Centers For Medicare Research Articles

Utilising the New Technology Add-on Payment (NTAP): Improving Medicare-insured patients’ access to innovative therapeutics

Andexanet alfa (Andexxa) is the first reversal agent for direct factor Xa inhibitors. It qualified as a new, novel therapeutic for the New Technology Add-on Payment (NTAP) reimbursement from the Centers for Medicare and Medicaid Services (CMS) in October 2018. This paper is the first analysis of a healthcare system (HCS) reporting its implementation and utilisation of the NTAP for a new therapeutic. The number of patients treated with Andexxa at the level 1 trauma centre of southern New Jersey, Cooper University Hospital (CUH) was analysed. This paper highlights the successful implementation of Andexxa as a treatment option for (non)traumatic intracranial haemorrhage and acute, nongastrointestinal haemorrhage requiring surgical management at CUH. This paper looked at how well CUH obtained the Andexxa NTAP from CMS for Medicare patients. During the 4-year reimbursement period, CUH treated a total of 88 patients with Andexxa, of which 53 were Medicare patients treated before the expiry of the Andexxa NTAP. The study found that CUH received NTAP for 81 per cent of Andexxa-treated Medicare patients and that CUH received the maximal NTAP amount of US$18,281.25 for 43 per cent of those same patients. The paper discusses how a large trauma centre implemented and received the NTAP for Andexxa and evaluates the effect of cost on reimbursement amounts during the Andexxa NTAP period. Finally, this paper should help healthcare providers, stakeholders and administrators better understand the process through which to obtain NTAP reimbursements from CMS and improve their HCS with new, innovative therapies for their patients.

Identifying states for targeted alloHCT access initiatives using social vulnerability, physician density, and unmet need.

1528 Background: Access to allogeneic hematopoietic cell transplantation (alloHCT) is limited by many factors, with only 1 in 3 patients who may need a transplant receiving one. This study examined associations between social vulnerability index (SVI), physician density (PD), and alloHCT unmet need across the United States (U.S.) to identify geographic areas that may be most at-risk of access challenges. Methods: A retrospective analysis aggregated public data across 3,141 U.S. counties, including: SVI [Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry]; National Provider Identifier [Center for Medicare and Medicaid Services] data for all registered hematology-oncology and HCT physicians; and 2017 – 2021 alloHCT unmet need [Center for International Blood and Marrow Transplant Research (CIBMTR), NMDP]. PD was defined as providers per 10,000 population. All variables were collapsed into ordinal categories (very low, low, moderate, high) based on quartiles. Counties with moderate/high SVI and unmet need and low/very low PD were defined as at-risk. By state, linear regression and mediation analysis assessed exploratory relationships. Results: Among 396 counties defined as at-risk, top states are shown (Table). State (n=51) percent unmet need was correlated with SVI (r=0.494, p<0.001) and PD (r=-0.295, p=0.036). Univariate analysis revealed SVI (b=-0.223, p<0.001) and PD (b=-0.187, p=0.036) as predictors of unmet need. However, multivariate regression showed only SVI as significant when included with PD. Race/ethnicity as 1 of 4 SVI subthemes (socioeconomic status [SES], household characteristics [including age], race/ethnicity, and housing/transportation) was not correlated with PD, but all other themes were. SES and household characteristics were found to fully mediate the relationship between PD and unmet need. Conclusions: This study can help prioritize targeted initiatives through a better understanding of how SVI, PD, and unmet need relate to alloHCT access. This study cannot draw causal conclusions and uses multiple population-level data sources. However, data can examine trends on a regional level within at-risk states to allocate resources to overcome barriers to alloHCT, with special attention on SES and household factors like age. Relationships between variables should be further examined. [Table: see text]

Patient reported outcomes among U.S. Veterans living with myeloproliferative neoplasms.

