Transitional Care Services from Hospital to Home Underutilized, Can Save Money and Readmissions

MedicalResearch.com Interview with:

Andrew B. Bindman, MD Professor of Medicine PRL- Institute for Health Policy Studies University of California San Francisco

Dr. Bindman


Andrew B. Bindman, MD

Professor of Medicine
PRL- Institute for Health Policy Studies
University of California San Francisco

MedicalResearch.com: What is the background for this study?  


Response:
The purpose of this study was to evaluate the use and impact of a payment code for transitional care management services which was implemented by Medicare in.

The transition of patients from hospitals or skilled nursing facilities back to the community often involves a change in a patient’s health care provider and introduces risks in communication which can contribute to lapses in health care quality and safety. Transitional care management services include contacting the patient within 2 business days after discharge and seeing the patient in the office within 7-14 days. Medicare implemented payment for transitional care management services with the hope that this would increase the delivery of these services believing that they could reduce readmissions, reduce costs and improve health outcomes.

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Predicting Death is Difficult, Making it Difficult To Save Money on End of Life Care

MedicalResearch.com Interview with:

Amy Finkelstein PhD John & Jennie S. MacDonald Professor of Economics MIT Department of Economics National Bureau of Economic Research Cambridge MA 02139 

Dr. Finkelstein

Amy Finkelstein PhD
John & Jennie S. MacDonald Professor of Economics
MIT Department of Economics
National Bureau of Economic Research
Cambridge MA 02139 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Although only 5% of Medicare beneficiaries die in a given year, they account for almost 25% of Medciare spending.

This fact about high end of life spending has been constantly used to refer to inefficiency of the US healthcare system. A natural observation is that the fact is retrospective, and it motivated us to explore a prospective analog, which would take as an input the probability of someone dying in a given year rather than her realized outcome. We therefore used machine learning techniques to predict death, and somewhat to our surprise we found that at least using standardized and detailed claims-level data, predicting death is difficult, and there are only a tiny fraction of Medicare beneficiaries for whom we can predict death (within a year) with near certainty.

Those who end up dying are obviously sicker, and our study finds that up to half of the higher spending on those who die could be attributed to the fact that those who die are sicker and sick individuals are associated with higher spending.   Continue reading

Coding Changes Limited Penalty Impact From CMS Hospital-Acquired Conditions Policy

MedicalResearch.com Interview with:

Michael S. Calderwood, MD, MPH, FIDSA Regional Hospital Epidemiologist Assistant Professor of Medicine Infectious Disease & International Health

Dr. Calderwood

Michael S. Calderwood, MD, MPH, FIDSA
Regional Hospital Epidemiologist
Assistant Professor of Medicine
Infectious Disease & International Health

MedicalResearch.com: What is the background for this study?  

Response: Prior work by Lee et al. (N Engl J Med 2012;367:1428–1437) found that the 2008 CMS Hospital-Acquired Conditions (HAC) policy did not impact already declining national rates of central line-associated bloodstream infections (CLABSIs) or catheter-associated urinary tract infections (CAUTIs). We studied why this policy did not have its intended impact by looking at coding practices and the impact of the policy on the diagnosis-related group (DRG) assignment for Medicare hospitalizations. The DRG assignment determines reimbursement for inpatient hospitalizations.

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Study Compares Hospitals Enrolled in Medicare’s Voluntary vs Mandatory Bundled Payment Programs

MedicalResearch.com Interview with:

Amol Navathe, MD, PhD Assistant Professor, Health Policy and Medicine Perelman School of Medicine University of Pennsylvania

Dr. Navathe

Amol Navathe, MD, PhD
Assistant Professor, Health Policy and Medicine
Perelman School of Medicine
University of Pennsylvania

MedicalResearch.com: What is the background for this study?

Response: Bundled payment is a key Medicare Alternative Payment Model (APM) developed by the Centers for Medicare and Medicaid Services (CMS) to increase health care value by holding health care organizations accountable for spending across an episode of care. The model provides financial incentives to maintain quality and contain spending below a predefined benchmark.

