 1 treatment patterns, resource utilization, and survival rate. We analyzed these outcomes in the Medicare fee-for-service (FFS) population by chemotherapy regimen and line of therapy (LOT). Methods: We identified patients with m-PANC using ICD-9/10 diagnosis codes in the 2013-2017 Medicare 100% Limited Data Set claims, which include all Medicare paid FFS claims, except professional services, for 45 million Medicare FFS beneficiaries. We studied mean costs and survival rate by regimen and LOT. Patients in our study had two or more claims with a pancreatic cancer (PANC) diagnosis more than 30 days apart and one or more claims with a secondary malignancy (metastasis) diagnosis on or after the first PANC diagnosis date. We defined index date as the earliest metastasis diagnosis date. We excluded patients with pre-index non-PANC malignancies and those without six months pre-index and three months (or until death, if earlier) post-index Medicare FFS enrollment. LOTs were assigned based on therapies used. LOTs ended the day before a new chemotherapy began, 28 days after the last chemotherapy (if no new chemotherapy), or upon death. Results: Gemcitabine monotherapy, gemcitabine/nab-paclitaxel, and FOLFIRINOX were most commonly used as first line (1L) therapy (91%, 80%, and 80%, respectively). Mean total Parts A and B (excluding professional) cost for 1L gemcitabine monotherapy was lower than gemcitabine/nab-paclitaxel or FOLFIRINOX ($14,601, $32,447, and $33,628, respectively), but FOLFIRINOX had a higher 90-day survival rate (86%) than gemcitabine-based regimens (76-79%). Liposomal irinotecan was most commonly used in second and third lines (2L, 3L) (54% and 28%, respectively); 97% of these patients previously received gemcitabine, consistent with approved labeling. Despite disease progression, 2L and 3L liposomal irinotecan had similar costs ($36,350 and $35,010, respectively) to 1L gemcitabine/nab-paclitaxel and FOLFIRINOX. As expected, 2L and 3L liposomal irinotecan 90-day survival rates were lower (68% and 73%, respectively). Conclusions: Mean total Parts A and B (excluding professional) costs for common 1L-3L regimens varied from less than $15,000 to greater than $30,000. 90-day survival rates for common regimens varied between 1L (86%) to 3L (68%).
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Muldoon, L. Daniel, Jared Hirsch, Gabriela Dieguez, and Paul Cockrum. "Monthly parts a and b costs by service and line of therapy for FDA-approved/NCCN category 1 treatments for patients with metastatic pancreatic cancer." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): e18365-e18365. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.e18365.
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e18365 Background: Real-world evidence is lacking regarding costs for FDA-approved/NCCN Category 1 treatments for patients with metastatic pancreatic cancer (m-PANC). We analyzed costs by service in the Medicare fee-for-service (FFS) population by chemotherapy regimen and line of therapy (LOT). Methods: Patients with m-PANC were identified using ICD-9/10 diagnosis codes in the 2013-2017 Medicare 100% Limited Data Set claims, which include all Medicare paid FFS claims, except professional services, for 45 million Medicare FFS beneficiaries. We studied mean monthly costs by service category, regimen, and LOT. Patients in our study had two or more claims with a pancreatic cancer (PANC) diagnosis more than 30 days apart and one or more claims with a secondary malignancy (metastasis) diagnosis on or after the first PANC diagnosis date. We defined index date as the earliest metastasis diagnosis date. We excluded patients with pre-index non-PANC malignancies and those without 6 months pre-index and 3 months (or until death, if earlier) post-index Medicare FFS enrollment. LOTs were assigned based on therapies used. LOTs ended the day before a new chemotherapy began, 28 days after the last chemotherapy (if no new chemotherapy), or upon death. We analyzed the FDA-approved/NCCN Category 1 treatments used most commonly in first line (1L): gemcitabine monotherapy, gemcitabine/nab-paclitaxel, and FOLFIRINOX; and in second or third line (2L, 3L): liposomal irinotecan. Results: Mean monthly Parts A and B (excluding professional) costs for 1L gemcitabine monotherapy were lower than gemcitabine/nab-paclitaxel or FOLFIRINOX ($5,267, $9,116, and $8,046, respectively). Part B drug costs other than chemotherapy were higher for FOLFIRINOX than gemcitabine/nab-paclitaxel or gemcitabine monotherapy ($3,881, $1,155, and $827, respectively). Inpatient services were similar across 1L regimens ($2,721-$3,303). Despite disease progression, mean monthly 2L and 3L costs for liposomal irinotecan were $10,809 and $12,225, respectively. Part B drugs other than chemotherapy ($2,133-$2,509) were comparable to 1L regimens, but inpatient services ($2,306-$2,405) were lower. Conclusions: The mean monthly cost increased by LOT for m-PANC FDA-approved/NCCN category 1 regimens. Interestingly, Part A inpatient costs decreased in 2L and 3L, while Part B drug costs other than chemotherapy were comparable.
