Analysis of Prescriptions Dispensed After Death and Associated Medicare Spending Following Reimbursement Policy Changes in Medicare.
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ABSTRACT:
SUBMITTER: Vouri SM
PROVIDER: S-EPMC10214031 | biostudies-literature | 2023 May
REPOSITORIES: biostudies-literature
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Analysis of Prescriptions Dispensed After Death and Associated Medicare Spending Following Reimbursement Policy Changes in Medicare.
Vouri Scott M SM Morris Earl J EJ Zhang Yongkang Y
JAMA network open 20230501 5
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Project description:ObjectivesTo compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost-sharing.Data sourcesTwenty percent random sample of fee-for-service (FFS) Medicare claims, 2000-2012.Study designUsing recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference-in-differences analysis to estimate the effects of eliminating cost-sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA.FindingsModel-based algorithms have higher sensitivity (0.53-0.99) than expert-based algorithms (0.35-0.39), but lower specificity (0.43-0.65 vs 0.79-0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24-93/10 000) and the 2011 cost-sharing change (range: 1.1-34/10 000). Difference-in-difference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm.ConclusionsScreening colonoscopy rates increased after eliminating cost-sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.
| S-EPMC6606542 | biostudies-literature
Project description:ObjectiveTo assess the impact of Florida's 3-day opioid prescription supply law, effective July 2018, on opioids dispensed for acute pain patients.MethodsPharmacy claims from a health plan serving a large Florida employer from January 2015 through March 2019 were analyzed. We used an interrupted time series study design accounting for autocorrelation of trends before and after policy change. Acute pain patients met inclusion criteria if they had not received any opioid containing medications in the past 180 days. Patients could contribute to additional new use time if subsequent opioid claims occurred ≥180 days since the previous claim. Outcomes included mean number of units dispensed of the initial opioid prescription, mean morphine milligram equivalents (MMEs) per day of initial prescription by month, and mean total MMEs per initial prescription by month.ResultsA total of 8,375 enrollees had 10,583 unique opioid starts in the given timeframe. Following the policy, there was an immediate significant decrease in the units dispensed per prescription of 4.9 (95% confidence interval [CI] -8.95, -.82 units). Additionally, there was a significant immediate reduction in total MMEs dispensed per prescription of 25.6 (95% CI -44.76, -6.44 MMEs).ConclusionsAmong a group of privately-insured plan enrollees in Florida, and as a result of the law, there were significant decreases in the number of units dispensed, and total MMEs of opioid prescriptions. The immediate reduction in new opioid utilization following policy implementation suggests effective policy; however, impacts on chronic pain patients were not assessed.
| S-EPMC8346917 | biostudies-literature
Project description:ImportanceIn 2016, the Centers for Medicare and Medicaid Services cut payments for robotic prostatectomy performed for Medicare beneficiaries. Although regulations mandate that billing for urethral suspension is only acceptable for preexisting urinary incontinence, reductions in reimbursement may incentivize billing for the use of this procedure in other scenarios.ObjectiveTo assess trends and geographic variations in payments for urethral suspension with robotic prostatectomy in the context of Medicare payment policy.Design, setting, and participantsThis US population-based retrospective cohort study analyzed data from the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental Database for men with employer-based insurance (primary commercial or Medicare supplemental coverage) who underwent robotic prostatectomy (Current Procedural Terminology [CPT] code 55866) between 2009 and 2019.ExposuresTime period and metropolitan statistical area of patient residence.Main outcomes and measuresPayment for urethral suspension (CPT code 51990) with robotic prostatectomy.ResultsWe identified 87 774 men with prostate cancer treated with robotic prostatectomy; 3352 (3.8%) had undergone urethral suspension. The mean (SD) patient age was 59.7 (6.5) years; 16 870 patients (19.2%) had Medicare supplemental coverage. From 2015 to 2016, median payments for robotic prostatectomy changed by -$358 (-17.0%) for Medicare beneficiaries vs -$9 (0%) for commercially insured patients. With urethral suspension vs without, median (IQR) episode payments for robotic prostatectomy were higher for commercially insured men ($3678 [$3090-$4503] vs $3322 [$2601-$4306]) and Medicare beneficiaries ($2927 [$2450-$3909] vs $2379 [$2014-$3512]). Compared with men treated between 2013 and 2015, those treated between 2016 and 2017 were twice as likely to undergo urethral suspension (8.5% vs 4.1%; odds ratio, 2.17 [95% CI, 1.96-2.38]). The proportion of patients who underwent urethral suspension was stable for 2018 to 2019 and 2016 to 2017 (8.5% vs 9.0%; odds ratio, 1.06 [95% CI, 0.96-1.18]). From 2015 to 2019, the proportion of patients who underwent urethral suspension was highest in Charleston, South Carolina (92.0%), Knoxville, Tennessee (66.0%), and Columbia, South Carolina (58.0%). These regions neighbored high-volume areas without patients who underwent prostatectomy with urethral suspension (eg, 146 patients in Greenville, South Carolina, and 173 in Nashville, Tennessee).Conclusions and relevanceIn this study, urethral suspension was associated with increased costs for patients with both commercial insurance and Medicare. Patients treated between 2016 and 2017 were more likely than those treated between 2013 and 2015 to undergo this procedure. Geographic variation in use exceeded what was expected for the preexisting condition for which billing is permitted for Medicare beneficiaries. Policy statements from professional societies highlighting appropriate billing for urethral suspension may have tempered, but not reversed, the broad adoption of this procedure.
