Study Finds Medicare Readmissions Penalties Have Not Increased Mortality from Heart Failure

MedicalResearch.com Interview with:

Teryl K. Nuckols, MD Vice Chair, Clinical Research Director, Division of General Internal Medicine Cedars Sinai Los Angeles, California

Dr. Nuckols

Teryl K. Nuckols, MD
Vice Chair, Clinical Research
Director, Division of General Internal Medicine
Cedars Sinai
Los Angeles, California

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

Response: The Medicare Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with increased 30-day readmission rates among seniors admitted with heart failure (HF).  Heart failure readmission rates declined markedly following the implementation of this policy. Two facts have raised concerns about whether the HRRP might have also inadvertently increased 30-day heart failure mortality rates.

First, before the policy was implemented, hospitals with higher heart failure readmission rates had lower 30-day HF mortality rates, suggesting that readmissions are often necessary and beneficial in this population. Second, 30-day HF mortality rose nationally after the HRRP was implemented, and the timing of the increase has suggested a possible link to the policy.

Are hospitals turning patients away, putting them at risk of death, or is the increase in heart failure mortality just a coincidence? To answer this question, we compared trends in 30-day HF mortality rates between penalized hospitals and non-penalized hospitals because 30-day HF readmissions declined much more at hospitals subject to penalties under this policy.

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More Than Half of Physician Guideline Authors for Expensive Medications Have Undeclared Conflicts of Interest

MedicalResearch.com Interview with:

Samir C. Grover MD, MEd, FRCPC Division of Gastroenterology Program Director Division of Gastroenterology Education Program  University of Toronto

Dr. Grover

Samir C. Grover MD, MEd, FRCPC
Division of Gastroenterology Program Director
Division of Gastroenterology Education Program
University of Toronto

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

Response: We know that physician-industry interactions are commonplace. Because of this, there has been a movement to make the presence of these relationships more transparent. For clinical practice guidelines, this is especially important as these documents are meant to be objectively created, evidence based, and intended to guide clinical practice.

The standard in the US come from the National Academy of Medicine report, “Clinical Practice Guidelines We Can Trust”, which suggests that guideline chairs should be free of conflicts of interest, less than half of the guideline committee should have conflicts, and that guideline panel members should declare conflicts transparently.

Other studies, however, have shown that some guidelines don’t adhere to this advice and have committee members who don’t disclose all conflicts. We thought to look at this topic among medications that generate the most revenue, hypothesizing that undeclared conflicts would be especially prevalent in this setting.

We found that, among 18 guidelines from 10 high revenue medications written by 160 authors, more than (57%) had a financial conflict of interest, meaning they received payments from pharmaceutical companies that make or market medications recommended in that guideline. About a quarter of authors also received, and didn’t disclose payments from one of these companies. Almost all the guidelines did not adhere to National Academy of Medicine standards.

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Primary Care Providers Can Encourage Patients To Focus on Vision Health

MedicalResearch.com Interview with:

Joshua Ehrlich, MD, MPH Assistant Professor of Ophthalmology and Visual Sciences University of Michigan

Dr. Ehrlich

Joshua Ehrlich, MD, MPH
Assistant Professor of Ophthalmology and Visual Sciences
University of Michigan 

MedicalResearch.com: –Describe the “important role” that primary care providers play in promoting eye health?

Response: Primary care is the entryway into the health system for many individuals. The poll suggests that when primary care providers discuss vision with their patients, they are more likely to get eye exams. It also suggests that primary care providers are having these conversations most often with those who have certain risk factors for eye disease, such as diabetes or a family history of vision problems, as well as those with fewer economic resources. Promoting these kinds of conversations could bolster this trend, increasing the number of diabetics and other high risk individuals who get appropriate eye care.

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Combination Brand Name Drugs Cost Medicare Millions More Than Separate Generic Pills

MedicalResearch.com Interview with:

Chana A. Sacks, MD, MPH Program On Regulation, Therapeutics, And Law (PORTAL) Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women’s Hospital

Dr. Sacks

Chana A. Sacks, MD, MPH
Program On Regulation, Therapeutics, And Law (PORTAL)
Division of Pharmacoepidemiology and Pharmacoeconomics
Brigham and Women’s Hospital

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

Response: Combination pills combine multiple medications into a single dosage form. There have been case reports in recent years of high prices for certain brand-name combination drugs – even those that are made up of generic medications.

Our study looks at this phenomenon in a systematic way using recently released Medicare spending data. We evaluated 29 combination drugs and found that approximately $925 million dollars could potentially have been saved in 2016 alone had generic constituents been prescribed as individual pills instead of using the combination products.

