FFS Program Research Articles

Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: A population-based cohort study

BackgroundGabapentinoids are increasingly prescribed to manage chronic noncancer pain (CNCP) in older adults. When used concurrently with opioids, gabapentinoids may potentiate central nervous system (CNS) depression and increase the risks for fall. We aimed to investigate whether concurrent use of gabapentinoids with opioids compared with use of opioids alone is associated with an increased risk of fall-related injury among older adults with CNCP.Methods and findingsWe conducted a population-based cohort study using a 5% national sample of Medicare beneficiaries in the United States between 2011 and 2018. Study sample consisted of fee-for-service (FFS) beneficiaries aged ≥65 years with CNCP diagnosis who initiated opioids. We identified concurrent users with gabapentinoids and opioids days’ supply overlapping for ≥1 day and designated first day of concurrency as the index date. We created 2 cohorts based on whether concurrent users initiated gabapentinoids on the day of opioid initiation (Cohort 1) or after opioid initiation (Cohort 2). Each concurrent user was matched to up to 4 opioid-only users on opioid initiation date and index date using risk set sampling. We followed patients from index date to first fall-related injury event ascertained using a validated claims-based algorithm, treatment discontinuation or switching, death, Medicare disenrollment, hospitalization or nursing home admission, or end of study, whichever occurred first. In each cohort, we used propensity score (PS) weighted Cox models to estimate the adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) of fall-related injury, adjusting for year of the index date, sociodemographics, types of chronic pain, comorbidities, frailty, polypharmacy, healthcare utilization, use of nonopioid medications, and opioid use on and before the index date. We identified 6,733 concurrent users and 27,092 matched opioid-only users in Cohort 1 and 5,709 concurrent users and 22,388 matched opioid-only users in Cohort 2. The incidence rate of fall-related injury was 24.5 per 100 person-years during follow-up (median, 9 days; interquartile range [IQR], 5 to 18 days) in Cohort 1 and was 18.0 per 100 person-years during follow-up (median, 9 days; IQR, 4 to 22 days) in Cohort 2. Concurrent users had similar risk of fall-related injury as opioid-only users in Cohort 1(aHR = 0.97, 95% CI 0.71 to 1.34, p = 0.874), but had higher risk for fall-related injury than opioid-only users in Cohort 2 (aHR = 1.69, 95% CI 1.17 to 2.44, p = 0.005). Limitations of this study included confounding due to unmeasured factors, unavailable information on gabapentinoids’ indication, potential misclassification, and limited generalizability beyond older adults insured by Medicare FFS program.ConclusionsIn this sample of older Medicare beneficiaries with CNCP, initiating gabapentinoids and opioids simultaneously compared with initiating opioids only was not significantly associated with risk for fall-related injury. However, addition of gabapentinoids to an existing opioid regimen was associated with increased risks for fall. Mechanisms for the observed excess risk, whether pharmacological or because of channeling of combination therapy to high-risk patients, require further investigation. Clinicians should consider the risk–benefit of combination therapy when prescribing gabapentinoids concurrently with opioids.

How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program?

Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level. The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions. Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries. A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013. Avoidable health care costs and hospital use from medication nonadherence. Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted. Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.

Impacts of an Integrated Medicaid Managed Care Program for Adults with Behavioral Health Conditions: The Experience of Illinois.

This study assessed the impact of the Integrated Care Program (ICP), a new Medicaid managed care model in Illinois, on health services utilization and costs for adults with behavioral health conditions. Data sources included Medicaid claims, encounter records, and state payment data for 28,127 persons with a behavioral health diagnosis. Difference-in-differences models, in conjunction with propensity score weighting, were used to compare utilization and costs between ICP enrollees and a fee-for-service (FFS) comparison group. The model considered the impact of the SMART Act, which restricted access to care for the comparison group. Before the SMART Act, ICP was associated with 2.8 fewer all-cause primary care visits, 34.6 fewer behavioral health-specific outpatient visits, and 2.5 fewer all-cause inpatient admissions per 100 persons per month, and $228 lower total costs per member per month relative to the FFS group. After the SMART Act, ICP enrollees had increased outpatient and dental services utilization without significantly higher costs. The relative increase in utilization was due primarily to decreased utilization in the restricted FFS group after the SMART Act. By the end of the study period, the ICP group had 13.3 more all-cause primary care visits, 1.5 more emergency department visits, and 1.4 more dental visits per 100 persons per month relative to the FFS program. A fully-capitated, integrated managed care program has the potential to reduce overall Medicaid costs for people with behavioral health conditions without negative effects on service utilization.

