Centers For Medicare Research Articles

Geographic trends in overall and long-acting opioid prescriptions under Medicaid and Medicare Part D in the United States, 2013–2021

ABSTRACT Background: Amid the national opioid epidemic, it is important to assess trends in opioid prescriptions. Long-acting opioids (LAOs) are of particular interest as they are among the most intensely misused prescription opioids. Moreover, understanding geographic trends in opioid prescriptions may help identify state-level variations, illustrating state-specific disparities. Objectives: The study aims to determine geographic trends in overall and LAO prescriptions under Medicaid and Medicare Part D from 2013 to 2021. Methods: We used data from the Centers for Medicare & Medicaid Services on opioid prescriptions from 2013 to 2021. The opioid prescribing proportion was calculated as the number of opioid claims divided by the total number of overall drug claims. The LAO prescribing proportion was calculated as number of LAO claims divided by total opioid claims. Results: Despite a general decrease nationwide, Medicaid opioid prescribing proportions increased in Iowa, Montana, and Virginia. There was an increasing trend in the national-level Medicaid LAO prescribing proportion from 2017 to 2021, with a 14.1% point increase (p for the annual percent change [APC]<0.05). For Medicare Part D, the overall prescribing proportions fell by 1.7% points from 2013 to 2021, while the LAO prescribing proportion fell by 3% points from 2016 to 2021 (p for APC < .05). Conclusions: The increasing trends in national-level Medicaid LAO prescribing and Medicaid opioid prescribing in Iowa, Montana, and Virginia are concerning, and have implications for clinical opioid prescribing. The decreasing trends in Medicare Part D may reflect ongoing efforts in opioid prescription management.

The Decline of Medicare Reimbursement in Anatomic Pathology

Abstract Introduction/Objective Lack of an annual inflationary update for physician reimbursement from the Centers for Medicare &amp; Medicaid Services (CMS) jeopardizes access to anatomic pathology services at healthcare institutions nationwide. The effects of recent inflationary trends on anatomic pathology physician reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2004 to 2024 for anatomic pathology procedures. Methods/Case Report The Physician Fee Schedule Look-Up Tool from the CMS was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the Consumer Price Index and reported in 2024 US dollars. The average annual and total percent change in reimbursement were calculated for included procedures. The compound annual growth rate (CAGR) was calculated using 2024 and 2000 inflation-adjusted monetary data. Results (if a Case Study enter NA) Prior to adjusting for inflation, the average physician reimbursement increased by 9.7% from 2004 to 2024 for all included anatomic pathology CPT codes. After adjusting for inflation, the average physician reimbursement decreased by 34.2% for included CPT codes. The greatest decrease in reimbursement observed from 2004 to 2024 was for outside slide consultation at 60.5% ($330.12 to $130.49), followed by pathology consultation during surgery at 59.0% ($83.54 to $34.29). The average CAGR was -2.19%. Conclusion Our study demonstrates that Medicare physician reimbursement for common anatomic pathology procedures is declining annually at an unsustainable rate. This downward trend necessitates policy action to prevent access barriers to quality anatomic pathology care nationwide, especially for Medicare beneficiaries.

