Medicaid Services Research Articles

Association Between Nursing Home Five-Star Ratings and Consumer Satisfaction

ObjectiveConsumers can currently access the Centers for Medicare and Medicaid Services Five-Star Quality Rating System when they choose a nursing home (NH). However, the system does not incorporate NH consumers’ opinions. Without having access to satisfaction or quality-of-life measures, consumers could make uninformed decisions. This study aims to investigate the association between five-star ratings and family/resident satisfaction scores. DesignSecondary data analysis was used. Setting and ParticipantsA unique, NH-level dataset of Ohio NHs that contains star ratings, satisfaction scores, and NH characteristics was constructed (N = 701). Data were drawn from the 2018 star rating data, 2018 Ohio Nursing Home Family Satisfaction Survey, 2017 Ohio Nursing Home Resident Satisfaction Survey, 2017 Ohio Biennial Survey of Long-Term Care Facilities, and the Certification and Survey Provider Enhanced Reports. MethodsChi-square and logistic regression analyses were conducted controlling other NH characteristics. ResultsChi-square results showed consumer satisfaction and star ratings were correlated, but imperfectly related. Regression results found that NHs with higher family satisfaction score received significantly higher star ratings across all domains except the quality-measure star rating. For each 1% point increase in the family satisfaction score, the probability of being a 4 or 5 overall star NH increases by 1.1% point (P < .01), and being a 4 or 5 health inspection star NH increases by 1.2% points (P < .01). NHs with higher resident satisfaction score received significantly higher star ratings. For every 1% point increase in the resident satisfaction score, the probability of being a 4 or 5 star NH increases by 0.7% point (P < .05) across all star ratings. Conclusions and ImplicationsEarly studies found little relationship between five-star ratings and consumer satisfaction scores. This study found consumer satisfaction is associated, although imperfectly, with star ratings. This highlights the need to publicly report NH consumer perspectives to help them make informed care decisions.

The TELEhealth Shared decision-making COaching and navigation in Primary carE (TELESCOPE) intervention: a study protocol for delivering shared decision-making for lung cancer screening by patient navigators.

Lung cancer screening (LCS) can reduce lung cancer mortality but has potential harms for patients. A shared decision-making (SDM) conversation about LCS is required by the Centers for Medicare & Medicaid Services (CMS) for LCS reimbursement. To overcome barriers to SDM in primary care, this protocol describes a telehealth decision coaching and navigationintervention for LCS in primary care clinics delivered by patient navigators. The objective of the study is to evaluate the effectiveness of the intervention and its implementation potential, compared with an enhanced usual care (EUC) arm. Patients (n = 420) of primary care clinicians (n = 120) are being recruited to a cluster randomized controlled trial. Clinicians are randomly assigned to 1) TELESCOPE intervention: prior to an upcoming non-acute clinic visit, patients participate in a telehealth decision coaching and navigationsession about LCS delivered by trained patient navigators and nurse navigators place a low-dose CT scan (LDCT) order for each TELESCOPE patient wanting LCS, or 2) EUC: patients receive enhanced usual care from a clinician. Usual care is enhanced by providing clinicians in both arms with access to a Continuing Medical Education (CME) webinar about LCS and an LCS discussion guide. Patients complete surveys at baseline and 1-week after the scheduled clinic visit to assess quality of the SDM process. Re-navigation is attempted with TELESCOPE patients who have not completed the LDCT within 3months. One month before being due for an annual screening, TELESCOPE patients whose initial LCS showed low-risk findings are randomly assigned to receive a telehealth decision coaching booster session with a navigator or no booster. Electronic health records are abstracted at 6, 12 and 18months after the initial decision coaching session (TELESCOPE) or clinic visit (EUC) to assess initial and annual LCS uptake, imaging results, follow-up testing for abnormal findings, cancer diagnoses, treatment, and tobacco treatment referrals. This study will evaluate factors that facilitate or interfere with program implementation using mixed methods. We will assess whether a decision coaching and patient navigation intervention can feasibly and effectivelysupport high-quality SDM for LCS and guideline-concordant LCS uptake for patients in busy primary care practices serving diverse patient populations. This study was registered at ClinicalTrials.gov (NCT05491213) on August 4, 2022. Version 1, April 10, 2024.

Rates of fall injuries across three claims databases, 2019

IntroductionIn 2021, among all age groups, falls ranked as the third leading cause of unintentional injury death in the USA. Unlike fatal data, which rely on death certificates as the...

