Medicare FFS Research Articles

Abstract WMP53: Venous Thromboembolism Among Medicare Beneficiaries Hospitalized With Acute Ischemic Stroke With And Without History Of Covid-19

Introduction: Venous thromboembolism (VTE) is a common medical complication following acute ischemic stroke (AIS). Studies have suggested that VTE rates were higher among patients with a history of COVID-19. We examined the risk of VTE in AIS patients with and without a history of COVID-19 among Medicare beneficiaries. Methods: We identified Medicare fee-for-service (FFS) beneficiaries aged ≥65 years with AIS hospitalizations from 04/01/2020 to 06/30/2021. COVID-19 cases were identified by the first diagnosis of COVID-19 on a claim at any health care setting. We defined AIS with COVID-19 if the dates of COVID-19 diagnoses were earlier than AIS admission dates. To identify VTE for each AIS admission, we used the following secondary diagnoses codes: ICD-CM-10: I80, I81, I82, I26. We compared the prevalence ratio (PR) of VTE between AIS patients with and without a history of COVID-19. Results: Among 178,830 Medicare FFS beneficiaries with AIS admissions, 6.1% had a history of COVID-19 and 2.6% had VTE as a complication. VTE prevalence among AIS patients with a history of COVID-19 was 3.98% (95% confidence interval (CI), 3.62-4.36%) and 2.53% (95% CI, 2.46-2.61%) among patients without a history of COVID-19. The adjusted PR of VTE was 1.55 (95% CI, 1.40-1.70, p<0.001) comparing AIS admissions with a history of COVID-19 and those without a history of COVID-19. Non-Hispanic Black patients had the highest VTE prevalence, 6.14% among those with a history of COVID-19 and 3.89% among those without a history of Covid-19, as compared to other race/ethnicity groups. Both Non-Hispanic White and non-Hispanic Black patients with a history of COVID-19 had >50% increased risk of VTE than those without a history of COVID-19 (Adjusted PR, 1.59, 95% CI, 1.42-1.78 for Non-Hispanic White, 1.58, 95% CI, 1.28-1.94 for Non-Hispanic Black, p<0.001). Conclusion: AIS patients with a history of COVID-19 had an increased risk of VTE compared with patients without COVID-19. Healthcare professionals should be aware of the increased risks of VTE among AIS patients with COVID-19 and implement protocols for early VTE prevention.

Clinical burden of recurrent Clostridioides difficile infection in the medicare population: A real-world claims analysis.

To describe 12-month outcomes for beneficiaries in the 100% Medicare Fee-for-Service (FFS) population with primary and recurrent Clostridioides difficile infection (CDI). A retrospective, descriptive, cohort study of CDI claims from the 100% Medicare FFS population, with a first CDI diagnosis between January 1, 2010, and December 31, 2016. Any US-based provider that submitted inpatient or outpatient CDI diagnosis claims to Medicare FFS. The study included patients aged ≥65 years with continuous enrollment in Medicare Parts A, B, and D during 12 months before and 12 months after the index period. The number of CDI and recurrent (rCDI) episodes, healthcare resource utilization, treatments, complications, and procedures were calculated for pre-index and follow-up periods. The data were stratified by number of rCDI episodes (ie, no rCDI, 1 rCDI, 2 rCDI, and ≥3 rCDI). Of 268,762 patients with an index CDI, 34.7% had at least 1 recurrence. Of those who had 1 recurrence, 59.1% had a second recurrence and of those who had 2 recurrences, 58.4% had ≥3 recurrences. Incident psychiatric conditions occurred in 11.3%-18.2% of each rCDI cohort; 6.0% of patients with rCDI underwent subtotal colectomy, and 1.1% of patients underwent diverting loop ileostomy. After each CDI episode, ∼1 in 5 patients had a documented sepsis event. Over the 12-month follow-up, 30% of patients experienced sepsis, and sepsis occurred in 27.0% of the cohort with no rCDI, compared to 35.5% of patients in the rCDI cohorts. Elderly patients with CDI and rCDI experienced a significant clinical burden and complications.

Did the Medicaid expansion reduce service utilization among the Medicare population?

ABSTRACT While a large and growing literature has examined the effects of the Affordable Care Act’s Medicaid expansion on newly eligible Medicaid recipients, relatively few studies have explored whether increased Medicaid service utilization has had any negative spillover effects on the Medicare population. This study uses county-level data on Medicare fee-for-service (FFS) utilization from 2007 to 2018 in conjunction with inverse probability of treatment adjusted difference-in-differences and event study models with a variety of inter-temporal controls and county-level fixed effects. It finds highly significant effects of modest magnitude providing evidence of negative spillovers on the traditional Medicare Fee-for-service (FFS) population. FFS Medicare Beneficiaries in Medicaid expansion states experienced a 1% reduction in Evaluation and Management (E&M) visits, a 2.1% reduction in testing services, collectively reducing their volume of visits across Berenson-Eggers Type of Service (BETOS) categories by 0.7%.

