The Cost of Transferring Dialysis Care From the Employer-Based Market to Medicare.
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SUBMITTER: Lin E
PROVIDER: S-EPMC7974636 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Importance:Primary care is increasingly delivered at or near workplaces, yet utilization and cost of employer-sponsored primary care services remain unknown. Objective:To 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 Participants:This 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). Exposures:Integrated primary care, mental health, and physical therapy delivered through on-site, near-site, and virtual clinics. Main Outcomes and Measures:Utilization (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. Results:A 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 Relevance:The 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:To understand the impacts of Medicare payment reform on the entry and exit of post-acute providers.Medicare Provider of Services data, Cost Reports, and Census data from 1991 through 2010.We 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.We 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.Payment 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.Payment 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:BACKGROUND:Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries. METHODS:Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed. RESULTS:Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30). CONCLUSION:The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale.
| S-EPMC6407198 | biostudies-other
Project description:OBJECTIVE:To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES:Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N = 204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN:We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS:There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS:ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.
| S-EPMC6052017 | biostudies-other
Project description:ImportanceMedicare is moving toward value-based payment. The Merit-Based Incentive Payment System (MIPS) program judges outpatient clinicians' performance on a measure of annual Medicare spending. However, this measure may disadvantage outpatient clinicians who care for vulnerable populations because the algorithm omits meaningful determinants of cost.ObjectivesTo determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, as well as local area health resources and economic conditions, are associated with Medicare total annual cost of care (TACC), and evaluate whether accounting for these factors is associated with improved TACC performance by outpatient safety-net clinicians.Design, setting, and participantsIn this retrospective observational study, we used the Medicare Current Beneficiary Survey (MCBS) to examine patient-reported neuropsychological and functional status and the Area Health Resources File to obtain information on local area characteristics. Included were Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non-safety-net clinics, contributing 76 927 person-years of data to the MCBS from 2006 through 2013. We used patient-level multivariable regression models to estimate the association between each factor and annual Medicare spending, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors.Main outcomes and measuresMedicare TACC, measured as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories.ResultsOur study included 111 414 unique identifiable physicians, and the final weighted sample included 213 904 324 patient-years (unweighted, 76 927 patient-years) from 30 058 unique patients, of whom 17 478 (58.1%) were women. The mean (SD) patient age was 71.84 (12.48) years. The mean TACC was $9117. Those with higher than mean TACC included beneficiaries with depression ($14 436), dementia ($18 311), and difficulty with 3 or more activities of daily living (ADLs, $19 113) or instrumental ADLs ($17 443). After adjusting for comorbidities, depression and dementia were still associated with $2740 (95% CI, $2200-$2739) and $2922 (95% CI, $2399-$3445) higher TACC, respectively. Difficulty with 3 or more ADLs ($3121 higher; 95% CI, $2633-$3609) or instrumental ADLs ($895 higher; 95% CI, $452-$1337) was also associated with higher TACC. Adding these neuropsychological and functional factors, as well as local residence area factors, to risk adjustment calculations reduced outpatient safety-net clinicians' underperformance on Medicare TACC relative to non-safety-net clinicians by 52% (from 0.098 to 0.047 difference in the observed to expected ratio).Conclusions and relevanceNeuropsychological and functional impairment are common in Medicare beneficiaries and are associated with increased annual Medicare spending. Failure to account for these factors may inappropriately penalize outpatient clinicians who care for these vulnerable groups, such as safety-net clinicians, for factors that are arguably beyond their control.
| S-EPMC6248196 | biostudies-literature
Project description:Background and objectivesPeritoneal dialysis (PD) use increased in the United States with the introduction of a new Medicare prospective payment system in January 2011 that likely reduced financial disincentives for facility use of this home therapy. The expansion of PD to a broader population and facilities having less PD experience may have implications for patient outcomes. We assessed the impact of PD expansion on PD discontinuation and patient mortality.Design, setting, participants, & measurementsA prospective cohort study was conducted of patients treated with PD at 90 days of ESKD. Patients were grouped by study start date relative to the Medicare payment reform: prereform (July 1, 2008 to December 31, 2009; n=10,585), interim (January 1, 2010 to December 31, 2010; n=7832), and reform period (January 1, 2011 to December 31, 2012; n=18,742). Patient characteristics and facility PD experience were compared at baseline (day 91 of ESKD). Patients were followed for 3 years for the major outcomes of PD discontinuation and mortality using Cox proportional hazards models.ResultsPatient characteristics, including age, sex, race, ethnicity, rurality, cause of ESKD, and comorbidity, were similar or showed small changes across the three study periods. There was an increasing tendency for patients on PD to be treated in facilities with less PD experience (from 34% during the prereform period being treated in facilities averaging <14 patients on PD per year to 44% in the reform period). Patients treated in facilities with less PD experience had a higher rate of PD discontinuation than patients treated in facilities with the most experience (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.10 to 1.23 for the first versus fifth quintile of PD experience). Nevertheless, the risk of PD discontinuation fell during the late interim period (HR, 0.88; 95% CI, 0.82 to 0.95) and most of the reform period (from HR, 0.85; 95% CI, 0.79 to 0.91 to HR, 0.94; 95% CI, 0.87 to 1.01). Mortality risk was stable across the three study periods.ConclusionsIn the context of expanding PD use and declining facility PD experience, the risk of PD discontinuation fell, and there was no adverse effect on mortality.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_09_12_CJN01610219.mp3.
| S-EPMC6777599 | biostudies-literature
Project description:ObjectiveTo estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes.Data sources/study settingWe linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries.Study designCross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care.Principal findingsPractices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care.ConclusionsLarge practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.
| S-EPMC6232442 | biostudies-literature
Project description: Not available
| S-EPMC9918879 | biostudies-literature