e18528 Background: Myeloproliferative Neoplasms (MPNs) profoundly affect patients' well-being, necessitating effective symptom relief. Patient-reported outcomes are pivotal for care improvement, aligning with Centers for Medicare and Medicaid Services priorities. This study aims to assess MPN symptom burden among U.S. Veterans, examining risk levels, thrombo-hemorrhagic complications, medication use, information access, care, and service-connected benefits. Methods: Conducted as a cross-sectional survey from December 1, 2023, - January 22, 2024, all Veterans in the MPN Advocacy Education & International database were recruited. Symptom burden was assessed using the validated MPN Symptom Assessment Form Total Symptom Score (MPN SAF TSS), with descriptive statistics and T-tests employed for analysis. Results: Of 61 respondents, 88% were male, 92% Caucasian, 88% served during the Vietnam war. The mean age was 73±7, with MPN diagnosis at 64±9 and a mean duration of 44±10 years from service-connected exposure. Key findings included 56% Polycythemia Vera, 26% Essential Thrombocythemia, 16% Primary Myelofibrosis, 70% JAK2, 10% CALR, 3% MPL, 14% unaware of their mutation status, and 34% unaware of MPN risk status. Seventeen (28%) underwent phlebotomy, 64% used Hydroxyurea, 29% Ruxolitinib, and 3% Interferon. Fatigue and itching were the predominant and severe symptoms (Table), with 43% reporting no symptom improvement. Mean MPN SAF TSS of all respondents was higher than prior study by Emanuel et.al. which adjusted for MPN subtype (36.4 vs. 21.6, p<0.0001). Twelve (20%) reported bleeding and 10% reported venous thrombosis after MPN diagnosis, while 13% reported arterial thrombosis before MPN diagnosis. Twenty-two (36%) are not seeing an MPN specialist and 61% are not seeing a hematologist at their local Veterans Affairs Medical Centers. Twenty-three (38%) did not seek a second opinion while 43% do not have a caregiver. Respondents turn to MPN organizations (75%), physician offices (74%), Google Search (49%), Webinars (41%), and Facebook (23%) for information. Five (8%) received service-connected disability benefits. Conclusions: Veterans with MPNs endure a substantial symptom burden, surpassing previous studies, signifying suboptimal management. Limited access to care persists, necessitating enhanced support. However, self-reporting bias and potential limitations in activity assessment must be acknowledged. Efforts to enhance MPN awareness, specialized care, and support mechanisms are imperative for comprehensive management. [Table: see text]

Medicare medication therapy Management: Beneficiary characteristics and utilization patterns in a national CMS Medicare fee-for-service sample (2013 to 2016)

BackgroundThe Medicare Medication Therapy Management (MTM) program has been available to eligible Medicare Part D beneficiaries since 2006, but research regarding program utilization and characterization is limited. ObjectiveTo describe enrollee and MTM program characteristics in a national sample of Medicare fee-for-service (FFS) beneficiaries (2013 to 2016). MethodsUsing a 5% random sample of Medicare FFS beneficiaries, we conducted a descriptive time series analysis to examine annual MTM enrollment and describe the type of MTM criteria at enrollment (Center for Medicare and Medicaid Services [CMS] vs. expanded). We investigated the offer of Comprehensive Medication Review (CMR) along with CMR receipt status, and delivery characteristics, as well as frequencies of Target Medication Reviews (TMRs). ResultBeneficiaries who met CMS enrollment criteria, compared to those eligible under expanded criteria, were significantly older, more likely to be of white race, more likely to be female, and had a significantly higher number of comorbidities. Of those meeting CMS criteria, the proportion receiving TMR increased from 95% in 2013% to 98.1% in 2016, and over 97% were offered a CMR. Although the proportion of beneficiaries offered a CMR was stable over the study period, the proportion who received a CMR increased from 17% in 2013% to 35.4% in 2016. Telephone CMR delivery was the most common method used (87.8% to 89.1% of CMRs over the study period). Over 95% of the CMRs were delivered by a pharmacist. ConclusionDuring the years 2013 to 2016, enrollment in the MTM program increased, as did the proportion of enrollees receiving TMRs and CMRs. However, uptake remained low and the main factors driving participation remain unclear. Significant differences in demographic characteristics between beneficiaries enrolled under the CMS MTM enrollment criteria and the expanded criteria suggest the need to further investigate the optimal provision of such programs.