Impacts of COVID-19 on the Utilization of the Medicare Hospice Benefit

The Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE) has had a substantial impact on the provision and utilization of healthcare services. Given the high mortality rate associated with COVID-19 amongst older adults, COVID-19 is likely to have a profound impact on all hospice users due to disruptions in providing services. Our work describes how Medicare beneficiaries have utilized the Medicare Hospice Benefit (MHB) during the PHE and how that compares to utilization of the MHB prior to the PHE. We conducted a retrospective analysis of 100% Part A and Part B Fee-for-Service (FFS) Medicare claims from January 1, 2019 – December 31, 2020. We identified approximately 42.3 million unique Medicare FFS beneficiaries from January 2019 through December 2020. Of these, 1.6 million (3.8%) had at least one hospice claim and 1.7 million (4.0%) had at least one Medicare Part A or Part B claim with a COVID-19 diagnosis during the same time period. The rate of COVID-19 amongst FFS Medicare patients who utilized hospice was 8.3%. Average per-beneficiary per-month hospice visits fell by 28.2% for aides and 15.4% for nurses from December 2019 (7.1 aide visits, 6.5 skilled nursing visits) through December 2020 (5.1 aide visits, 5.5 skilled nursing visits). CMS should continue to monitor the prevalence of COVID-19 amongst hospice users and measures of hospice utilization amongst all hospice users in order to better understand how the PHE impacts the provision of the MHB and ensure beneficiaries continue to have access to needed services.

1416. Medicare Spending on Urinary Tract Infections: A Retrospective Database Analysis

BackgroundMedical visits for UTIs represent 1%-6% of all healthcare visits (~7 million visits) and are estimated to cost the United States (US) healthcare system at least &1.6 billion annually. UTIs are associated with significant morbidity; particularly among the elderly, where UTIs are most prevalent. Little is known about the specific costs to Medicare of UTI; here, we seek to examine overall Medicare spending on UTI.MethodsWe conducted a retrospective multicenter cohort study of the Medicare fee-for-service (FFS) data. Patients were included for analysis if the following criteria were met: (1) enrolled in Medicare FFS from January 1, 2016 through December 31, 2019, (2) not enrolled in Medicare Advantage during that time period, (3) did not have any UTI diagnoses in 2016, and (4) enrolled in Medicare Part D. Individuals were categorized as having uncomplicated UTI (uUTI), complicated UTI (cUTI), or those who first had a uUTI that progressed to a cUTI (uUTI to cUTI). Medicare spending in the 12 months post-diagnosis was calculated, and patients were stratified by home- or institutionally-based (eg, nursing home, long-term care facility, etc.).Results2,330,123 patients were included for analysis; 92% were home-based, 8% were institutionally-based. Mean Charlson Comorbidity Index (CCI) across all patients was 2.16. In the 12 months after initial diagnosis, average Medicare spend was &33,984, &9,941 of which was UTI-related. Annual UTI-related costs were approximated &9,000 for home-based vs. &21,444 for institutionally-based patients. Mean drug spend per patient on antibiotics was &872. Broadly, uUTI patients were least expensive, followed by cUTI patients, with uUTI to cUTI patients being most expensive. Higher costs for were observed for institutionally-based patients, largely due to more frequent acute hospitalizations and more Part A-paid skilled nursing stays.ConclusionUTI-related spending represents approximately one-third of total annual Medicare spend for patients diagnosed with a UTI. Given average Medicare spending of approximately &12,000 per person in 2019, UTI is associated with substantially increased per patient cost and represents a significant source of spending for Medicare.Disclosures Kate Sulham, MPH, Spero Therapeutics (Consultant) Eric Hammelman, MBA, AbbVie Pharmaceuticals (Consultant)Edwards Lifesciences (Consultant)Genentech (Consultant)Spero Therapeutics (Consultant)Vertex Pharmaceuticals (Consultant)