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Hornbrook, Mark C., Jennifer Malin, Jane C. Weeks, Solomon B. Makgoeng, Nancy L. Keating, and Arnold L. Potosky. "Did Changes in Drug Reimbursement After the Medicare Modernization Act Affect Chemotherapy Prescribing?" Journal of Clinical Oncology 32, no. 36 (December 20, 2014): 4042–49. http://dx.doi.org/10.1200/jco.2013.52.6780.
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Purpose The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) decreased fee-for-service (FFS) payments for outpatient chemotherapy. We assessed how this policy affected chemotherapy in FFS settings versus in integrated health networks (IHNs). Patients and Methods We examined 5,831 chemotherapy regimens for 3,613 patients from 2003 to 2006 with colorectal cancer (CRC) or lung cancers in the Cancer Care Outcomes Research Surveillance Consortium. Patients were from four geographically defined regions, seven large health maintenance organizations, and 15 Veterans Affairs Medical Centers. The outcome of interest was receipt of chemotherapy that included at least one drug for which reimbursement declined after the MMA. Results The odds of receiving an MMA-affected drug were lower in the post-MMA era: the odds ratio (OR) was 0.73 (95% CI, 0.59 to 0.89). Important differences across cancers were detected: for CRC, the OR was 0.65 (95% CI, 0.46 to 0.92); for non–small-cell lung cancer (NSCLC), the OR was 1.60 (95% CI, 1.09 to 2.35); and for small-cell lung cancer, the OR was 0.63 (95% CI, 0.34 to 1.16). After the MMA, FFS patients were less likely to receive MMA-affected drugs: OR, 0.73 (95% CI, 0.59 to 0.89). No pre- versus post-MMA difference in the use of MMA-affected drugs was detected among IHN patients: OR, 1.01 (95% CI, 0.66 to 1.56). Patients with CRC were less likely to receive an MMA-affected drug in both FFS and IHN settings in the post- versus pre-MMA era, whereas patients with NSCLC were the opposite: OR, 1.60 (95% CI, 1.09 to 2.35) for FFS and 6.33 (95% CI, 2.09 to 19.11) for IHNs post- versus pre-MMA. Conclusion Changes in reimbursement after the passage of MMA appear to have had less of an impact on prescribing patterns in FFS settings than the introduction of new drugs and clinical evidence as well as other factors driving adoption of new practice patterns.
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Landrum, Mary Beth, Nancy L. Keating, Elizabeth B. Lamont, Samuel R. Bozeman, Steven H. Krasnow, Lawrence Shulman, Jennifer R. Brown, Craig C. Earle, Michael Rabin, and Barbara J. McNeil. "Survival of Older Patients With Cancer in the Veterans Health Administration Versus Fee-for-Service Medicare." Journal of Clinical Oncology 30, no. 10 (April 1, 2012): 1072–79. http://dx.doi.org/10.1200/jco.2011.35.6758.
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Purpose The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. Patients and Methods We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. Results VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non–small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large–B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. Conclusion The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.
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Seal, Brian S., Meghan Mooradian, Candice Yong, Amy L. Schroeder, Dana Macher, Biruk Bekele, and Allison Petrilla. "Concordance of provider treatment patterns with NCCN oncology treatment guidelines (NCCN Guidelines) for metastatic non-small cell lung cancer (mNSCLC)." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): e21574-e21574. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.e21574.