For example, Medicare reported spending more than $20 per dose of the combination pill Duexis, more than 70 times the price of its two over-the-counter constituent medications, famotidine and ibuprofen.

The findings in this study held true even for brand-name combination products that have generic versions of the combination pill. For example, Medicare reported spending more than $14 for each dose of brand-name Percocet for more than 4,000 patients, despite the existence of a generic combination oxycodone/acetaminophen product. Continue reading

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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Safety Net and Smaller Hospitals Not Well Represented in Medicare’s Bundled Payment Program for Heart Disease

MedicalResearch.com Interview with:

Dan Blumenthal, MD, MBA Assistant in Medicine, Division of Cardiology Massachusetts General Hospital Instructor in Medicine Harvard Medical School

Dr. Blumenthal

Dan Blumenthal, MD, MBA
Assistant in Medicine, Division of Cardiology
Massachusetts General Hospital
Instructor in Medicine
Harvard Medical School 

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

Response: Despite dramatic advances in the treatment of cardiovascular disease (CVD) over the past half-century, CVD remains a leading cause of death and health care spending in the United States (US) and worldwide. More than 2000 Americans die of CVD each day, and more than $200 billion dollars is spent on the treatment of CVD each year in the US By 2030, over 40% of the US population is projected to have some form of CVD, at a cost of $1 trillion to the US economy.

The tremendous clinical and financial burden of cardiovascular illness has helped motivated policymakers to develop policy tools that have the potential to improve health care quality and curb spending.  Alternative payment models, and specifically bundled payments—lump sum payment for defined episodes of care which typically subsume an inpatient hospitalization and some amount of post-acute care—represent a promising tool for slowing health care spending and improving health care value.

Despite broad interest in implementing bundled payments to achieve these aims, our collective understanding of the effects of bundled payments on .cardiovascular disease care quality and spending, and the factors associated with success under this payment model, are limited.

Medicare’s Bundled Payments of Care Improvement (BPCI) is an ongoing voluntary, national pilot program evaluating bundled payments for 48 common conditions and procedures, including several common cardiovascular conditions and interventions.   In this study, we compared hospitals that voluntarily signed up for the four most commonly subscribed cardiac bundles—those for acute myocardial infarction, congestive heart failure, coronary artery bypass graft surgery, and percutaneous coronary intervention—with surrounding control hospitals in order to gain some insight into the factors driving participation, and to assess whether the hospitals participating in these bundles were broadly representative of a diverse set of U.S. acute care hospitals.  Continue reading

Voluntary Bundled Payment Program For Care After Acute Hospitalization Unable to Achieve Broad Participation

MedicalResearch.com Interview with:

A Jay Holmgren Doctoral Student, Health Policy and Management Harvard Business School

A Jay Holmgren

A Jay Holmgren
Doctoral Student, Health Policy and Management
Harvard Business School

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

Response: Post-acute care, care that is delivered following an acute care hospitalization, is one of the largest drivers of variation in US health care spending.

To address this, Medicare has created several payment reform systems targeting post-acute care, including a voluntary bundled payment program known as the Model 3 of the Bundled Payment for Care Improvement (BPCI) Initiative for post-acute care providers such as skilled nursing facilities, long-term care hospitals, or inpatient rehabilitation facilities. Participants are given a target price for an episode of care which is then reconciled against actual spending; providers who spend under the target price retain some of the savings, while those who spend more must reimburse Medicare for some of the difference.

Our study sought to evaluate the level of participation in this program and identify what providers were more likely to participate. We found that fewer than 4% of eligible post-acute care providers ever participated in the program, and over 40% of those who did participate dropped out. The providers more likely to remain in the program were skilled nursing facilities that were higher quality, for-profit, and were part of a multi-facility organization.

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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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Maryland’s Global Budget Plan Did Not Change Hospital or Primary Care Usage

MedicalResearch.com Interview with:

Eric T. Roberts, PhD Assistant Professor of Health Policy & Management University of Pittsburgh Graduate School of Public Health Pittsburgh, PA 15261

Dr. Roberts

Eric T. Roberts, PhD
Assistant Professor of Health Policy & Management
University of Pittsburgh Graduate School of Public Health
Pittsburgh, PA 15261

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

Response: There is considerable interest nationally in reforming how we pay health care providers and in shifting from fee-for-service to value-based payment models, in which providers assume some economic risk for their patients’ costs and outcomes of care.  One new payment model that has garnered interest among policy makers is the global budget, which in 2010 Maryland adopted for rural hospitals.  Maryland subsequently expanded the model to urban and suburban hospitals in 2014.  Maryland’s global budget model encompasses payments to hospitals for inpatient, emergency department, and hospital outpatient department services from all payers, including Medicare, Medicaid, and commercial insurers.  The intuition behind this payment model is that, when a hospital is given a fixed budget to care for the entire population it serves, it will have an incentive to avoid costly admissions and focus on treating patients outside of the hospital (e.g., in primary care practices).  Until recently, there has been little rigorous evidence about whether Maryland’s hospital global budget model met policy makers’ goals of reducing hospital use and strengthening primary care.

