The Cost of Transferring Dialysis Care From the Employer-Based Market to Medicare.
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ABSTRACT:
SUBMITTER: Lin E
PROVIDER: S-EPMC7974636 | biostudies-literature | 2021 Mar
REPOSITORIES: biostudies-literature
Publications
The Cost of Transferring Dialysis Care From the Employer-Based Market to Medicare.
JAMA network open 20210301 3
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Project description:ImportancePrimary care is increasingly delivered at or near workplaces, yet utilization and cost of employer-sponsored primary care services remain unknown.ObjectiveTo compare the health care utilization and cost of an employer-sponsored on-site, near-site, and virtual comprehensive primary care service delivery model with those of traditional community-based primary care.Design, setting, and participantsThis population-based cohort study of 23 518 commercially insured employees and dependents of an engineering and manufacturing firm headquartered in southern California was performed from January 1, 2016, to July 1, 2019. A subset of the population with most (≥50%) primary care visits through employer-sponsored on-site, near-site, or virtual care clinics was matched to a subset not having most such visits through the employer-sponsored clinics using propensity score matching (n = 1983 each). In sensitivity analyses, employees were matched to dependents at neighboring firms that lacked access to the employer-sponsored primary care delivery model (additional n = 1680).ExposuresIntegrated primary care, mental health, and physical therapy delivered through on-site, near-site, and virtual clinics.Main outcomes and measuresUtilization (inpatient, outpatient, emergency department, pharmaceutical, radiology, and laboratory visits per 1000 member-months) and spending (2019 costs per member per month in US dollars) by service type.ResultsA total of 23 518 individuals (mean [SD] age, 27 [15] years; 14 604 [62.1%] male) were included in the full population sample and had been enrolled in the employer-sponsored health plan for a mean of 29 months (interquartile range, 14-48 months). Of eligible members, 5292 (22.5%) used the employer-sponsored services, with 2305 (9.8%) using them for most of their primary care. The mean (SD) cost of employer-sponsored service delivery was $87 ($32) per member month. Among the matched populations (mean [SD] age, 31 [11] years; 3349 [84.5%] male) of primary users vs control individuals, total spending was 45% lower per member per month (95% CI, 35%-55%; cost difference, -$167 per member per month; 95% CI, -$204 to -$130; P < .001) among users after adjustment. The lower spending was associated with lower spending on non-primary care services, such as emergency department (-33%; 95% CI, -44% to -22%) and hospital visits (-16%; 95% CI, -22% to -10%), despite higher spending on primary care (109%; 95% CI, 102%-116%) and mental health (20%; 95% CI, 13%-27%).Conclusions and relevanceThe findings suggest that individuals who used the models' services for most of their primary care had lower total spending despite higher primary care spending, which may be associated with self-selection of lower-risk persons to the employer-sponsored services and/or with the use of comprehensive primary care.
| S-EPMC7193330 | biostudies-literature
Project description:ObjectiveTo estimate the effect of growth in health care costs that outpaces gross domestic product (GDP) growth ("excess" growth in health care costs) on employment, gross output, and value added to GDP of U.S. industries.Study settingWe analyzed data from 38 U.S. industries for the period 1987-2005. All data are publicly available from various government agencies.Study designWe estimated bivariate and multivariate regressions. To develop the regression models, we assumed that rapid growth in health care costs has a larger effect on economic performance for industries where large percentages of workers receive employer-sponsored health insurance (ESI). We used the estimated regression coefficients to simulate economic outcomes under alternative scenarios of health care cost inflation.ResultsFaster growth in health care costs had greater adverse effects on economic outcomes for industries with larger percentages of workers who had ESI. We found that a 10 percent increase in excess growth in health care costs would have resulted in 120,803 fewer jobs, US$28,022 million in lost gross output, and US$14,082 million in lost value added in 2005. These declines represent 0.17 to 0.18 percent of employment, gross output, and value added in 2005.ConclusionExcess growth in health care costs is adversely affecting the economic performance of U.S. industries.
| S-EPMC2754542 | biostudies-literature
Project description:ObjectiveExamine associations between patient experiences with care and service use across markets.Data sources/study settingMedicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index.Study designWe estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets.Data collection/extractionWe merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid.Principal findingsOverall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care.ConclusionsMedicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.
| S-EPMC2875753 | biostudies-literature
Project description:ObjectiveTo assess changes in physicians' provision of care to duals (low-income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare's cost sharing for office visits with these patients. This policy-a provision of the Affordable Care Act-effectively increased payments for office visits with duals by 0%-20%, depending on the state, in 2013 and 2014.Data sourcesFee-for-service claims for a 5% random sample of Medicare beneficiaries in 2010-2016.Study designWe conducted a difference-in-differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)-the largest subpopulation of duals for whom payment rates were affected by this policy-to changes among other low-income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple-differences analysis that compared changes between QMBs and other low-income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases.Data collectionThe study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low-income Medicare beneficiaries (1 914 073 beneficiary-years from 2010 to 2016).Principal findingsNationally, we did not find a differential increase in office visits among QMBs versus other low-income beneficiaries that coincided with this payment change. In the triple-differences analysis, we did not observe a greater increase in visits among QMBs vs other low-income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple-differences estimate: -0.12 annual visits, 95% CI: -0.28, 0.04; P = 0.15).ConclusionsPhysicians' provision of care to low-income Medicare beneficiaries may not be responsive to short-run payment changes.