823. Characteristics, Comorbidities, and Medication Burden among People Living with HIV in the U.S. Medicare Program

Abstract Background Among the 1.2 million people living with HIV (PLWH) in the U.S., many are covered by Medicare, a federally funded health insurance program for elderly (≥65 years) and disabled (< 65 years) individuals. Medicare has emerged as a major source of HIV care for PLWH. Given limited research in this population, a better understanding of patient characteristics, comorbidities, and comedication use among PLWH in the Medicare program is needed to help optimize clinical care. Methods A retrospective claims analysis of a national cross-sectional sample of fee-for-service (FFS) Medicare beneficiaries with continuous medical and prescription coverage in 2018 was conducted using 100% Medicare administrative claims. The PLWH group included individuals with ≥1 HIV diagnosis code in medical claims and ≥1 pharmacy claim for an anchor antiretroviral (ARV) drug (i.e., NNRTI, PI or InSTI) in 2018. The comparison group included a random sample of Medicare beneficiaries without HIV (PLWoH). Sociodemographic characteristics, comorbidities, and medication use were compared between PLWH and PLWoH. Results The study sample included 86,856 PLWH and 552,645 PLWoH. PLWH were more likely to be younger (mean age: 57.4 vs 71.1 years and < 65 years: 72% vs 18%), male (75% vs 42%), Black (42% vs 10%), eligible for Medicare due to disability (83% vs 27%) and receiving full low-income subsidies (77% vs 31%); all p< 0.001. Prevalence of >3 comorbidities was high in PLWH (70.2%) and only slightly lower than in PLWoH (71.7% p< 0.001). Prevalence of neuropsychiatric conditions, chronic kidney disease, liver disease, COPD, hepatitis B, and hepatitis C were higher in PLWH (Figure 1). The mean hierarchical condition categories risk score was higher in PLWH vs PLWoH (1.81 vs. 1.32; p< 0.001). On average, polypharmacy was higher among PLWH vs PLWoH (annual number of unique medications: 12.6 vs. 9.4 for all drugs and 10.3 vs. 9.4 for non-ARV drugs, both p< 0.001). Figure 1. Percentage of PLWH and PLWoH with multimorbidity and selected comorbid conditions. Abbreviations: COPD=chronic obstructive pulmonary disease; GI=gastrointestinal; PLWH=people living with HIV; PLWoH=people living without HIV All p-values <0.001 except GI Disorders (p=0.14). Conclusion In the Medicare FFS population, multimorbidity and polypharmacy were highly prevalent in PLWH despite their substantially younger age compared to PLWoH. Our findings highlight the need to consider comorbidities and comedications in HIV management including ARV regimens to minimize medication burden and drug interactions, which might improve clinical outcomes. Disclosures Pengxiang Li, PhD, Avalon Health Economics LLC (Consultant)COVIA Health Solutions (Consultant)Healthstatistics, LLC (Consultant) Jianbin Mao, PhD, Merck (Employee)Merck (Shareholder) Girish Prajapati, M.B.B.S., MPH , Merck & Co., Inc. (Employee, Shareholder) Robert Gross, MD, MSCE, Pfizer (Other Financial or Material Support, Serve on DSMB for drug unrelated to HIV) Jalpa A. Doshi, PhD, Acadia (Consultant, Advisor or Review Panel member)Allergan (Advisor or Review Panel member)Biogen (Grant/Research Support)Boehringer Ingelheim (Other Financial or Material Support, Scientific lecture)Catabasis (Consultant)Humana (Grant/Research Support)Janssen, Inc. (Consultant, Grant/Research Support)MeiraGTX (Consultant)Merck (Grant/Research Support, Advisor or Review Panel member)Novartis (Grant/Research Support)Otsuka (Advisor or Review Panel member)Regeneron (Grant/Research Support)SAGE Therapeutics (Consultant)Sanofi (Grant/Research Support)Shire (Advisor or Review Panel member)The Medicines Company (Advisor or Review Panel member)

Catastrophic out-of-pocket costs for around 10% of Medicare FFS patients with HF in the USA

Catastrophic out-of-pocket costs for around 10% of Medicare FFS patients with HF in the USA

Trends in use of one, two, and three-line NCCNcategory 1 regimens among Medicare fee-for-service (FFS) patients receiving treatment for metastatic pancreatic cancer.

297 Background: There is limited research evaluating the share of patients (pts) with metastatic pancreatic cancer (m-PANC) treated according to NCCN guidelines. Methods: We identified pts with m-PANC using ICD-10 diagnosis codes in the 2016-2019 Medicare Parts A/B/D 100% Research Identifiable Files. Study pts had 2+ claims with a pancreatic cancer diagnosis and Medicare FFS coverage for 6 months pre- and 3 months post-metastatic disease diagnosis. A line of therapy (LOT) was assigned based on the order and number of therapies used. Pts with one, two, or three LOTs were defined as treated according to NCCN Category 1 guidelines if, in each LOT, pts used one of the following regimens: FOLFIRINOX (FFX), gemcitabine/nab-paclitaxel (gem/nab), gemcitabine + erlotinib, gemcitabine monotherapy, or 5-FU + leucovorin + liposomal irinotecan. Multi-drug LOTs were excluded from the analysis. Results: We identified 31,782 pts with m-PANC. 21,304 received one LOT, 7,352 received two LOTs, and 3,126 received three LOTs between 2016 and 2019. Among pts who received one or two LOTs, a higher portion were treated according to NCCN Category 1 guidelines in 2019 (72% and 43%, respectively) than in 2016 (64% and 33%, respectively). Among pts who received three LOTs, a higher portion were treated according to NCCN Category 1 guidelines in 2019 (17%) than in 2017 (12%); too few pts were treated in 2016 to make a comparison. From 2016 to 2019, FFX had the largest increase in share of pts receiving only one NCCN Category 1 LOT (11% to 27%) and gem-mono had the largest decrease (30% to 17%). Among pts receiving two NCCN Category 1 LOTs, gem/nab to liposomal irinotecan sequences had the largest increase in share of pts (18% to 32%) and gem/nab to FFX had the largest decrease (17% to 10%). Among pts receiving three NCCN Category 1 LOTs, patient share for FFX to gem/nab to Liposomal irinotecan was 35% in 2019, while gem/nab to FFX to Liposomal was 8%; pt counts in earlier years were too small to calculate patient share. Conclusions: The use of NCCN Category 1 therapies increased consistently from 2016 to 2019 among pts that received one, two, and three lines of therapy. FFX drove increases in NCCN Category 1 utilization among patients receiving one line of therapy, and gem/nab to liposomal irinotecan sequences were the primary drivers of the increase among patients receiving two lines of therapy. FFX to gem/nab to liposomal irinotecan was the primary driver of increase among patients receiving three lines of therapy.

