Medicare Access Research Articles

Intersecting Inequities for Older LGBTQ+ Adults of Color in the Advent of Medicare Access: A Structural Vulnerability Framework

Intersecting Inequities for Older LGBTQ+ Adults of Color in the Advent of Medicare Access: A Structural Vulnerability Framework

Trends in heart failure costs for commercially insured patients in the United States (2006–2021)

BackgroundAlthough prior research has estimated the overarching cost burden of heart failure (HF), a thorough analysis examining medical expense differences and trends, specifically among commercially insured patients with heart failure, is still lacking. Thus, the study aims to examine historical trends and differences in medical costs for commercially insured heart failure patients in the United States from 2006 to 2021.MethodsA population-based, cross-sectional analysis of medical and pharmacy claims data (IQVIA PharMetrics® Plus for Academic) from 2006 to 2021 was conducted. The cohort included adult patients (age > = 18) who were enrolled in commercial insurance plans and had healthcare encounters with a primary diagnosis of HF. The primary outcome measures were the average total annual payment per patient and per cost categories encompassing hospitalization, surgery, emergency department (ED) visits, outpatient care, post-discharge care, and medications. The sub-group measures included systolic, diastolic, and systolic combined with diastolic, age, gender, comorbidity, regions, states, insurance payment, and self-payment.ResultsThe study included 422,289 commercially insured heart failure (HF) patients in the U.S. evaluated from 2006 to 2021. The average total annual cost per patient decreased overall from $9,636.99 to $8,201.89, with an average annual percentage change (AAPC) of -1.11% (95% CI: -2% to -0.26%). Hospitalization and medication costs decreased with an AAPC of -1.99% (95% CI: -3.25% to -0.8%) and − 3.1% (95% CI: -6.86–0.69%). On the other hand, post-discharge, outpatient, ED visit, and surgery costs increased by an AAPC of 0.84% (95% CI: 0.12–1.49%), 4.31% (95% CI: 1.03–7.63%), 7.21% (95% CI: 6.44–8.12%), and 9.36% (95% CI: 8.61–10.19%).ConclusionsThe study’s findings reveal a rising trend in average total annual payments per patient from 2006 to 2015, followed by a subsequent decrease from 2016 to 2021. This decrease was attributed to the decline in average patient costs within the Medicare Cost insurance category after 2016, coinciding with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, expenses related to surgical procedures, emergency department (ED) visits, and outpatient care have shown substantial growth over time. Moreover, significant differences across various variables have been identified.

What Every Colorectal Surgeon Should Know About the Updated Medicare Access and Children's Healthcare Insurance Program Reauthorization Act and the Merit-Based Incentive Program System Legislation.

What Every Colorectal Surgeon Should Know About the Updated Medicare Access and Children's Healthcare Insurance Program Reauthorization Act and the Merit-Based Incentive Program System Legislation.

Impact of Primary Care Providers and Health Insurance Type on Colorectal Cancer Screening in the United States.

Colorectal cancer (CRC) is a major cause of cancer deaths. We evaluated the effect of health insurance type and primary care provider (PCP) access on CRC screening. HINTS data were used to analyze CRC screening. Individuals aged 50 to 65 years had comparable screening rates across all insurance types. Beyond 65 years, individuals with Medicare or Medicare with private insurance were more likely to undergo screening than private insurance users. PCP access increased CRC screening rates. Among PCP users, Medicare, income, and smoking status influenced screening. Medicare and PCP access influence CRC screening. All individuals should be linked with PCPs.

The Inflation Reduction Act: Implications for Medicare spending and access to biologic therapies for chronic rhinosinusitis with nasal polyposis and asthma.

In 2021, Medicare spending on biologics was $926million in Part B (FFS) and $1.3 billion in Part D (FFS/MA). Between 2017 and 2021, annual Medicare spending on biologics increased by approximately 200%. Between 2023 and 2025, Medicare Part D OOP costs for biologics will decrease by an estimated 50%-60%.

