Medicare Physician Research Articles

Value of care by reducing treatment terminations during radiation therapy.

6 Background: Disruptions in cancer care adversely affect patient clinical outcomes, particularly when a patient does not complete the prescribed course of treatment. Adverse outcomes include decreased overall survival and earlier/increased disease relapse or progression requiring additional salvage, palliative, and/or supportive therapies. We have reported on the incidence of treatment terminations (TT) in a large multi-center academic radiation medicine department. This study addresses the healthcare expenditure toward sub-optimal treatment associated with TT. Methods: TT of patients undergoing radiation treatment between 1/2013 and 1/2023 were prospectively tracked as part of departmental quality and safety monitoring. A TT was defined as the discontinuation of therapy at any point following informed consent and treatment simulation. The rate of TT was calculated as a percentage of all new patients who start radiation treatments. Cost of care was estimated using mean values from the 2023 Medicare Part B Fee schedule for New York, accounting for consultation, simulation and planning, treatment delivery, and weekly physician and physics treatment checks prior to TT. Cuts to the Medicare Physician Fee Schedule, Medicare reimbursement, and stagnant Medicare Conversion Factor relative to inflation over the 10 years were not accounted for. Results: There were a total of 1,467 TTs out of 28,707 planned treatment courses (5.1%). The average expenditure prior to TT was $8,584 per patient. Aggregated over the past decade, $12.59 million represents an underestimate of healthcare spend toward these situations at one institution. The rate of TT decreased from 9.3% in 2013 to 3.3% in 2022. As discussed separately, this TT rate was reduced via prospective analysis as part of our ongoing department quality and safety program, with incremental changes to pre-treatment evaluation, on-treatment management, and scheduling processes. Assuming stagnant clinical volume, this translates into decreased spend of $1.48 million annually toward incomplete (sub-optimal) treatments. Conclusions: Radiation TTs reflect major deviations from the original care plan. By understanding reasons for TT, we have more effectively selected optimal treatment paradigms and supported patients proactively through their treatment course. Avoiding divergence from intended cancer care decreases adverse outcomes, thereby improving value of the treatment course.

Financial Impact of Imaging Examination Site of Service in the Medicare Population.

The financial sustainability of the US healthcare system is a growing concern in an environment of declining reimbursement and rising costs. Variable Centers for Medicare and Medicaid (CMS) reimbursement and denial rates for specific imaging examinations exist across sites of service, adding complexity to financial planning for healthcare organizations. Understanding the financial implications of site of service in existing CMS reimbursement for imaging may be of strategic importance for organizations going forward. Current Procedural Terminology (CPT) codes were obtained for common cross-sectional imaging examinations using the 2022 CMS Medicare Physician Fee Schedule. Using reimbursement rates with historical volumes and denial rates, a simulation was created to estimate the overall reimbursement of paired hospital outpatient departments (HOPD) and free-standing office (FSO) sites. A baseline simulation was performed with random allocation of imaging examinations between sites of service, and an optimized simulation was performed to estimate the maximum financial impact of targeted allocation between sites. These simulations were performed for paired CT and MR scanners separately. For CT, the baseline simulation estimated annual average reimbursement for combined HOPD and FSO was $3.25M. Reimbursement increased to $3.51M after optimized reallocation of studies between sites of service, resulting in an expected gain of $260,162 for a set of paired HOPD and FSO scanners. For MR, the same approach resulted in baseline reimbursement of $2.51M, increasing to $2.60M upon reallocation between sites for an expected gain of $87,532. Assuming a stable cost of service delivery, this approach would result in improved margins of 8% for CT and 3.5% for MR. There were 28 CT and 19 MRI daily patient imaging appointments at each respective HOPD and FSO scanners, unchanged between baseline and optimized cases. Differences in reimbursement rates between sites were the dominant driver of increased margins at low denial rates, although denial rates became dominant at values greater than 50%. Given CMS payment and denial rate variability, optimally allocating imaging studies between sites of service may improve reimbursement for the same services delivered. Although financial incentives exist for site allocation, such decisions should require physician input to assess safety and appropriate level of care. This work contributes to an understanding of financial incentives of existing reimbursement policy and may guide future policy design towards high value care.

Geographic accessibility to palliative care clinicians for patients with newly diagnosed stage 4 cancer in the United States.