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e21574 Background: mNSCLC clinical treatment guidelines are rapidly evolving, however, their influence on prescriber use of anti-cancer treatment regimens is not known. This retrospective study evaluated whether US patients with mNSCLC received first line (1LOT), second (2LOT), or third (3LOT) line treatment regimens that were concordant with NCCN Category 1-2A recommendations. Methods: mNSCLC patients who initiated treatment between 2014-2017 were identified using medical and pharmacy claims from the 100% Medicare Fee-for-Service (FFS) Part A/B/D sample and multi-payer Inovalon MORE2 Registry. Claims-based algorithms identified mNSCLC and LOT following diagnosis; patients with other primary cancers or < 6 months follow-up were excluded. Treatment regimens were compared to active NCCN Guidelines at time of treatment to determine if regimen was concordant with Category 1-2A recommendations. Genetic mutation/biomarker status was not available. Results: 6,523 patients with mNSCLC met criteria for analysis (FFS/Medicare Advantage:78.6%; commercial:14.0%, managed Medicaid:7.4%; mean age:69.3 [SD:9.2]). For 1LOT, 81% received platinum-based doublet regimens; most common monotherapy included erlotinib, nivolumab, and pembrolizumab; 18% of 1LOT patients received maintenance therapy. For 2LOT, approximately one-third received nivolumab monotherapy, one-third received platinum-based doublets, and remainder received other regimens. Most common 3LOT included monotherapy nivolumab, pemetrexed, paclitaxel, and docetaxel. NCCN Guidelines concordance varied: 1LOT (90.5%), 2LOT (58.5%), 3LOT (71.9%). Non-concordant regimens included nivolumab as 1LOT and early adoption of platinum agent+(pemetrexed or paclitaxel) in 2LOT, and chemotherapy as 2LOT in anaplastic lymphoma kinase rearrangement-positive or epidermal growth factor receptor mutation-positive disease. Conclusions: In Medicare and non-Medicare patients with mNSCLC, 1LOT closely followed NCCN Guidelines. Most variability was observed in 2LOT where 58.5% regimens were concordant with Category 1-2A recommendations. Non-concordance may be driven by lack of effective second-line regimens and early adoption of innovative therapies.
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Gladieux, Jennifer E. "Medicare+Choice Appeal Procedures: Reconciling Due Process Rights and Cost Containment." American Journal of Law & Medicine 25, no. 1 (1999): 61–116. http://dx.doi.org/10.1017/s0098858800009497.
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By signing the Balanced Budget Act of 1997 (BBA) on August 5, 1997, President Clinton made the most significant changes to Medicare, since its inception in 1965, by adopting market-driven reforms in an effort to balance the federal budget. One of the most significant Medicare reforms in the BBA was the creation of the Medicare+Choice program that provides Medicare beneficiaries access to a wide array of private health plan choices as well as traditional fee-for-service (FFS) Medicare. In addition, Medicare+Choice enables Medicare to further utilize delivery innovations, including preferred provider organizations (PPOs), openended health maintenance organizations (HMOs), point-of-service plans, provider sponsored organizations (PSOs), integrated delivery systems (IDSs) and primary care case management, that have helped the private sector contain costs and expand health care delivery options.
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Tomai, Lisa. "Personalized Preventive Care for Patients at Risk of Heart Attack or Stroke." Community Medicine and Public Health Care 8, no. 1 (August 30, 2021): 1–4. http://dx.doi.org/10.24966/cmph-1978/100080.
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This study examines the impact of MDVIP enrollment on incidence of acute myocardial infarction (AMI) or stroke/transient ischemic attack (TIA) for an at-risk population of Medicare fee-for-service (FFS) beneficiaries.
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Mobley, Lee R., Tzy-Mey Kuo, Mei Zhou, Yamisha Rutherford, Seth Meador, and Julia Koschinsky. "What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?" Journal of Racial and Ethnic Health Disparities 6, no. 2 (September 19, 2018): 273–91. http://dx.doi.org/10.1007/s40615-018-0522-x.
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Fout, Betty, Michael Plotzke, and Thomas Christian. "Using Predicted Therapy Visits in the Medicare Home Health Prospective Payment System." Home Health Care Management & Practice 29, no. 2 (November 22, 2016): 81–90. http://dx.doi.org/10.1177/1084822316678384.
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A criticism of Medicare’s home health prospective payment system is its partial reliance on cost-based reimbursement of therapy services provided by home health agencies (HHAs) to Medicare fee-for-service (FFS) beneficiaries, potentially overincentivizing the provision of therapy services. Using Medicare FFS home health claims and assessment data, we estimated a model to predict therapy use as a proxy for clinical need and replace actual therapy use with the prediction in the home health payment system. We estimated a $1.178 billion (95% confidence interval, $1.171-$1.184) decrease in home health payments relative to levels under the current system. The majority of the decrease was due to the model predicting fewer high therapy episodes than actually occurred. It may therefore be more appropriate to predict both therapy and nontherapy use, requiring an overhaul of the current system.