Mass shootings, firearm injuries, and mental health

IntroductionThe correlation between mass shootings, firearm injuries, and mental health is an ongoing polarized debate within the U.S., making it essential to develop public policy on mental illness and firearm injuries exacerbated by a significant increase in firearm sales in March 2020. Although many mass shooters are labeled “mentally ill,” mental illness is only present in a small minority of cases. Most mentally ill people are never violent but are more likely to be the victims of violence.Easy access to firearms and a triggering event deriving from social and economic inequalities are primary causes of mass shootings and growing online radicalization. Radicalization can easily lead to fatal firearm injuries, particularly for individuals with diagnosed or undiagnosed mental illness. RecommendationsProposed solutions include permits for firearms purchase, including a 25-year-old age limit, universal background checks, and banning large-capacity magazines. Additionally, a speedy and effective law enforcement response is the sole factor and the most reliable way to stop a mass shooting once it has started. The research identified several other recommendations, including expanding Medicare and mental health care access, expanding school safety and law enforcement training, and promoting public education about mental health and firearm safety.

Trends in Medicare Reimbursement for Interventional Radiology Procedures: 2007-2020.

Declining physician reimbursement has been occurring across multiple specialties due to changes in Medicare legislation, including theDeficit Reduction Omnibus Reconciliation Act (DRA),the Balanced Budget Act, and the Sustainable Growth Rate. The purpose of this study was to evaluate trends in Medicare reimbursement rates for various procedural classes in interventional radiology from 2007 to 2020. Common interventional radiology procedures were selected across multiple procedural classes: gastrointestinal, biliary, urinary, fallopian dilatation, other injection/change/removal, iliac vascular, femoral/popliteal vascular, tibial/peroneal vascular, hepatobiliary, and vascular emergency. The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for current procedural terminology (CPT) codes to extract reimbursement data. All monetary data were adjusted for inflation using the United States consumer price index (CPI). The compound annual growth rate (CAGR) and average annual change in reimbursement were calculated based on these adjusted trends. Aside from urinary and vascular emergency procedures, all other procedural classes experienced decreases in inflation-adjusted Medicare reimbursement from 2007 to 2020. The greatest mean decrease in reimbursement rates was observed in biliary procedures (-$21.25), while the largest mean increase in reimbursement rates was observed in vascular emergency procedures ($3.23). All procedures with increases in reimbursement rates and 36.8% of procedures with decreases in reimbursement rates have a CPT code change between 2007 and 2020. After accounting for inflation, reimbursement rates were shown to decline for all procedural classes except for urinary and vascular emergencies. Congressional policies, such as the Deficit Reduction Act (DRA) and the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015, may clarify some of these trends.

Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care.

To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation. Retrospective, Observational cohort study. Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019. Adult patients that electively underwent 1 of 19 major procedures. None. The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 (n = 2,103,836) and PostM: 2016-2019 (n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts. We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

The Value of Medicare Coverage on Depressive Symptoms Among Older Immigrants.

The immigrant population, the primary driver of U.S. population growth, is aging and many immigrants remain uninsured. Lack of health insurance limits access to care, aggravating the already high level of depression for older immigrants. However, there is scarce evidence on how health insurance, particularly Medicare, affects their mental health. Using the Health and Retirement Study, this study examines the effect of Medicare coverage on depressive symptoms of older immigrants in the United States. Exploiting the fact that many immigrants are not covered by Medicare after passing age 65, we use a difference-in-difference model with propensity score weighting to compare differences in depressive symptoms pre- and post-age-65. We further stratify the sample by socioeconomic status and by race/ethnicity. Medicare coverage was significantly associated with a reduction in the probability of reporting depressive symptoms for immigrants with low socioeconomic status, especially for those below median wealth levels. The beneficial effect of Medicare coverage was also statistically significant for non-White immigrants-Black, Hispanic, and Asian/Pacific Islander-even when holding socioeconomic status constant. Our findings imply that immigration policies that expand health care protection to older immigrants can lead to further health benefits and reduce existing disparities for the aging population. Policy reforms such as providing limited Medicare access to immigrants who paid sufficient taxes but are still awaiting permanent residency status could increase coverage for the uninsured and improve participation of immigrants in the payroll system.

Geographic disparities in Medicare telehealth utilization and access to specialized cancer care in the United States.

