Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.
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ABSTRACT: Objective
To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries.Data sources
The 2005-2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule.Study design
Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we calculated the Medicare payment-service volume elasticities for noncomplex (CPT 66984) and complex (CPT 66982) cataract surgeries.Data extraction
Service volume data were extracted from the CMS Part B National Summary and Carrier Summary Data Files. Payment data were extracted from the Medicare Physician Fee Schedule.Principal findings
From 2005 to 2009, the proportion of total cataract services billed as complex increased from 3.2 to 6.7 percent. Every 1 percent decrease in Medicare payment was associated with a nonsignificant change in noncomplex cataract service volume (elasticity = 0.15, 95 percent CI [-0.09, 0.38]) but a statistically significant increase in complex cataract service volume (elasticity = -1.12, 95 percent CI [-1.60, -0.63]).Conclusions
Reduced Medicare payment was associated with a significant increase in complex cataract service volume but not in noncomplex cataract service volume, resulting in a shift toward performing a greater proportion of complex cataract surgeries from 2005 to 2009.
SUBMITTER: Gong D
PROVIDER: S-EPMC5517675 | biostudies-literature | 2017 Aug
REPOSITORIES: biostudies-literature
Publications
Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.
Gong Dan D Jun Lin L Tsai James C JC
Health services research 20160728 4
<h4>Objective</h4>To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries.<h4>Data sources</h4>The 2005-2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule.<h4>Study design</h4>Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we cal ...[more]
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Project description:ImportanceLow-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.ObjectiveTo describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.Design, setting, and participantsObservational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.ExposuresReceipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.Main outcomes and measuresCascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.ResultsAmong 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.Conclusions and relevanceCare cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
| S-EPMC6547245 | biostudies-literature
Project description:BackgroundOlder patients who undergo mitral valve surgery (MVS) have high 1-year survival rates, but little is known about the experience of survivors. Our objective was to determine trends in 1-year hospital readmission rates and length of stay (LOS) in these individuals.MethodsWe included 100% of Medicare Fee-for-Service patients ?65 years of age who underwent MVS between 1999-2010 and survived to 1 year (N = 146,877). We used proportional hazards regression to analyze the post-MVS 1-year readmission rate in each year, mean hospital LOS (after index admission), and readmission rates by subgroups (age, sex, race).ResultsThe 1-year survival rate among patients undergoing MVS was 81.3%. Among survivors, 49.1% experienced a hospital readmission within 1 year. The post-MVS 1-year readmission rate declined from 1999-2010 (49.5% to 46.9%, P<0.01), and mean hospital LOS decreased from 6.2 to 5.3 (P<0.01). Readmission rates were highest in oldest patients, but declined in all age subgroups (65-74: 47.4% to 44.4%; 75-84: 51.4% to 49.2%, ?85: 56.4% to 50.0%, all P<0.01). There were declines in women and men (women: 51.7% to 50.8%, P<0.01; men: 46.9% to 43.0%, P<0.01), and in whites and patients of other race, but not in blacks (whites: 49.0% to 46.2%, P<0.01; other: 55.0% to 48.9%, P<0.01; blacks: 58.1% to 59.0%, P = 0.18).ConclusionsAmong older adults surviving MVS to 1 year, slightly fewer than half experience a hospital readmission. There has been a modest decline in both the readmission rate and LOS over time, with worse outcomes in women and blacks.