Generic entry and effect of market competition on outpatient pharmacy drug prices

This study assessed the impact of generic drug market competition on prices, accessibility, and savings. It analyzed delays in generic drug market entry and the effect of competition on the price trends of outpatient pharmacy drugs facing generic competition from 2013 to 2018. Data were extracted from the FDA website, including a list of new generic drugs, and from the Centers for Medicare and Medicaid Services, including National Average Drug Acquisition Cost (NADAC) and Average Manufacturer Price (AMP). Descriptive and time-series analyses were conducted. On average, generic drugs entered the market 8.4 months after FDA approval and 16.6 years after the initial FDA approval of the brand-name drugs. The median NADAC price of generic drugs was 65.7% of the brand-name drugs’ price at market entry and decreased to 26.0% after three years. The median brand-name drug NADAC price increased by 1.0% per month before generic entry, remained stable during the generic entry period, and increased by 0.4% per month afterwards. Generic competition not only lowered drug prices but also influenced brand-name drug price trends both before and after generic entry. The price reductions from generic competition exceeded previous estimates that only compared prices at the time of generic market entry.

Trends in hospital price transparency after implementation of the CMS Final Rule.

To assess trends in hospital price disclosures after the Centers for Medicare & Medicaid Services (CMS) Final Rule went into effect. The Turquoise Health Price Transparency Dataset was used to identify all US hospitals that publicly displayed pricing from 2021 to 2023. Price-disclosing versus nondisclosing hospitals were compared using Pearson's Chi-squared and Wilcoxon rank sum tests. Bayesian structural time-series modeling was used to determine if enforcement of increased penalties for nondisclosure was associated with a change in the trend of hospital disclosures. Not applicable. As of January 2023, 5162 of 6692 (77.1%) US hospitals disclosed pricing of their services, with the majority (2794 of 5162 [54.1%]) reporting their pricing within the first 6 months of the final rule going into effect in January 2021. An increase in hospital disclosures was observed after penalties for nondisclosure were enforced in January 2022 (relative effect size 20%, p = 0.002). Compared with nondisclosing hospitals, disclosing hospitals had higher annual revenue, bed number, and were more likely to be have nonprofit ownership, academic affiliation, provide emergency services, and be in highly concentrated markets (p < 0.001). Hospital pricing disclosures are continuously in flux and influenced by regulatory and market factors.

Demographic and Systemic Risk Factors for Persistent Corneal Edema Following Cataract Surgery in Patients With and Without Diabetes

PurposeTo identify risk factors associated with the development of corneal edema (CE) and the need for corneal transplantation following cataract surgery. DesignRetrospective cohort study. MethodsSetting: Nation-wide sample of Medicare beneficiaries from 2011-2015. Study PopulationMedicare beneficiaries aged over 65 years who received cataract surgery between 2011-2014 with at least 1 year of continuous follow-up. Data was retrieved from the Denominator and Physician Supplier Part B file from the Center for Medicare and Medicaid Services. Main Outcome(s) and Measure(s)The main outcome was the association between demographic characteristics (e.g. age, sex, race/ethnicity) and systemic factors including diabetes status, hypertension, and tobacco use on the incidence of CE and the subsequent need for corneal transplantation following cataract surgery. ResultsAmong 187,746 beneficiaries, 67,734 had diabetes and 120,012 did not. Beneficiaries with diabetes were more likely to develop CE compared to those without (Odds ratio [OR] 1.19, 95% Confidence Interval [CI] [1.02-1.40]). Compared to those aged 65-74, beneficiaries aged 75-84 and over 85 were more likely to develop CE (OR 1.29 [1.09-1.52]) and OR 1.96 [1.55-2.46], respectively). Asian (OR 2.42 [1.66-3.40]), Hispanic (OR 2.60 [1.73-3.74]), and North American Native (OR 3.59 [1.78-6.39]) race was associated with increased likelihood of developing CE. North American Native beneficiaries had higher risk of requiring corneal transplantation compared to White beneficiaries (OR 9.30 [2.26-25.31]). Female sex decreased likelihood of requiring corneal transplantation post-operatively (OR 0.56 [0.36-0.87]). Amongst those with diabetes, the presence of proliferative diabetic retinopathy increased the likelihood of developing CE (OR 1.94 [1.05-3.39]). ConclusionOlder age, diabetes, and non-White race elevate the risk of CE following cataract surgery, with race incurring the highest risk. Further research is needed to understand the factors underlying the significantly increased risk of CE in racial and ethnic minorities within the United States.