Medicare Cancer Screening in the Context of Clinical Guidelines

Cancer screening is a ubiquitous and controversial public health issue, particularly in the elderly population. Despite extensive evidence-based guidelines for screening, it is unclear how cancer screening has changed in the Medicare population over time. We characterize trends in cancer screening for the most common cancer types in the Medicare fee-for-service (FFS) program in the context of conflicting guidelines from 2000 to 2012. We performed a descriptive analysis of retrospective claims data from the Medicare FFS program based on billing codes. Our data include all claims for Medicare part B beneficiaries who received breast, colorectal (CRC), or prostate cancer screening from 2000 to 2012 based on billing codes. We utilize a Monte Carlo permutation method to detect changes in screening trends. In total, 231,416,732 screening tests were analyzed from 2000 to 2012, representing an average of 436.8 tests per 1000 beneficiaries per year. Mammography rates declined 7.4%, with digital mammography extensively replacing film. CRC cancer screening rates declined overall. As a percentage of all CRC screening tests, colonoscopy grew from 32% to 71%. Prostate screening rates increased 16% from 2000 to 2007, and then declined to 7% less than its 2000 rate by 2012. Both the aggressiveness of screening guidelines and screening rates for the Medicare FFS population peaked and then declined from 2000 to 2012. However, guideline publications did not consistently precede utilization trend shifts. Technology adoption, practical and financial concerns, and patient preferences may have also contributed to the observed trends. Further research should be performed on the impact of multiple, conflicting guidelines in cancer screening.

Trends in Medicaid fee-for-service outpatient drug utilization, expenditures, and pharmacy reimbursement rates (2010–2012)

Purpose: To assess drug utilization and expenditure trends in Medicaid fee-for-service program during the period 2010 – 2012 in the United States of America. Methods: A retrospective, descriptive analysis of the trend in drug utilization and expenditures in the Medicaid fee-for-service (FFS) program was performed using Medicaid state drug utilization data provided by Centers for Medicare and Medicaid Services (CMS) in the United States. Descriptive analyses were performed for all variables in the study. Association between prescription-drug utilization and reimbursement rate was examined using a linear regression model. Results: The results indicate that prescription-drug utilization of Medicaid FFS program decreased by 20 % during the period (2010 – 2012) as also drug expenditure during the same period. Although constituting nearly 70 % and about 75 % of the total drug utilization in 2010 and 2012, respectively, generics represent only around 18 % of the total drug expenditures. No statistically significant association was found between total expenditures and the reimbursement rate. Conclusion: FFS Medicaid drug expenditures decreased from 2010 to 2012 mainly due to a reduction in the total number of prescriptions as also the prices of generic drugs. Thus, higher utilization of generic drugs may offer substantial savings to Medicaid programs at the state level. Keywords: Fee-for-service programs, Medicaid program, Generic drug utilization; Branded drugs, Patient Protection and Affordable Care Act

Social Determinants of Health in Managed Care Payment Formulas

Managed care payment formulas commonly allocate more money for medically complex populations, but ignore most social determinants of health (SDH). To add SDH variables to a diagnosis-based payment formula that allocates funds to managed care plans and accountable care organizations. Using data from MassHealth, the Massachusetts Medicaid and Children's Health Insurance Program, we estimated regression models predicting Medicaid spending using a diagnosis-based and SDH-expanded model, and compared the accuracy of their cost predictions overall and for vulnerable populations. MassHealth members enrolled for at least 6 months in 2013 in fee-for-service (FFS) programs (n = 357 660) or managed care organizations (MCOs) (n = 524 607). We built cost prediction models from a fee-for-service program. Predictors in the diagnosis-based model are age, sex, and diagnoses from claims. The SDH model adds predictors describing housing instability, behavioral health issues, disability, and neighborhood-level stressors. Overall model explanatory power and overpayments and underpayments for subgroups of interest for all Medicaid-reimbursable expenditures excepting long-term support services (mean annual cost = $5590 per member). We studied 357 660 people who were FFS participants and 524 607 enrolled in MCOs with a combined 806 889 person-years of experience. The FFS program experience included more men (49.6% vs 43.6%), older patients (mean age of 26.1 years vs 21.6 years), and sicker patients (mean morbidity score of 1.16 vs 0.89) than MCOs. Overall, the SDH model performed well, but only slightly better than the diagnosis-based model, explaining most of the spending variation in the managed care population (validated R2 = 62.4) and reducing underpayments for several vulnerable populations. For example, raw costs for the quintile of people living in the most stressed neighborhoods were 9.6% ($537 per member per year) higher than average. Since greater medical morbidity accounts for much of this difference, the diagnosis-based model underpredicts costs for the most stressed quintile by about 2.1% ($130 per member per year). The expanded model eliminates the neighborhood-based underpayment, as well as underpayments of 72% for clients of the Department of Mental Health (observed costs of about $30 000 per year) and of 7% for those with serious mental illness (observed costs of about $16 000 per year). Since October 2016, MassHealth has used an expanded model to allocate payments from a prespecified total budget to managed care organizations according to their enrollees' social and medical risk. Extra payments for socially vulnerable individuals could fund activities, such as housing assistance, that could improve health equity.