| S-EPMC4493110 | biostudies-literature
Project description:ImportanceDecreasing use of low-value care is a major goal for Medicare given the potential to decrease costs and harms. Compared with traditional fee-for-service Medicare (TM), Medicare Advantage (MA) is more strongly financially incentivized to decrease use of low-value care.ObjectivesTo compare use of low-value care among individuals enrolled in TM and those enrolled in MA overall and to examine trends in use of low-value care in both programs from 2006 to 2015.Design, setting, and participantsThis cross-sectional study analyzed individuals enrolled in TM and MA using data from the 2006 to 2015 Medical Expenditure Panel Survey. To account for differences in characteristics between individuals enrolled in TM and those enrolled in MA, a propensity score-based approach was used. Data were analyzed from August 2020 through January 2021.ExposuresBeing enrolled in MA or TM.Main outcomes and measuresBinary measures of use were collected for 13 low-value services in 4 categories (ie, [1] cancer screening: cervical, colorectal, and prostate cancer screening in older adults; [2] antibiotic use: antibiotic for acute upper respiratory infection and antibiotic for influenza; [3] medication: anxiolytic, sedative, or hypnotic in an adult older than 65 years; benzodiazepine for depression; opioid for headache; opioid for back pain; and nonsteroidal anti-inflammatory drug [NSAID] for hypertension, heart failure, or chronic kidney disease; and [4] imaging: magnetic resonance imaging [MRI] or computed tomography [CT] for back pain, radiograph for back pain, and MRI or CT for headache) and 4 low-value composites corresponding to the categories (ie, cancer screening composite, antibiotic use composite, medication composite, and imaging composite).ResultsAmong 11 677 individuals enrolled in TM and 5164 individuals enrolled in MA, 9429 (56.0%) were women and the mean (SD) age was 74.5 (6.3) years. Of 13 low-value services and 4 low-value composites, statistically significant differences were found in 2 measures. For the low-value medication composite, 2054 of 11 636 eligible individuals enrolled in TM (adjusted mean, 17.6%; 95% CI, 16.8%-18.3%) received the care, and 981 of 5141 eligible individuals enrolled in MA (adjusted mean, 19.7%; 95% CI, 18.3%-21.2%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.2 percentage points (95% CI, 0.5-3.8 percentage points; P = .02). For the NSAID use for hypertension, heart failure, or kidney disease metric, 807 of 7832 individuals enrolled in TM (adjusted mean, 10.0%; 95% CI, 9.2%-10.8%) received the care, and 447 of 3566 individuals enrolled in MA (adjusted mean, 12.9%; 95% CI, 19.7%-27.1%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.9 percentage points (95% CI, 1.3-4.6 percentage points; P = .001). Overall, there were no decreases in use of low-value care in TM or MA over time.Conclusions and relevanceThis cross-sectional study found that use of low-value care was similarly prevalent in MA and TM, suggesting that MA enrollment was not associated with decreased provision of low-value care compared with TM.
| S-EPMC7970337 | biostudies-literature
Project description:BACKGROUND:The Relative Value Scale Update Committee (RUC) of the American Medical Association plays a central role in determining physician reimbursement. The RUC's role and performance have been criticized but subjected to little empirical evaluation. METHODS:We analyzed the accuracy of valuations of 293 common surgical procedures from 2005 through 2015. We compared the RUC's estimates of procedure time with "benchmark" times for the same procedures derived from the clinical registry maintained by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review corrected them. RESULTS:At the time of 108 RUC reviews, the mean absolute discrepancy between RUC time estimates and benchmark times was 18.5 minutes, or 19.8% of the RUC time. However, RUC time estimates were neither systematically shorter nor longer than benchmark times overall (?, 0.97; 95% confidence interval, 0.94 to 1.01; P?=?0.10). Our analyses suggest that whereas orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used ($160 million and $40 million more, respectively, in Medicare reimbursement in 2011 through 2015), cardiothoracic surgeons, neurosurgeons, and vascular surgeons received lower payments ($130 million, $60 million, and $30 million less, respectively). The accuracy of RUC time estimates improved in 47% of RUC revaluations, worsened in 27%, and was unchanged in 25%. (Percentages do not sum to 100 because of rounding.). CONCLUSIONS:In this analysis of frequently conducted operations, we found substantial absolute discrepancies between intraoperative times as estimated by the RUC and the times recorded for the same procedures in a surgical registry, but the RUC did not systematically overestimate or underestimate times. (Funded by the National Institutes of Health.).
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Project description:ImportanceLow-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown.ObjectiveTo assess national trends in low-value care use and spending.Design, setting, and participantsIn this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020.ExposureBeing enrolled in fee-for-service Medicare for a period of time, in years.Main outcomes and measuresThe Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation.ResultsAmong 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level.Conclusions and relevanceThis cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.
| S-EPMC7887655 | biostudies-literature
Project description:ImportanceOwing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date.ObjectiveTo determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits.Design, setting, and participantsThis retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019.ExposuresEligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits).Main outcomes and measuresAge- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing.ResultsMean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P?<?.001) and then declined to 316 in 2016 (P?<?.001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P?<?.001) and heart failure (72.6% to 80.1%; P?<?.001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P?<?.001) but then declined to 2.5% in 2016 (P?<?.001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P?=?.03) but then declined to 30.8% in 2014 (P?<?.001).Conclusions and relevanceRates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.
| S-EPMC6804029 | biostudies-literature
Project description:Importance:Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach. Objective:To examine the association between the CR policy and access to cataract surgery in Thailand. Design, Setting, and Participants:Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation. Main Outcomes and Measures:The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles. Results:During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77?897 in 2005 to 192?290 in 2015. At the national level, the CSR per 100?000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100?000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed. Conclusions and Relevance:This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.