#365 Dialysis centers performance: socioeconomic and environmental determinants

Abstract Background and Aims Healthcare outcomes in hemodialysis centers are intricately shaped by a myriad of factors extending beyond clinical realms. This study explores the interplay of socioeconomic and environmental determinants on the performance of 7638 hemodialysis centers in the United States during 2022. Leveraging data from the Centers for Medicare &amp; Medicaid Services, the United States Census Bureau, and the National Center for Environmental Information, our analysis encompasses outcomes like mortality, hospitalization, readmission rates, and emergency department visit rates. Method A dataset comprising information from 7638 US hemodialysis centers, spanning January to December 2022, was obtained through the Centers for Medicare &amp; Medicaid Services, US Census Bureau and environmental data, and from the National Center for Environmental Information. The study assessed mortality, hospitalization, readmission, and emergency department visits within one-month post-hospitalization. Independent variables included dialysis center characteristics, state-specific socioeconomic and environmental data, analysed through descriptive statistics and a linear regression model. Results Results reveal a significant correlation between racial composition and outcomes, with states having higher Latino populations exhibiting lower ED visit rates, contrasting with elevated mortality rates in states with higher African American populations. Socioeconomic factors, such as education and insurance status, influence ED visit rates. Environmental determinants, specifically average yearly state temperature, impact mortality and hospitalization rates. Operational characteristics matter: for-profit centres and those providing higher number of hemodialysis bed correlate with decreased mortality rates, while centres offering peritoneal dialysis or late-shift services demonstrate lower emergency department visit rates. Conclusion Our study unveils a nuanced interplay of factors influencing outcomes in hemodialysis centers. Disparities rooted in race and socioeconomic status underscore the need for targeted interventions. Environmental considerations further contribute to the complexity, while operational characteristics reveal intriguing trends, challenging conventional expectations. This analysis provides a foundation for tailored strategies to enhance the performance and equity of hemodialysis centers.

Advancing Access to Cell and Gene Therapies in Medicaid

This Viewpoint presents the components of the payment model and the implementation challenges among the Center for Medicare and Medicaid Innovation, state Medicaid agencies, patients, and manufacturers.

Estimating the size and scope of the academic emergency physician workforce.

Academic emergency medicine (EM) is foundational to the EM specialty through the development of new knowledge and clinical training of resident physicians. Despite recent increased attention to the future of the EM workforce, no evaluations have specifically characterized the U.S. academic EM workforce. We sought to estimate the national proportion of emergency physicians (EPs) identified as academic and the proportion of emergency department (ED) visits that take place at academic sites. We performed a cross-sectional analysis of EPs and EDs using data from the American Hospital Association, the Centers for Medicare & Medicaid Services, and Doximity's Residency Navigator. EPs were identified as "academic" if they were affiliated with at least one facility determined to be academic, defined as EDs officially designated by the Accreditation Council for Graduate Medical Education (ACGME) as clinical training sites at accredited EM residency programs. Our primary outcomes were to estimate the national proportion of EPs identified as academic and the proportion of ED visits performed at academic sites. Our analytic sample included 26,937 EPs practicing clinically across 4920 EDs and providing care during 130,471,386 ED visits. Among EPs, 11,720 (43.5%) were identified as academic, and among EDs, 635 (12.9%) were identified as academic sites, including 585 adult/general sites, 45 pediatric-specific sites, and 10 sites affiliated with the Department of Veterans Affairs. In 2021, academic EDs provided care for 42,794,106 ED visits or 32.8% of all ED visits nationally. Approximately four in 10 EPs practice in at least one clinical training site affiliated with an ACGME-accredited EM residency program, and approximately one in three ED visits nationally occur in these academic EDs. We encourage further work using alternative definitions of an academic EPs and EDs, along with longitudinal research to identify trends in the workforce's composition.

Do Postsurgical Follow-Up Calls Reduce Unplanned 30-Day Readmissions in Neurosurgery Patients? A Quality Improvement Project in a University Hospital

