Medicare FFS Beneficiaries Research Articles

PCN19 PATIENT CHARACTERISTICS AND FIRST LINE TREATMENTS AMONG MEDICARE PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER (MNSCLC)

Pembrolizumab was the first programmed cell death receptor ligand 1 (PD-L1) inhibitor approved 10/2016 for first line monotherapy in mNSCLC patients with high PD-L1 expression (Tumor Proportion Score (TPS) ≥ 50%). Pembrolizumab with pemetrexed and carboplatin (immuno-oncology (IO) + chemotherapy) was approved 5/2017 for nonsquamous disease. The primary study objective is to describe patient characteristics and treatment patterns of Medicare Fee-for-Service (FFS) patients with mNSCLC. A retrospective cohort analysis was conducted among Medicare FFS beneficiaries diagnosed with mNSCLC 10/2015-6/2017 and treated with regimens classified as an NCCN Guideline Category 1 or 2A recommendation. Patients were followed from date of metastatic disease to: death, loss of Medicare coverage, or end of follow-up. PD-L1 expression was available for a subset of patients using linked diagnostic testing results from Prognos. Baseline characteristics, 1LoT, and PD-L1 expression level were measured (PD-L1 negative = TPS <1.0%; PD-L1 positive = TPS ≥1%). A total of 41,431 patients were included (51.1% female; mean age: 74.3 years; mean follow up: 12 months). Of the 2,476 patients with confirmed PD-L1 expression, 66.3% were PD-L1 positive. Patients with positive/negative PD-L1 expression were similar in age, sex and comorbidities. Across the full study sample (n=41,431), the most common 1LoT included: doublet chemotherapy (43.4%), IO monotherapy (19.7%), single agent chemotherapy (14.6%), tyrosine kinase inhibitors (TKI) (10.7%), IO + chemotherapy (1.0%), or other regimens (10.3%). Among patients with PD-L1 positive tumors, the most common 1LoT were doublet chemotherapy (42.6%), pembrolizumab monotherapy (25.5%) or TKI (9.5%); patients with PD-L1 negative tumors commonly received doublet chemotherapy (54.9%) or TKI (14.0%). Treatments in Medicare population were largely in line with NSCLC treatment guidelines. As expected, doublet chemotherapy was the most commonly prescribed 1LoT. Additional research will explore economic outcomes associated with 1LoT selection by PD-L1 status.

Assessment of variation in 30-day mortality following cancer surgeries among older adults across US hospitals.

BackgroundWhile public reporting of surgical outcomes for noncancer conditions is common, cancer surgeries have generally been excluded. This is true despite numerous studies showing outcomes to differ between hospitals based on their characteristics. Our objective was to assess whether three prerequisites for quality assessment and reporting are present for 30‐day mortality after cancer surgery: low burden for timely reporting, hospital variation, and potential for public health gains.Study DesignWe used Fee‐for‐Service (FFS) Medicare claims to examine the extent of variation in 30‐day cancer surgical mortality between 3860 US hospitals. We included 340 489 surgeries for 12 cancer types for FFS Medicare beneficiaries aged ≥66 years, 2011‐2013. Hierarchical mixed‐effects logistic regression models adjusted for patient and hospital characteristics and with a random hospital effect were fit to obtain hospital‐specific risk‐standardized mortality rates (RSMRs) and 99% confidence intervals (CI). We calculated a hospital odds ratio to describe the difference in mortality risk for a hospital above vs below average quality and estimated the potential mortality reduction.ResultsThe median number of cancer surgeries per hospital was 34. The median RSMR overall was 2.41% (99% CI 2.28%, 2.66%). In aggregate and for most cancers, variation between hospitals exceeded that due to differences in patient and hospital characteristics. For individual cancers, relative differences exceeded 20% in mortality risk between patients undergoing surgery at a hospital below vs above average quality, with the potential for an estimated 500 deaths prevented annually given hypothetical improvements.ConclusionQuality measurement and reporting of 30‐day mortality for cancer surgery is worthy of consideration.

State-Level Variations in the Utilization of Lung Cancer Screening Among Medicare Fee-for-Service Beneficiaries: An Analysis of the 2015 to 2017 Physician and Other Supplier Data

Lung cancer screening (LCS) is an important secondary prevention measure to reduce lung cancer mortality. The goal of this study was to assess state-level variations in LCS among the US elderly during the first 3 years since Medicare began its LCS reimbursement policy in2015. This ecological study examined the relations between LCS utilization density, defined as the number of low-dose CT (LDCT) or shared decision-making and counseling (SDMC) services per 1,000 Medicare fee-for-service (FFS) beneficiaries derived from the Medicare Provider Utilization and Payment Data: Physician and Other Supplier public use file, and state-level factors from several publicly available data sources. The study included Kruskal-Wallis tests and a cluster analysis. In 2017, the median utilization density per 1,000 Medicare FFS beneficiaries was 3.32 for LDCT and 0.46 for SDMC, which was 24 and 13 times the 2015 level, respectively. From 2015 to 2017, the total number of unique providers billed for LCS increased from 222 to 3,444 for LDCT imaging and from 20 to 523 for SDMC. Higher utilizations for both LDCT and SDMC services tended to concentrate in the northeastern and upper Midwest states than in the southwest states. The cluster of states with high utilization density did not include those states with the most lung cancer mortality and/or smoking prevalence. A steady increase was noted in LCS utilization since Medicare began its reimbursement policy. The utilization and its growth varied across the United States and differed between LDCT imaging and SDMC, indicating large growth potentials for LCS and for states with high lung cancer mortality and smoking prevalence.