New Jersey mental health providers say FFS program puts communities at risk

Mental Health WeeklyVolume 27, Issue 16 p. 1-3 Articles New Jersey mental health providers say FFS program puts communities at risk Valerie A. Canady, Valerie A. CanadySearch for more papers by this author Valerie A. Canady, Valerie A. CanadySearch for more papers by this author First published: 24 April 2017 https://doi.org/10.1002/mhw.31006Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume27, Issue1624 April 2017Pages 1-3 RelatedInformation

Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care

Value-driven payment system reform is a potential tool for aligning economic incentives with the improvement of quality and efficiency of health care and containment of cost. Such a payment system has not been researched satisfactorily in full-cycle cancer care. To examine the association of outcomes and medical expenditures with a bundled-payment pay-for-performance program for breast cancer in Taiwan compared with a fee-for-service (FFS) program. Data were obtained from the Taiwan Cancer Database, National Health Insurance Claims Data, the National Death Registry, and the bundled-payment enrollment file. Women with newly diagnosed breast cancer and a documented first cancer treatment from January 1, 2004, to December 31, 2008, were selected from the Taiwan Cancer Database and followed up for 5 years, with the last follow-up data available on December 31, 2013. Patients in the bundled-payment program were matched at a ratio of 1:3 with control individuals in an FFS program using a propensity score method. The final sample of 17 940 patients included 4485 (25%) in the bundled-payment group and 13 455 (75%) in the FFS group. Rates of adherence to quality indicators, survival rates, and medical payments (excluding bonuses paid in the bundled-payment group). The Kaplan-Meier method was used to calculate 5-year overall and event-free survival rates by cancer stage, and the Cox proportional hazards regression model was used to examine the effect of the bundled-payment program on overall and event-free survival. Sensitivity analysis for bonus payments in the bundled-payment group was also performed. The study population included 17 940 women (mean [SD] age, 52.2 [10.3] years). In the bundled-payment group, 1473 of 4215 patients (34.9%) with applicable quality indicators had full (100%) adherence to quality indicators compared with 3438 of 12 506 patients (27.5%) with applicable quality indicators in the FFS group (P < .001). The 5-year event-free survival rates for patients with stages 0 to III breast cancer were 84.48% for the bundled-payment group and 80.88% for the FFS group (P < .01). Although the 5-year medical payments of the bundled-payment group remained stable, the cumulative medical payments for the FFS group steadily increased from $16 000 to $19 230 and exceeded pay-for-performance bundled payments starting in 2008. In Taiwan, compared with the regular FFS program, bundled payment may lead to better adherence to quality indicators, better outcomes, and more effective cost-control over time.

MULTIPLE IMPUTATION FOR MISSINGNESS DUE TO NONLINKAGE AND PROGRAM CHARACTERISTICS: A CASE STUDY OF THE NATIONAL HEALTH INTERVIEW SURVEY LINKED TO MEDICARE CLAIMS.

Record linkage is a valuable and efficient tool for connecting information from different data sources. The National Center for Health Statistics (NCHS) has linked its population-based health surveys with administrative data, including Medicare enrollment and claims records. However, the linked NCHS-Medicare files are subject to missing data; first, not all survey participants agree to record linkage, and second, Medicare claims data are only consistently available for beneficiaries enrolled in the Fee-for-Service (FFS) program, not in Medicare Advantage (MA) plans. In this research, we examine the usefulness of multiple imputation for handling missing data in linked National Health Interview Survey (NHIS)-Medicare files. The motivating example is a study of mammography status from 1999 to 2004 among women aged 65 years and older enrolled in the FFS program. In our example, mammography screening status and FFS/MA plan type are missing for NHIS survey participants who were not linkage eligible. Mammography status is also missing for linked participants in an MA plan. We explore three imputation approaches: (i) imputing screening status first, (ii) imputing FFS/MA plan type first, (iii) and imputing the two longitudinal processes simultaneously. We conduct simulation studies to evaluate these methods and compare them using the linked NHIS-Medicare files. The imputation procedures described in our paper would also be applicable to other public health-related research using linked data files with missing data issues arising from program characteristics (e.g., intermittent enrollment or data collection) reflected in administrative data and linkage eligibility by survey participants.