| S-EPMC9533184 | biostudies-literature
Project description: Not available
| S-EPMC2709674 | biostudies-literature
Project description:ObjectiveTo determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012-2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File).MethodsIndividual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services.ResultsWe identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (-6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially.ConclusionsThe Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.
| S-EPMC7605505 | biostudies-literature
Project description:BackgroundSignificant variation in regional utilization of home health (HH) services has been documented. Under Medicare's Home Health Interim and Prospective Payment Systems, reimbursement policies designed to curb expenditure growth and reduce regional variation were instituted.ObjectiveTo examine the impact of Medicare reimbursement policy on regional variation in HH care utilization and type of HH services delivered.Research designWe postulated that the reimbursement changes would reduce regional variation in HH services and that HH agencies would respond by reducing less skilled HH aide visits disproportionately compared with physical therapy or nursing visits. An interrupted time-series analysis was conducted to examine regional variation in the month-to-month probability of HH selection, and the number of and type of visits among HH users.SubjectsA 100 percent sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected.ResultsBefore the reimbursement changes, there was great variability in the probability of HH selection and the number of HH visits provided across regions. In response to the reimbursement changes, though there was little change in the variation of probability of HH utilization, there were marked reductions in the number and variation of HH visits, with greatest reductions in regions with highest baseline utilization. HH aide visits were the source of the baseline variation and accounted for the majority of the reductions in utilization after implementation.ConclusionsThe HH interim and prospective payment policies were effective in reducing regional variation in HH utilization.
| S-EPMC2739026 | biostudies-literature
Project description:ContextThe Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs.ObjectiveTo estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid.DesignQuasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix.SettingTen physician groups from across the United States.Patients and participantsThe intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid.Main outcome measureAnnual spending per Medicare fee-for-service beneficiary.ResultsAnnual savings per beneficiary were modest overall (adjusted mean $114, 95% CI, $12-$216). Annual savings were significant in dually eligible beneficiaries (adjusted mean $532, 95% CI, $277-$786), but were not significant among nondually eligible beneficiaries (adjusted mean $59, 95% CI, $166 in savings to $47 in additional spending). The adjusted mean spending reductions were concentrated in acute care (overall, $118, 95% CI, $65-$170; dually eligible: $381, 95% CI, $247-$515; nondually eligible: $85, 95% CI, $32-$138). There was significant variation in savings across practice groups, ranging from an overall mean per-capita annual saving of $866 (95% CI, $815-$918) to an increase in expenditures of $749 (95% CI, $698-$799). Thirty-day medical readmissions decreased overall (-0.67%, 95% CI, -1.11% to -0.23%) and in the dually eligible (-1.07%, 95% CI, -1.73% to -0.41%), while surgical readmissions decreased only for the dually eligible (-2.21%, 95% CI, -3.07% to -1.34%). Estimates were sensitive to the risk-adjustment method.ConclusionsSubstantial PGPD savings achieved by some participating institutions were offset by a lack of saving at other participating institutions. Most of the savings were concentrated among dually eligible beneficiaries.
