To reduce episode spending for twenty-nine predefined clinical conditions, the Centers for Medicare and Medicaid Services (CMS) implemented the voluntary Bundled Payments for Care Improvement (BPCI) ...Advanced Model program in 2018. Under this program, hospitals gain or lose revenue depending on their episode spending relative to target prices set by CMS. The relationship between target prices and hospital participation in BPCI Advanced is unknown, as are the financial implications for CMS. Using Medicare claims, we estimate that each $1,000 increase in target prices increased the probability of participation by 0.78 percentage points across all episodes. We then used Medicare claims before the start of BPCI Advanced to evaluate mean reversion, or the tendency for episode spending at individual hospitals to move closer to average episode spending over time, especially for hospitals having higher target prices. Hospitals with spending that was 10 percent more than target prices at baseline could expect spending to decline by 7.43 percent in the performance period, hospitals with spending that was 20 percent more saw spending decline by 9.80 percent, and hospitals with spending that was 30 percent more saw spending decline by 11.93 percent. Our findings suggest that CMS will end up paying substantial bonuses to hospitals that resulted from mean reversion rather than from meaningful reductions in costs.
IMPORTANCE: Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills (“surprise bills”) from out-of-network clinicians they did not choose. ...In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. OBJECTIVE: To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair 116 749; laparoscopic cholecystectomy 82 372; hysterectomy 67 452; total knee replacement 42 313; breast lumpectomy 18 018; colectomy 14 074; coronary artery bypass graft surgery 6378) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. EXPOSURE: Patient, clinician, and insurance factors potentially related to out-of-network bills. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. RESULTS: Among 347 356 patients (mean age, 48 SD, 11 years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% 95% CI, 3.9%-8.9%; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% 95% CI, 5.8%-8.8%; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. CONCLUSIONS AND RELEVANCE: In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.
To evaluate severe complications and mortality over years of independent practice among general surgeons.
Despite concerns that newly graduated general surgeons may be unprepared for independent ...practice, it is unclear whether patient outcomes differ between early and later career surgeons.
We used Medicare claims for patients discharged between July 1, 2007 and December 31, 2019 to evaluate 30-day severe complications and mortality for 26 operations defined as core procedures by the American Board of Surgery. Generalized additive mixed models were used to assess the association between surgeon years in practice and 30-day outcomes while adjusting for differences in patient, hospital, and surgeon characteristics.
The cohort included 1,329,358 operations performed by 14,399 surgeons. In generalized mixed models, the relative risk (RR) of mortality was higher among surgeons in their first year of practice compared with surgeons in their 15th year of practice 5.5% (95% CI: 4.1%-7.3%) vs 4.7% (95% CI: 3.5%-6.3%), RR: 1.17 (95% CI: 1.11-1.22). Similarly, the RR of severe complications was higher among surgeons in their first year of practice compared with surgeons in their 15th year of practice 7.5% (95% CI: 6.6%-8.5%) versus 6.9% (95% CI: 6.1%-7.9%), RR: 1.08 (95% CI: 1.03-1.14). When stratified by individual operation, 21 operations had a significantly higher RR of mortality and all 26 operations had a significantly higher RR of severe complications in the first compared with the 15th year of practice.
Among general surgeons performing common operations, rates of mortality and severe complications were higher among newly graduated surgeons compared with later career surgeons.
Comprehensive Primary Care Plus (CPC+) was a multipayer payment reform model that provided incentives for primary care practices to lower spending and improve quality performance. Although CPC+ has ...been evaluated in Medicare, little is known about its impact in the private sector. Using claims and enrollment data from the period 2013-20 from two large insurers in Michigan, we performed difference-in-differences analyses and found that CPC+ was not associated with changes in total spending (-$44.70 per year) or overall quality performance (-0.1 percentage point). These changes did not vary systematically across CPC+ cohorts, tracks, regions, or participation in prior primary care innovations. We conclude that CPC+ did not improve spending or quality for private-plan enrollees in Michigan, even before accounting for payouts to providers. This analysis adds to existing evidence that CPC+ may cost payers money in the short term, without concomitant improvements to care quality.
Objective
To determine the relationship between Medicare's site‐based outpatient billing policy and hospital‐physician integration.
Data sources
National Medicare claims data from 2010 to 2016.
Study ...Design
For each physician‐year, we calculated the disparity between Medicare reimbursement under hospital ownership and under physician ownership. Using logistic regression analysis, we estimated the relationship between these payment differences and hospital‐physician integration, adjusting for region, market concentration, and time fixed effects. We measured integration status using claims data and legal tax names.
Data Collection
The study included integrated and non‐integrated physicians who billed Medicare between January 1, 2010, and December 31, 2016 (n = 2 137 245 physician‐year observations).