The Decline of Medicare Reimbursement in Clinical Pathology

Abstract Introduction/Objective Access to clinical pathology services nationwide is threatened by the lack of an annual inflationary update for physician reimbursement from the Centers for Medicare &amp; Medicaid Services (CMS). Most recently, the 2024 Medicare Physician Fee Schedule (MPFS) implemented an overall 2.0% reduction in pathology reimbursement. The effects of recent inflationary trends on clinical pathology physician reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2004 to 2024 for clinical pathology procedures. Methods/Case Report The Physician Fee Schedule Look-Up Tool from the CMS was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the Consumer Price Index and reported in 2024 US dollars. The average annual and total percent change in reimbursement were calculated for included procedures. A subset analysis was conducted to assess physician pathology clinical consultation services average annual and total percent change in reimbursement pre- and post- 2022 MPFS Update. The compound annual growth rate (CAGR) was calculated using 2024 and 2000 inflation- adjusted monetary data. Results (if a Case Study enter NA) Prior to adjusting for inflation, the average physician reimbursement decreased by 6.8% from 2004 to 2024 for included clinical pathology CPT codes. After adjusting for inflation, the average physician reimbursement decreased by 44.0% for included CPT codes. The greatest decrease in reimbursement observed from 2004 to 2024 was for flow cytometry interpretation, 2-8 minutes at 69.5% ($114.44 to $34.95) followed by flow cytometry interpretation, 9-15 minutes at 57.8% ($142.77 to $60.25) and flow cytometry interpretation, &amp;gt;16 minutes at 56.6% ($188.05 to $81.55). The average CAGR was -2.86%. Prior to adjusting for inflation, the average physician reimbursement for clinical pathology consultation services pre-2022 decreased by 0.9%, and when adjusted for inflation, decreased by 30.0%. Post-2022 MPFS revision, the average physician reimbursement for clinical pathology consultation services decreased by 3.5%, and when adjusted for inflation, decreased by 12.2%. The average CAGR pre-2022 was -2.0% and post-2022 was -4.3%. Conclusion Medicare physician reimbursement for common clinical pathology procedures is decreasing at an untenable rate annually. It is critical that policymakers understand these trends to ensure continued access to quality clinical pathology care at healthcare institutions.

Evaluation of hemoglobin A1c control among Medicare advantage patients not meeting non‐insulin diabetes medication adherence metric

AbstractBackgroundClinical pharmacists are often tasked with improving medication‐related performance metrics such as medication adherence to diabetes medications (MAD). Although the primary goal in patient care is excellent clinical outcomes, it is unknown if poor diabetes disease state control correlates with nonadherence to diabetes medications per the Centers for Medicare and Medicaid Services (CMS) MAD metric specifications. This retrospective study aimed to identify the degree of disease state control in patients identified as nonadherent to their diabetes medications among patients in value‐based Medicare Advantage payer‐provider reimbursement models and its impact on the clinical pharmacist.MethodsPatients attributed to a health system‐employed primary care provider group from January 1, 2022 to December 31, 2022 and identified as non‐adherent (percentage of days covered [PDC] &lt;80%) for non‐insulin diabetic medications were included in the study.ResultsOf the 370 patients who met criteria for study inclusion, 256 (69%) had a controlled hemoglobin A1C of &lt;7.5%; 305 patients also had a previous A1c available in the electronic medical record. Of those, 260 (85%) had an A1C that had improved or was unchanged between the two most recent readings. One hundred sixty (43%) patients had a reason listed for gaps within refill history including verbal dose change, adverse reaction, manufacturer‐supplied medications, fills from Veteran's Affairs pharmacy, provider samples, or nondiabetes diagnosis.ConclusionA large percentage of patients identified as non‐adherent had a high degree of disease state control suggesting an issue with the measurement of adherence rather than a true reflection of patients' adherence with prescribed drug regimens. Strategies to improve diabetes medication adherence based on PDC will likely need to look beyond disease state control.

"I never thought of it as payment": Qualitative evaluation of workshops with advanced practice registered nurses on pharmaceutical industry payment reporting.

With the expansion of professional autonomy and prescriptive authority of advanced practice registered nurses (APRNs), interactions with industry are under greater scrutiny. As of July 1, 2021, pharmaceutical and medical device companies must publicly report all payments to APRNs through the Centers for Medicare and Medicaid Services' Open Payments website. To gauge APRNs' familiarity with, and perceptions of the Open Payments database and discuss whether and how APRNs should respond. Virtual workshops consisting of a didactic presentation and interactive exercises with APRNs recruited through professional networks, associations, and conferences. Transcripts were analyzed using a qualitative interpretive approach, grounded in an everyday ethics theoretical framework. Thirty-six APRN clinicians, students, and faculty participated in nine workshops. Seeing sponsored meals reported in Open Payments as "payments" prompted participants to see familiar interactions in a new way. Participants valued the enhanced transparency as a way to identify risks of bias but were concerned that reporting might undermine public trust in APRNs. Emphasizing awareness as a precursor to action, participants desired greater preparation for ensuring independence in practice. The importance of tackling the ethical issues associated with industry interactions is heightened within the context of an existing climate of distrust within health care. However, many participants were concerned about the effects of transparency on public trust rather than how APRNs individually or collectively can be more trustworthy. Open Payments can serve as a useful tool to catalyze broader conversations about ethics, integrity in decision making, and health policy advocacy.