Varied Differences in the Health Status Between Medicare Advantage and Fee-for-Service Enrollees

This article examines the differences in mortality measured health status between the Medicare Advantage (MA) program and Fee-for-Service (FFS) program from 1999 to 2007. At the national level, differences in mortality rates were associated with MA market share. In some counties, enrollees in the MA program were 40% less likely to die than their peers in the FFS program, but in other counties, they were 20% more likely to die. Cost shifting between the two programs could bias county classifications of average FFS spending, and enlarged disparities in health status could make it difficult to evaluate risk adjusters.

Clinical and Economic Burden of Community‐Acquired Pneumonia in the Medicare Fee‐for‐Service Population

To estimate current community-acquired pneumonia (CAP) incidence and its associated economic burden in the Medicare fee-for-service (FFS) population. Retrospective. The 2007/08 Medicare Standard Analytic Files, a nationally representative random sample (5%) of Medicare beneficiaries enrolled in the FFS program. Residents of one of the 50 U.S. states or the District of Columbia aged 18 and older on July 1, 2007, with continuous Part A and Part B coverage during calendar year 2007. Incidence, episode length, mortality, and costs were assessed. All-cause costs were assessed using three methodologies: costs during the episode, and incremental costs using CAP cases as self-control (before-after) and with matched controls (case-control). Sixty-five thousand eight hundred four CAP episodes (39% inpatient-treated episodes) were identified. Average inpatient and outpatient episode lengths were 32.8 ± 46.9 and 12.4 ± 27.3 days, respectively, and overall incidence was 4,482/100,000 person-years. Thirty-day case fatality was 8.5% for inpatient and 3.8% for outpatient CAP. The average CAP episode cost was $8,606 ($18,670 for inpatient, $2,394 for outpatient). The incremental cost of a CAP episode in the before-and-after and case-control analyses was approximately $10,000. An estimated 1.3 million CAP cases and 74,000 CAP-related deaths were found, with an economic burden of $13 billion annually in the Medicare fee-for-service population. Preventing CAP in this population may substantially reduce healthcare costs.

PMS40 Medication Adherence among Patients with Rheumatoid Arthritis

The main objective of this study was to assess the medication adherence among individuals with rheumatoid arthritis (RA) enrolled in a state Medicaid fee-for-service (FFS) program. Factors influencing medication adherence were identified. Lastly, the role of adherence in influencing the utilization of acute care services (hospitalization/emergency room visit) was ascertained. The target population included nonelderly adult recipients (21-64 years) who were continuously enrolled in the Mississippi Medicaid FFS program from January 1, 2006 to December 31, 2007. Recipients who had a medical services claim with a primary or secondary diagnosis of RA in calendar year 2006 were identified. Medication adherence (measured as proportion of days covered (PDC)) was determined using calendar year 2007 data. Recipients with adherence (PDC) ≥80% were classified as adherent. Logistic regression analyses were used to determine factors predicting medication adherence and the effect of adherence on acute care services utilization. Roughly 20% of recipients with RA were adherent. Older age (odds ratio (OR) = 1.031; p<0.005), white race (OR= 1.684; p<0.005), and lower Charlson comorbidity index (CCI) score (OR= 0.785; p<0.005) were significant predictors of adherence. Adherence did not have a significant association with acute care services utilization after controlling for demographic and disease-related covariates. Only one in five Medicaid recipients with RA were found to be adherent. Lower levels of adherence among individuals with RA could contribute to poor outcomes in these individuals over time. Policy makers should undertake intervention programs aimed at increasing medication adherence in this underprivileged population.

Declining mammography screening in a state Medicaid Fee-for-Service program: 1999-2008.

To evaluate and compare annual and biennial mammography screening rates across age, race, and geographic location (rural-urban) and to determine mammography screening persistence over 10 years among women enrolled in the West Virginia (WV) Medicaid Fee-for-Service (FFS) program. The WV Medicaid FFS administrative claims data for women recipients aged 40-64 from 1999 to 2008 were used for study purposes. Annual and biennial screening rates and persistence with screening were determined for women who were continuously enrolled in the WV Medicaid FFS program for respective calendar years. A steady decline in the annual and biennial screening rates over a 10-year period (1999-2008) was observed among women recipients aged 40-64 years in the WV Medicaid FFS program, and screening persistence was also lower. Both annual and biennial screening rates and persistence varied by different demographic characteristics. Although mammography screening services are covered under Medicaid programs, underuse persists as a major concern. The results of this study emphasize the need to identify and address barriers to mammography screening in low-income rural populations.