In 2013, CMS launched the Bundled Payments for Care Improvement (BPCI) initiative to expand bundled payment nationwide. BPCI’s bundled payment design formed the basis for CMS’s Comprehensive Care for Joint Replacement (CJR) Model beginning in 2016. While the programs are similar in design, BPCI is voluntary while CJR is mandatory for hospitals in selected markets. Moreover, CJR is narrower in scope, focusing only on lower extremity joint replacement (LEJR) and limiting participation to hospitals.

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Rate of End-of-Life Medicare Spending Falls

MedicalResearch.com Interview with:

William B Weeks, MD, PhD, MBA The Dartmouth Institute

Dr. Weeks

William B Weeks, MD, PhD, MBA
The Dartmouth Institute

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The background for the study is that a common narrative is that end-of-life healthcare costs are driving overall healthcare cost growth.  Growth in end-of-life care has been shown, in research studies through the mid 2000’s, to be attributable to increasing intensity of care at the end-of-life (i.e., more hospitalizations and more use of ICUs).

The main findings of our study are that indeed there have been substantial increases in per-capita end-of-life care costs within the Medicare fee-for-service population between 2004-2009, but those per-capita costs dropped pretty substantially between 2009-2014.  Further, the drop in per-capita costs attributable to Medicare patients who died (and were, therefore, at the end-of-life) accounts for much of the mitigation in cost growth that has been found since 2009 in the overall Medicare fee-for-service population.

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Increased Hospital Spending After Heart Attack Linked To Modestly Lower Mortality

MedicalResearch.com Interview with:
Dr. Rishi K. Wadhera MD
Clinical Fellow in Medicine
Brigham and Women’s Hospital 

MedicalResearch.com: What is the background for this study?  

Response: The Hospital Value Based Purchasing program, in which over 3,000 hospitals participate, is a Centers for Medicare and Medicaid Services (CMS) pay-for-performance program that links hospital fee per service reimbursement to performance, through measures like 30-day mortality rates after an acute myocardial infarction (a heart attack), and other measures such as average spending for an episode of care for Medicare beneficiaries. Hospitals that perform poorly on these measures are financially penalized by CMS.

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Nonphysician Clinicians Provide Wide Variety of Dermatology Services To Medicare Patients

MedicalResearch.com Interview with:

Adewole Adamson, MD, MPP Department of Dermatology UNC – Chapel Hill North Carolina

Dr. Adamson

Adewole Adamson, MD, MPP
Department of Dermatology
UNC – Chapel Hill North Carolina 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Nurses practitioners and physician assistants, collectively known as non-physician clinicians (NPCs), provide many dermatology services, some which are billed for independently. Little is known about the types of these services provided. Even less is known about where these independently billed services are provided. Given that there is a purported shortage of dermatologists in the United States (US),  NPCs have been suggested as way to fill in the gap.

In this study, we found that NPCs independently billed for many different types of dermatology associated procedures, including surgical treatment of skin cancer, flaps, grafts, and billing for pathology. Most of these NPCs worked with dermatologists. Much like dermatologists, NPCs were unevenly distributed across the US, concentrating mostly in non-rural areas.

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Maryland All-Payer Model Produced Outpatient and ER Medicare Savings

MedicalResearch.com Interview with:
Susan G. Haber, Sc.D.

Director, Health Coverage for Low-Income and Uninsured Populations
RTI International
Waltham, MA

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: In 2014, the state of Maryland and the federal Centers for Medicare and Medicaid Services (CMS) began testing an alternative payment structure for inpatient and outpatient hospital services. Known as the All-Payer Model, the new system limits hospitals’ revenues from Medicare, Medicaid, and private insurers to a global budget for the year. This builds on Maryland’s hospital rate-setting system that had operated since the 1970s, where all payers pay the same rates. CMS wanted to test whether global budgets could help Maryland limit cost growth and reduce avoidable hospital use. The goal of the model is to limit per capita total hospital cost growth for both Medicare and all payers and to generate $330 million in Medicare savings over 5 years.