The Prevalence of Diagnosis of Major Eye Diseases and their Associated Payments in the Medicare Fee-for-Service Program

ABSTRACT Purpose To estimate the prevalence of diagnosis of major eye disorders and their associated payments, in total and per-person diagnosed, among Medicare fee-for-service (FFS) beneficiaries in 2018. Methods We analyzed 100% Medicare Part B FFS claims and Part D Events among beneficiaries continuously enrolled for 12 months in 2018 to calculate the proportion of beneficiaries with ≥1 claim indicating age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), or glaucoma, and their associated payments, including Medicare and patient out-of-pocket. Eye disease and eye care services were identified using case definitions from the Centers for Disease Control and Prevention’s (CDC) Vision & Eye Health Surveillance System (VEHSS). Outcomes are reported by disease overall and by age group (0–39, 40–64, 65–84, 85+ years), sex, race/ethnicity, and U.S. state. Results Among nearly 30 million Medicare Part B FFS beneficiaries in 2018, over 41% (12.4 million) had a claim containing a diagnosis of at least one of the four eye disorders; 33.7% with cataract, 13.3% with glaucoma, 9.2% with AMD and 3.2% with DR. Payments for eye care services and drugs associated with these four conditions were $10.1billion; $3.6 billion for cataract, $3.5 billion for AMD, $2.2 billion for glaucoma and $0.8 billion for DR. The average cost per beneficiary diagnosed was $816: $1,290 for AMD, $781 for DR, $543 for glaucoma, and $360 for cataract. Conclusions Major eye disorders are common among Medicare FFS beneficiaries and account for approximately 4.3% of Medicare Part B and 1% of Medicare Part D spending.

Utilization and Expenditures of Vertebral Augmentation Continue to Decline: An Analysis in Fee-For-Service (FFS) Recipients from 2009 to 2018

Despite the high prevalence of vertebral compression fractures (VCFs) associated with refractory pain, deformity, or progressive neurological symptoms, minimally invasive vertebral augmentation procedures, including vertebroplasty and kyphoplasty, have been declining in their relative utilization, along with expenditures. This investigation was undertaken to assess utilization and expenditures for vertebral augmentation procedures, including vertebroplasty and kyphoplasty, in the fee-for-service (FFS) Medicare population from 2009 to 2018. The present study was designed to assess utilization and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript:• A patient was described as receiving vertebral augmentation over the course of the year.• An episode was considered as one treatment per region per day utilizing primary codes only. • Services or procedures were considered to be procedures including multiple levels.A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted for inflation to 2018 US dollars. In 2009, there were 76,860 episodes of vertebral augmentation with a rate of 168 per 100,000 Medicare population, which declined to 58,760, or 99 per 100,000 population for a total decline of 41%, or an annual rate of decline of 5.7% per 100,000 Medicare population. Vertebroplasty interventions declined more dramatically than kyphoplasty from 2009. Total episodes of vertebroplasty were 27,380 with an annual rate of 60 per 100,000 Medicare population, decreasing to 9,240, or 16 per 100,000 Medicare population, a 66% decline in episodes and a 74% decline in overall rate with an annual decline of 11.4% and 13.9%. In contrast, kyphoplasty interventions were 49,480, for a rate per 100,000 population of 108 in 2009 compared to 49,520 in 2018 with a rate of 83, for a decrease of 23% and 2.9% annual decrease. Evaluation of expenditures showed a net decrease of $30,102,809, or 8%, from $378,758,311 in 2009 to $348,655,502 in 2018. However, inflation-adjusted expenditures decreased overall by 21% and 3% annually from $443,147,324 in 2009 to $345,655,502 in 2018. In addition, inflation-adjusted total expenditures per 100,000 Medicare population decreased from $967,549 to $584,992, for an overall decrease of 40%, or an annual decrease of 5%. Per patient expenditures decreased 2% overall with 0% decrease per year. Vertebral augmentation procedures were assessed only in the FFS Medicare service population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. This study shows a significant decline in relative utilization patterns of vertebroplasty and kyphoplasty procedures, along with reductions in overall expenditures. The inflation-adjusted total expenditures of kyphoplasty and vertebroplasty decreased 21% with an annual decline of 3%. The inflation-adjusted expenditures per 100,000 of Medicare population decreased 40% overall and 5% per year. In addition, vertebroplasty has seen substantial declines in utilization and expenditure patterns compared to kyphoplasty procedures, which showed trends of decline.