84 Background: Early integration of palliative care is recommended for patients with newly diagnosed advanced cancer. However, many patients with cancer only receive this essential care during hospitalization or at the end of life, likely resulting in poor symptom management and increased morbidity, suffering, and financial burden for patients and families. This study aimed to examine disparities in geographical access to palliative care in the US. Methods: The study utilized data from the 2018-2019 National Cancer Database (NCDB) and CMS Medicare Physician and Other Practitioners dataset. Included patients were newly diagnosed with stage 4 cancer with geographic information for patients’ residential and their treating facilities’ zip codes. We geocoded the addresses of practices where physicians provided palliative care services 2018 -2019. The OpenStreetMap and Open Source Routing Machine (OSRM) model was employed to estimate the travel distance between patients' residences and the nearest palliative care clinician, as well as between their treating facilities and the nearest palliative care clinicians. Results: 335,191 stage 4 cancer patients and 1,063 clinicians who specialize in palliative care were included in the analysis. The most common cancer diagnoses were lung (28.8%), colorectal (10.2%), pancreatic (7.8%), and breast (4.9%) cancers. Distance to the nearest palliative care clinician was more than 12.5 miles for 63.4% of patients and 45.4% of treating facilities, and more than 50 miles for 24.1% of patients and 19.1% of treating facilities (Table). Patients who lived ≥50 miles away from the nearest palliative care clinic tended to be White, have a lower household income, and live in rural areas. Facilities located ≥50 miles away from the nearest palliative care clinics tended to be in rural areas and community or comprehensive community facilities. (all p<0.0001). Conclusions: 63.4% and 24.1% patients with newly diagnosed stage 4 cancers lived at least 12.5 miles and 50 miles from their nearest palliative care clinicians. Geographic disparities in palliative care availability underscore the need for policy and practice interventions aimed at improving equitable access to palliative care for patients with advanced cancer.[Table: see text]

Complications and associated risk factors after surgical management of proximal femoral fractures.

This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes? Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management.

Hospital payment systems and physician reimbursement: A primer for radiology residents

Prior to practicing independently, radiology trainees spend considerable time and energy to learn and understand the practice of radiology. However, upon graduation trainees are often deficient in understanding the business of hospitals and the structure of reimbursement. Specifically, the workflow of relative value units (RVUs) and its impact on practice of radiology after completing training. In this manuscript, we provide a resource for trainees to understand the workflow of physician reimbursement. This article includes information on the mixed model healthcare structure of the United States and two government programs that influence reimbursement: Diagnosis-Related Groups (DRG) and Hospital Value-Based Purchasing (HVBP) programs. Furthermore, we explain the method by which the Center of Medicare and Medicate Service's (CMS) reimburses physicians via the Medicare Physician Fee Schedule (MPFS) using the Resource Based Relative Value Scale. Understanding the structure of these payments along with the challenges and current landscape of radiology reimbursement will help new radiologists prior to seeking employment where reimbursements are integral to contract expectations.

Interpretable machine learning accurately reclassifies lobectomy surgical approaches by cost

BackgroundThe volume of robotic lung resection continues to increase despite its higher costs and unproven superiority to video-assisted thoracoscopic surgery. We evaluated whether machine learning can accurately identify factors influencing cost and reclassify high-cost operative approaches into lower-cost alternatives. MethodsThe Florida Agency for Healthcare Administration and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets were queried for patients undergoing open, video-assisted thoracoscopic surgery and robotic lobectomy. K-means cluster analysis was used to identify robotic clusters based on total cost. Predictive models were built using artificial neural networks, Support Vector Machines, Classification and Regression Trees, and Gradient Boosted Machines algorithms. Models were applied to the high-volume robotic group to determine patients whose cost cluster changed if undergoing a video-assisted thoracoscopic surgery approach. A local interpretable model-agnostic explanation approach personalized cost per patient. ResultsOf the 6,618 cases included in the analysis, we identified 4 cost clusters. Application of artificial neural networks to the robotic subgroup identified 1,642 (65%) cases with no re-assignment of cost cluster, 583 (23%) with reduced costs, and 300 (12%) with increased costs if they had undergone video-assisted thoracoscopic surgery approach. The 5 overall highest cost predictors were patient admission from the clinic, diagnosis of metastatic cancer, presence of cancer, urgent hospital admission, and dementia. ConclusionK-means cluster analysis and machine learning identify a patient population that may undergo video-assisted thoracoscopic surgery or robotic lobectomy without a significant difference in total cost. Local interpretable model-agnostic explanation identifies individual patient factors contributing to cost. Application of this modeling may reliably stratify high-cost patients into lower-cost approaches and provide a rationale for reducing expenditure.

Association of Provider Zip Code Sociodemographic Characteristics with Radiation Therapy Modality Use in the Medicare Population