RTI researchers studied the impact of hospital global budgets on Medicare beneficiary expenditures and utilization, using Medicare claims data to compare changes in Maryland before and after adoption of global budgets with changes in matched comparison areas outside of the state. Our report found Maryland has reduced total Medicare expenditures by approximately $293 million and total hospital expenditures by about $200 million in its first two years of operation. The reduction in overall expenditures indicates that “squeezing the balloon” on hospital expenditures did not simply produce a cost-shift to other health care sectors. Hospital expenditure savings for Medicare were achieved by reducing expenditures for outpatient emergency department and other hospital outpatient department services. Although inpatient admissions declined, there were no savings in Medicare expenditures for inpatient hospital services because the payment per admission increased. Maryland hospitals reduced avoidable utilization, including admissions for ambulatory care sensitive conditions, and readmissions and emergency department visits following hospital discharge. Despite the success in reducing expenditures, interviews with senior leaders at Maryland hospitals and focus group discussions with physicians and nurses suggest that many hospitals had not yet made fundamental changes in how they operate or developed partnerships with community physicians to divert care from the hospital, although there was variation in how hospitals responded.

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Global Budget in Maryland Saved Medicare Money By Limiting Hospital Costs

MedicalResearch.com Interview with:
RTI
Susan G. Haber, Sc.D. 
Director, Health Coverage for Low-Income and Uninsured Populations
RTI International
Waltham, MA 02452-8413

MedicalResearch.com: What is the background for this study?

Response: In 2014, the state of Maryland and the federal Centers for Medicare and Medicaid Services (CMS) began testing an alternative payment structure for inpatient and outpatient hospital services. Known as the All-Payer Model, the new system limits hospitals’ revenues from Medicare, Medicaid, and private insurers to a global budget for the year. This builds on Maryland’s hospital rate-setting system that had operated since the 1970s, where all payers pay the same rates. CMS wanted to test whether global budgets could help Maryland limit cost growth and reduce avoidable hospital use. The goal of the model is to limit per capita total hospital cost growth for both Medicare and all payers and to generate $330 million in Medicare savings over 5 years.

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Medicare Has Cut Radiology Payments To Physicians by 33% Over Ten Years

MedicalResearch.com Interview with:
David C. Levin, MD

Department of Radiology
Thomas Jefferson University Hospital
Philadelphia, PA 19107.

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Radiology had been previously identified as the most rapidly growing of all physician services in the Medicare program during the early years of the 2000-2009 decade. But there have been deep cuts in imaging reimbursement since then. We wanted to determine how these cuts have affected total Medicare payments for imaging.

Our main findings were that since 2006, payments to physicians for imaging under the Medicare Physician Fee schedule have dropped by $4 billion per year, or about 33%.

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End-of-Life Care Transition Patterns of Medicare Beneficiaries

MedicalResearch.com Interview with:
Shi-Yi Wang MD, PhD.

Department of Chronic Disease Epidemiology
Yale School of Public Health
New Haven, CT

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Care at the end of life is often fragmented and poorly coordinated across different health providers. Multiple transitions in care settings can be burdensome to patients and their families as well as costly to society. Despite these concerns about care transitions in the end of life, we lack contemporary data on the number, timing, and overall pattern of healthcare transitions in the last 6 months of life.

This study adds to the extant literature by understanding transition trajectories, national variation of the transitions, and factors associated with transitions. We found that more than 80% of Medicare fee-for-service decedents had at least one health care transition and approximately one-third had ≥ 4 transitions in the last 6 months of life. We produced Sankey diagrams to visualize the sequences of healthcare transitions. The most frequent transition pattern involving at least four transitions: home-hospital-home (or skilled nursing facility)-hospital-healthcare setting other than hospital. There was substantial geographic variation in healthcare transitions in the United States. We found that several factors were associated with a significantly increased risk of having multiple transitions, including female gender, blacks, residence in lower income areas, presence of heart disease or kidney disease.