Real-World Treatment Patterns and Overall Survival Among Medicare Fee-for-Service Beneficiaries Newly Diagnosed with Peripheral T-Cell Lymphoma

Background: Peripheral T-cell lymphomas (PTCL) are a rare and heterogeneous group of lymphoid malignancies characterized by a clinically aggressive course with poor prognosis. A majority of PTCL patients are ≥60 years of age and typically present with advanced stage disease and multiple comorbidities. There remains no consensus standard of care for patients with most PTCL subtypes. Multi-agent chemotherapy, consisting of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or CHOP with etoposide (CHOEP), are guideline recommended options for nodal subtypes. Limited contemporary real-world data exist on the treatment patterns and overall survival (OS) of PTCL patients treated with CHOP or non-CHOP regimens in the United States before the FDA approval of brentuximab vedotin in combination with chemotherapy in November 2018 based on the ECHELON-2 trial. Objective: To evaluate treatment patterns and OS prior to the approval of brentuximab vedotin among Medicare Fee-for-Service (FFS) beneficiaries newly diagnosed with PTCL. Methods: The 100% sample of Medicare FFS claims (Parts A/B/D) was used to identify patients aged ≥65 years with ≥1 inpatient or ≥2 distinct outpatient diagnosis claims for PTCL (index event) from January 2011 to December 2017. Patients were required to have a least 6 months prior and 12 months post-index continuous Medicare enrollment, and were followed until disenrollment, death, or the end of the study period, whichever occurred first. OS, defined as the time from initial episode or treatment start date to the validated date of death, was measured using the Kaplan-Meier method; patients without a death date were assumed to be alive at the time of analysis and were censored. Results: A total of 2551 Medicare FFS beneficiaries with a PTCL diagnosis met study criteria and were included for analysis. The majority of patients were white (86.9%), over half were male (52.9%), and mean age was 75 years. Patients had multiple comorbidities at diagnosis (Charlson Comorbidity Index (CCI) score 4.47), including hypertension (77.3%), diabetes (32.9%), and chronic obstructive pulmonary disease (28.1%). Among the 2551 patients in the study cohort, 62.4% (n=1593 of 2551) received at least one identifiable drug regimen; 25.5% of treated patients received CHOP (n=407), 3.1% CHOEP (n=50) and 71.2% (n=1134) other regimens. Of patients treated with other regimens, 37.7% (n=427) received steroids only, 22.4% (n=254) steroids with unidentifiable chemotherapy, 6.9% (n=78) cyclophosphamide, 6.2% (n=70) methotrexate, 4.6% (n=52) brentuximab vedotin, 3.6% (n=41) bendamustine, 3.5% (n=40) romidepsin, and 15.2% (n=172) other therapy combinations. Among patients who were treated with CHOP, 16.6% (n=66) received an identifiable second line of therapy (LoT), 48.7% (n=194) an unidentifiable second LoT, and the remainder (34.7%, n=138) had no evidence of further anti-cancer treatment. The median time from CHOP initiation to a subsequent LoT was 5.6 months. The mean baseline CCI score for patients treated with CHOP was 4.33 (±2.93) compared with 4.76 (±2.97) for patients treated with other therapies (p=0.0118). In patients receiving an identifiable first LoT, median OS among CHOP and non-CHOP recipients was 4.8 years (95% CI 3.0-6.1) and 4.4 years (95% CI 3.0-4.9), respectively (Table). The 5-year OS estimate was 49% in patients receiving CHOP compared with 46% for non-CHOP recipients. Conclusions: Fewer than 30% of Medicare beneficiaries newly diagnosed with PTCL were treated with intensive chemotherapy as first LoT. Acknowledging a possible selection bias for more fit PTCL patients receiving CHOP, this group had increased OS compared with patients receiving non-CHOP therapy. However, the 5-year OS across all cohorts was less than 50%. New therapies such as brentuximab vedotin may fill the need for PTCL Medicare beneficiaries who may not be able to tolerate CHOP or CHOP-based regimens. Disclosures Shah: Avalere Health, An Inovalon Company: Employment. Petrilla:Avalere Health, An Inovalon Company: Employment. Rebeira:Seattle Genetics: Employment. Feliciano:Seattle Genetics: Employment, Equity Ownership. LeBlanc:Astra Zeneca: Consultancy, Research Funding; Duke University: Research Funding; Jazz Pharmaceuticals: Research Funding; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; Helsinn: Consultancy; Agios: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; NINR/NIH: Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Otsuka: Consultancy, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Consultancy, Research Funding; CareVive: Consultancy; Celgene: Honoraria; Flatiron: Consultancy; American Cancer Society: Research Funding; Heron: Membership on an entity's Board of Directors or advisory committees; Medtronic: Membership on an entity's Board of Directors or advisory committees; Pfizer Inc: Consultancy. Lisano:Seattle Genetics, Inc.: Employment, Equity Ownership.