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Yang, Quanhe, Xin Tong, Mary G. George, Anping Chang, and Robert K. Merritt. "COVID-19 and Risk of Acute Ischemic Stroke Among Medicare Beneficiaries Aged 65 Years or Older." Neurology 98, no. 8 (February 3, 2022): e778-e789. http://dx.doi.org/10.1212/wnl.0000000000013184.
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Background and ObjectivesFindings of association between coronavirus disease 2019 (COVID-19) and stroke remain inconsistent, ranging from significant association to absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The current study examined the association between COVID-19 and risk of acute ischemic stroke (AIS).MethodsWe included 37,379 Medicare fee-for-service (FFS) beneficiaries aged ≥65 years diagnosed with COVID-19 from April 1, 2020, through February 28, 2021, and AIS hospitalization from January 1, 2019, through February 28, 2021. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incidence rate ratios (IRRs) by comparing incidence of AIS in risk periods (0–3, 4–7, 8–14, 15–28 days after diagnosis of COVID-19) vs control periods.ResultsAmong 37,379 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.4 (interquartile range 73.5–87.1) years and 56.7% were women. When AIS at day of exposure (day = 0) was included in the risk periods, IRRs at 0–3, 4–7, 8–14, and 15–28 days following COVID-19 diagnosis were 10.3 (95% confidence interval 9.86–10.8), 1.61 (1.44–1.80), 1.44 (1.32–1.57), and 1.09 (1.02–1.18); when AIS at day 0 was excluded in the risk periods, the corresponding IRRs were 1.77 (1.57–2.01) (day 1–3), 1.60 (1.43–1.79), 1.43 (1.31–1.56), and 1.09 (1.01–1.17), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities.DiscussionRisk of AIS among Medicare FFS beneficiaries was 10 times (day 0 cases in the risk period) as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65–74 years and those without prior history of stroke.Classification of EvidenceThis study provides Class IV evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with increased risk of AIS in the first 3 days after diagnosis in Medicare FFS beneficiaries ≥65 years of age.
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Moss, Haley A., Laura J. Havrilesky, Frances F. Wang, Mihaela V. Georgieva, Laura H. Hendrix, and Michaela A. Dinan. "Simulated Costs of the ASCO Patient-Centered Oncology Payment Model in Medicare Beneficiaries With Newly Diagnosed Advanced Ovarian Cancer." Journal of Oncology Practice 15, no. 12 (December 2019): e1018-e1027. http://dx.doi.org/10.1200/jop.19.00026.
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PURPOSE: Efforts to curb the rising costs of cancer care while improving quality include alternative payment models (APMs), which offer incentives to reduce avoidable spending and provide high-quality and cost-efficient care. The impact of proposed APMs has not been quantified in real-world practice. In this study, we evaluated ASCO’s Patient-Centered Oncology Payment (PCOP) model in existing fee-for-service (FFS) Medicare beneficiaries to understand the magnitude of potential cost savings. MATERIALS AND METHODS: SEER-Medicare data were used to identify women with advanced ovarian cancer diagnosed between 2000 and 2012 who either (1) underwent primary debulking surgery followed by chemotherapy or (2) received neoadjuvant chemotherapy followed by surgery. Medicare payments in each cohort were used to compare FFS and PCOP and to estimate the potential for cost savings across health care services received, including outpatient emergency department visits, hospitalizations, and imaging. RESULTS: Three thousand seven hundred seventy-seven primary debulking surgery and 866 neoadjuvant chemotherapy patients were included in the study, with mean total costs of $75,433 and $95,138 in 2016 US$, respectively Most costs were related to chemotherapy or hospitalization. Additional PCOP-related payments would be offset if hospitalizations could be reduced by 11.6% or imaging claims by 88%. CONCLUSION: APMs have the potential to reduce costs of current FFS reimbursement via either a large reduction in imaging or a modest reduction in hospitalizations during treatment of ovarian cancer. PCOP is a reasonable payment structure for oncologists if the additional payments can provide the necessary resources to invest in improved coordination of care.