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Early Findings on Care Coordination in Capitated Medicare-Medicaid Plans under the Financial Alignment Initiative

MedicalResearch.com Interview with:
Angela Greene

Deputy director of Aging, Disability and Long Term Care Program
RTI International

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The Medicare-Medicaid Coordination Office and the Innovation Center at the Centers for Medicare & Medicaid Services created the Financial Alignment Initiative to test integrated care models for Medicare -Medicaid enrollees (dual-eligible beneficiaries). CMS contracted with RTI International to monitor the implementation of these demonstrations and to evaluate their impact on beneficiary experience, access, quality, utilization, and cost.

Care coordination is a key component of all demonstrations under this Initiative. Specifically, CMS and participating States believe that care coordination will improve quality and cost outcomes by increasing preventive and timely care, reducing avoidable hospitalizations, improving the beneficiary experience, and delaying institutionalization.
Our report provides an update on the status of care coordination activities and early findings on successes and challenges of providing care coordination services for the nine capitated model demonstrations implemented between October 2013 and February 2015.

Our early findings around care coordination suggest that although states are implementing demonstrations that differ in some ways, participating plans in each state are implementing new care coordination approaches designed to integrate care across medical, long term services and supports, and behavioral health systems and that they have overcome several challenges in doing so. Once dual-eligible beneficiaries become familiar with their care coordinators and develop relationships with them, they find them to be useful in coordinating care and improving access to services.

MedicalResearch.com: What should readers take away from your report?

Response: In addition to the findings mentioned earlier, our study shows care coordinators are providing a new service that dual-eligible beneficiaries generally feel is beneficial. CMS, States, and participating plans are all invested in this process and are working to make it succeed despite several challenges.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: A major goal of the evaluation is to monitor how care coordination is affecting the beneficiary experience, access to needed services, quality of care and cost. Our team will continue to track beneficiary experience with care coordination in several ways, including through focus groups and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We will also be using Medicare and Medicaid claims and encounter data to assess the effect on utilization, quality and cost.

This research was funded by the Centers for Medicare & Medicaid Services.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:
Early Findings on Care Coordination in Capitated Medicare-Medicaid Plans under the Financial Alignment Initiative

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

More Medical Research Interviews on MedicalResearch.com

ACA Medicare Changes Increased Diagnosis of Early-Stage Colorectal Cancer Among Seniors.

MedicalResearch.com Interview with:

Nengliang “Aaron” Yao PhD Assistant professor Department of Public Health Sciences University of Virginia

Dr. Nengliang Yao

Nengliang “Aaron” Yao PhD
Assistant professor
Department of Public Health Sciences
University of Virginia

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The ACA made several changes in Medicare that could increase the use of cancer screening and thus lead to more early cancer diagnoses. This includes waiving patient cost-sharing for screening, waiving patient cost-sharing for one wellness visit per year, and paying bonuses to physicians for doing more work in a primary care setting.

We studied how effective those changes were in facilitating more early diagnoses of breast and colorectal cancers. We found that the changes had no effect on early breast cancer diagnoses (likely because costs and other access barriers for mammograms were already low), but increased the number of early colorectal cancer diagnoses by 8 percent.

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When Patients Can’t Choose: Out-of-Network Care Can Be Costly

MedicalResearch.com Interview with:

Ge Bai, PhD, CPA Assistant Professor The Johns Hopkins Carey Business School Washington, DC 20036

Dr. Ge Bai

Ge Bai, PhD, CPA
Assistant Professor
The Johns Hopkins Carey Business School
Washington, DC 20036 

MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The average anesthesiologist, emergency physician, pathologist and radiologist charge more than four times what Medicare pays for similar services, often leaving privately-insured out-of-network patients stuck with surprise medical bills that are much higher than they anticipated.

The average physician charged roughly 2.5 times what Medicare pays for the same service. There are also regional differences in excess charges. Doctors in Wisconsin, for example, have almost twice the markups of doctors in Michigan (3.8 vs. two).