e13683 Background: Access to specialized cancer care varies by place of residence, partly due to differences in geographic proximity to designated cancer centers. Telehealth services can help alleviate some of these geographic disparities. In response to the COVID-19 pandemic, Medicare telehealth services were expanded rapidly. In this study, we sought to describe the geographic variations in Medicare telehealth utilization and their relationship with locations of designated cancer centers in the United States. We hypothesized that differences in telehealth utilization might be reflective of barriers to telehealth access for Medicare beneficiaries in these regions. Methods: We used the Medicare Telehealth Trends data file and calculated the proportion of Medicare users who used a telehealth service (% Telehealth Users) across all quarters of 2021. To obtain % Telehealth Users in a state, the number of telehealth users were divided by the total number of telehealth-eligible users. Then, using % Telehealth Users as a metric of telehealth utilization, we ranked all US states by overall % Telehealth Users, and % Telehealth Users in rural and urban locations. Finally, we correlated these ranks with the presence of an NCI (National Cancer Institute) Designated Cancer Center within the states. Results: The % Telehealth Users ranged from 15%-53% overall, 16%-54% for rural locations, and 14%-54% for urban locations, across lowest ranked to highest ranked states. The 5 lowest ranking states and their respective % Telehealth Users overall were- Wyoming (20%), Montana (20%), Iowa (20%), South Dakota (18%), Nebraska (17%), and North Dakota (15%). The lowest ranking states in terms of rural % Telehealth Users were Montana, Kansas, Iowa, Tennessee, Wyoming (19% each), and South Dakota and Nebraska (16% each). The lowest ranking states in terms of urban % Telehealth Users were Montana (20%), Wyoming (20%), Nebraska (19%), South Dakota (16%), and North Dakota (14%). 4 out of 6 states overall, 3 out of 7 in the rural category, and 4 out of 5 states in the urban category that were ranked the lowest in telehealth utilization did not have an in-state NCI designated cancer center. Conclusions: Telehealth services can bridge gaps in access to specialty cancer care for patients that do not live in geographic proximity of cancer centers. However, regions lacking geographic proximity to cancer centers were also regions with poorest telehealth utilization. Advocacy and policy efforts directed towards increasing access to telehealth can ensure equitable and timely access to specialized cancer care in these regions of need.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act.

The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA. Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation. Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation. Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Practice patterns of dermatologists who have opted out of Medicare

Practice patterns of dermatologists who have opted out of Medicare

Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance.

Lloyd R, Morgenthaler TI, Donald R, etal. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673-2680.

Society of General Internal Medicine Position Statement on Social Risk and Equity in Medicare's Mandatory Value-Based Payment Programs.

The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations - a "Reverse Robin Hood" effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.

Measuring improvement in psoriasis and dermatitis: The development of pruritus clinical quality measures

To the Editor: The Medicare Access and CHIP Reauthorization Act of 2015 created the Merit-based Incentive Payment System (MIPS). Physicians can demonstrate quality and receive incentives by reporting data in performance measures. The Performance Measurement Committee (PMC) of the American Academy of Dermatology (AAD) creates measures specific to dermatology, covering a range of elements of practice.

Chasm Between Cancer Quality Measures and Electronic Health Record Data Quality.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires eligible clinicians to report clinical quality measures (CQMs) in the Merit-Based Incentive Payment System (MIPS) to maximize reimbursement. To determine whether structured data in electronic health records (EHRs) were adequate to report MIPS CQMs, EHR data aggregated by ASCO's CancerLinQ platform were analyzed. Using the CancerLinQ health technology platform, 19 Oncology MIPS (oMIPS) CQMs were evaluated to determine the presence of data elements (DEs) necessary to satisfy each CQM and the DE percent population with patient data (fill rates). At the time of this analysis, the CancerLinQ network comprised 63 active practices, representing eight different EHR vendors and containing records for more than 1.63 million unique patients with one or more malignant neoplasms (1.73 million cancer cases). Fill rates for the 63 oMIPS-associated DEs varied widely among the practices. The average site had at least one filled DE for 52% of the DEs. Only 35% of the DEs were populated for at least one patient record in 95% of the practices. However, the average DE fill rate of all practices was 23%. No data were found at any practice for 22% of the DEs. Since any oMIPS CQM with an unpopulated DE component resulted in an inability to compute the measure, only two (10.5%) of the 19 oMIPS CQMs were computable for more than 1% of the patients. Although EHR systems had relatively high DE fill rates for some DEs, underfilling and inconsistency of DEs in EHRs render automated oncology MIPS CQM calculations impractical.