Principal Findings
Medicare reimbursement for physician services would have been $114 000 higher per physician per year if a physician were integrated compared to being non‐integrated. Primary care physicians faced a 78% increase, medical specialists 74%, and surgeons 224%. These payment differences exhibited a modest positive relationship to hospital‐physician vertical integration. An increase in this outpatient payment differential equivalent to moving from the 25th to 75th percentile was associated with a 0.20 percentage point increase in the probability of integrating with a hospital (95% CI: 0.0.10‐0.30). This effect was slightly larger among primary care physicians (0.27, 95% CI: 0.18 to 0.35) and medical specialists (0.26, 95% CI: 0.05 to 0.48), while not significantly different from zero among surgeons (−0.02; 95% CI: −0.27 to 0.22).
Conclusions
The payment differences between outpatient settings were large and grew over time. Even routine annual outpatient payment updates from Medicare may prompt some hospital‐physician vertical integration, particularly among primary care physicians and medical specialists.
Ankylosing spondylitis (AS) is an autoimmune disorder with a strong genetic risk, especially with HLA-B27. Clinical testing for HLA-B27 has been used to help diagnose patients with signs and symptoms ...of AS. Testing methods used by clinical laboratories for HLA-B27 fall into the broad categories of serologic/antibody- or molecular-based methods and have evolved over time. The College of American Pathologists (CAP) offers a proficiency testing survey for HLA-B27.
To analyze HLA-B27 testing trends and their performance in the past decade, using the proficiency testing survey data submitted to CAP.
We analyzed the HLA-B27 CAP proficiency testing data from 2010 to 2020 for the method used, participant concordance, and error rates. Results from case scenarios to understand evolving scientific data around HLA-B27 risk alleles were also analyzed.
Antibody-based flow cytometry is the most common method, though it has decreased from 60% in 2010 to 52% in 2020, with a corresponding increase in molecular methods. Among the molecular methods, real-time polymerase chain reaction has increased from 2% to 15%. Flow cytometry had the highest error rate (5.33%), and sequence-specific oligonucleotide (0%) is the most accurate (0%). Results of case scenarios demonstrated that most participants understood that allele-level HLA-B27 typing results inform clinical interpretation, for example HLA-B*27:06 is not associated with AS.
These data demonstrated the changing trends for HLA-B27 testing during the past decade. HLA-B27 allelic typing provides a better understanding of AS association. This is possible by testing for the second field with methods like next-generation sequencing.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
OBJECTIVE:To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery.
BACKGROUND:ACOs have proliferated ...rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown.
METHODS:We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach.
RESULTS:Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments difference-in-differences estimate=-$72, confidence interval (CI95%)-$228 to +$84 or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates.
CONCLUSION:Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.
Objective
To test the effect of hospital‐physician integration on primary care physicians' (PCP) clinical volume in traditional Medicare.
Data Sources and Study Setting
Nationwide retrospective ...longitudinal study using Medicare claims and other data sources from 2010 to 2016.
Study Design
We identified 70,000 PCPs, some of whom remained non‐integrated and some who became hospital‐integrated during this study period. We used an event study design to identify the effect of integration on key measures of physicians' clinical volume, including the number of claims, work‐relative value units (RVUs), professional revenue generated, number of patients treated, and facility fee revenue generated.
Principal Findings
Per‐physician clinical volume declined by statistically and economically significant margins. Relative to the comparison group who remained non‐integrated, work RVUs fell by 7% (95% confidence interval CI: −8.6% to −5.5%); the number of patients treated fell by 4% (95% CI: −5.8% to −2.6%); and claims volume among PCPs who became hospital‐integrated fell by over 15% (95% CI: −16.8% to −13.5%). Though professional revenue declined by $29,165 (95% CI: −$32,286 to −$26,044), this loss was almost entirely offset by increased facility fee revenue of $28,556 (95% CI: 26,909 to 30,203).
Conclusions
Hospital‐physician integration may affect the quantity of clinical services delivered by PCPs to traditional Medicare beneficiaries. Reductions in clinical volume associated with integration may have long‐term consequences for the supply of physician services and patient access to primary care. Future research on physician time use and patient access following hospital integration would further add to the evidence base.
OBJECTIVE:To assess whether a hospitalʼs percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and ...penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed.
SUMMARY OF BACKGROUND DATA:In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need.
METHODS:100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients.
RESULTS:A total of 695,775 patients from 2923 hospitals were included. As a hospitalʼs percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR 95% CI1.451.42–1.47). Similar patterns were observed for high disproportionate share hospital (OR 95% CI1.44 1.42–1.47; absolute difference+7.4 percentage-points) and low socioeconomic status-serving (1.381.35–1.40; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points.
CONCLUSIONS:Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.
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