Impacts of the Home Health Value‐Based Purchasing (HHVBP) Model After the First Payment Adjustment Year

Research ObjectiveThe Home Health Value‐Based Purchasing (HHVBP) Model provides financial incentives for quality improvement to home health agencies in nine states with the goal of improving quality and efficiency of care for Medicare beneficiaries. The maximum Medicare payment adjustment increases during each of the five years of the model, ranging from ±3% in 2018 to ±8% in 2022. Our goal is to understand the early impact of the HHVBP Model on quality, utilization, and Medicare spending during its first three years (2016–2018), which includes the first year in which payment adjustments to agencies took effect.Study DesignCMS randomly selected nine states to participate in the HHVBP Model starting January 2016, with mandatory participation from all agencies. Agencies in these states received performance scores for 20 measures of quality of care used to determine their payment adjustment relative to other agencies within their state. To evaluate the effects of HHVBP, we used a difference‐in‐differences design and multivariate linear regression to compare differences in the changes in outcomes of the nine HHVBP states with those in the 41 comparison states for three years pre‐intervention (2013–2015) through the first three years of the model (2016–2018). We evaluated agency performance using Outcome and Assessment Information Set (OASIS)‐based quality measures and measures of claims‐based Medicare fee‐for‐service (FFS) health care utilization and spending.Population StudiedMedicare and Medicaid patients receiving home health care in the nine HHVBP states and forty‐one comparison states.Principal FindingsWe found evidence of slightly greater improvements in most measures of improved functional status used to determine payment adjustments in HHVBP states relative to non‐HHVBP states. Compared to non‐HHVBP states, Medicare FFS beneficiaries who received home health care in the nine HHVBP states had a relative decrease in unplanned hospitalization rate (−1.8%) and in skilled nursing facility (SNF) stays (−4.9%) from pre‐HHVBP implementation average levels. Conversely, we observed a 2.4% increase in emergency department (ED) visits relative to the average pre‐implementation rates for HHVBP states. Overall, we found evidence of a 1.2% reduction in Medicare spending due to HHVBP, corresponding to an average $141 million reduction in annual Medicare spending in HHVBP states over the first three years of the model. The reduction in spending among home health Medicare FFS patients was driven primarily by reductions in inpatient hospital spending (−2%) and SNF spending (−4%). We did not find an appreciable difference in savings between the third year—in which payment adjustments were applied—and the first two years of the model prior to HHVBP agencies receiving payment adjustments.ConclusionsThrough the HHVBP Model's first three years—which includes the first year of payment adjustments to agencies—we found modest impacts of HHVBP: lower growth in Medicare spending, declines in unplanned hospitalizations and use of SNFs, somewhat greater increases in ED use, and somewhat greater improvements in many OASIS‐based quality measures among home health patients in the HHVBP states.Implications for Policy or PracticeThe findings from current and subsequent research will inform policymakers, home health care patients, and other stakeholders about potential benefits of expanding the model to include agencies in other states.Primary Funding SourceCenters for Medicare and Medicaid Services.

Predicting Fragmented Care: Beneficiary, Primary Care Physician, and Practice Characteristics

Research ObjectiveIdentifying characteristics of beneficiaries, primary care physicians, and primary care practice sites that predict highly fragmented ambulatory care (that is, care spread across multiple providers without a dominant provider) is essential to develop effective interventions targeted at reducing fragmentation. High care fragmentation is associated with unnecessary procedures and testing, increased emergency department visits and hospitalizations, and increased medical costs.Study DesignThis study was conducted in the context of the Comprehensive Primary Care Plus Model (CPC+), a large primary care redesign initiative. We used Medicare claims data from January through December 2018 on Medicare fee‐for‐service (FFS) beneficiaries attributed to primary care practice sites participating in CPC+ and to comparison practices that were similar at baseline. We used hierarchical linear models to predict the likelihood of a beneficiary receiving highly fragmented care, defined as having a fragmentation score (measured by the reversed Bice‐Boxerman Index) ≥ 0.85. We used an extensive set of explanatory variables at each level (74 total variables) and group‐level random intercepts to understand how characteristics at each level help explain variation in fragmentation. We estimated separate models for the two CPC+ transformation/payment tracks.Population Studied3,541,136 Medicare FFS beneficiaries attributed to 26,344 primary care physicians in 9300 primary care practice sites.Principal FindingsThe three sets of explanatory variables (beneficiary, physician, and practice site) together only explained about 5 percent of the variation in the likelihood of high care fragmentation. Unobserved differences between primary care physicians and between primary care practice sites together accounted for only 4 percent of the variation. Instead, more than 91 percent of the variation in fragmentation consisted of unobserved residual variance. We identified several characteristics of beneficiaries (age, reason for original Medicare entitlement, and dual status), physicians (gender and measures of comprehensiveness of care), and practice sites (size, being part of a system/hospital, and census region) that had small associations with high fragmentation. Findings were similar by track.ConclusionsAlthough we identified a number of characteristics that predict high care fragmentation, most of the variation in fragmentation was not explained by observed beneficiary, primary care physician, or primary care practice characteristics. This suggests other providers and beneficiaries' preferences may be important factors.Implications for Policy or PracticeOur findings show that primary care physician and practice site characteristics explain only a small share of variation in care fragmentation. Behaviors of other health care providers not captured by regional controls, as well as unmeasured patient preferences, are likely to be important predictors of high care fragmentation.One implication of these findings is that interventions focused on primary care need to be sizable and targeted to decrease fragmentation. Further, future health care innovations might need to expand their focus beyond primary care to consider how specialists and hospitals work with primary care, ways to modify beneficiaries' self‐referral behavior, and the effect of market factors on the primary care practice environment. In addition, fully understanding the factors that drive fragmentation (and opportunities to reduce it) will require more data on specialists and their practices.Primary Funding SourceCenters for Medicare and Medicaid Services.