Hospital utilization and expenditures among a nationally representative sample of Medicare fee-for-service beneficiaries 2 years after receipt of an Annual Wellness Visit

Medicare's Annual Wellness Visit (AWV) provides an opportunity to link beneficiaries to cancer screenings and immunizations, however, research has not examined its effectiveness. The aim of this study was to examine the effect of receiving an AWV on outcomes while accounting for the healthy user effect.This study used 2013–2017 Medicare claims data to compare hospital utilization and total expenditures among a 5% random sample of Medicare fee-for-service (FFS) beneficiaries with and without AWV use in 2014 (228,053 AWV users were propensity-score matched to 228,053 nonusers). Linear fixed effects regression models examined differences in study outcomes 12 and 24 months after AWV use, controlling for baseline differences in sociodemographics, health status, utilization, and accountable care organization attribution.The proportion of Medicare FFS beneficiaries that used the AWV increased from 13% in 2013 to 24% in 2017. Users of the AWV had a marginally significant reduction in Medicare spending 12 months (−$122, 95% CI −$256, $11, p = 0.073) and significant reductions (−$162, 95% CI, −$310, −$14, p = 0.032) 24 months after the visit, relative to non-users. However it remains unclear what is driving these savings as there was no change in hospital-related utilization and results may still be biased due to inherent differences between users and non-users.The AWV provides an opportunity for providers to focus on prevention and geriatric needs not covered in typical office visits. Practices adopting AWVs have noted increased revenue, more stable patient populations, and stronger provider-patient relationships. While utilization remains low, it is steadily increasing over time.

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance

BackgroundChronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries.MethodsIn a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression.ResultsAmong the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist.ConclusionsThere is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.

High-Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes.

OBJECTIVESHigh‐need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes.DESIGNLatent class analysis was used to identify phenotypes within a sample of HN fee‐for‐service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post‐acute assessment data.SETTINGNot applicable.PARTICIPANTSTwo cross‐sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643).MEASUREMENTSThe following variables were used to identify phenotypes: acute and post‐acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes.RESULTSFive phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4.CONCLUSIONSOur findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70–77, 2019

1651-P: Diabetes Incidence among Medicare Beneficiaries, 2001-2014

Diabetes mellitus affects more than 12% of the U.S. adult population and has doubled in prevalence between 1990 and 2010. Older adults are particularly affected by the increasing prevalence, which doubles roughly every decade of life and then peaks in the mid-60s at more than 25%. However, there was no change in prevalence or incidence nationally between 2009 and 2012 based on data from the National Health Interview Survey. Increasing prevalence rates are due in part to a higher incidence among adults aged 65 and older. However, these estimates are based on survey research with relatively small numbers of geriatric adults. Administrative data sets built from Medicare claims contain millions of cases, affording an opportunity to explore both trends over time and heterogeneity within the geriatric population. Although most older adults in the U.S. are enrolled in Medicare, claims are only available for those beneficiaries who are enrolled in Fee-for-Service (FFS or Parts A and B). Because beneficiaries can switch between FFS and Medicare Advantage plans, the criteria for identifying prevalent and incident cases of diabetes in FFS claims must be defined carefully. To ensure we had all claims for our study population, we included the 50.4 million Medicare FFS beneficiaries (mean age 68.9 y) who were enrolled for all 60 months of each five-year window centered on index years 2001-2014. We identified prevalent cases as those with either one inpatient or two outpatient diabetes claims within two years. Incident cases were required to have a two year “clean” period with no diabetes diagnostic code. The overall national prevalence of diabetes among Medicare FFS beneficiaries increased from 23.3% in 2001 to a high of 32.2% in 2012, and then remained level through 2014. The overall incidence rate increased from 3.4% in 2001 to a high of 4.1% in 2006-7, then decreased to 3.2% in 2014. Diabetes prevalence and incidence varied considerably across states and were higher among blacks, Hispanics and Asians than among whites. Disclosure L.J. Andes: None. Y. Li: None. M. Srinivasan: None. D.B. Rolka: None. E. Gregg: None.