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Dahal, Roshani, Stephanie Jarosek, and Beth Virnig. "EMERGENCY DEPARTMENT USE FOR DENTAL PROBLEMS AMONG MEDICARE FEE-FOR-SERVICE OLDER ADULTS IN THE U.S. (2016 TO 2020)." Innovation in Aging 6, Supplement_1 (November 1, 2022): 797. http://dx.doi.org/10.1093/geroni/igac059.2877.
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Abstract Medicare Fee-for-Service (FFS) does not include dental coverage for older adults (65 years of age and older) but does cover emergency visits for dental problems. This study leverages Medicare Limited Data Sets to examine the use of emergency department (ED) for preventable, non-traumatic dental conditions (NTDCs) among Medicare FFS older adults from 2016 to 2020. Nationally, ~43.6 million beneficiaries sought care at the ED (average: ~8.7 million annually). Among these, ~550,000 ED visits (1.27%; ~110K annually) were for NTDCs as one of the diagnosis codes and ~200,000 ED visits (0.45%; ~40K annually) were for NTDCs as a primary diagnosis. Approximately, 5–6% of older adults with ED-NTDCs have multiple visits (94% with 1 ED-NTDC visit annually). Rates were similar in most years; however, ED use was lower in 2020 (COVID-19 pandemic). The most common diagnosis reasons include periapical abscess (tooth infection), sialadenitis, dental caries, jaw pain, and lesions of oral mucosa. Younger (65 to 74 years) and Black older adults were more likely to have primary ED-NTDC visits. Medicare paid ~$190 million for ED-NTDC visits (average: $38 million annually). Costs vary by inpatient (9%) and outpatient visits (91%). For ED-NTDCs as a primary diagnosis, the average Medicare payments for outpatient and inpatient visits were approximately $330 and $8,100, respectively. ED use for NTDCs indicates inappropriate use of valuable resources, because care provided in the EDs is incomplete (e.g., antibiotics, pain medication). Lack of follow-up with a dentist likely results in return ED visits, thus increasing costs to beneficiaries and public programs.
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Manchikanti,, Laxmaiah. "Reversal of Growth of Utilization of Interventional Techniques in Managing Chronic Pain in Medicare Population Post Affordable Care Act." Pain Physician 7, no. 20;7 (November 12, 2017): 551–67. http://dx.doi.org/10.36076/ppj/2017/7.551.
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Background: Over the past 2 decades, the increase in the utilization of interventional techniques has been a cause for concern. Despite multiple regulations to reduce utilization of interventional techniques, growth patterns continued through 2009. A declining trend was observed in a previous evaluation; however, a comparative analysis of utilization patterns of interventional techniques has not been performed showing utilization before and after the enactment of the Affordable Care Act (ACA). Objectives: Our aim is to assess patterns of utilization and variables of interventional techniques in chronic pain management in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-ACA. Study Design: Utilization patterns and variables of interventional techniques were assessed from 2000 to 2009 and from 2009 to 2016 in the FFS Medicare population of the United States in managing chronic pain. Methods: The master data from the Centers for Medicare & Medicaid Services (CMS) physician/ supplier procedure summary from 2000 to 2016 was utilized to assess overall utilization and comparative utilization at various time periods. Results: The analysis of Medicare data from 2000 to 2016 showed an overall decrease in utilization of interventional techniques 0.6% per year from 2009 to 2016, whereas from 2000 to 2009, there was an increase of 11.8% per year per 100,000 individuals of the Medicare population. In addition, the United States experienced an increase of 0.7% per year of population growth, 3.2% of those 65 years or older and a 3% annual increase in Medicare participation from 2009 to 2016. Further analysis also showed a 1.7% annual decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000 individuals of the Medicare population, with a 2.2% decrease for disc procedures and other types of nerve blocks, whereas there was an increase of 0.8% annually for facet joint interventions and sacroiliac joint blocks from 2009 to 2016. Epidural and adhesiolysis procedures showed an 8.9% annual increase, facet joint interventions and sacroiliac joint blocks showed a 17.6% increase, and disc procedures and other types of nerve blocks showed a 7.2% increase annually per 100,000 individuals of the Medicare population from 2000 to 2009. Limitations: The limitations of this assessment include lack of analysis of individual procedures. Additional limitations include lack of inclusion of patients from Medicare Advantage plans and lack of complete and accurate data for statewide utilization. Conclusion: From 2009 to 2016, interventional techniques decreased at an annual rate of 0.6% with an overall decrease of 3.9%, compared to an overall increase of 173.6% from 2000 to 2009 with an annual increase of 11.8%. An additional analysis of data with individual procedures is essential to gain further insights into utilization patterns. Key words: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks
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Terveen, Daniel, John Berdahl, Mukesh Dhariwal, and Qian Meng. "Real-World Cataract Surgery Complications and Secondary Interventions Incidence Rates: An Analysis of US Medicare Claims Database." Journal of Ophthalmology 2022 (April 6, 2022): 1–7. http://dx.doi.org/10.1155/2022/8653476.