Declining trends in Medicare physician reimbursements for surgical procedures in orthopaedic oncology from 2002 to 2018: a retrospective review of payment data

Background: As the United States (US) healthcare system evolves towards cost-containment and value-based approaches, evaluating trends in procedure reimbursements will be critical for assessing and ensuring financial stability of highly specialized fields, such as orthopaedic oncology. Methods: The Medicare Physician Fee Schedule (MPFS) look-up tool was accessed through the official Center for Medicaid and Medicare Services website and used to retrieve average reimbursement rates for 28 common orthopaedic oncologic procedures (radical resections of soft tumors, bone tumors, and prophylactic treatment, nailing, or pinning) from 2002 to 2018. All reimbursement data were adjusted for inflation to 2018 dollars. For each Current Procedural Terminology (CPT) code, average reimbursement percentage change from 2002 to 2018 was calculated. Results: Based on the included codes, physician payment data for 28 surgical procedures from 2002 to 2018 were retrieved from the MPFS database. After adjusting all data for inflation, the average reimbursement for all included procedures decreased by 9.9% from 2002 to 2018, representing an estimated average decrease of 1.1% every couple of years. Reimbursement percentage decreases were the most significant prior to the Medicare Access and CHIP Reauthorization Act (MACRA), with reimbursements decreasing by an average of 5.8% from 2002 to 2014. However, reimbursement rates still declined by an average of 4.3% from 2014 to 2018 (after MACRA). Discussion: Reimbursements for orthopaedic oncologic procedures have steadily decreased over time. With orthopaedic oncology being a highly specialized field with few practicing providers, health policy makers need to understand the financial implications of the declining reimbursement rates to ensure financial stability and viability of the specialty. Level of Evidence: Level III.

Medicare Must Provide Additional Cost and Access Information to Enhance Decision Making Around Trade Offs Between Medicare Advantage and Medigap.

Health insurance coverage options are complicated and often leave Medicare beneficiaries, families, advocates, and brokers confused. Medicare should make small changes to its existing “Compare Coverage Options” tool that would enhance the public’s understanding of the trade-offs between Medicare Advantage and supplemental Medigap with Fee-for-Service Medicare. For cost considerations, Medicare should include a projection of annual out-of-pocket (OOP) spending, whether an OOP cap applies and whether the ability to alter OOP for additional clinical benefit is offered. For access considerations, Medicare should provide access to information to educate the public on coverage and costs associated with dental, vision, and hearing benefits, network adequacy, prior authorization, and supplemental benefits. These changes will enhance transparency and decision making.

Development of a qualified clinical data registry for emergency medicine.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 marked a fundamental transition in physician payment by the Centers for Medicare and Medicaid Services (CMS) from traditional fee‐for service to value‐based models. MACRA led to the creation of the CMS Quality Payment Program (QPP), which bases the value of physician care in large part on physician quality reporting. The QPP enabled a shift away from legacy CMS‐stewarded quality measures that had limited applicability to individual specialties toward specialty‐specific quality measures developed and stewarded by physician specialty societies using Qualified Clinical Data Registries (QCDRs). This article describes the development of the first nationally available emergency medicine QCDR as a means for emergency physicians to participate in the QPP, measure, and benchmark emergency physician quality.

Barriers to participation and success in value-based care (VBC) models.

70 Background: The enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 initiated the transition from a fee-for-service to a fee-for-value payment system in healthcare. Two government-sponsored VBC models (Oncology Care Model [OCM] and Merit-Based Incentive Payment System [MIPS]) were introduced in 2016 and 2017. Several commercial payers followed suit with similar value-based contracts. Implementing and complying with the performance metrics of these models comes with challenges. This qualitative research study sought to assess participation in both government-sponsored and commercial-insurance-sponsored VBC models among oncology providers and their perceptions regarding the ability to perform successfully. Methods: Between February and April 2021, medical oncologists/hematologists (mO/H) from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 307 mO/H across the U.S. completed the survey: 73% practice in a community setting; 47% identify as hospital employees. The participants spend a median of 90% of their working time in direct patient care, have a median of 16 years of clinical experience, and see a median of 20 patients per day on clinic days. Half participate in a government-sponsored VBC model (21% MIPS and 28% OCM), and 20% participate in a commercial VBC model. A third reported that it is difficult to perform favorably in VBC models (37% government and 35% commercial). Primary challenges deterring favorable performance were navigating the payer landscape and reimbursements (27%), identifying cost-reduction opportunities (20%), tracking costs across an episode (18%), and clinical decision support and compliance (17%). One-third are not satisfied with currently available technology to effectively support their performance in VBC models. Almost half would like to see more seamless integration into practice workflows (49%) and interoperability across platforms including EHRs (42%), and 24% would like artificial intelligence or machine learning features integrated into solutions tools. Conclusions: Oncology practices find it challenging to perform favorably in government and private payer-sponsored VBC models. They are generally dissatisfied with current technology and see an unmet need for interoperability and artificial intelligence to better support their performance in these programs. Further research is needed to determine how best to design and implement VBC programs.