Increasing Utilization of Intratympanic Injections among Medicare Fee-for-Service Providers.

To characterize national practice patterns and geographic variations in intratympanic injections among Medicare providers. Retrospective cross-sectional analysis of intratympanic injections performed in the Medicare fee-for-service population from 2013 to 2021. Center for Medicare & Medicaid Services Physician and Other Practitioners database. Providers performing outpatient intratympanic injections, documented by Current Procedural Terminology code 69801. Intratympanic injections. The number of intratympanic injections performed by individual providers, states, and geographic regions, as well as reimbursements, was analyzed annually. A total of 159,236 in-office intratympanic injections were performed. The Center for Medicare & Medicaid Services reimbursed $25,407,086; out-of-pocket patient costs were $6,591,514. The mean Medicare reimbursement rate and out-of-pocket cost per injection were $159.56 and $41.38, respectively. From 2013 to 2021, the number of intratympanic injections increased from 13,117 to 20,711 injections, representing a 57.9% increase. On linear regression, an additional 989.9 injections were performed each year (95% CI 766.4-1,213.4, p < 0.001). The number of providers performing injections also increased from 1,828 to 2,834 from 2013 to 2021 (b = 125.6 [95% CI 111.3-140.0], p < 0.001). The population-controlled annual mean number of injections varied substantially across the United States, ranging from 12.0 injections per 100,000 beneficiaries in Oklahoma to 255.2 injections per 100,000 beneficiaries in Alabama. The number of intratympanic injections administered in the Medicare population has increased from 2013 to 2021. There is variability in practice patterns and utilization of intratympanic injections among otolaryngologists in the United States.

The Underuse of Clozapine and Long-Acting Injectable Antipsychotics.

Schizophrenia is among the most devastating and costly human diseases. The public face of the failure to appropriately treat schizophrenia includes approximately 100,000 homeless individuals with schizophrenia and related psychoses and 200,000 incarcerated individuals with similar diagnoses. Clozapine and long-acting injectable antipsychotics are among the most effective treatments, but both are markedly underused. The following organizations should take responsibility for fixing this problem: National Institute of Mental Health, Patient-Centered Outcomes Research Institute, Substance Abuse and Mental Health Services Administration, Centers for Medicare and Medicaid Services, U.S. Food and Drug Administration, American Psychiatric Association, and patient and family advocacy groups.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis.

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity. An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR. Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity. Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR. Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

A Quality Improvement Initiative for Inpatient Advance Care Planning

The Centers for Medicare & Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied. To determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes. This nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024. Billed ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death). The total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P < .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant. This nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

Nationwide Availability of and Enrollment in Medicare and Medicaid Dual-Eligible Special Needs Plans With Exclusively Aligned Enrollment