| S-EPMC8143678 | biostudies-literature
Project description:ObjectiveTo understand the impacts of Medicare payment reform on the entry and exit of post-acute providers.Data sourcesMedicare Provider of Services data, Cost Reports, and Census data from 1991 through 2010.Study designWe examined market-level changes in entry and exit after payment reforms relative to a preexisting time trend. We also compared changes in high Medicare share markets relative to lower Medicare share markets and for freestanding relative to hospital-based facilities.Data extraction methodsWe calculated market-level entry, exit, and total stock of home health agencies, skilled nursing facilities, and inpatient rehabilitation facilities from Provider of Services files between 1992 and 2010. We linked these measures with demographic information from the Census and American Community Survey, information on Certificate of Need laws, and Medicare share of facilities in each market drawn from Cost Report data.Principal findingsPayment reforms reducing average and marginal payments reduced entries and increased exits from the market. Entry effects were larger and more persistent than exit effects. Entry and exit rates fluctuated more for home health agencies than skilled nursing facilities. Effects on number of providers were consistent with entry and exit effects.ConclusionsPayment reform affects market entry and exit, which in turn may affect market structure, access to care, quality and cost of care, and patient outcomes. Policy makers should consider potential impacts of payment reforms on post-acute care market structure when implementing these reforms.
| S-EPMC3796101 | biostudies-literature
Project description:ImportanceMedicare finances health care for most US patients with end-stage kidney disease (ESKD), regardless of age. Medicare enrollment may have slowed for patients with incident ESKD who gained access to new private insurance options with the 2014 passage of the Affordable Care Act (ACA) and introduction of the ACA Marketplace.ObjectiveTo describe trends in public and private insurance coverage and dialysis spending among patients with incident ESKD from 2012 to 2017.Design, setting, and participantsThis serial cross-sectional study included patients 18 to 64 years old in Colorado who were not enrolled in Medicare at dialysis initiation. Data analysis was conducted from May to August 2023.ExposureIntroduction of the ACA Marketplace in 2014.Main outcomes and measuresMedicare, Medicaid, or private insurance enrollment in the first year after dialysis initiation, and dialysis spending by insurance type.ResultsOf 2005 patients included in the sample, 1416 (70.6%) were 45 to 64 years old, and 1259 (62.8%) were male. A lower proportion of patients with incident ESKD starting dialysis were newly enrolled in Medicare in the years following the ACA (361 of 713 [50.6%]) compared to 2 years prior (420 of 595 [70.6%]). Unadjusted rates of switching from Medicaid to Medicare 1 year after dialysis initiation decreased 14.3 percentage points over time (68.9% in 2012-2013 vs 58.3% and 54.6% in 2014-2015 and 2016-2017, respectively). Unadjusted rates of switching from private insurance to Medicare 1 year after dialysis initiation decreased by 22.3 percentage points (68.1% in 2012-2013 vs 52.2% and 45.8% in 2014-2015 and 2016-2017, respectively). Over the entire 2012 to 2017 period, quarterly dialysis spending in the first year of dialysis among patients with private insurance was higher than among those with Medicare coverage ($26 351-$29 781 vs $10 039-$12 741).Conclusions and relevanceThis cross-sectional study demonstrates that lower Medicare enrollment rates over time among those initiating dialysis may be inducing higher social spending. This finding raises concerns about the effectiveness of Medicare policies and federal leverage to improve access, outcomes, and value of dialysis care.
| S-EPMC11624581 | biostudies-literature
Project description:ImportanceMedicare finances health care for most US patients with end-stage kidney disease (ESKD), regardless of age. The 2011 Medicare prospective payment system (PPS) for dialysis reduced reimbursement for hemodialysis, and the 2014 Patient Protection and Affordable Care Act (ACA) Marketplace increased patient access to new private insurance options, potentially influencing organizations that provide health care, such as hospitals, nursing homes, and dialysis facilities, to adjust their payer mix away from Medicare sources.ObjectiveTo describe Medicare enrollment trends among patients with incident ESKD in 2006 to 2016.Design, setting, and participantsThis retrospective cohort study involved US patients aged 18 to 64 years who were not enrolled in Medicare at dialysis initiation in 2006 to 2016, with 1-year follow-up through 2017. Data analysis was conducted April 2021 to June 2022.ExposuresThe exposure of interest was a 3-category indicator of time, whether patients initiated dialysis before policies were enacted (2006-2010), in the first years of the Medicare ESKD PPS (2011-2013), or during the Medicare ESKD PPS and implementation of the ACA Marketplace (2014-2016).Main outcomes and measuresPatient-level Medicare enrollment through the first year of dialysis. Logistic regression and Cox models were used to examine associations of time, patient characteristics, and Medicare enrollment, adjusting for patient demographic, clinical, and market-level characteristics.ResultsOf 335 157 patients aged 18 to 64 years with ESKD not actively enrolled in Medicare when they initiated dialysis in 2006 to 2016, the mean (SD) age was 49.9 (10.8) years, 198 164 (59.1%) were men, 188 290 (56.2%) were White, and 313 622 (93.6%) received in-center hemodialysis. New Medicare enrollment was higher in 2006 to 2010 (110 582 patients [73.1%]) than after the Medicare ESKD PPS and ACA Marketplace in 2014 to 2016 (55 382 patients [58.5%]). In adjusted analyses, declining Medicare enrollment was associated with implementation of 2011 Medicare ESKD PPS and 2014 ACA policies and was disproportionately lower among younger, racially minoritized, and ethnically Hispanic patients.Conclusions and relevanceThere was declining Medicare enrollment among new dialysis patients associated with the 2011 Medicare ESKD PPS and 2014 ACA Marketplace that raise concerns about benefits and harms to patients and payers and continued disparities in kidney care. As the dialysis payer mix moves toward higher proportions of patients not covered by Medicare, it will be important to understand the implications for health care system and patient outcomes.