Patient‐Reported Outcomes from the Comprehensive Care for Joint Replacement Evaluation

Research ObjectiveThe Comprehensive Care for Joint Replacement (CJR) model is intended to encourage participant hospitals to reduce Medicare payments by coordinating care with the physicians, post‐acute care (PAC) providers, and other providers involved in an episode of care for a lower extremity joint replacement (LEJR), which comprises the surgery plus the services provided in the 90 days after hospital discharge. Previous studies have documented reductions in institutional PAC attributable to the model.1 The shift towards less intensive PAC could affect patient experiences and recovery. We surveyed Medicare fee‐for‐service (FFS) beneficiaries after LEJR surgery to document their self‐reported functional status, pain, satisfaction with care management and overall recovery, care transitions, and dependence on caregivers for help with activities of daily living. These patient‐reported outcomes are important indicators of quality that cannot be measured using secondary data.Study DesignIn 2018, participation in CJR was mandatory for hospitals that that did not meet rural or low‐volume exemptions, and were located in 34 randomly‐selected, historically high‐payment metropolitan statistical areas (MSAs). We surveyed a census of Medicare FFS beneficiaries who had LEJR surgery in mandatory CJR hospitals, and those who had LEJR surgery in hospitals within 47 high‐payment MSAs randomly assigned to the control group. Patients received the survey approximately 90 to 120 days after hospital discharge. We estimated risk‐adjusted differences between CJR and control respondents.Population StudiedWe sampled beneficiaries who had LEJR surgery in March, April, August or September 2018 from the CJR group (12,478 beneficiaries) and the control group (13,137 beneficiaries). Response rates for the survey were similar for the CJR and control groups (67.6% and 68.6%, respectively).Principal FindingsThe CJR model did not have a significant impact on patient‐reported functional status, pain, satisfaction with care management or satisfaction with overall recovery. However, CJR respondents were 1.2 percentage points less likely to report that they received the right amount of care in the two weeks after hospital discharge than control respondents (p < 0.01), and CJR respondents required more caregiver help at home than control respondents (a difference of 1.9 points on a 100‐point scale, p < 0.01).ConclusionsThe CJR model resulted in a small increase in the number of respondents who reported that they needed caregiver help after returning home. This is consistent with previous findings that CJR patients were less likely to use institutional PAC and were more likely to go directly home after surgery than control respondents. However, this did not result in decreased functional status or satisfaction with care management and recovery. This suggests that greater dependence on caregivers did not translate to lower satisfaction or worse functional recovery.Implications for Policy or PracticeResults show that CJR reduced Medicare payments by reducing institutional PAC.1 Despite decreasing the use of institutional PAC, the model generally did not affect patient‐reported functional recovery or satisfaction. However, more research is needed to assess the possible impact of the model on caregivers and on patients with physical or social risk factors who may be more vulnerable to changes in care. 1https://innovation.cms.gov/Files/reports/cjr‐secondannrpt.pdf Primary Funding SourceCenters for Medicare and Medicaid Services.

Opioid and CNS-Depressant Medication Prescribing among Older Adults Enrolled in Medicare Advantage Versus Fee-for-Service Medicare

ObjectiveTo examine whether prescription fills of opioids and central nervous system (CNS) depressants are lower in Medicare Advantage (MA) plans, which aim to provide more coordinated and integrated care, than fee-for-service (FFS) Medicare. MethodsData from the 2015 National Health and Aging Trends Study linked with Medicare claims. Community-dwelling adults ≥65 enrolled in Medicare Part D were included (n = 5,652). Prescription fills of opioids, antipsychotics, benzodiazepines, gabapentinoids, and co-prescriptions of opioids with the other medications in MA versus FFS Medicare were examined using multivariate logistic models. Propensity score weighting was applied to account for differences in characteristics between MA and FFS beneficiaries. ResultsMA enrollees were less likely to fill prescriptions for benzodiazepines (15.6% versus 19.0%; marginal difference: -3.4%, t = -2.54, df = 56, p = 0.01), and co-prescriptions of opioids and gabapentinoids (5.1% versus 6.7%; marginal difference: -1.6%, t = -2.07, df = 56, p = 0.04) than FFS beneficiaries. There were no significant differences among the other prescription outcomes. ConclusionsMA was associated with slightly lower likelihood of receiving opioids and some CNS depressants.