Assessing the utilization of Current Procedural Terminology codes in pharmacists' services using MarketScan data.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The Medicare Prescription Drug, Improvement, and Modernization Act and Centers for Medicare and Medicaid Services affirmation enabled pharmacists to use Current Procedural Terminology (CPT) codes for documentation and billing of clinical services. Despite legislative support and potential availability of pharmacists' clinical services, a gap may exist between the reported availability and actual prevalence of these services in real-world settings. The objective was to assess the prevalence of selected CPT codes (99605-99607, 98966-989968, and 99211-99215) in documenting and billing potential pharmacists' clinical services using recent available data. This retrospective study utilized the Merative MarketScan Medicare database from the period January 1, 2016, to December 31, 2020. The dataset included deidentified patient information and CPT codes. Patients with CPT codes for face-to-face medication therapy management (MTM) services (99605-99607), codes for telephonic assessment and management (A/M) services (98966-98968), and/or codes for evaluation and management (E/M) services (99211-99215) were identified from outpatient claims. Descriptive statistics, including prevalence rates, were calculated. This study was approved by an institutional review board and followed STROBE guidelines. There were claims data for 2,784,629 enrollees from 2016 through 2020. Prevalence rates varied during this period, with lower rates for MTM face-to-face CPT codes (0.06%) and telephonic A/M codes (0.58%), while E/M CPT codes showed higher prevalence rates (87%). Study findings exhibited a limited adoption rate for MTM CPT codes for billing pharmacists' clinical services. Future research may focus on assessing pharmacists' perceptions and identifying facilitators and barriers to using CPT codes in billing clinical services.

Conflicts of Interest in Bronchoscopy Research - Is Self-Reporting Sufficient?

Robotic assisted bronchoscopy has been enthusiastically adopted in the U.S. and transformed the management of patients with indeterminate pulmonary nodules. Unprecedented industry investments in research, development, and marketing have profoundly affected the bronchoscopy landscape, leading to concerns that conflicts of interest could influence the validity of bronchoscopy studies. Disclosures of conflicts of interest in research are predicated on open and transparent self-reporting. Are self-reported relevant conflicts of interest in articles pertaining to robotic assisted bronchoscopy accurate when compared to publicly available payments on the Centers of Medicare & Medicaid Services' Open Payments Database? All articles pertaining to robotic assisted bronchoscopy indexed on PubMed between 2016 and 2022 were screened for relevance. Articles appearing in the five journals with the most relevant publications were selected. General, research, and associated research payments reported in the Open Payments Database were recorded for each US physician-author with available data. "Relevant payments" refer to transactions made to authors by bronchoscopy-related companies. Documentation of all payments involving these companies during the three years prior to an article's submission date was obtained. These payments were compared to the self-reported conflicts of interest for each author, per article, and the number and value of payments were categorized and totaled. Twenty-seven articles were included, accounting for 75 U.S. physicians with data reported in the Open Payments Database. Of the $17 million in relevant payments reported, $9.9 million were not disclosed (57%). Sixty-eight of 75 (91%) of authors had incomplete physician disclosures. Excluding food and beverage payments, sixty authors had incomplete disclosures (80%). Relevant conflicts of interest appear to be inconsistently disclosed in publications on robotic assisted bronchoscopy, suggesting self-reporting may be an insufficient strategy. A centralized disclosure process that is automated or easier to use should be considered.

American Thyroid Association Policy Statement: Impact of Changes in Fine Needle Aspiration Biopsy Reimbursement on Clinical Care of Patients with Thyroid Nodules in the United States.

Introduction: The Clinical Affairs Committee of the American Thyroid Association has developed this statement to describe recent changes in the billing and coding of ultrasound-guided fine needle aspiration procedures of thyroid nodules, and to raise awareness of the adverse consequences that have arisen as a result. Review: A reduction in payment of ultrasound-guided fine needle aspiration procedures was enacted by the Centers for Medicare and Medicaid Services in 2019. The Clinical Affairs Committee has sought to examine the effects of the change in reimbursement on the care of patients with thyroid diseases. Summary: The historical background of the changes in payment structure for ultrasound-guided fine needle aspiration of thyroid nodules is discussed. The years 2019 and 2020 saw a significant decline in claims for ultrasound-guided fine needle aspiration procedures, concomitant with a shift in the performance of these procedures away from non-facility outpatient settings and a rise in costs to the health care system. Conclusion: Several negative consequences of the decrease in reimbursement for ultrasound-guided fine needle aspiration of thyroid nodules have arisen. This has led to significant concern among clinicians who care for patients with thyroid diseases regarding delays in patient access to care and diagnosis, and a diminished pool of qualified thyroid specialists to perform these procedures in the future.