Prevalence, Healthcare Utilization, and Costs of Breast Cancer in a State Medicaid Fee-for-Service Program

The purpose of this study was to determine the prevalence, medical services and treatment utilization, and costs associated with breast cancer in a socioeconomically underprivileged population covered by a state Medicaid fee-for-service (FFS) program. We analyzed the West Virginia (WV) Medicaid FFS administrative claims data for women recipients 21-64 years of age enrolled continuously in the program during the calendar year 2005. Breast cancer-related medical services and treatment use and costs were calculated for women recipients with breast cancer. The excess burden of breast cancer was calculated by comparing the all-cause healthcare utilization and costs among women recipients with breast cancer to a matched control group of women recipients without breast cancer. Healthcare costs incurred during the 1-year study period were calculated from the perspective of state Medicaid. Cost estimates in the study excluded out-of-pocket expenses and indirect costs of breast cancer. In 2005, the prevalence of breast cancer in the WV Medicaid FFS program was 22.7/1000. More than 98% of breast cancer-related medical services utilization occurred in the office setting. Approximately 73% of women recipients with breast cancer had at least one claim for breast cancer treatment, with hormone therapy being the most common (55.1%) treatment. The all-cause healthcare costs were significantly higher for women recipients with breast cancer compared to those without breast cancer ($16,345 vs. $13,027, p<0.001). Consistent with our expectations, breast cancer diagnosis among women recipients in the WV Medicaid FFS program was found to be associated with higher all-cause healthcare use and costs compared to women recipients in the matched control group. The excess cost burden associated with breast cancer could be attributed to higher office visit, emergency room visit, and prescription medication use among recipients with breast cancer.

Comparing CMS Spending for a Special Needs Plan’s Enrollees with Medicare Fee-for-Service

The objective of this analysis was to compare the capitation payments that the Centers for Medicare & Medicaid Services (CMS) makes to SCAN for enrollees in its largest SNP with the payments that CMS would have otherwise made to providers if those individuals incurred claims in the FFS program. The analysis found that, controlling for individuals’ demographic and clinical characteristics, CMS’s payments to SCAN for its enrollees were lower than CMS’s payments to providers for Part A and Part B services delivered to FFS beneficiaries. The analysis was run twice – first with the actual payments received by SCAN and second adjusting the SCAN Health Plan payments to reflect ultimate payment policy (full risk adjustment and no frailty factor). In both cases we have made adjustments for CMS’s payments to physicians and for durable medical equipment (DME) under the FFS program, as discussed in detail in the technical appendix. In the first case, CMS’s average annual payment to SCAN for each enrollee was $1,522 lower than CMS’s average annual payment for services for each FFS beneficiary. That implies about $129 million and $137 million in savings to the Medicare program from SCAN enrollees in calendar years 2006 and 2007, respectively. In the second case, CMS’s average annual payment to SCAN for each enrollee was $2,300 lower than CMS’s average annual payment for services for each FFS beneficiary. That implies about $195 million and $207 million in savings to the Medicare program from SCAN enrollees during 2006 and 2007, respectively, had these payment rules been in place. As healthcare reform discussions continue to take shape, these findings suggest that further exploration of certain MA plan types that care for the frailest or most clinically complex Medicare beneficiaries may be warranted.

Enhancing the Medical Homes Model for Children With Asthma

Medical Home is an evolving concept of patient-centered care yet little information is available on its effect on health care expenditures for children. To quantify differences in patterns of care and costs to the North Carolina (NC) Medicaid program for children with asthma across 3 programs: fee-for-service (FFS), primary care case management (PCCM), and Medical Homes. NC Medicaid claims from 1998-2001 for children with asthma were used to examine monthly expenditures and patterns of health care use, including emergency department and hospital use. Children in the FFS program served as controls for trends in asthma care over the study period. Tests examined the potential for selection by program and fixed-effect 2-part model regressions were used to control for differences in program enrollees. Children under age 21 with asthma. Monthly Medicaid expenditures and measures of health service use. We found considerable evidence of quality improvement in patterns of care for children enrolled in both the PCCM and Medical Homes models in NC. After controlling for selection into these programs, use of maintenance as well as rescue medications increased, use of services increased, and emergency department and hospital use went down. Total spending (asthma and nonasthma related) on children in the Medical Homes program was $148 greater than spending for FFS children (95% bootstrapped confidence interval: $140-$158) per child per month and no difference in spending between Medical Homes and PCCM was detected. Our results indicate that enhancement of PCCM programs is one way for Medicaid programs to improve care, but may require substantial investments by states.