In 2021, the Centers for Medicare & Medicaid Services designated a new category of dual-eligible special needs plans (D-SNPs) with exclusively aligned enrollment (receive Medicare and Medicaid benefits through the same plan or affiliated plans within the same organization). To assess the availability of and enrollment in D-SNPs with exclusively aligned enrollment and to compare the characteristics of beneficiaries enrolled in D-SNPs with exclusively aligned enrollment available vs beneficiaries without such enrollment available. Full-benefit beneficiaries enrolled in D-SNPs for 6 months or longer in 2021 or 2022. Availability of and beneficiary enrollment in D-SNPs were assessed by year and county for D-SNPs with exclusively aligned enrollment available vs D-SNPs without exclusively aligned enrollment available. The D-SNP enrollees residing in counties with aligned plans available were compared based on demographic, social, health, and area characteristics vs D-SNP enrollees in counties without such plans available. Comparisons were also made based on beneficiaries who enrolled in the aligned D-SNPs vs those who did not enroll (were enrolled in unaligned D-SNPs). The data analyses were conducted from October 1, 2023, to August 2, 2024. Availability of aligned D-SNPs and beneficiary residence by county; enrollment in exclusively aligned D-SNPs vs unaligned D-SNPs; and beneficiary demographic, social, health, and area characteristics. Of 2 197 732 beneficiaries enrolled in D-SNPs in 2021, 881 736 (40.1%) were living in counties with aligned enrollment available and 251 305 (11.4%) enrolled. Of 2 689 045 beneficiaries enrolled in D-SNPs in 2022, 1 047 223 (38.9%) were living in counties with aligned enrollment available and 318 906 (11.9%) enrolled. Beneficiaries enrolled in D-SNPs residing in counties without aligned enrollment available were more likely to live in rural or micropolitan areas (21.9%) vs beneficiaries in counties with aligned enrollment available (8.1%) (standardized mean difference [SMD], 0.38 [95% CI, 0.38-0.38]), be entitled to disability (44.4% vs 27.3%, respectively; SMD, 0.36 [95% CI, 0.36-0.36]), or be Black individuals (27.4% vs 21.4%; SMD, 0.14 [95% CI, 0.14-0.14]); were less likely to be Hispanic individuals (15.4% vs 33.7%; SMD, 0.45 [95% CI, 0.45-0.45]) or Asian or Pacific Islander individuals (6.1% vs 12.2%; SMD, 0.22 [95% CI, 0.22-0.22]); and lived in zip codes with a higher area deprivation index (mean, 66.8 [SD, 26.4] vs mean, 43.2 [SD, 29.0]; SMD, 0.86 [95% CI, 0.86-0.86]). Beneficiaries enrolled in aligned D-SNPs were more likely to be receiving long-term institutionalized care vs beneficiaries in nonaligned D-SNPs (4.3% vs 1.0%, respectively; SMD, 0.24 [95% CI, 0.24-0.25]) or have dementia or Alzheimer disease (9.2% vs 5.9%; SMD, 0.13 [95% CI, 0.13-0.13]). This study found that availability of and enrollment in D-SNPs with exclusively aligned enrollment are increasing, but the overall proportion enrolled remains low. Further reforms are needed to promote aligned enrollment.

Exploring the Relationship Between Hospital Patient Safety Culture and Performance on Measures of Hospital-Acquired Conditions

Objective The aim of the study is to examine the relationship between hospital perceptions of patient safety culture and the incidence of hospital-acquired conditions (HACs) included in Medicare’s HAC Reduction Program utilizing updated and standardized metrics. Methods The pooled cross-sectional study design utilized the 2018 and 2021 datasets from (1) the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPS), (2) the American Hospital Association’s annual survey, and (3) the Center for Medicare and Medicaid’s Hospital Compare dataset. The final analytic sample included 131 acute care, nonfederal, U.S. facilities. Multivariable linear regression models were used to compare the HSOPS domains of patient safety culture to CMS’s HAC metrics. Results Controlling for hospital structural and patient-mix characteristics, hospitals with higher staff-reported ratings of overall patient safety culture (‘overall perceptions of patient safety’ and ‘patient safety grade’) had significantly lower rates of HACs, including total HAC rate, catheter-associated urinary tract infections, and central line-associated blood stream infections (P’s &lt; 0.000–0.044). Higher HSOPS domain scores were variably associated with lower HAC rates, with consistently significant associations found for domains related to nonpunitive, open communication (P’s &lt; 0.05). Conclusions Our relatively robust results suggest that while patient safety culture may not be the only strategy necessary to improve HAC rates, it needs to be aligned with other efforts to improve quality and safety. This underscores the importance of cultivating a culture of psychological safety that promotes open feedback and communication about errors.