Unplanned 30-day readmissions after surgery are a source of patient dissatisfaction, monitored by the Centers for Medicare and Medicaid Services, have financial penalties for hospitals and are publicly reported. Neurosurgical operations unfortunately have a higher 30-day unplanned readmission rate after the index discharge than other specialties. After a simple initiative for a 48-72-hour post discharge phone call, there was an observed significant drop-in readmission rate from 17% to 8% in 7 months at Thomas Jefferson University. To better understand the role of post operation phone calls for this reduction a retrospective evaluation over a longer period was performed. Assessment of quality improvement initiative using patient records between August 2018 and May 2023. The primary observed subject is the 30-day unplanned readmission rate and secondarily a change in physician communication score. 30-day unplanned readmission rate and physician communication scores before and after the phone call initiative were compared besides checking for difference, variance and correlation. 874 readmissions, average of 28 (95% CI 25.3 - 29.3) per month, 12.9% (95% CI 11.9 - 13.9) before phone call. 673 readmissions, average of 26 (95% CI 23 - 28.8) per month, 12.9% (95% CI 11.6 - 14.1) afterwards. Neither significant difference nor variance of scores or rates, nor correlation of rate with communication score was noted before and after the initiative. Phone calls and peri-discharge efficient communication is needed after neurological surgeries. This approach decreased unplanned readmissions in certain instances while not having a significant impact on neurosurgical patients.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice

Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied. To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services. This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024. Live hospice discharge. Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death. This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions. This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

Statewide Hospital Admissions for Adult Survivors of Infant Surgical Diseases Over a 10-Year Period

IntroductionThe number of patients with congenital disease living to adulthood continues to grow. Often undergoing surgical correction in infancy, they continue to require lifelong care. Their numbers are largely unknown. We sought to evaluate hospital admissions of adult patients with esophageal atresia with tracheoesophageal fistula (EA/TEF), congenital diaphragmatic hernia (CDH), and Hirschsprung disease (HD). MethodsThe Florida Agency for Healthcare Administration inpatient database was merged with the Distressed Communities Index and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets. The dataset was queried for adult patients (≥18 y, born after 1970) with EA/TEF, CDH, and HD in their problem list from 2010 to 2020. Patient demographics, hospitalization characteristics, and discharge information were obtained. ResultsIn total, 1140 admissions were identified (266 EA/TEF, 135 CDH, 739 HD). Patients were mostly female (53%), had a mean age of 31.6 y, and often admitted to an adult internist in a general hospital under emergency. Principal diagnoses and procedures (when performed) varied with diagnosis and age at admission. EA patients were admitted with dysphagia and foregut symptoms and often underwent upper endoscopy with dilation. CDH patients were often admitted for diaphragmatic hernias and underwent adult diaphragm repair. Hirschsprung patients were often admitted for intestinal obstructive issues and frequently underwent colonoscopy but trended toward operative intervention with increasing age. ConclusionsAdults with congenital disease continue to require hospital admission and invasive procedures. As age increases, diagnoses and performed procedures for each diagnoses evolve. These data could guide the formulation of multispecialty disease-specific follow-up programs for these patients.

In-State Retention Rates of Female Neurosurgery Graduates

We sought to determine the rate of retaining female neurosurgery graduates in the same states as their medical education and identify medical school and state characteristics associated with high retention rates. Database from the Centers for Medicare & Medicaid Services was used to extract female physicians indicating "neurosurgery" as their specialty. The top 25 medical schools with the highest number of female neurosurgery graduates were selected. Descriptive analysis was used to determine the retention rate of female neurosurgery graduates. Univariable and multivariable analyses were used to identify medical school and state characteristics associated with high retention rates. Medical schools with the highest retention rate included the University of California, San Francisco (60%), the University of Alabama (60%), and the University of Pennsylvania (60%). Univariable and multivariable analysis showed the number of female neurosurgery attendings (β=0.036, 95% confidence interval [CI]=0.003 to 0.070, P=0.04 and β=0.036, CI=0.001 to 0.071, P=0.04.) and the healthcare employment rate (β=0.098, CI=0.011 to 0.186, P=0.03 and β=0.117, CI=0.021 to 0.212, P=0.02) to be positively associated with the retention rate of female neurosurgery graduates. Retaining female neurosurgery graduates within a state is essential for addressing the physician shortage and gender inequality. To encourage female medical students to practice in the same state, medical schools and states should work collectively to improve the visibility of female neurosurgeons and increase employment opportunities.