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Purpose. To characterize cataract patients and postoperative outcomes in the Medicare fee-for-service (FFS) population. Design. A retrospective observational cohort study. Methods. Medicare fee-for-service (A&B) databases were queried from October 2015 to December 2017. Patients with procedural claims using CPT codes (66982 or 66984) and with 1–12 months of postcataract follow-up data were included in the analysis. Results. 133,896 records of 82,246 CMS FFS claims were included in the analysis. The average patient age was 73.8, and 58.2% were females. The cataract surgery setting was ASC (71.3%) followed by HOPD (27.6%). The median time between first and second surgery was 15 days. The most common comorbidities included diabetes (28.6%), glaucoma (22.1%), and macular degeneration (21.7%). Posterior capsule rupture occurred in 0.2% of cases. The <6 months cumulative incidence of most common secondary surgical interventions was 4.7%, 0.2%, and 0.2% for Nd:YAG capsulotomy, IOL exchange, and IOL repositioning, respectively. Discussion. Real-world complication rates of cataract surgery may help reduce postcataract complications and procedure burden. Synopsis for Table of Contents. This study focused on a sample of the US Medicare beneficiary cataract population and describes its demographic characteristics and reports the cumulative incidence of common postcataract surgery complications and secondary surgical interventions (SSI).
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Cetin, Karynsa, Shuling Li, Anne Hudson Blaes, Scott Stryker, Alexander Liede, and Thomas J. Arneson. "Prevalence of nonmetastatic (M0) prostate cancer (PC) patients on continuous androgen deprivation therapy (ADT) in the United States." Journal of Clinical Oncology 30, no. 15_suppl (May 20, 2012): 4659. http://dx.doi.org/10.1200/jco.2012.30.15_suppl.4659.
Full textAbstract:
4659 Background: ADT is the cornerstone treatment of metastatic PC, but the nature and extent of its use in the M0 setting is less well-described. We sought to estimate the current prevalence of M0 PC patients actively receiving continuous ADT (≥6 months) in the US. Methods: Two point-prevalent cohorts on 12/31/2008 with continuous insurance coverage in 2008 were assembled: men aged 45-64 years (yrs) enrolled in commercial health plans (MarketScan) and men aged ≥67 yrs enrolled in fee-for-service (FFS) Medicare (Medicare 5% sample). Among those with evidence of PC and no evidence of metastases, we selected men who had continuous exposure to gonadotropin-releasing hormone agonists during at least the last 6 months of 2008 or received bilateral orchiectomy prior to 7/1/2008. The number of prevalent ADT users was extrapolated to the entire national commercially insured population aged 45-64 yrs and to the entire Medicare FFS population aged ≥65 yrs using person-level weights. Applying age-specific prevalence estimates to the US Census population on 12/31/2008, we estimated the number of prevalent ADT users in the total US male population aged ≥45 yrs. Results: An estimated 11,935 (95% confidence interval [CI]: 11,310-12,561) commercially insured men aged 45-64 yrs and 115,468 (95% CI: 112,304-118,633) Medicare FFS men aged ≥65 yrs were M0 PC patients actively receiving continuous ADT for ≥6 months on 12/31/2008. Extrapolated to the total US male population aged ≥45 yrs, this estimate was 188,916 (95% CI: 184,104-193,727). Age-specific prevalence (N [95% CI]) on 12/31/2008 is presented in the table. Conclusions: We projected nearly 190,000 US men with M0 PC were actively receiving continuous ADT for ≥6 months at the end of 2008, and the vast majority (91%) of these men were aged ≥65 yrs. Additional work will address timing of initiation, duration, and other aspects of ADT use in this large population of M0 PC patients. [Table: see text]