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Bundled Payment For Joint Replacements Saved Hospitals and CMS Money

MedicalResearch.com Interview with:

MedicalResearch.com Interview with: Amol Navathe, MD PhD University of Pennsylvania Staff Physician, CHERP, Philadelphia VA Medical Center Assistant Professor of Medicine and Health Policy, Perelman School of Medicine Senior Fellow, Leonard Davis Institute of Health Economics, The Wharton School Co-Editor-in-Chief, HealthCare: the Journal of Delivery Science and Innovatio

Dr. Amol Navathe


Amol Navathe, MD PhD

University of Pennsylvania
Staff Physician, CHERP,
Philadelphia VA Medical Center
Assistant Professor of Medicine and Health Policy, Perelman School of Medicine
Senior Fellow, Leonard Davis Institute of Health Economics, The Wharton School
Co-Editor-in-Chief, HealthCare: the Journal of Delivery Science and Innovation

MedicalResearch.com: What is the background for this study?

Response: Bundled payments pay a fixed price for an episode of services that starts at hospital admission (in this case for joint replacement surgery) and extends 30-90 days post discharge (30 days in this study). This includes physician fees, other provider services (e.g. physical therapy), and additional acute hospital care (hospital admissions) in that 30 day window.

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NYU’s Orthopedic Bundled Care Plan Reduced Readmissions and Costs

MedicalResearch.com Interview with:

Richard Iorio, MD Dr. William and Susan Jaffe Professor of Orthopaedic Surgery Chief of the Division of Adult Reconstructive Surgery NYU Langone Medical Center

Dr. Richard Iorio

Richard Iorio, MD
Dr. William and Susan Jaffe Professor of Orthopaedic Surgery
Chief of the Division of Adult Reconstructive Surgery
NYU Langone Medical Center 


MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Iorio: NYU Langone Medical Center’s Department of Orthopaedic Surgery realized early that alternate payment strategies based on value rather than volume were going to be increasing in prevalence and represent the future of compensation strategies  As leaders in orthopaedics, we knew that we must embrace this change and develop strategies and effective protocols to successfully navigate this alternative payment universe.

In 2011, NYU Langone’s Hospital for Joint Diseases was chosen as a pilot site for CMS’s Bundled Payment Care Initiative, focusing on Medicare patients undergoing a total joint replacement. Beginning in 2013, we implemented protocols developed at our hospital focusing on preoperatiive patient selection criteria in an effort to ensure better outcomes for Medicare patients who underwent total joint replacements. Under a bundled payment program, hospitals assume financial responsibility for any complications over the entire episode of care 90 days after surgery, including postsurgical infections and hospital readmissions.

We compared year over year outcomes from year 1 to year 3 of this program, and found:

  • Average hospital length of stay decreased from 3.58 days to 2.96 days;
  • Discharges to inpatient rehabilitation or care facilities decreased from 44 percent to 28 percent;
  • Average number of readmissions at 30 days decreased from 7 percent to 5 percent; from 11 percent to 6.1 percent at 60 days; and from 13 percent to 7.7 percent at 90 days;
  • The average cost to CMS of the episode of care decreased from $34,249 to $27,541 from year one to year three of the program.

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Unrecognized Cognitive Impairment in Heart Failure Patients Increases Costs and Readmissions

MedicalResearch.com Interview with:

Mark W Ketterer PhD, ABPP Health Psychology Henry Ford Hospital Detroit Michigan

Dr. Mark Ketterer

Mark W Ketterer PhD, ABPP
Health Psychology
Henry Ford Hospital
Detroit Michigan

MedicalResearch.com: What is the background for this study? What are the main findings? 

Dr. Ketterer:  Reducing wasteful healthcare costs is a high priority For Medicare/Medicaid, Obamacare and all third party payors.  Cognitive impairment (CI) is highly prevalent in patients  with chronic illnesses identified as having high readmission rates by the Center for Medicare and Medicaid Services (1,2,3), such as Congestive Heart Failure (4,5), End Stage Renal Disease (6,7) and Chronic Obstructive Pulmonary Disease (8-14). CI  is also a known prospective predictor of longer term admissions and deaths (15-18). Poor adherence is a frequent consequence of cognitive impairment (19,20), particularly when the family and/or patient have not yet recognized and intervened for the evolving problem, or the patient is not in a setting (e.g., Nursing Homes) that supervises medication administration

MedicalResearch.com: What should clinicians and patients take away from your report? 