Effect of End-Stage Renal Disease Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure

Introduction: The Center for Medicare and Medicaid Services introduced an End-Stage Renal Disease Prospective Payment System (PPS) in 2011 to increase the utilization of home dialysis modalities, including peritoneal dialysis (PD). Several studies have shown a significant increase in PD utilization after PPS implementation. However, its impact on patients with kidney allograft failure remains unknown. Methods: We conducted an interrupted time series analysis using data from the US Renal Data System (USRDS) that include all adult kidney transplant recipients with allograft failure who started dialysis between 2005 and 2019. We compared the PD utilization in the pre-PPS period (2005–2010) to the fully implemented post-PPS period (2014–2019) for early (within 90 days) and late (91–365 days) PD experience. Results: A total of 27,507 adult recipients with allograft failure started dialysis during the study period. There was no difference in early PD utilization between the pre-PPS and the post-PPS period in either immediate change (0.3% increase; 95% CI: −1.95%, 2.54%; p = 0.79) or rate of change over time (0.28% increase per year; 95% CI: −0.16%, 0.72%; p = 0.18). Subgroup analyses revealed a trend toward higher PD utilization post-PPS in for-profit and large-volume dialysis units. There was a significant increase in PD utilization in the post-PPS period in units with low PD experience in the pre-PPS period. Similar findings were seen for the late PD experience. Conclusion: PPS did not significantly increase the overall utilization of PD in patients initiating dialysis after allograft failure.

Calculation of Overall Hospital Quality Star Ratings With and Without Inclusion of the Peer Grouping Step.

The Centers for Medicare & Medicaid Services (CMS) Overall Star Rating is widely used by patients and consumers, and there is continued stakeholder curiosity surrounding the inclusion of a peer grouping step, implemented to the 2021 Overall Star Rating methods. To calculate hospital star rating scores with and without the peer grouping step, with the former approach stratifying hospitals into 3-, 4-, and 5-measure group peer groups based on the number of measure groups with at least 3 reported measures. This cross-sectional study used Care Compare website data from January 2023 for 3076 hospitals that received a star rating in 2023. Data were analyzed from April 2023 to December 2023. Peer grouping vs no peer grouping. The primary outcome was the distribution of star ratings, with 1 star being the lowest-performing hospitals and 5 stars, the highest. Analyses additionally identified the number of hospitals with a higher, lower, or identical star rating with the use of the peer grouping step compared with its nonuse, stratified by certain hospital characteristics. Among 3076 hospitals that received a star rating in 2023, most were nonspecialty (1994 hospitals [64.8%]), nonteaching (1807 hospitals [58.7%]), non-safety net (2326 hospitals [75.6%]), non-critical access (2826 hospitals [91.9%]) hospitals with fewer than 200 beds (1822 hospitals [59.2%]) and located in an urban geographic designations (1935 hospitals [62.9%]). The presence of the peer grouping step resulted in 585 hospitals (19.0%) being assigned a different star rating than if the peer grouping step was absent, including considerably more hospitals receiving a higher star rating (517 hospitals) rather than a lower (68 hospitals) star rating. Hospital characteristics associated with a higher star rating included urbanicity (351 hospitals [67.9%]), non-safety net status (414 hospitals [80.1%]), and fewer than 200 beds (287 hospitals [55.6%]). Collectively, the presence of the peer grouping step supports a like-to-like comparison among hospitals and supports the ability of patients to assess overall hospital quality. In this cross-sectional study, inclusion of the peer grouping in the CMS star rating method resulted in modest changes in hospital star ratings compared with application of the method without peer grouping. Given improvement in face validity and the close association between the current peer grouping approach and stakeholder needs for peer-comparison, the current CMS Overall Star Rating method allows for durable comparisons in hospital performance.

Verification of Death by Neurologic Criteria: A Survey of 12 Organ Procurement Organizations Across the United States.