Provider Network Structure and Black-to-White Disparity Gaps for Medicare Patients with Diabetes: County-Level Analysis of Cost, Utilization, and Clinical Care.

Prior work has shown that provider network structures correlate with outcomes such as patient costs, utilization, and care. However, it remains unknown whether certain provider networks are associated with reduced disparity gaps. We study the population of Medicare beneficiaries with diabetes who were continuously enrolled in Medicare FFS in 2016. Using multivariable regression analysis of county-level risk adjusted cost, hospitalization, emergency department visits, A1c testing, and preventable diabetes-related hospitalizations, we measure the effect that the relative network connectivity of primary care providers (PCPs) in relation to medical and surgical specialists (PCP/Specialist degree centrality ratio), derived from Medicare patient sharing data, has on non-Hispanic black-to-white disparity gaps controlling for county-level socioeconomic and demographic variables and state fixed effects. Relative to non-Hispanic white, our adjusted results show that non-Hispanic black beneficiaries have $1673 (p<0.001) higher risk adjusted total costs, 2.6 (p<0.001) more hospitalizations (per 1000 beneficiaries), 11.6 (p<0.001) more ED visits (per 1000 beneficiaries), receive 2.2% (p<0.001) less A1c testing, and have 69.4 (p<0.01) more (per 100,000) avoidable diabetes-related hospital admissions. Our main results show that increasing the PCP/Specialist degree centrality ratio by one standard deviation is associated with a disparity gap decrease of 25.3% (p<0.01) in hospitalizations, 8.3% (p<0.05) in ED visits, 2.8% (p<0.01) in A1c testing, and 26.9% (p<0.1) in the volume of preventable diabetes-related hospital admissions. Network structures where PCPs are more central relative to medical and surgical specialists are associated with reduced non-Hispanic black-to-white disparity gaps, suggesting that how we organize and structure our health systems has implications for disparity gaps between non-Hispanic black and white Medicare beneficiaries with diabetes.

Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018

Spinal cord stimulation has been utilized with increasing frequency in managing chronic intractable spinal pain and complex regional pain syndrome (CRPS) in addition to other neuropathic pain states. The literature has shown the effectiveness of spinal cord stimulation in managing chronic pain with improvement in quality of life and cost utility. There have not been any reviews performed in the fee-for-service (FFS) Medicare population in reference to utilization and expenditure patterns of spinal cord stimulators. This investigation was undertaken to assess the utilization and expenditures for spinal cord stimulation in the FFS Medicare population from 2009 to 2018. The present study was designed to assess the utilization patterns and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars only trials and implants were included. Utilization patterns showed that spinal cord stimulation trials increased from 12,680 in 2009 to 36,280 in 2018, a 186% increase with an annual increase of 12.4%. The rate of trials per 100,000 population increased from 28 in 2009 to 61 in 2018 with a 120% increase, or an annual increase of 9.1%. The pulse generator implants increased from 7,640 in 2009 to 22,960 in 2018, an increase of 201%, with an annual increase of 13%. In addition, percutaneous placement with pulse generator implants increased from 4,080 in 2009 to 14,316 in 2018, a 252% increase, or 15% annual increase. In contrast, implantation of neurostimulator electrodes with paddle leads with laminectomy and placement of spinal pulse generator increased from 3,560 in 2009 to 8,600 in 2018, a 142% increase or an annual increase of 10.3%. Analysis of expenditures showed total inflation-adjusted expenditures increased from $292,153,701 in 2009 to $1,142,434,137 in 2018, a 291% increase from 2009 to 2018 and 16.4% annual increase. These expenditures were 125% higher than facet joint interventions and 138% higher than epidural interventions in 2018. In contrast, these expenditures were 55% below the expenditures of facet joint interventions and 66% lower than epidural injections in 2009.Trial to implant ratio improved from 42.5% in 2009 to 63.6% in 2018. An overwhelming majority of trials (90%) were performed by nonsurgical physicians, whereas, 56% of implants were performed by non-surgeons. This assessment includes only FFS Medicare population, thus eliminating approximately 30% of the population with Medicare Advantage plans. In addition, this study has not taken into consideration various revisions not included in 3 specific codes. The analysis of spinal cord stimulators in the FFS Medicare population from 2009 to 2018 showed explosive increases of trials, implants and overall costs.