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 Racial Health Equity Progress Report: A Data-Driven Equity Action Tool

Health care leaders in Illinois, with support from the Commonwealth Fund, expanded their statewide Racial Health Equity Progress Report (Progress Report) into a nationwide pilot. This effort aims to mobilize data-driven action to achieve health equity across four domains of health care organizational influence: people (employees), organization, patients, and community. The goal of the Progress Report is to address the complex challenges of advancing equity across health care organizations. The Progress Report is a 34-item Web-based self-assessment questionnaire that measures an organization’s performance in implementing processes to address racial health and other health inequities. The questionnaire includes open-text response options as well as a specialized 0–5 Likert scale that assesses the degree of progress of an organization’s racial health equity efforts as Not in Place (0), Internal Socialization (1), Initiation (2), Piloting (3), Implementation (4), and Best Practice (5). The initiative includes individualized data analytic reports designed to assist boards and leaders in advancing health equity strategies and initiatives across their organizations. The Progress Report is aligned with both The Joint Commission and the U.S. Centers for Medicare & Medicaid Services regulatory standards for achieving health equity. The Progress Report also functions as a benchmarking mechanism, allowing health care organizations to measure progress over time, compare their performance with other organizations, and learn from others. Participants are encouraged to translate their Progress Report data into actionable strategies for improvement, including participating in 8-week virtual Improvement Action Networks. This framework highlights the importance of examining all aspects of an organization — not patient care alone — for inequities to successfully eliminate health inequities. Here, the authors describe the origins of the program, its development, and the preliminary results from the Progress Report responses submitted by 92 U.S.-based hospitals and health centers, as well as prospects for expanding and scaling the initiative.

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.

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.

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.

Untangling the complex web of avoidable nursing home-to-hospital transfers of residents with dementia.

Nursing home (NH) residents with Alzheimer's disease or related dementias (ADRD) are at high risk for hospital transfer. We aimed to (1) describe characteristics and predictors of avoidable transfer of residents with ADRD and (2) explore how "what matters" influences the decision to transfer. We applied an exploratory, mixed methods design using data collected as part of a Centers for Medicare and Medicaid Services demonstration project. Advanced practice registered nurses documented retrospective details about nursing home (NH)-to-hospital transfers (n=3687) from 16 NHs. NH residents with ADRD had 1.22 times higher odds of having an avoidable NH-to-hospital transfer (odds ratio=1.22; 95% confidence interval=1.03, 1.45). Factors contributing to avoidable transfers were age, stage of ADRD, what matters to the resident and their family, changes in condition, and resources available in the NH. These findings highlight the need for enhanced specificity in the discussion and documentation of resident and family preferences and continued investments in the NH workforce. This article reports on factors contributing to avoidable nursing home (NH)-to-hospital transfer of residents with Alzheimer's disease and related dementias (ADRD). The mixed methods design used in this study offers insight beyond what is possible using a single-method design. Using data collected from a Centers for Medicare and Medicaid Services demonstration project, advanced practice registered nurses documented retrospective details about NH-to-hospital transfers (n=3687) of residents. NH residents with ADRD were more likely to have an avoidable NH-to-hospital transfer. Factors contributing to avoidable transfers were age, stage of ADRD, what matters to the resident and their family, changes in condition, and resources available in the NH. These findings highlight the need for enhanced specificity in discussion and documentation of resident and family preferences and continued investments in the NH workforce.

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.

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.

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 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.

Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members.

The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program. This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending, defined as medical spending during a 6-month episode. Secondary outcomes included hospitalization and emergency department (ED) utilization and quality measures. From the pre-OCM to the OCM period, mean total episode payments increased from $45,504 in US dollars (USD) to $46,239 USD for OCM-participating practices, and increased from $50,519 USD to $58,591 USD for non-OCM practices (adjusted difference-in-differences -$6,287 USD [95% CI, -$10,076 USD to -$2,498 USD], P = .001). The OCM was associated with adjusted spending decreases for both high-risk (-$6,756 USD [95% CI, -$10,731 USD to -$2,781 USD], P = .001) and low-risk (-$4,171 USD [95% CI, -$7,799 USD to -$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (-$5,243 USD [95% CI, -$8,589 USD to -$1,897 USD], P = .002) and infused/injected anticancer drug (-$3,031 USD [95% CI, -$5,193 USD to -$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care. The OCM was associated with reductions in spending for nontargeted members, a spillover effect.