Monthly parts a and b costs by service and line of therapy for FDA-approved/NCCN category 1 treatments for patients with metastatic pancreatic cancer.

e18365 Background: Real-world evidence is lacking regarding costs for FDA-approved/NCCN Category 1 treatments for patients with metastatic pancreatic cancer (m-PANC). We analyzed costs by service in the Medicare fee-for-service (FFS) population by chemotherapy regimen and line of therapy (LOT). Methods: Patients with m-PANC were identified using ICD-9/10 diagnosis codes in the 2013-2017 Medicare 100% Limited Data Set claims, which include all Medicare paid FFS claims, except professional services, for 45 million Medicare FFS beneficiaries. We studied mean monthly costs by service category, regimen, and LOT. Patients in our study had two or more claims with a pancreatic cancer (PANC) diagnosis more than 30 days apart and one or more claims with a secondary malignancy (metastasis) diagnosis on or after the first PANC diagnosis date. We defined index date as the earliest metastasis diagnosis date. We excluded patients with pre-index non-PANC malignancies and those without 6 months pre-index and 3 months (or until death, if earlier) post-index Medicare FFS enrollment. LOTs were assigned based on therapies used. LOTs ended the day before a new chemotherapy began, 28 days after the last chemotherapy (if no new chemotherapy), or upon death. We analyzed the FDA-approved/NCCN Category 1 treatments used most commonly in first line (1L): gemcitabine monotherapy, gemcitabine/nab-paclitaxel, and FOLFIRINOX; and in second or third line (2L, 3L): liposomal irinotecan. Results: Mean monthly Parts A and B (excluding professional) costs for 1L gemcitabine monotherapy were lower than gemcitabine/nab-paclitaxel or FOLFIRINOX ($5,267, $9,116, and $8,046, respectively). Part B drug costs other than chemotherapy were higher for FOLFIRINOX than gemcitabine/nab-paclitaxel or gemcitabine monotherapy ($3,881, $1,155, and $827, respectively). Inpatient services were similar across 1L regimens ($2,721-$3,303). Despite disease progression, mean monthly 2L and 3L costs for liposomal irinotecan were $10,809 and $12,225, respectively. Part B drugs other than chemotherapy ($2,133-$2,509) were comparable to 1L regimens, but inpatient services ($2,306-$2,405) were lower. Conclusions: The mean monthly cost increased by LOT for m-PANC FDA-approved/NCCN category 1 regimens. Interestingly, Part A inpatient costs decreased in 2L and 3L, while Part B drug costs other than chemotherapy were comparable.

Treatment patterns, survival rate, and Parts A and B costs by line of therapy for FDA-approved/NCCN Category 1 treatments for patients with metastatic pancreatic cancer.

e18357 Background: There is currently limited real-world evidence regarding metastatic pancreatic cancer (m-PANC) FDA-approved/NCCN Category 1 treatment patterns, resource utilization, and survival rate. We analyzed these outcomes in the Medicare fee-for-service (FFS) population by chemotherapy regimen and line of therapy (LOT). Methods: We identified patients with m-PANC using ICD-9/10 diagnosis codes in the 2013-2017 Medicare 100% Limited Data Set claims, which include all Medicare paid FFS claims, except professional services, for 45 million Medicare FFS beneficiaries. We studied mean costs and survival rate by regimen and LOT. Patients in our study had two or more claims with a pancreatic cancer (PANC) diagnosis more than 30 days apart and one or more claims with a secondary malignancy (metastasis) diagnosis on or after the first PANC diagnosis date. We defined index date as the earliest metastasis diagnosis date. We excluded patients with pre-index non-PANC malignancies and those without six months pre-index and three months (or until death, if earlier) post-index Medicare FFS enrollment. LOTs were assigned based on therapies used. LOTs ended the day before a new chemotherapy began, 28 days after the last chemotherapy (if no new chemotherapy), or upon death. Results: Gemcitabine monotherapy, gemcitabine/nab-paclitaxel, and FOLFIRINOX were most commonly used as first line (1L) therapy (91%, 80%, and 80%, respectively). Mean total Parts A and B (excluding professional) cost for 1L gemcitabine monotherapy was lower than gemcitabine/nab-paclitaxel or FOLFIRINOX ($14,601, $32,447, and $33,628, respectively), but FOLFIRINOX had a higher 90-day survival rate (86%) than gemcitabine-based regimens (76-79%). Liposomal irinotecan was most commonly used in second and third lines (2L, 3L) (54% and 28%, respectively); 97% of these patients previously received gemcitabine, consistent with approved labeling. Despite disease progression, 2L and 3L liposomal irinotecan had similar costs ($36,350 and $35,010, respectively) to 1L gemcitabine/nab-paclitaxel and FOLFIRINOX. As expected, 2L and 3L liposomal irinotecan 90-day survival rates were lower (68% and 73%, respectively). Conclusions: Mean total Parts A and B (excluding professional) costs for common 1L-3L regimens varied from less than $15,000 to greater than $30,000. 90-day survival rates for common regimens varied between 1L (86%) to 3L (68%).