Exploring the Link Between Factors in Musculoskeletal Oncology Surgery Fellowships and Industry Supplemental Income.

Introduction In the complex landscape of healthcare economics, the financial relationship between physicians and industry remains a topic of significant interest and reflection. While the dynamics of industry relationships in certain orthopedic subspecialties have been well documented, the intricacies of industry payments within musculoskeletal (MSK) oncology programs have yet to be thoroughly explored. In this study, we aim to examine the relationship between academic and industry productivity at the fellowship level. Additionally, we seek to identify the associations between the flow of industry supplemental income to orthopedic oncologists and the specific residency and fellowship training programs they are affiliated with. Methodology A comprehensive retrospective analysis was conducted using data from the Centers for Medicare and Medicaid Services, Scopus, and other relevant databases in 2023. This study included 19 fellowship programs across the United States, encompassing a total of 68 faculty physicians. Various variables were examined, including H-index, lifetime supplemental income, geographical location, residency affiliation, and association with top-ranked hospitals. Results A statistically significant correlation was found between academic and industry productivity at the individual faculty level (p = 0.003), but not at the fellowship level (p = 0.198). The top 10% of earners accounted for approximately 70% of the total lifetime supplemental income among all fellowship faculty. Additionally, there was no statistically significant association between lifetime supplemental income or academic productivity per fellowship and geographical region, nor with the ranking of affiliated residency programs or hospitals. Conclusions Industry productivity among individual faculty in MSK oncology fellowship programs in the United States is significantly associated with academic productivity; however, this association was not observed at the fellowship level. Furthermore, no statistically significant relationship was found regarding the region or the ranking of the affiliated residency programs or hospitals.

Outcomes of patients with cancer cared for in a multisite home hospital program.

394 Background: Home hospital provides hospital-level care for acutely ill patients in their homes as a substitute for care in brick-and-mortar hospitals. Since the Centers for Medicare and Medicaid Services’ acute hospital care at home waiver in November 2020, 330 hospitals have received approval to launch home hospital programs. Prior research has shown that patients cared for in home hospital have improved physical activity, and lower mortality and readmission rates. However, many of these programs exclude patients with cancer, and data describing outcomes of patients with cancer cared for in home hospital programs are limited. Methods: We identified patients admitted to a multisite home hospital program affiliated with an urban health system between February 1, 2020 and May 1, 2024 who had a diagnosis of cancer (ICD-10: C00-C96) or myelodysplastic syndrome (ICD-10: D46) managed by an oncologist within the health system. For each admission we conducted chart reviews to determine whether the malignancy was active at the time of admission, defined by ongoing antineoplastic treatment or an admission directly related to the malignancy. We also captured the patient’s cancer diagnosis, the admission diagnosis, total length of stay, and length of time in home hospital. We identified readmissions within 30 days of discharge and escalations of care, defined as a return to a brick-and-mortar hospital for additional care spanning at least one midnight, and calculated rates of these outcomes. Results: There were 141 home hospital admissions among 128 patients with cancer diagnoses (mean age: 77, 36% female). The most common oncologic diagnoses were lymphoma (16%, N = 22), chronic leukemias and MDS (14%, N = 20), and lung cancer (13%, N = 18). Seventy-one patients (50%) had active cancer at the time of admission. The leading admission diagnoses were pneumonia (N = 28, 16%), heart failure exacerbations (N = 19, 13%), complicated urinary tract infections (N = 12, 9%) and soft tissue infections (N = 10, 7%). The mean total length of stay was 7.9 days (SD 5.6) and patients were admitted to home hospital for a mean of 4.9 days (SD: 3.5). Escalation rates and 30-day readmission rates were 7% (N = 10) and 13% (N = 19), respectively, among all patients, and 5% (N = 4) and 14% (N = 10) among patients with active malignancies. Conclusions: These data describe a cohort of patients with cancer cared for in a multisite home hospital program. They show low rates of transfer back to brick-and-mortar hospitals and low 30-day readmission rates, and they demonstrate that patients with cancer can be safely cared for in a home hospital. As home hospital programs build new capabilities, a larger proportion of oncology patients will be eligible for home hospital. More work is needed to estimate risk-adjusted outcomes among these populations and to understand the patient and caregiver experience with oncology home hospital.