Dr. Ketterer:  

  • Aggressive evaluation of heart failure patients for cognitive impairment.
  • Involvement of family in maximizing adherence is better care, and more efficient care.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Ketterer:  A randomly-assigned, controlled clinical trial of this intervention is warranted, needed and should be a high priority in healthcare research.

MedicalResearch.com: Is there anything else you would like to add? 

Dr. Ketterer:  As currently constructed, our healthcare system neglects common behavioral causes of waste, misdiagnosis and treatment failure.  Nonrecognition of cognitive impairment in heart failure patients is about 90%.  This can be a catastrophic failure for a given patient, resulting in a preventable death.

Citation:

Cognitive Impairment and Reduced Early Readmissions in Congestive Heart Failure? –

Mark W. Ketterer, PhD; Jennifer Peltzer, PsyD; Usamah Mossallam, MD; Cathy Draus, RN; John Schairer, DO; Bobak Rabbani, MD; Khaled Nour, MD; Gayathri Iyer, MD; Michael Hudson, MD; and James McCord, MD –

American Journal Managed Care Published Online: January 25, 2016

Mark W Ketterer PhD, ABPP (2016). Unrecognized Cognitive Impairment in Heart Failure Patients Increases Costs and Readmissions 

Higher C-Section Rates Correlated With Increased Medicare Spending

Dr. Sarah Elizabeth Little, MD Obstetrics/Gynecology Department of Obstetrics and Gynecology Brigham and Women's Hospital

Dr. Little

MedicalResearch.com Interview with:
Dr. Sarah Elizabeth Little, MD
Obstetrics/Gynecology
Department of Obstetrics and Gynecology
Brigham and Women’s Hospital

Medical Research: What is the background for this study? What are the main findings?

Dr. Little: This study investigates the variation in cesarean delivery rates across hospital services areas (a geographic unit designed by the Dartmouth Atlas to represent local markets for primarily hospital-based medical services). We looked at whether variation in cesarean delivery rates was related to broader variation in overall medical spending and utilization in that area, which we measured with Medicare spending and hospital use at the end-of-life. We found that an area’s cesarean delivery rate was correlated with these other measures; in other words, the hospital services areas that are doing the most cesarean deliveries are the same ones that are spending more and doing more to non-obstetric patients as well.
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Gap in Public-Private Insurance Payments Contines to Widen

MedicalResearch.com Interview with:
Thomas Selden, Ph.D.

Director of the Division of Research and Modeling
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland. 

Medical Research: What is the background for this study? What are the main findings?

Dr. Selden: Spending on hospital care is expected to exceed $1 trillion for the first time in 2015, and it is important to understand the differences between public and private payment rates if we want to achieve the goals of better care, smarter spending, and healthier people – the triple aims found in HHS’ National Quality Strategy.  Our study examined data on inpatient hospital stays between 1996 and 2012, finding that payments to hospitals from private insurers in 2012 were 75 percent greater than Medicare’s – a sharp increase from the approximate 10 percent difference between 1996 and 2001. 

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Even After ‘Doughnut Hole’ Closes, Cancer Drugs May Still Be Expensive For Medicare Patients

Dr. Stacie B. Dusetzina, PhD Assistant professor in the Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina

Dr. Dusetzina

MedicalResearch.com Interview with:
Dr. Stacie B. Dusetzina, PhD
Assistant professor in the Division of Pharmaceutical Outcomes and Policy
Eshelman School of Pharmacy
University of North Carolina 

Medical Research: What is the background for this study? What are the main findings?