PCN302 COMPARING SERVICE UTILIZATION AND COSTS FOR MEDICARE FFS PATIENTS WITH METASTATIC PANCREATIC CANCER BY CHEMOTHERAPY REGIMEN AND LINE OF THERAPY

To analyze treatment patterns, costs, and survival rate for patients with metastatic pancreatic cancer (m-PANC) by line of therapy (LOT). We identified patients with m-PANC using ICD-9/10 diagnosis codes in the 2013-2017 Medicare 100% Limited Data Set claims, which include all Medicare paid fee-for-service (FFS) claims, except professional services, for 45 million Medicare FFS beneficiaries. We studied treatment patterns, costs, and survival rate by LOT. Patients in our study had two or more claims with a pancreatic cancer (PANC) diagnosis more than 30 days apart and one or more claims with a secondary malignancy (metastasis) diagnosis on or after the first PANC diagnosis date. We defined index date as the earliest metastasis diagnosis date. We excluded patients with pre-index non-PANC malignancies and those without six months pre-index and three months post-index (or until death) Medicare FFS enrollment. LOTs were assigned based on therapies used. LOTs ended the day before a new chemotherapy began, 28 days after the last chemotherapy (if no new chemotherapy), or upon death. We identified 31,426 m-PANC patients (average age at index: 73.5 years; average Charlson comorbidity index score: 2.8); 10,874 patients (35%) received first line (1L) chemotherapy, 3,197 (10%) received a second line (2L), and 885 (3%) received a third line (3L). Across LOTs, common regimens included gemcitabine/nab-paclitaxel (38% of patients), gemcitabine monotherapy (21%), FOLFIRINOX (11%), FOLFOX (6%), and liposomal irinotecan (3%). Average LOT duration decreased from 150 days in 1L to 108 days in 3L. Average LOT cost varied by regimen from under $15,000 to more than $30,000. The 90-day survival rate decreased from 79% in 1L to 73% in 3L. 35% of Medicare FFS m-PANC patients received chemotherapy, of which the majority received gemcitabine-based therapy. Average LOT costs varied by regimen. LOT duration and 90-day survival rate decreased by LOT.

PMU50 COMPARING UTILIZATION, COST AND QUALITY IN DUAL ELIGIBLE MEDICARE ADVANTAGE AND FEE-FOR-SERVICE MEDICARE BENEFICIARIES

As policymakers look to encourage value-driven, cost-effective, quality care delivery models, there is growing interest in comparing traditional Fee-for-Service (FFS) Medicare and Medicare Advantage (MA). To date, there is little comprehensive information on the performance of MA compared to FFS due in part to a lack of access to comparable MA encounter data. The objective of this study was to compare healthcare utilization, cost, and quality outcomes across 2 large national samples of dual eligible MA and FFS Medicare beneficiaries. A descriptive cross-sectional cohort design was used to analyze 1,581,822 MA beneficiaries from a large national claims database and 1,212,698 FFS beneficiaries from Medicare Standard Analytic Files (SAF). Beneficiaries were required to be continuously enrolled with medical and pharmacy benefit coverage for the 12-month reporting year 2015. Dual eligible MA beneficiaries had 32.9% fewer inpatient stays and 42.1% fewer ER visits than FFS Medicare. Total cost of care for duals was 16.7% higher in FFS Medicare ($13,398 versus $11,159 in MA). MA duals experienced a 24.1% lower rate of potentially avoidable hospitalizations (19.2% versus 25.3% of FFS Medicare). Despite having a higher percentage of beneficiaries with clinical and social risk factors, the MA population had lower utilization of costly healthcare services. These findings support the notion that the flexibility MA plans have to provide coordinated care and additional benefits results in improved outcomes and lower costs. Starting in 2019, regulatory changes will expand the scope of supplemental benefits that MA plans can offer, including benefits that are not primarily health related. A better understanding of high-cost, high-need patients is essential to developing targeted and innovative benefit programs aimed at reducing costs and improving outcomes in this growing population.

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.

Differences in Management of Coronary Artery Disease in Patients With Medicare Advantage vs Traditional Fee-for-Service Medicare Among Cardiology Practices