Our Health Affairs study evaluated how the 2010 implementation of global budgets in rural Maryland hospitals affected hospital utilization among Medicare beneficiaries.  This study complements work our research group published in JAMA Internal Medicine (January 16, 2018) that examined the impact of the statewide program on hospital and primary care use, also among Medicare beneficiaries.

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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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Penalties for Readmissions Widens Financial Losses At Delta Safety Net Hospitals

MedicalResearch.com Interview with:

Hsueh-Fen Chen, Ph.D. Associate Professor Department of Health Policy and Management College of Public Health University of Arkansas for Medical Sciences Little Rock, AR 72205

Dr. Chen

Hsueh-Fen Chen, Ph.D.
Associate Professor
Department of Health Policy and Management
College of Public Health
University of Arkansas for Medical Sciences
Little Rock, AR 72205

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

Response: The Centers for Medicare and Medicaid Services announced the Hospital Readmissions Reduction Program (HRRP) and Hospital Value-based Purchasing (HVBP) Program in 2011 and implemented the two programs in 2013. These two programs financially motivate hospitals to reduce readmission rates and improve quality of care, efficiency, and patient experience. The Mississippi Delta Region is one of the most impoverished areas in the country, with a high proportion of minorities occupying in the region.  Additionally, these hospitals are  safety-net resources for the poor. It was largely unknown what the financial performance for the hospitals in the Mississippi Delta Region was under the HRRP and HVBP programs.

Dr. Chen and colleagues in the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences compared the financial performance between Delta hospitals and non-Delta hospitals (namely, other hospitals in the nation) from 2008 through 2014 that were covered before and after the implementation of the HRRP and HVBP programs. The financial performance was measured by using the operating margin (profitability from patient care) and total margin (profitability from patient care and non-patient care)

Before the implementation of the HRRP and HVBP programs, Delta hospitals had weaker financial performance than non-Delta hospitals but their differences were not statistically significant. After the implementation of the HRRP and HVBP programs, the gap in financial performance between Delta and non-Delta hospitals became wider and significant. The unadjusted operating margin for Delta hospitals was about -4.0% in 2011 and continuously fell to -10.4% in 2014, while the unadjusted operating margin for non-Delta hospitals was about 0.1% in 2011 and dropped to -1.5% in 2014. The unadjusted total margin for Delta hospitals significantly fell from 3.6% in 2012 to 1.1% in 2013 and reached 0.2% in 2014, while the unadjusted total margin for non-Delta hospitals remained about 5.3% from 2012 through 2014. After adjusting hospital and community characteristics, the difference in financial performance between Delta and non-Delta remained significant.

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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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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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Low Uptake of Medicare Obesity Counseling Benefit

MedicalResearch.com Interview with:

John A. Batsis, MD, FACP, AGSF Associate Professor of Medicine and The Dartmouth Institute Geisel School of Medicine at Dartmouth Section of General Internal Medicine - 3M Dartmouth-Hitchcock Medical Center Lebanon, NH

Dr. John Batsis

John A. Batsis, MD, FACP, AGSF
Associate Professor of Medicine and The Dartmouth Institute
Geisel School of Medicine at Dartmouth
Section of General Internal Medicine – 3M
Dartmouth-Hitchcock Medical Center
Lebanon, NH

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

Response: In 2011, the Centers for Medicare and Medicaid implemented a regulatory coverage benefit to cover 22 brief, targeted 15-minute counseling visits by clinicians over the course of a 12-month period for Medicare beneficiaries with a body mass index exceeding 30kg/m2. This was an important policy determination in tackling the obesity epidemic in the United States. An emphasis on the importance of counseling, or intensive behavioral therapy, in a primary care setting set the foundation for this benefit.

Yet, it was unclear how and if this benefit (which would be free of charge without a copay or deductible for beneficiaries) was being implemented in clinical care. We therefore identified fee-for-service Medicare claims for the years 2012 and 2013 to determine whether the G0477 code (Medicare Obesity benefit code) was billed. We additionally explored the rate of uptake of the Medicare benefit in relation to the prevalence of obesity using the 2012 Behavior Risk Factor Surveillance System data.

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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