Dataset Information

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries.

ABSTRACT: Importance:Fraud and abuse contribute to unnecessary spending in the Medicare program, and federal agencies have prioritized fund recovery and the exclusion of health care practitioners who violate policy. However, the human costs of fraud and abuse in terms of patient health are unknown. Objective:To assess whether Medicare beneficiaries' receipt of health care services from fraud and abuse perpetrators (FAPs) is associated with worse health outcomes. Design, Setting, and Participants:Retrospective cross-sectional study comparing mortality and emergency hospitalization rates of 8204 patients treated by an FAP with those among patients treated by a randomly selected non-FAP in 2013. Known FAPs were identified from the December 2018 List of Excluded Individuals/Entities (LEIE) published by the Office of the Inspector General in the Department of Health and Human Services. Patients were identified in a 5% sample of Medicare claims data and were enrolled in the Fee-for-Service program. Exposures:Treatment by a health care professional subsequently excluded from Medicare for fraud, patient harm, or a revoked license. Main Outcomes and Measures:All-cause mortality between 2013 and 2015 and 2013 emergency hospitalizations. Results:A total of 8204 Medicare beneficiaries in the study sample (mean [SD] age, 69.2 [14.2] years; 58.2% female, and 23.0% nonwhite) saw an FAP for the first time in 2013. Of these, 5054 (61.6%) were treated by fraud perpetrators, 1157 (14.1%) by patient harm perpetrators, and 1193 (24.3%) by revoked license perpetrators. Compared with 296?298 beneficiaries treated by non-FAPs (mean [SD] age, 71.1 [12.4] years; 58.6% female, and 16.5% nonwhite), beneficiaries exposed to an FAP were more likely to be eligible for both Medicare and Medicaid (34.7% [2845 of 8204] vs 21.9% [64?989 of 296?298]; P?

SUBMITTER: Nicholas LH

PROVIDER: S-EPMC6820041 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries.

Nicholas Lauren Hersch LH Hanson Caroline C Segal Jodi B JB Eisenberg Matthew D MD

JAMA internal medicine 20200101 1

<h4>Importance</h4>Fraud and abuse contribute to unnecessary spending in the Medicare program, and federal agencies have prioritized fund recovery and the exclusion of health care practitioners who violate policy. However, the human costs of fraud and abuse in terms of patient health are unknown.<h4>Objective</h4>To assess whether Medicare beneficiaries' receipt of health care services from fraud and abuse perpetrators (FAPs) is associated with worse health outcomes.<h4>Design, setting, and part ...[more]

PMID: 31657838

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Project description:BackgroundPatient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models.ObjectiveWe measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes.DesignCross-sectional, propensity score-weighted, multivariable regression analysis.ParticipantsA convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites.Main measuresPCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011.Key resultsNearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]).ConclusionsImplementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

Project description:BACKGROUND:Recent policy efforts have focused on improving the value of acute myocardial infarction (AMI) care. Medicare payment programs, for example, increasingly evaluate hospital performance based on spending, as determined by payments made to institutions and providers, and outcome measures for a longitudinal episode of AMI care. Little is known about the relationship between total 30-day payments-both in the inpatient and immediate postdischarge timeframe-and outcomes after an admission for AMI. METHODS AND RESULTS:Using Medicare claims data, we identified Medicare fee-for-service beneficiaries ?65 years of age who were hospitalized at an acute-care hospital for AMI between July 1, 2011, and June 30, 2014, and examined the association between hospital-level 30-day payments for an episode of AMI care and patient 30-day mortality using mixed regression models with a logit link function and random hospital intercepts. Our cohort included 642 105 index hospitalizations for AMI at 2319 acute-care hospitals. Overall mean 30-day episode payments per beneficiary were $22 128 (SD, $1750). The observed 30-day mortality rate was 12.9%. Higher 30-day payments were associated with lower 30-day mortality after adjustment for patient characteristics and comorbidities (adjusted odds ratio for additional $1000 payments, 0.986; 95% confidence interval, 0.979-0.992; P<0.001). Additional adjustment for potential mediating factors, including hospital characteristics, coronary revascularization rates, and discharge disposition, did not significantly attenuate the relationship (adjusted odds ratio for additional $1000 payments, 0.987; 95% confidence interval, 0.980-0.994; P<0.001). CONCLUSIONS:Higher hospital-level 30-day payments-both inpatient and in multiple settings after discharge-for AMI care were associated with lower 30-day mortality among beneficiaries. This may have implications for payment programs that incent reduction in payments without considering value.