One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA), Medicare's private plan option. Medicare Advantage incentivizes performance on evidence-based care, but limited information exists using reliable clinical data to determine whether this translates into better quality for patients with coronary artery disease (CAD) enrolled in MA compared with those enrolled in traditional fee-for-service (FFS) Medicare. To determine differences in evidence-based secondary prevention treatments and intermediate outcomes among patients with CAD enrolled in MA vs FFS Medicare. In this observational, retrospective, cohort study, deidentified data from patients 18 years or older diagnosed as having CAD between January 1, 2013, and May 1, 2014, at cardiology practices participating in the Practice Innovation and Clinical Excellence (PINNACLE) registry were studied, including 35 563 patients enrolled in MA and 172 732 enrolled in FFS Medicare. Data were analyzed from March to July 2018. Medicare Advantage enrollment. Medication prescription patterns among eligible patients and intermediate outcomes, including blood pressure and low-density lipoprotein cholesterol. Of the 35 563 patients with CAD enrolled in MA, 20 193 (56.8%) were male, and the mean (SD) age was 76.7 (7.6) years; of the 172 732 patients with CAD enrolled in FFS Medicare, 100 025 (57.9%) were male, and the mean (SD) age was 77.5 (8.0) years. Patients enrolled in MA were younger, less likely to be white, and more likely to be female and to have heart failure, diabetes, and chronic kidney disease compared with those enrolled in FFS Medicare. Compared with FFS Medicare beneficiaries, MA beneficiaries were more likely to receive secondary prevention treatments, including β-blockers (80.6% vs 78.8%; P < .001), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (70.7% vs 65.1%; P < .001), and statins (68.4% vs 64.5%; P < .001). Patients enrolled in MA were also more likely to receive all 3 medications when eligible (48.9% vs 40.4%; P < .001). After adjustment, MA beneficiaries had higher odds of receiving guideline-recommended therapy compared with FFS Medicare beneficiaries for β-blockers (odds ratio, 1.10; 95% CI, 1.04-1.17; P = .002), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (odds ratio, 1.13; 95% CI, 1.08-1.19; P < .001), and all 3 medications (odds ratio, 1.23; 95% CI, 1.001-1.50; P = .047). There were no significant differences in intermediate outcomes between those enrolled in MA and FFS Medicare, including systolic and diastolic blood pressure and low-density lipoprotein cholesterol levels. Among patients with CAD in the PINNACLE registry, MA beneficiaries had more comorbidities than FFS Medicare beneficiaries and were more likely to receive secondary prevention treatments. However, this did not translate into differences in intermediate outcomes. These findings suggest that MA plans may drive improvements in process-based quality measures for Medicare beneficiaries, although this may have a limited effect on improving patient outcomes over FFS Medicare.

The Prevalence and Cost of Medicare Beneficiaries Diagnosed and At Risk for Opioid Abuse, Dependence, and Poisoning.

Reliance on prescription opioids to manage pain has been associated with increases in diversion, overdose, and addiction. Prevalence of misuse and abuse has been shown to be higher among government-insured populations than commercially insured populations. However, the prevalence and costs of misuse/abuse among the Medicare fee-for-service (FFS) population has not been studied. To (a) determine the prevalence and costs of prescription opioid misuse/abuse and (b) evaluate the prevalence and costs associated with those identified as at risk for opioid misuse/abuse in Medicare FFS beneficiaries. This retrospective case-control study used Medicare claims data for the calendar years of 2010 and 2011 and included Medicare beneficiaries aged at least 18 years. The index date was the date of first diagnosed misuse/abuse or at risk for abuse and had to occur between July 1, 2010, and June 30, 2011, and beneficiaries had to have at least 6 months continuous eligibility before and after the index date. Matching (1:1) was used for comparing opioid misusers/abusers with nonabuser controls, as well as comparing patients at risk for opioid abuse with controls not at risk for abuse. Controls were matched to cases by gender, age, disability, and geographic region. The index date of the control patient was set equal to the index date of the matched case. Prevalence of misuse/abuse in the Medicare FFS population was 13.1 per 1,000 persons, with the majority among patients receiving Medicare based on disability (76.2%). The prevalence of at risk for misuse/abuse was 117.4 per 1,000 persons. Approximately half of the Medicare FFS patients used an opioid. Overall total annual unadjusted mean costs of health care resources were significantly greater for abusers than for matched controls ($46,194 vs. $21,964; P < 0.0001), with a mean annual excess cost of $24,230. The overall total adjusted 6-month post-index mean costs of health care resources for abusers was significantly greater than that of matched controls ($33,942 vs. $10,754; P < 0.0001), with a mean excess cost of $23,188. The prevalence of diagnosed abuse among Medicare FFS population (13.1 per 1,000 persons) was higher than other payer groups studied using similar ICD-9-CM codes, and the majority of abuse was among those receiving Medicare based on disability (76.2%). The prevalence of at-risk abuse was 9 times higher than the prevalence of diagnosed abuse. As with other studies, health care resource utilization and costs were significantly greater for diagnosed abuse than matched controls. This study was sponsored by Pfizer. Roland is a Pfizer employee and stockholder and was involved in all aspects of the study as part of a mid-career fellowship in pharmacoeconomics with the University of Utah. Ye and Stevens are employees of University of Utah, and Oderda was an employee of University of Utah, which received financial support from Pfizer in connection with the development of this manuscript. Oderda also reports consulting fees from Pfizer, Trevena, and Pacira, unrelated to this study. The results of this study were presented at the Academy of Managed Care Pharmacy Nexus 2015; October 26-29, 2015; Orlando, FL, and the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA.