The Center for Medicare and Medicaid Services requires Organ Procurement Organizations (OPOs) to verify and document that any potential organ donor has been pronounced dead per applicable legal requirements of local, state, and federal laws. However, OPO practices regarding death by neurologic criteria (DNC) verification are not standardized, and little is known about their DNC verification processes. This study aimed to explore OPO practices regarding DNC verification in the United States. An electronic survey was sent to all 57 OPOs in the United States from June to September 2023 to assess verification of policies and practices versus guidelines, concerns about policies and practices, processes to address concerns about DNC determination, and communication practices. Representatives from 12 OPOs across six US regions completed the entire survey; 8 of 12 reported serving > 50 referral hospitals. Most respondents (11 of 12) reported comparing their referral hospital's DNC policies with the 2010 American Academy of Neurology Practice Parameter and/or other (4 of 12) guidelines. Additionally, most (10 of 12) reported independently reviewing and verifying each DNC determination. Nearly half (5 of 12) reported concerns about guideline-discordant hospital policies, and only 3 of 12 thought all referral hospitals followed the 2010 American Academy of Neurology Practice Parameter in practice. Moreover, 9 of 12 reported concerns about clinician knowledge surrounding DNC determination, and most (10 of 12) reported having received referrals for patients whose DNC declaration was ultimately reversed. All reported experiences in which their OPO requested additional assessments (11 of 12 clinical evaluation, 10 of 12 ancillary testing, 9 of 12 apnea testing) because of concerns about DNC determination validity. Accurate DNC determination is important to maintain public trust. Nearly all OPO respondents reported a process to verify hospital DNC policies and practices with medical society guidelines. Many reported concerns about clinician knowledge surrounding DNC determination and guideline-discordant policies and practices. Educational and regulatory advocacy efforts are needed to facilitate systematic implementation of guideline-concordant practices across the country.

Funding of evidence included within public comments submitted to inform Medicare national coverage determinations.

The Centers for Medicare & Medicaid Services (CMS) relies on public comments submitted in response to proposed national coverage determinations to assist the agency in determining the coverage of items and services for Medicare beneficiaries. In a cross-sectional study, we characterized the cited evidence and what funding supported the cited evidence submitted in public comments to CMS for all therapeutic medical device national coverage determinations finalized between June 2019 and June 2022. Of 681 public comments, 159 (23%) cited at least 1 identifiable published scientific journal article. Within these 159 public comments, 198 unique articles were cited, 170 (86%) of which included funding statements or author disclosures. Among these, 96 (56%) disclosed funding from manufacturers that would benefit from Medicare coverage and/or were written by author(s) who received funding from these manufacturers. In summary, most public commenters for national coverage determinations did not cite published scientific journal articles to support their positions. Among those who did, more than half of articles were directly funded by manufacturers that would benefit from coverage. Greater funding of independent, non-industry-supported research may help provide unbiased evaluations of benefits and harms to support Medicare coverage decisions.

Tennessee hospital noncompliance with price transparency legislation for 8 common laboratory tests.

The goal of this study was to assess hospital compliance with federal price transparency mandates and barriers to pricing information in Tennessee. All hospitals websites were queried for gross, cash, and BlueCross BlueShield of Tennessee prices for 8 high-frequency laboratory tests in 2 Centers for Medicare & Medicaid Services-mandated pricing sources: (1) a machine-readable file of all available services and (2) a consumer-friendly display of 300 shoppable services. Barriers, including click counts, data availability, and intrahospital price discrepancies, were noted. Of the 145 Tennessee hospitals assessed, 97.2% were noncompliant with the Centers for Medicare & Medicaid Services final rule. Subanalysis of available machine-readable files, price estimators, and shoppable services files demonstrated 49.6%, 95.1%, and 78.6% noncompliance, respectively. Barriers to pricing information included requiring protected health information (55.9%), missing at least 1 pricing source (7.6%), having no pricing sources available (6.2%), and involving more than 3 clicks to access the cash price in machine-readable files (54.1%) and price estimators (68.6%.) Average intrahospital discrepancy for basic metabolic panel cash prices across pricing sources was $101.30 (range, $0-1012.40). Our study showed high levels of noncompliance with price transparency laws, inconsistent and inaccessible pricing, and continued challenges facing patients in Tennessee.

Best Practices in Documenting and Coding High-Value Care in Workers' Compensation Encounters-ACOEM Guidance Statement.

Workers' compensation outpatient care requires attention to causation, functional assessment, work disability prevention, and return-to-work planning, elements not usually addressed in other types of outpatient encounters. Because these elements of care deviate from the usual pattern of ambulatory services, providers of workers' compensation care have faced challenges in billing and auditing practices resulting in underpayment when providing high-value care based on evidence-based guidelines. Recent changes in Centers for Medicare & Medicaid Services rules on documentation requirements for coding outpatient evaluation and management encounters offer an opportunity for occupational health clinicians to be paid appropriately for care that follows occupational medicine practice guidelines. There remains a need to define the elements of documentation that should be expected in delivering high-value workers' compensation care. This article provides guidance for documenting high-value workers' compensation care.