Orthopaedic Provider Coding Trends After 2021 Changes to the Current Procedural Terminology Evaluation and Management Coding Guidelines: A Retrospective Cohort Study

Background: The goal of this study was to determine changes in orthopaedic coding practices between December 2020 and January 2021 after training providers on the 2021 Current Procedural Terminology Evaluation and Management (E&amp;M) Centers for Medicare and Medicaid Services guideline changes. Methods: Outpatient encounters in December 2020, January 2021, December 2021, and January 2023 were grouped by provider and E&amp;M code level. The codes used for established patients were 99211, 99212, 99213, 99214, and 99215, ordered from low to high-complexity visits. The codes used for new patients were 99201, 99202, 99203, 99204, and 99205 also in order of complexity from low to high. Results: A statistically significant increase was noted in coding levels for both new and established patients from December 2020 to January 2021 (P &lt; 0.001). For new patients, there was an increase in level 4 codes from 16% to 54% and an increase in level 5 codes from 3% to 6% (P &lt; 0.0001). This notable increase in level 4 and 5 codes was maintained through 2 years (January 2023) for new patients. Conclusions: A statistically significant increase was noted in coding levels for both new and established patients since E&amp;M guideline changes. This change was maintained for 2 years.

An Analysis of the Otolaryngology Workforce in Pennsylvania.

This study aims to analyze the distribution of otolaryngologists between urban and rural counties in Pennsylvania. Retrospective database. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) database and Centers for Medicare and Medicaid Services (CMS) Database. The AAO-HNS database (Entnet.org) and the CMS Database were used to identify otolaryngologists, their primary location, and their state of training. The 2023 Rural-Urban Continuum Codes were used to classify metropolitan (codes 1-3) and nonmetropolitan counties (codes 4-9) and determine county populations. A total of 388 otolaryngologists were identified across 67 Pennsylvania counties (33 metropolitan, 34 nonmetropolitan), 80% of which were male. There were 354 otolaryngologists in metropolitan counties serving 11.2 million people, with an average of 2.4 otolaryngologists per 100,000 people (/100 k). The majority of otolaryngologists (n = 235, 60.6%) are located in counties designated by code 1. There were 34 otolaryngologists in nonmetropolitan counties serving 1.8 million people, with an average of 2.4 otolaryngologists/100 k. Montour County (code 6) is home to a large academic center and accounts for 14/34 otolaryngologists in the nonmetropolitan counties. With the exception of Montour County, the remaining nonmetropolitan counties averaged 1.0 otolaryngologist/100 k. Only 3 metropolitan counties did not have otolaryngologists compared to 19 nonmetropolitan counties without otolaryngologists. Most otolaryngologists received their residency training in Pennsylvania (n = 177). New York (n = 35) and Maryland (n = 24) were the second most common states for training. There is a lack of otolaryngologists in rural counties of Pennsylvania, except in counties home to large academic centers.

The impact of oral oncology drugs in the era of value-based care.