The cost impact to Medicare of shifting treatment of worsening heart failure from inpatient to outpatient management settings.

PurposeThe aim of this study was to quantify the potential cost savings to Medicare of shifting the site of treatment for worsening heart failure (HF) from inpatient to outpatient (OP) settings for a subset of worsening HF episodes among the Medicare fee-for-service (FFS) population.Materials and methodsA cross-sectional analysis of a random 5% sample of 2014 FFS Medicare beneficiaries was conducted. Incidence and cost of worsening HF episodes in both inpatient and OP settings were identified. These results were used to calculate cost savings associated with shifting a proportion of worsening HF episodes from the inpatient to OP settings.ResultsA total of 151,908 HF beneficiaries were identified. The estimated annual cost for the treatment of worsening HF across both inpatient and OP settings ranged from US$9.3 billion to US$17.0 billion or 2.4%–4.3% of total Medicare FFS spend. The cost saving associated with shifting worsening HF treatment from inpatient hospital setting to OP settings was US$667.5 million or 0.17% of total Medicare spend when 10% of HF admissions were targeted and 60% of targeted HF admissions were successfully shifted. The cost savings increased to US$2.098 billion or 0.53% of total Medicare spend when 20% of HF admissions were targeted and 90% of targeted HF admissions were successfully shifted.ConclusionTreatment options that can shift costly hospital admissions for worsening HF treatment to less expensive OP settings potentially lead to significant cost savings to Medicare. Pursuit of OP therapy options for treating worsening HF might be considered a viable alternative.

Evaluation of a Hospital: Community Partnership to Reduce 30-Day Readmissions.

To evaluate the ComPass program by (1) effectiveness in reducing 30-day hospital readmissions, (2) reach of program into target population, and (3) implementation of key program elements. An academic hospital in New England (John Dempsey Hospital). Retrospective analysis of Medicare fee-for-service (FFS) beneficiaries hospitalized at John Dempsey Hospital between May 1, 2012, and November 30, 2014. The program reached 34% of eligible Medicare FFS beneficiaries (n = 832; 61% female, mean age = 79 years). The unadjusted 30-day all-cause readmission rate decreased from 21% to 16.2% (p = .03). Implementation was high for postdischarge phone calls (89%) but low for home visits (34%). The mean change in patient activation scores following completion of the program was 0.15 (SD = 4.79), with no change in patient activation level, χ (6) = 3.82, p = .70. The ComPass program was consistent with the philosophy and standards of case management practice. Case managers will want to utilize an evidence-based instrument with real-time information to identify patients at risk for 30-day readmission. A physical presence of ComPass coaches within the hospital enabled a strong hospital-community-based organization (CBO) partnership, facilitating the coordination, communication, and collaboration. Case managers will want to advocate for policy incentivizing hospital-CBO partnerships. Patient activation is essential; case managers may benefit from training in motivational interviewing to improve patient activation and outcomes. Additional research is needed to further elucidate and mitigate barriers to posttransition home visits and patient activation.

Impact of Medicare Advantage Enrollment on Utilization of Intensity-Modulated Radiation Therapy and Cost of Care for Cancer Treatment

Intensity-modulated radiation therapy (IMRT) is an important driver of rising costs in oncology care, but the level of evidence supporting its routine use varies across disease sites, including breast, lung, and prostate. While Medicare Advantage (MA) plans have incentives to reduce health care spending, the effect of MA enrollment on utilization of high-cost medical services and quality of care is unclear, especially for cancer patients. We examined differences in IMRT utilization and health care spending between MA and traditional fee-for-service (FFS) Medicare for patients receiving radiation therapy (RT) across these disease sites. We performed a retrospective cohort study using 2009-2012 health insurance claims data from the Health Care Cost Institute (HCCI) and the Centers for Medicare and Medicaid Services (CMS). We identified 2,571 MA and 6,062 FFS Medicare beneficiaries from the HCCI and CMS databases, respectively, who were newly diagnosed with non-metastatic breast, lung, or prostate cancer in 2011 and were treated with external beam RT within 12 months of diagnosis. We measured utilization rate of IMRT, unit price of RT delivery, and RT-specific spending among patients within each cancer-type cohort. Outcomes were adjusted for differences in patient characteristics (age, sex, and Charlson co-morbidity index) and geography between MA and FFS beneficiaries. Statistical significance of the differences between groups was assessed using two-sample t tests. In both MA and FFS Medicare, the adjusted rate of IMRT utilization was highest among prostate patients and lowest among breast patients. Across all three disease sites, IMRT utilization was lower in MA than FFS Medicare, but the difference was statistically significant only for the prostate cohort (18.0 vs. 20.2%, p=0.149 for breast; 32.8 vs. 36.0%, p=0.385 for lung; 94.0 vs. 98.5%, p<0.001 for prostate). Average unit price of IMRT delivery was not significantly different in MA versus FFS Medicare. However, per patient RT-related costs were lower among MA patients in the breast and prostate cancer cohorts ($12,630 vs. $13,214 and $25,990 vs. $27,685, respectively; p=0.005 and p<0.001), but not significantly different among lung cancer patients ($15,653 vs. $15,024; p=0.301). IMRT utilization rates in both MA and FFS Medicare were consistent with the relative level of evidence supporting its use in each disease site. MA enrollment was associated with modestly lower IMRT utilization for all patients, with no evidence of a differential impact based on cancer type. The unit price of IMRT delivery was similar in MA versus FFS Medicare. We found no evidence that MA plans adopted utilization management tools that more effectively targeted high-cost therapies based on clinical evidence than in traditional Medicare.