Project description:ImportanceNonadherence to buprenorphine may increase patient risk of opioid overdose and increase health care spending. Quantifying the impacts of nonadherence can help inform clinician practice and policy.ObjectiveTo estimate the association between buprenorphine treatment gaps, opioid overdose, and health care spending.Design, setting, and participantsThis longitudinal case-control study compared patient opioid overdose and health care spending in buprenorphine-treated months with treatment gap months. Individuals who were US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder who received at least 1 two-week period of continuous buprenorphine treatment between 2010 and 2017 were included. Analysis took place between January 2010 and December 2017.InterventionsA gap in buprenorphine treatment in a month lasting more than 15 consecutive days.Main outcomes and measuresOpioid overdose and total, medical, and drug spending (combined patient out-of-pocket and Medicare spending).ResultsOf 34 505 Medicare beneficiaries (17 927 [520%] male; 16 578 [48.1%] female; mean [SD] age, 49.5 [12.7] years; 168 [0.5%] Asian; 2949 [8.5%] Black; 2089 [6.0%] Hispanic; 266 [0.8%] Native American; 28 525 [82.7%] White; 508 [1.5%] other race), 11 524 beneficiaries (33.4%) experienced 1 or more buprenorphine treatment gaps. Treatment gap beneficiaries, compared with nontreatment gap beneficiaries, were more likely to be younger, be male, have a disability, and be Medicaid dual-eligible while less likely to be White, close to a buprenorphine prescriber, and treated with buprenorphine monotherapy (ie, buprenorphine hydrochloride). Beneficiaries were 2.89 (95% CI, 2.20-3.79) times more likely to experience an opioid overdose during buprenorphine treatment gap months compared with treated months. During treatment gap months, spending was $196.41 (95% CI, $110.53-$282.30) more than in treated months. Patients who continued to take buprenorphine dosages of greater than 8 mg/d and 16 mg/d were 2.61 and 2.84 times more likely to overdose in a treatment gap month, respectively, while patients taking buprenorphine dosages of 8 mg/d or less were 3.62 times more likely to overdose in a treatment gap month (maintenance of >16 mg/d: hazard ratio (HR), 2.64 [95% CI, 1.80-3.87]; maintenance of >8 mg/d: HR, 2.84 [95% CI, 2.13-3.78]; maintenance of ≤8 mg/d: HR, 3.62 [95% CI, 1.54-8.50]). Buprenorphine monotherapy was associated with greater risk of overdose and higher spending during treatment gaps months than buprenorphine/naloxone.Conclusions and relevanceMedicare patients treated with buprenorphine between 2010 and 2017 had a lower associated opioid overdose risk and spending during treatment months than treatment gap months.

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.

Project description:Importance:Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types. Objective:To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US. Design, Setting, and Participants:This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019. Exposures:Medicare insurance plan type, TM or MA. Main Outcomes and Measures:Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge. Results:The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types. Conclusions and Relevance:This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.

Project description:Importance:Use of locum tenens physicians has increased in the United States, but information about their quality and costs of care is lacking. Objective:To evaluate quality and costs of care among hospitalized Medicare beneficiaries treated by locum tenens vs non-locum tenens physicians. Design, Setting, and Participants:A random sample of Medicare fee-for-service beneficiaries hospitalized during 2009-2014 was used to compare quality and costs of hospital care delivered by locum tenens and non-locum tenens internal medicine physicians. Exposures:Treatment by locum tenens general internal medicine physicians. Main Outcomes and Measures:The primary outcome was 30-day mortality. Secondary outcomes included inpatient Medicare Part B spending, length of stay, and 30-day readmissions. Differences between locum tenens and non-locum tenens physicians were estimated using multivariable logistic regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects, which enabled comparisons of clinical outcomes between physicians practicing within the same hospital. In prespecified subgroup analyses, outcomes were reevaluated among hospitals with different levels of intensity of locum tenens physician use. Results:Of 1 818 873 Medicare admissions treated by general internists, 38 475 (2.1%) received care from a locum tenens physician; 9.3% (4123/44 520) of general internists were temporarily covered by a locum tenens physician at some point. Differences in patient characteristics, demographics, comorbidities, and reason for admission between locum tenens and non-locum tenens physicians were not clinically relevant. Treatment by locum tenens physicians, compared with treatment by non-locum tenens physicians (n = 44 520 physicians), was not associated with a significant difference in 30-day mortality (8.83% vs 8.70%; adjusted difference, 0.14%; 95% CI, -0.18% to 0.45%). Patients treated by locum tenens physicians had significantly higher Part B spending ($1836 vs $1712; adjusted difference, $124; 95% CI, $93 to $154), significantly longer mean length of stay (5.64 days vs 5.21 days; adjusted difference, 0.43 days; 95% CI, 0.34 to 0.52), and significantly lower 30-day readmissions (22.80% vs 23.83%; adjusted difference, -1.00%; 95% CI -1.57% to -0.54%). Conclusions and Relevance:Among hospitalized Medicare beneficiaries treated by a general internist, there were no significant differences in overall 30-day mortality rates among patients treated by locum tenens compared with non-locum tenens physicians. Additional research may help determine hospital-level factors associated with the quality and costs of care related to locum tenens physicians.

Project description:ImportanceMuch of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality.ObjectiveTo evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery.Design, setting, and participantsCross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022.ExposuresPhysician practice participation in the bundled payment program.Main outcomes and measuresThe primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions).ResultsThe final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]).Conclusions and relevanceIn this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

Dataset Information

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries.

Publications

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries.

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