15 Background: Oncology drug expenditures are a significant contributor to increasing total cost of care (TCOC). Oral oncolytics (OO), such as small molecule inhibitors (CDK 4/6 inhibitors, tyrosine kinase inhibitors, etc.), and immunomodulators, have revolutionized the treatment landscape for many cancers. We evaluated the patterns of OO use and spend for Medicare patients over time at a large community oncology practice participating in the Center for Medicare and Medicaid Innovation (CMMI)’s Value-based care (VBC) Program, the Oncology Care Model (OCM), with a focus on the seven cancers that are part of a successor model, the Enhancing Oncology Model. Methods: Using CMMI claims for attributed 6-month OCM episodes, we evaluated drug use and expenditures by performance period (PP) from July 2016 – June 2022 (11 PPs), with an emphasis on OO drugs. We used Part D expenditures as a proxy for OO. Results: From 2016-22, average TCOC per PP increased by 15.5% in the 7 EOM diagnoses (breast, lung, colon, prostate cancer, myeloma, lymphoma, and chronic leukemia). Average drug expenditures per PP grew 33% percent and represented 71% of total cost by PP11, up from 61% in PP1. Average expenditures per episode increased by 11.7% for Part B and 82.6% for Part D drugs (p&lt;0.01). Increase in Part D drug expenditures was partly due to an increase in the number of unique oral drugs which grew by 32% over the evaluation period. The greatest increases in Part D drug expenditures occurred in breast cancer (87%) and lymphoma (153.7%). Table reports average OO expenditures per PP, percent change from PP1 to PP11, and the change in the % Part D drugs contributed to TCOC. Conclusions: Increases in drug expenditures represent the greatest impact on TCOC for cancer patients. OO medicines have an increasing role in the treatment landscape and represent a growing focus in VBC models. Utilization and cost of OO medication have a significant bearing on VBC performance. Diagnosis Avg. OO Expenditures PP1 Avg. OO Expenditures PP11 Avg. OO Expenditures Change Contribution of OO to TCOC Change from PP1 - 11 Breast $4,208 $7,869 87.0% 9.9% Leukemia $25,334 $41,128 62.3% 19.9% CRC $1,206 $2,158 78.9% 3.1% Lung $3,650 $3,625 -0.7% -2.5% Lymphoma $4,193 $10,637 153.7% 13.0% Myeloma $25,109 $39,298 56.5% 6.7% Prostate $18,815 $20,114 6.9% 3.2% Total $8,291 $15,140 82.6% 10.8%

Evaluating the concordance between International Classification of Diseases, Tenth Revision Code and stroke severity as measured by the National Institutes of Health Stroke Scale

BackgroundThe National Institutes of Health Stroke Scale (NIHSS) scores have been used to evaluate acute ischaemic stroke (AIS) severity in clinical settings. Through the International Classification of Diseases, Tenth Revision...

A systematic review of cost-effectiveness analyses of gene therapy for hemophilia type A and B.

In 2022-2023, the US Food and Drug Administration approved 2 novel gene therapies, valoctocogene roxaparvovec and etranacogene dezaparavovec, for hemophilia A and B, respectively. These one-time-administered gene therapies have been marketed at prices that create financial challenges for payers and patients. Understanding the magnitude and uncertainties around the long-term value of these therapies and how they can potentially relate to managed care practices is of high interest to the payer and patient community. To conduct a systematic review of cost-effectiveness analysis (CEA) studies to assess (1) the long-term value of valoctocogene roxaparvovec and etranacogene dezaparavovec and (2) the relevance and validity of the underlying data and assumptions used in the CEA models and discuss how they relate to the challenges identified for CEAs of gene therapies. A systematic review of cost-effectiveness studies of novel hemophilia A and B gene therapy was conducted. PubMed and Embase were searched for published studies from inception to January 12, 2024. Original research articles published in English that conducted a CEA on gene therapy treatments for hemophilia A and B, with a comparison of incremental costs and health effects, were considered. Critical appraisal of the quality of reporting and the underlying modeling assumptions were conducted to assess the relevance and validity of the results. Two hundred thirty-eight studies were identified, of which 4 met the inclusion criteria. Three studies were conducted from a US health care perspective and 1 from a Dutch societal perspective. Despite the high upfront costs of the gene therapies, all included studies' (3 hemophilia A and 1 hemophilia B) modeled results showed that gene therapies had lower overall costs and better health outcomes compared with factor concentrate replacement therapies and emicizumab. The results were driven by the assumption that gene therapies will have a durable effect of at least 10 years and offset the high cost of the current standard of care. The modeled health improvements varied substantially across studies, showing that the long-term value is sensitive to varying clinical and economic assumptions. The novel hemophilia gene therapy treatments can potentially be a cost-effective use of treatment resources if the treatment effects are durable over time. To reduce the risk for payers while still facilitating patient access, outcomes-based agreements similar to what has recently been proposed by the Centers for Medicare & Medicaid Services for sickle-cell therapies are well supported.