Utilization of health care services among Medicare beneficiaries who visit federally qualified health centers

BackgroundPrevious studies have disagreed on whether patients who receive primary care from federally qualified health centers (FQHCs) have different utilization patterns than patients who receive care elsewhere. Our objective was to compare patterns of healthcare utilization between Medicare beneficiaries who received primary care from FQHCs and Medicare beneficiaries who received primary care from another source.MethodsWe compared characteristics and ambulatory, emergency department (ED), and inpatient utilization during 2013 between 130,637 Medicare beneficiaries who visited an FQHC for the majority of their primary care in 2013 (FQHC users) and a random sample of 1,000,000 Medicare fee-for-service (FFS) beneficiaries who did not visit an FQHC (FQHC non-users). We then created a propensity-matched sample of 130,569 FQHC users and 130,569 FQHC non-users to account for differences in observable patient characteristics between the two groups and repeated all comparisons.ResultsBefore matching, the two samples differed in terms of age (42% below age 65 for FQHC users vs. 16% among FQHC non-users, p < 0.001 for all comparisons), disability (52% vs. 24%), eligibility for Medicaid (56% vs. 21%), severe mental health disorders (17% vs. 10%), and substance abuse disorders (6% vs. 3%). FQHC users had fewer ambulatory visits to primary care or specialist providers (10.0 vs. 12.0 per year), more ED visits (1.2 vs. 0.8), and fewer hospitalizations (0.3 vs. 0.4). In the matched sample, FQHC users still had slightly lower utilization of ambulatory visits to primary care or specialist providers (10.0 vs. 11.2) and slightly higher utilization of ED visits (1.2 vs. 1.0), compared to FQHC users. Hospitalization rates between the two groups were similar (0.3 vs. 0.3).ConclusionsIn this population of Medicare FFS beneficiaries, FQHC users had slightly lower utilization of ambulatory visits and slightly higher utilization of ED visits, compared to FQHC non-users, after accounting for differences in case mix. This study suggests that FQHC care and non-FQHC care are associated with broadly similar levels of healthcare utilization among Medicare FFS beneficiaries.

USING NEUROSCIENCE-BASED TECHNOLOGY TO GENERATE CLINICAL DECISION SUPPORT AND CUSTOMIZED CARE PLANS FOR G0505

The new 2017 Physician Fee Schedule released a new code, G0505 for clinicians who diagnose and care for patients with Alzheimer's Disease and related Dementias (ADRD). The CPT code, released by the Centers of Medicare and Medicaid (CMS), allows for 70 minutes to evaluate patients with cognitive impairment and neurobehavioral symptoms in order to create a custom care plan. National population health data demonstrates diagnosed ADRD prevalence is 30% in dual-eligible fee-for-service (FFS) beneficiaries 65+ and older and 11.5% in all FFS Medicare beneficiaries 65 and older. Most ADRD patients are seen by primary care clinicians, as there is a shortage of memory disorder physicians and behavioral neurologists. An IRB-approved research study was conducted with one senior-level nurse practitioner (NP) in an outpatient community setting in Illinois, a state with a high ADRD prevalence. A web-based ADRD clinical decision support software and care planning program, Neurocern, was used. A full assessment of neurobehavioral symptoms was reported by a knowledgeable informant using an online screener either at the clinician's office or at home before the clinical visit. Answers were automatically translated into a custom care plan that consisted of clinical care recommendations rootedin best practices in nursing and social work. The care plan that was generated also met all requirements by CMS. A total of 8 patients consisting of 100% Medicare were enrolled in the program. 50% completed the Neurocern screener at home before the NP visit and 50% performed the screener at the office. Average time to complete the screener in the office was 15 minutes. The experienced NP was in agreement with the Neurocern software system 100% of the time. 100% of patients met the G0505 clinical code requirements. The average time spent during the visit was 40 minutes discussing the diagnosis, treatment, and care plan. Due to provider shortages in neurology, clinical decision support software and care planning tools may assist non-neurologists in ADRD diagnosis and care planning specifically for the G0505 code. Provider productivity may also be enhanced through the use of time-saving, neuroscience-based technology for ADRD diagnosis and care planning.