Dr. Dusetzina: As part of the Affordable Care Act the Medicare Part D “doughnut hole” is closing – reducing Medicare beneficiaries out-of-pocket expenses during this phase of coverage from 100% of drug costs to 25% between 2010 and 2020.  In this study we analyzed 3,344 Medicare formularies that spell out how insurers cover prescription drugs. We found that in 2010, a typical course of oral chemotherapy drugs costs patients on average up to $8,100 per year. When the doughnut hole closes in 2020, patients will still have to pay on average $5,600 out of pocket per year, more than what the average Medicare beneficiary’s household spends on food each year. Even after the doughnut hold is closed oral chemotherapy drugs will still be out of reach for millions of Americans.

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Hospitals Vary in Rates of Missed Acute Myocardial Infarction Diagnosis

MedicalResearch.com Interview with:
Philip G. Cotterill PhD
Centers for Medicare & Medicaid Services
Baltimore, MD

Medical Research: What is the background for this study? What are the main findings?

Dr. Cotterill: Chest pain is one of those elusive complaints where patients can seem initially low-risk based on symptoms or risk factors, and subsequently have an acute myocardial infarction (AMI) or die in a short period of time. Using combinations of history and physical examination findings to discriminate patients with serious causes of chest pain is often not possible. In our study, we demonstrated wide variation in the decision to hospitalize Medicare beneficiaries with chest pain – nearly two fold between the lowest (38%) and highest (81%) quintile of hospitals – and that patients treated in hospitals with higher admission rates for chest pain are less likely to have an acute myocardial infarction within 30-days of the index event and less likely to die.

While the findings were statistically significant – differences in outcomes were small: 4 fewer AMIs and 3 fewer deaths per 1,000 patients comparing the highest and lowest admission quintiles. Stated differently, these numbers suggest that if low admitting hospitals were to behave more like high admitting hospitals, 250 patients would need to be admitted to prevent one AMI and 333 cases to prevent one death.

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Medicare’s Inconsistent Drug Coverage Policies Can Impede Access To New Technologies

Joshua P. Cohen Ph.D Research Associate Professor Tufts Center for the Study of Drug Development Boston, MassachusettsMedicalResearch.com Interview with:
Joshua P. Cohen Ph.D
Research Associate Professor
Tufts Center for the Study of Drug Development
Boston, Massachusetts

Medical Research: What is the background for this study?

Dr. Cohen: Florbetapir 18F was the first radioactive diagnostic agent approved by the US Food and Drug Administration for positron emission tomography imaging of the brain to evaluate amyloid â neuritic plaque density.

Medical Research: What are the main findings?

Dr. Cohen: Medicare has restricted coverage of florbetapir in the US, whereas conspicuously the UK NHS decided to reimburse the radiopharmaceutical. Note, the British NHS is generally more restrictive with regard to coverage of new technologies than the Centers for Medicare and Medicaid Services. Historically Medicare has rejected coverage of 25% of diagnostics approved by the FDA, but covers all FDA approved drugs administered in the physician’s office. Furthermore, Medicare has subjected labeled use of diagnostics, including a half-dozen Alzheimer’s diagnostics, to its coverage with evidence development program while not subjecting any labeled uses of drugs to coverage with evidence development. In sum, diagnostics are subject to a level of scrutiny by Medicare that is rarely given Medicare Part B drugs (physician-administered).

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Lump Sum Payments To Long-term Care Hospitals May Have Created Incentive To Discharge Patients

Yan S. Kim, MD PhD Delivery Science Fellow Division of Research Kaiser Permanente Northern California Oakland, CA 94612MedicalResearch.com Interview with:
Yan S. Kim, MD PhD
Delivery Science Fellow Division of Research
Kaiser Permanente Northern California
Oakland, CA 94612

Medical Research: What is the background for this study? What are the main findings?

Dr. Kim: Long-term care hospitals first emerged in the 1980s as an alternative to lengthy acute-care hospital stays for patients with complex medical problems who need prolonged hospital-level care.  In 2002, Medicare changed its payment method for these facilities from cost-based to a lump sum per admission based on the diagnosis.  Under this system, which is still in place, Medicare pays these hospitals a higher rate for patients who stay a minimum number of days based on the patient’s condition.  Shorter stays are paid much less and longer stays do not necessary generate higher reimbursements.