| S-EPMC3484377 | biostudies-literature
Project description:BackgroundOver 6 million Americans have Alzheimer's Disease or Related Dementia (ADRD) but whether spikes in spending surrounding a new diagnosis reflect pre-diagnosis morbidity, diagnostic testing, or treatments for comorbidities is unknown.MethodsWe used the 1998-2018 Health and Retirement Study and linked Medicare claims from older (≥65) adults to assess incremental quarterly spending changes just before versus just after a clinical diagnosis (diagnosis cohort, n = 2779) and, for comparative purposes, for a cohort screened as impaired based on the validated Telephone Interview for Cognitive Status (TICS) (impairment cohort, n = 2318). Models were adjusted for sociodemographic and health characteristics. Spending patterns were examined separately by sex, race, education, dual eligibility, and geography.ResultsAmong the diagnosis cohort, mean (SD) overall spending was $4773 ($9774) per quarter - 43% of which was spending on hospital care ($2048). In adjusted analyses, spending increased by $8400 (p < 0.001), or 156%, from $5394 in the quarter prior to $13,794 in the quarter including the diagnosis. Among the cohort in which impairment was incidentally detected using the TICS, adjusted spending did not change from just before to after detection of impairment, from $2986 before and $2962 after detection (p = 0.90). Incremental spending changes did not differ by sex, race, education, dual eligibility, or geography.ConclusionLarge, transient spending increases accompany an ADRD diagnosis that may not be attributed to impairment or changes in functional status due to dementia. Further study may help reveal how treatment for comorbidities is associated with the clinical diagnosis of dementia, with potential implications for Medicare spending.
| S-EPMC9790668 | biostudies-literature
Project description:This paper investigates how office-based physicians respond to Medicare reimbursement changes. Using variation from an Affordable Care Act policy that increased reimbursements for office-based care in four states, we use a triple difference analysis, comparing physicians with higher and lower reimbursement changes in treated states to similar physicians in untreated states. We find two mechanisms through which physicians respond. First, the reimbursement change affected integration-physicians with larger increases in office-based reimbursement were less likely to vertically integrate with hospitals and more likely to continue providing office-based care than physicians with smaller reimbursement increases. Second, we find some evidence that physicians who continued practicing in an office setting increased the volume of services provided.
| S-EPMC10843488 | biostudies-literature
Project description:ImportanceThe measured severity of illness of hospitalized Medicare beneficiaries has increased. Whether this change is associated with payment reforms, concentrated among hospitalizations with principal diagnoses targeted by payment reform, and reflective of true increases in severity of illness is unknown.ObjectivesTo assess whether the expansion of secondary diagnosis codes in January 2011 and the incentive payments for health information technology under the US Health Information Technology for Economic and Clinical Health Act were associated with changes in measured severity of illness and whether those changes are reflective of true increases in underlying patient severity.Design, setting, and participantsThis cohort study of Medicare fee-for-service beneficiary discharges (N = 47 951 443) between January 1, 2008, and August 31, 2015, used a regression-discontinuity design to evaluate changes in measured severity of illness after the expansion of secondary diagnoses. Discharge-level linear regression model with hospital fixed effects was used to evaluate changes in measured severity of illness after hospitals' receipt of incentives for health information technology. The change in predictive accuracy of measured severity of illness on 30-day readmissions after the implementation of both policies was evaluated. Data analysis was performed from November 1, 2018, to March 5, 2019.Main outcomes and measuresThe primary outcome was patients' measured severity of illness determined by the number of condition categories from secondary discharge diagnosis codes. Measured severity of illness for diagnoses commonly targeted by Medicare policies and untargeted diagnoses was assessed.ResultsIn total, 47 951 443 discharges at 2850 hospitals were included. In 2008, these beneficiaries included 3 882 672 women (58.5%) with a mean (SD) age of 78.5 (8.4) years. In 2014, the discharges included 3 377 137 women (57.8%) with the mean (SD) age of 78.4 (8.7) years. The Centers for Medicare & Medicaid Services expansion of secondary diagnoses was associated with a 0.348 (95% CI, 0.328-0.367; P < .001) change in condition categories for all diagnoses, 0.445 (95% CI, 0.419-0.470; P < .001) for targeted diagnoses, and 0.321 (95% CI, 0.302-0.341; P < .001) for untargeted diagnoses. Health information technology incentives were associated with a 0.013 (95% CI, 0.004-0.022; P = .005) change in condition categories for all diagnoses, 0.195 (95% CI, 0.184-0.207; P < .001) for targeted diagnoses, and -0.016 (95% CI, -0.025 to -0.007; P < .001) for untargeted diagnoses. Minimal improvements in predictive accuracy were observed.Conclusions and relevanceChanges in Centers for Medicare & Medicaid Services policies appear to be associated with increases in measured severity of illness; these increases do not appear to reflect substantive changes in true patient severity.
| S-EPMC6503517 | biostudies-literature