Billing patterns for in-office computerized tomography scans of the face/sinus by otolaryngologists

PurposeTo evaluate billing trends, Medicare reimbursement, and practice setting for Medicare-billing otolaryngologists (ORLs) performing in-office face computerized tomography (CT) scans. MethodsThis retrospective study included data on Medicare-billing ORLs from Medicare Part B: Provider Utilization and Payment Datafiles (2012–2018). Number of Medicare-billing ORLs performing in-office CT scans, and total sums and medians for Medicare reimbursements, services performed, and number of patients were gathered along with geographic and practice-type distributions. ResultsIn 2018, roughly 1 in 7 Medicare-billing ORLs was performing in-office CT scans, an increase from 1 in 10 in 2012 (48.2% growth). From 2012 to 2018, there has been near-linear growth in number of in-office CT scans performed (58.2% growth), and number of Medicare fee-for-service (FFS) patients receiving an in-office CT scan (64.8% growth). However, at the median, the number of in-office CT scans performed and number of Medicare FFS patients receiving an in-office CT, per physician, has remained constant, despite a decline of 42.3% (2012: $227.67; 2018: $131.26) in median Medicare reimbursements. ConclusionThough sharp declines have been seen in Medicare reimbursement, a greater proportion of Medicare-billing ORLs have been performing in-office face CT scans, while median number of in-office CT scans per ORL has remained constant. Although further investigation is certainly warranted, this analysis suggests that ORLs, at least in the case of the Medicare FFS population, are utilizing in-office CT imaging for preoperative planning, pathologic diagnosis, and patient convenience, rather than increased revenue streams. Future studies should focus on observing these billing trends among private insurers.

Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending

Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation. To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending. This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH. 2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context. Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P < .001). The total contribution (including through both direct and indirect pathways) of SDoH was 37.7% ($1428 of $3785) of this variation, compared with 59.8% ($2265 of $3785) by patient clinical risk, 14.5% ($549 of $3785) by supply of health care resources, and 19.8% ($751 of $3785) by patient demographic characteristics. When all factors were included within the same model, the direct contribution of SDoH was associated with 5.8% of the variation, compared with 4.6% by supply, 4.7% by patient demographic characteristics, and 62.0% by patient clinical risk. These findings suggest social determinants of health are associated with considerable proportions of geographic variation in Medicare spending. Policies addressing SDoH for disadvantaged patients in certain regions have the potential to contain health care spending and improve the value of health care; patient SDoH may need to be accounted for in publicly reported physician performance, and in value-based purchasing incentive programs for health care professionals.

PSS13 Evaluation of Sociodemographic Characteristics, Perceived Vision Impairment, and Functional Status in Patients With Retinal Disease: Analysis of the Medicare Current Beneficiary Survey (MCBS) Data

To characterize sociodemographic characteristics and overall functional status of community-dwelling patients with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) using data from a nationally representative survey of Medicare beneficiaries. A descriptive analysis was conducted using pooled cross-sectional data from the MCBS linked with Medicare fee-for-service (FFS) claims in 2006–2013 and 2015–2018. Community-dwelling beneficiaries (aged ≥18 years) diagnosed with nAMD or DME and with full-year Medicare Part A and B enrollment were identified separately from Medicare FFS claims. Those with other vision-threatening diseases were excluded. Sociodemographic characteristics, perceived vision, and overall functioning measured by activities of daily living (ADL) and instrumental ADL (IADL) were described for each disease cohort. Of 1228 nAMD beneficiaries (mean [SE] age, 83 [0.4] years; 62% female; 96% non-Hispanic White) and 101 DME beneficiaries (mean [SE] age, 72 [1.5] years; 50% female; 80% non-Hispanic White) identified, the majority resided in metropolitan areas (nAMD, 72%; DME, 66%) and lived above 200% of the federal poverty line (nAMD, 60%; DME, 55%); 59% and 66% of the nAMD and DME cohorts, respectively, received no more than high school education. During the survey years, in the nAMD and DME cohorts, respectively, 26% and 17% reported visual impairment/blindness; 37% and 47% reported difficulty in ≥1 ADL, with the most common ADL being walking (nAMD, 33%; DME, 39%); 52% and 53% reported difficulty in ≥1 IADL, with the most common IADL being heavy housework, such as scrubbing floors (44% for both cohorts); and 30% and 39% reported experiencing falls. About 1/3 patients with nAMD or DME in the Medicare population reported difficulty in walking and experiencing falls. Difficulty with heavy housework was the most commonly reported IADL. Further analyses of the MCBS data linked with claims could highlight the burden of nAMD, DME, and other retinal diseases.

PDB2 TOTAL Cost of Care and Utilization Among Medicare Fee-for-Service (FFS) Patients with Metastatic Pancreatic Cancer Treated with FDA-Approved/NCCN® Category 1 Regimens at Teaching VS. NON-Teaching Hospitals

To compare total cost of care (TCOC) and utilization for Medicare FFS patients (pts) with metastatic pancreatic cancer (m-PANC) treated at teaching or non-teaching hospitals, by NCCN® Category 1 regimen.