Using Medicare data, we analyzed a national sample of patients who required prolonged mechanical ventilation – the most common, and among the most costly, conditions for patients in long-term care hospitals – to examine whether this payment policy has created incentives to base discharge decisions on payments.  We found that in the years after the policy’s implementation there was a substantial spike in the percentage of discharges on and immediately after the minimum-stay threshold was met, while very few patients were discharged before the threshold. By contrast, prior to 2002, discharges were evenly distributed around the day that later became the short-stay threshold.  These findings confirm that the current payment policy has created unintended incentives for long-term care hospitals to base the timing of patient discharges on payments and highlight how responsive these hospitals are to payment incentives.

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Decreased Medicare Payment Did Not Mean Increased Volume For Most Glaucoma Procedures

MedicalResearch.com Interview with: Dan Gong BA Yale University School of MedicineMedicalResearch.com Interview with:
Dan Gong BA
Yale University School of Medicine
————

James C. Tsai, M.D., M.B.A.
President – New York Eye and Ear Infirmary of Mount Sinai
Delafield-Rodgers Professor and Chair Department of Ophthalmology Icahn School of Medicine at Mount Sinai

Medical Research: What is the background for this study? What are the main findings?

  • Congress first introduced the Medicare Physician Fee Schedule built on the resource-based relative value scale (RBRVS) in the Omnibus Budget Reconciliation Act of 1989. Until recently, Medicare payments to physicians were adjusted annually based on the sustainable growth rate (SGR) formula.
  • When adjusting physician payments, one controversial belief by policymakers was the assumption that in response to fee reductions, physicians would recuperate one-half of lost revenue by increasing the volume and complexity of services.
  • This study questioned this assumption that this inverse relationship between Medicare payment and procedural volume is uniform across all procedures. In particular, glaucoma procedures have not been studied in the past.
  • Using a fixed effects regression model, we found that for six commonly performed glaucoma procedures, four did not have any significant Medicare payment and procedural volume relationship (laser trabeculoplasty, trabeculectomy with and without previous surgery, aqueous shunt to reservoir). Two procedures, laser iridotomy and scleral reinforcement with graft, did have significant and inverse associations between Medicare payment and procedural volume. Continue reading

Medicare RAC Audits Fraught With Delays, High Costs and Lack of Transparency

Ann M. Sheehy, M.D., M.S. Associate Professor Division Head, Hospital Medicine University of Wisconsin Department of MedicineMedicalResearch.com Interview with:
Ann M. Sheehy, M.D., M.S.

Associate Professor
Division Head, Hospital Medicine
University of Wisconsin Department of Medicine

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Sheehy: Outpatient (observation) and inpatient status determinations are important for hospitalized Medicare beneficiaries. The Recovery Audit program, more commonly known as the RACs (Recovery Audit Contractors), is charged with surveillance and enforcement of such status determinations. Surveillance in the Medicare program is necessary, and Medicare fraud and abuse should not be tolerated. However, there are increasing concerns regarding RAC accuracy, auditor financial incentives, and the volume of audits and overpayment determinations auditors allege. We therefore studied Complex Medicare Part A RAC audits at 3 academic medical centers, the University of Wisconsin, the University of Utah, and Johns Hopkins, to determine the impact and trends of such audits.

There was a nearly 300% increase in RAC overpayment determinations in just 2 years at the study hospitals. Each year, the hospitals won a greater percent of contested cases, winning 68.0% of cases with decisions in 2013. Two-thirds of all favorable decisions for the hospitals occurred in the discussion period. Because discussion is not considered part of the formal appeals process, this is omitted from reports of RAC accuracy. None of the overpayment determinations contested the need for the care delivered, rather contested the billing location, outpatient or inpatient. The hospitals averaged 5 FTE each to manage the audit and appeals process. Claims still in appeals had been in process for a mean of 555 days without decisions.

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