| S-EPMC9490494 | biostudies-literature
Project description:This research investigates labor market discrimination based on physical appearance in Israel's Certified Public Accountant firms. Using a survey questionnaire, we showed that accountants in managerial positions prefer to hire more physically attractive candidates. This beauty premium is larger among the five biggest Certified Public Accountant firms and can be explained by the perception that attractive candidates possess essential traits for becoming successful accountants. An important implication of our results is that even among accounting firms, where professionalism is well defined, discrimination against candidates based on traits such as physical appearance can ineffectively eliminate suitably qualified interns.
| S-EPMC9372560 | biostudies-literature
Project description:Background As the pharmacy profession transforms toward practice centered around direct patient care and clinical services, upskilling the existing workforce may be required for pharmacists to take on expanded roles, especially in an increasingly competitive job market. Objective To explore pharmacist employer perceptions of a primary care certificate training program including its design, value, and relevance and to develop and implement a pharmacist primary care certificate training program based on study results. Methods Focus groups were conducted to a point of saturation in December 2020 via video conference. Participants were identified via the study institution's continuing professional development registrant listserv and invited to participate via self-selection. Interviews were recorded, transcribed, and underwent inductive thematic analysis. Results Four focus groups were conducted with 15 pharmacist employers. Employers perceived primary care certificate training as valuable, helping pharmacists sustain shifting roles and increasing opportunities in a competitive job market. A combination of clinical and practice management topics with emphasis on an experiential component was recommended to achieve expected competency levels and favorably influence hiring decisions. The primary care certificate was specifically recommended to pharmacists aiming to transition into primary care or for pharmacists who did not complete residency training. Conclusions This study's findings informed development of a pharmacist primary care certificate program containing didactic and experiential training on a variety of key topics. As pharmacists' roles evolve, this program may prepare pharmacists to engage in direct patient care and develop skills and expertise necessary to succeed in outpatient primary care. Highlights • Employers prioritize and expect training beyond terminal degrees to bridge the gap between education and practice.• Employers valued primary care certificate programs for making candidates more marketable and influencing hiring decisions.• A primary care certificate program will prepare pharmacists to develop skills to succeed in outpatient primary care.
| S-EPMC9579043 | biostudies-literature
Project description:ObjectiveTo compare the characteristics of dialysis facilities used by traditional Medicare (TM) and Medicare advantage (MA) enrollees with end-stage kidney disease (ESKD).Data sourcesWe used 20% TM claims and 100% MA encounter data from 2018 and publicly available data from the Centers for Medicare and Medicaid Services.Study designWe compared the characteristics of the dialysis facilities treating TM and MA patients in the same ZIP code, adjusting for patient characteristics. The outcome variables were facility ownership, distance to the facility, and several measures of facility quality.Data collection/extractionWe identified point prevalent dialysis patients as of July 15, 2018.Principal findingsCompared to TM patients in the same ZIP code, MA patients were 1.84 percentage points more likely to be treated at facilities owned by the largest two dialysis organizations and 1.85 percentage points less likely to be treated at an independently owned facility. MA patients went to further and lower quality facilities than TM patients in the same ZIP code. However, these differences in facility quality were modest. For example, while the mean dialysis facility mortality rate was 21.85, the difference in mortality rates at facilities treating MA and TM patients in the same ZIP code was 0.67 deaths per 100 patient-years. Similarly, MA patients went to facilities that were, on average, 0.15 miles further than TM patients in the same ZIP code.ConclusionMA enrollees with ESKD were more likely than TM enrollees in the same ZIP code to use the dialysis facilities owned by the two largest chains, travel further for care, and receive care at lower quality facilities. While the magnitude of differences in facility distance and quality was modest, the direction of these results underscores the importance of monitoring dialysis network adequacy as ESKD MA enrollment continues to grow.
| S-EPMC10480079 | biostudies-literature