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Project description:ImportancePrescription drug spending is a topic of increased interest to the public and policymakers. However, prior assessments have been limited by focusing on retail spending (Part D-covered drugs), omitting clinician-administered (Part B-covered) drug spending, or focusing on all fee-for-service Medicare beneficiaries, regardless of their enrollment into prescription drug coverage.ObjectiveTo estimate the proportion of health care spending contributed by prescription drugs and to assess spending for retail and clinician-administered prescriptions.Design, setting, and participantsDescriptive, serial, cross-sectional analysis of a 20% random sample of fee-for-service Medicare beneficiaries in the United States from 2008 to 2019 who were continuously enrolled in Parts A (hospital), B (medical), and D (prescription drug) benefits, and not in Medicare Advantage.ExposureCalendar year.Main outcomes and measuresNet spending on retail (Part D-covered) and clinician-administered (Part B-covered) prescription drugs; prescription drug spending (spending on Part B-covered and Part D-covered drugs) as a percentage of total per-capita health care spending. Measures were adjusted for inflation and for postsale rebates (for Part D-covered drugs).ResultsThere were 3 201 284 beneficiaries enrolled in Parts A, B, and D in 2008 and 4 502 718 in 2019. In 2019, beneficiaries had a mean (SD) age of 71.7 (12.0) years, documented sex was female for 57.7%, and 69.5% had no low-income subsidies. Total per-capita spending was $16 345 in 2008 and $20 117 in 2019. Comparing 2008 with 2019, per-capita Part A spending was $7106 (95% CI, $7084-$7128) vs $7120 (95% CI, $7098-$7141), Part B drug spending was $720 (95% CI, $713-$728) vs $1641 (95% CI, $1629-$1653), Part B nondrug spending was $5113 (95% CI, $5105-$5122) vs $6702 (95% CI, $6692-$6712), and Part D net spending was $3122 (95% CI, $3117-$3127) vs $3477 (95% CI, $3466-$3489). The proportion of total annual spending attributed to prescription drugs increased from 24.0% in 2008 to 27.2% in 2019, net of estimated rebates and discounts.Conclusions and relevanceIn 2019, spending on prescription drugs represented approximately 27% of total spending among fee-for-service Medicare beneficiaries enrolled in Part D, even after accounting for postsale rebates.
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Project description:ObjectiveTo determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001-2006.MethodsWe model utilization rates for colonoscopy or sigmoidoscopy as impacted by both market supply and demand factors. We use spatial regression to perform ecological analysis of county-area utilization rates over two time intervals (2001-2003, 2004-2006) following Medicare benefits expansion in 2001 to cover colonoscopy for persons of average risk. We examine each technology in separate cross-sectional regressions estimated over early and later periods to assess differential effects on diffusion over time. We discuss selection factors in managed care markets and how failure to control perfectly for market selection might impact our managed care spillover estimates.ResultsAreas with worse socioeconomic conditions have lower utilization rates, especially for colonoscopy. Holding constant statistically the socioeconomic factors, we find that managed care spillover effects onto FFS Medicare utilization rates are negative for colonoscopy and positive for sigmoidoscopy. The spatial lag estimates are conservative and interpreted as a lower bound on true effects. Our findings suggest that managed care presence fostered persistence of the older technology during a time when it was rapidly being replaced by the newer technology.
| S-EPMC3227000 | biostudies-literature
Project description:IntroductionDementia is among the costliest of medical conditions, but it is not known how these costs vary by dementia subtype.MethodsThe effect of dementia diagnosis subtype on direct health care costs and utilization was estimated using 2015 California Medicare fee-for-service data. Potential drivers of increased costs in Lewy body dementia (LBD), in comparison to Alzheimer's disease, were tested.Results3,001,987 Medicare beneficiaries were identified, of which 8.2% had a dementia diagnosis. Unspecified dementia was the most common diagnostic category (59.6%), followed by Alzheimer's disease (23.2%). LBD was the costliest subtype to Medicare, on average, followed by vascular dementia. The higher costs in LBD were explained in part by falls, urinary incontinence or infection, depression, anxiety, dehydration, and delirium.DiscussionDementia subtype is an important predictor of health care costs. Earlier identification and targeted treatment might mitigate the costs associated with co-occurring conditions in LBD.
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