Dataset Information

Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014.

ABSTRACT: Importance:Nurse practitioners (NPs) and physician assistants (PAs) are nonphysician clinicians (NPCs) who can deliver dermatology services. Many of these services are provided independently. Little is known about the types of services provided or where NPCs provide independent care. Objective:To examine characteristics of dermatology care for Medicare enrollees billed independently by NPCs. Design, Setting, and Participants:Retrospective review of the 2014 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File, which reflects fee-for-service payments to clinicians for services rendered to Medicare beneficiaries. Clinician location was matched with county-level demographic data from the American Community Survey, US Census Bureau. Clinicians identified using National Provider Identifier as NPs or PAs with at least 11 claims for common dermatology-associated Healthcare Common Procedure Coding System procedure codes were included. Main Outcomes and Measures:Total services provided by service type category, density of dermatologists and nondermatologists who perform dermatology-related services, and geographic location by county. Results:Among the cohort of NPCs were 824 NPs (770 [93.5%] female) and 2083 PAs (1602 [76.9%] female) who independently billed Medicare $59?438?802 and $171?645?943, respectively. Dermatologists were affiliated with 2667 (92%) independently billing NPCs. Most payments were for non-evaluation and management services including destruction of premalignant lesions, biopsies, excisions of skin cancer, surgical repairs, flaps/grafts, and interpretation of pathologic analysis. Nurse practitioners and PAs billed for a similar distribution of service categories overall. A total of 2062 (70.9%) NPCs practiced in counties with dermatologist density of greater than 4 per 100?000 population. Only 3.0% (86) of independently billing NPCs practiced in counties without a dermatologist. Both dermatologists and NPCs were less likely to be in rural counties than in urban counties. Conclusions and Relevance:Nonphysician clinicians independently billed for a wide variety of complex dermatologic procedures. Most independently billing NPCs practice in counties with higher dermatologist densities, and nearly all these NPCs were affiliated with dermatologists. Further study of NPC training and integration with the dermatology discipline is an important part of addressing the changing US dermatology workforce.

SUBMITTER: Adamson AS

PROVIDER: S-EPMC5833583 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014.

Adamson Adewole S AS Suarez Elizabeth A EA McDaniel Philip P Leiphart Paul A PA Zeitany Alana A Kirby Joslyn S JS

JAMA dermatology 20180101 1

<h4>Importance</h4>Nurse practitioners (NPs) and physician assistants (PAs) are nonphysician clinicians (NPCs) who can deliver dermatology services. Many of these services are provided independently. Little is known about the types of services provided or where NPCs provide independent care.<h4>Objective</h4>To examine characteristics of dermatology care for Medicare enrollees billed independently by NPCs.<h4>Design, setting, and participants</h4>Retrospective review of the 2014 Medicare Provide ...[more]

PMID: 29167867

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Project description:Background/objectiveThe Centers for Medicare & Medicaid Services (CMS) reimburses clinicians for advance care planning (ACP) discussions with Medicare patients. The objective of the study was to examine the association of CMS-billed ACP visits with end-of-life (EOL) healthcare utilization.DesignPatient-level analyses of claims for the random 20% Medicare fee-for-service (FFS) sample of decedents in 2017. To account for multiple comparisons, Bonferroni adjusted P value <.008 was considered statistically significant.SettingNationally representative sample of Medicare FFS beneficiaries.ParticipantsA total of 237,989 Medicare FFS beneficiaries who died in 2017 and included those with and without a billed ACP visit during 2016-17.InterventionThe key exposure variable was receipt of first billed ACP (none, >1 month before death).MeasurementsSix measures of EOL healthcare utilization or intensity (inpatient admission, emergency department [ED] visit, intensive care unit [ICU] stay, and expenditures within 30 days of death, in-hospital death, and first hospice within 3 days of death). Analyses was adjusted for age, race, sex, Charlson Comorbidity Index, expenditure by Dartmouth hospital referral region (high, medium, or low), and dual eligibility.ResultsOverall, 6.3% (14,986) of the sample had at least one billed ACP visit. After multivariable adjustment, patients with an ACP visit experienced significantly less intensive EOL care on four of six measures: hospitalization (odds ratio [OR] = .77; 95% confidence interval [CI] = .74-.79), ED visit (OR = .77; 95% CI = .75-.80), or ICU stay (OR = .78; 95% CI = .74-.81) within a month of death; and they were less likely to die in the hospital (OR = .79; 95% CI = .76-.82). There were no differences in the rate of late hospice enrollment (OR = .97; 95% CI = .92-1.01; P = .119) or mean expenditures ($242.50; 95% CI = -$103.63 to $588.61; P = .169).ConclusionBilled ACP visits were relatively uncommon among Medicare FFS decedents, but their occurrence was associated with less intensive EOL utilization. Further research on the variables affecting hospice use and expenditures in the EOL period is recommended to understand the relative role of ACP.

Project description:ImportanceLow-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.ObjectivesTo compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.Design, setting, and participantsThis cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.ExposuresEnrollment in MA vs TM.Main outcomes and measuresLow-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.ResultsAmong a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.Conclusions and relevanceIn this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.

Project description:ImportancePrivate Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking.ObjectiveTo examine differences in home health service intensity and patient outcomes between MA and TM.Design, setting, and participantsThis cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024.ExposureTM vs MA plan.Main outcomes and measuresHome health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health.ResultsOf 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08).Conclusions and relevanceThe results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.

Project description:ImportanceBetter evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.ObjectiveTo compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees.Design, setting, and participantsThis cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design.ExposuresEnrollment in MA and dual eligibility for Medicare and Medicaid.Main outcomes and measuresPostacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services.ResultsIncluded in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility.Conclusions and relevanceIn this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.

Dataset Information

Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014.

Publications

Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014.

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