Impact of a tubeless, disposable insulin pump on emergency department visits and inpatient admissions among a Medicare population.

A tubeless, disposable insulin pump (Omnipod DASH Insulin Management System, Insulet Corporation) has demonstrated improved glycemic outcomes for people with diabetes who require insulin. The impact of the system on downstream health care events has not been studied. To assess health care resource utilization for a Medicare population before and after starting tubeless, disposable insulin pump therapy. This retrospective, observational analysis used data from the Centers for Medicare & Medicaid Services 100% Research Identifiable Files. Study outcomes included change in event rates for diabetes-related emergency department (DRED) visits, all-cause emergency department (ACED) visits, diabetes-related inpatient (DRIP) admissions, and all-cause inpatient (ACIP) admissions among Medicare beneficiaries who started the tubeless, disposable insulin pump in 2020 (postpump observation period) as compared with the same duration and calendar period in 2019 (prepump observation period) with no pump use. Subgroup analyses were performed based on Medicare entitlement reason, diabetes type, and diagnosis status for depressive disorder. A total of 811 users met the criteria for analysis: 46.2% had type 2 diabetes, a majority (59.2%) were aged 65 years or older, and 37.0% had a diagnosis for depressive disorder. Significant reductions were observed for DRED of -46.9% (95% CI = -63% to -23%); ACED of -29.0% (95% CI = -37% to -20%); ACIP of -19.9% (95% CI = -32% to -6%). DRIP rates declined notably (-36.6%; 95% CI = -61% to 4%). Event rates observed across subgroups demonstrated consistent downward trends; however, not all were statistically significant. These findings demonstrate that use of the tubeless, disposable insulin pump was associated with reductions in DRED, ACED, and ACIP. Our results provide real-world evidence to support the use of the tubeless, disposable insulin pump among Medicare beneficiaries who require insulin, regardless of diabetes type or Medicare entitlement reason. Additional studies are recommended to further evaluate the effect of insulin pumps on health care utilization among the Medicare population and other insurance populations.

Enhancing care coordination through transitional care management.

232 Background: West Cancer Center and Research Institute (WCCRI) serves Memphis and the Arkansas, Mississippi, and Tennessee tri-state region as the comprehensive care leader in adult cancer care and research, amounting to over 260,000 visits across 57,000 unique patients in 2023. Cancer patients are predisposed for higher risk of hospital admissions, making uniform care coordination between the discharging hospital and their outpatient oncology care home essential to care continuity. While WCCRI attempted to mitigate readmissions, there was no formalized managed care approach for capturing and responding to unplanned patient hospital visits to prevent readmission. Auditing of claims data suggested nearly 500 patient care opportunities within a four-month period. Methods: To improve continuity of care and decrease preventable readmissions, WCCRI implemented a care transitions process based on the Centers for Medicare and Medicaid's Transitional Care Management (TCM). This required a repeatable approach of proactive outreach to patient upon discharge, a clinical assessment of patient need, and an office visit within fourteen days of discharge. To maximize impact, this project was scoped to patients with unplanned hospital admissions who are at moderate to high risk for readmission. Results: Twelve months after implementation, WCCRI has proactively identified 974 patients qualifying for TCM and successfully scheduled 91.48% for a hospital follow-up appointment with their oncologist. Proactive outreach to patients has led to a 35% increase in office visits within fourteen days of discharge, a key measure of care continuity. Conclusions: Learnings from this implementation project have been spread to formalize hospital follow-up approaches across WCCRI. By aligning policies, engaging stakeholders, and fostering a culture of collaboration and accountability, WCCRI has delivered high-quality, coordinated care, and achieved better patient outcomes.