Variations in healthcare delivery by provider and patient-level characteristics have been well studied in the US health system as a whole, though these patterns are not as well defined in radiation oncology. We evaluated the association of provider zip-code level sociodemographic characteristics with variations in radiation therapy (RT) modality use. We used the Centers for Medicare & Medicaid Services (CMS) Physician and Other Supplier Public Use File, CMS Physician Compare, and National Neighborhood Data Archive databases to link non-facility based radiation oncologists and their submitted Medicare charges in 2020 with sociodemographic information of the provider's zip code. We selected radiation oncologists who submitted for any of the following RT treatments: proton RT (PRT), stereotactic body RT (SBRT), intensity modulated RT (IMRT), 3D conformal RT (3DCRT), and brachytherapy (BT). Sociodemographic covariates included predominant race/ethnicity of area (Black, White, or Hispanic), percentage of population earning above $75,000 annually, provider rurality (metropolitan vs non-metropolitan), and predominant education level attained of area (Bachelor's degree vs no Bachelor's degree). We measured the association of these covariates with the use of different RT modalities with multivariable logistic regression. We identified 1,126 radiation oncologists for analysis. PRT was more likely to be used by providers in areas with a predominantly Black population compared with providers in areas with a predominantly White or Hispanic population (Black as reference, White odds ratio (OR) 0.11; 95% CI 0.05-0.24; Hispanic OR 0.23; 95% CI 0.08-0.56). IMRT was more likely to be used by providers in areas with a predominantly White or Hispanic population compared with providers in areas with a predominantly Black population (White OR 3.40; 95% CI 1.63-6.78; Hispanic OR 2.46; 95% CI 1.04-5.97). SBRT was less likely to be used in non-metro areas compared with metro areas (OR 0.28, 95% CI 0.12-0.56). The annual income measure was not associated with any RT modality. Providers in areas with predominantly Bachelor's degree attained were more likely to use PRT (Bachelor's degree as reference, OR 0.34; 95% CI 0.17-0.64) and less likely to use SBRT (OR 1.53; 95% CI 1.04-2.26), IMRT (OR 2.04; 95% CI 1.20-3.48), and 3DCRT (OR 1.52; 95% CI 1.04-2.22). No covariates were associated with BT use. We identified notable variations in RT delivery with multiple sociodemographic factors. A predominantly Black population was associated with a higher likelihood of PRT use, and BT use was not associated with any sociodemographic covariate. These findings might reflect reduced barriers to care afforded by the universal healthcare setting of Medicare or ongoing improvements in RT delivery with respect to previously identified health disparities. Additional work is needed to further elucidate these patterns of RT use and determine if they represent effective care.

Cost Analysis of MR-Guided vs. CT-Guided Radiation Therapy for Locally Advanced Pancreatic Cancer

Stereotactic magnetic resonance guided on-table adaptive radiotherapy (SMART) is an increasingly utilized radiotherapy (RT) treatment for locally advanced pancreatic cancer (LAPC), providing improved local control and overall survival with reduced toxicity. Computed tomography (CT) guided RT options include stereotactic body radiotherapy (SBRT) and hypofractionated RT with volumetric modulated arc therapy (VMAT). Currently there are no financial comparisons for MR vs CT-guided RT for LAPC. We completed a cost analysis comparing the physician and hospital charges associated with RT options for LAPC. To compare RT costs, we identified Current Procedural Terminology (CPT) codes utilized for 5-fraction SMART with adaptation (50 Gy, biological effective dose (BED) 100 Gy), 5-fraction CT-guided SBRT (33 Gy, BED 55 Gy), and 15-fraction CT-guided hypofractionated VMAT (67.5 Gy, BED 98 Gy) in a hospital-based practice setting. Physician and hospital Medicare prices associated with these codes together summarize the overall cost. We determined physician fees using the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule Search to search the Healthcare Common Procedure Coding System (HCPCS) for "professional" costs included within "facility" costs. We determined hospital fees using the Outpatient Prospective Payment System addendum. To standardize costs, we searched for national payment amounts for the 2022 calendar year. Total cost of SMART with adaptation was 136% higher than the cost of CT-SBRT and 149% higher than the cost of hypofractionated RT. Physician fees for SMART were 173% higher and 157% higher than the fees for CT-SBRT and hypofractionated RT, respectively. Hospital fees for SMART were 129% higher and 147% higher than the fees for CT-SBRT and hypofractionated RT, respectively. The total cost of CT-SBRT was only 5% higher than cost of hypofractionated RT. The physician fees for hypofractionated RT were 6% higher than those for CT-SBRT, while the outpatient fees for CT SBRT were 7% higher than those for hypofractionated RT. With recent data demonstrating favorable efficacy and toxicity rates for SMART, practices may increasingly consider investing in this treatment modality. This is the first cost analysis comparing SMART to CT-guided SBRT and hypofractionated RT in LAPC. We demonstrate higher costs of SMART compared to CT-guided RT, attributable primarily to higher number of dosimetry calculations for this modality and for adapted fractions. We also demonstrate comparable costs of lower BED CT-guided SBRT and higher BED hypofractionated RT. Further investigation is needed to assess whether the survival benefit of SMART translates to favorable cost per quality adjusted life year.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

Budget Neutrality and Medicare Physician Fee Schedule Reimbursement Trends for Radiologists, 2005 to 2021

PurposeThe Medicare program, by law, must remain budget neutral. Increases in volume or relative value units (RVUs) for individual services necessitate declines in either the conversion factor or assigned RVUs for other services for budget neutrality. This study aimed to assess the contribution of budget neutrality on reimbursement trends per Medicare fee-for-service beneficiary for services provided by radiologists. MethodsThe study used aggregated 100% of Medicare Part B claims from 2005 to 2021. We computed the percentage change in reimbursement per beneficiary, actual and inflation adjusted, to radiologists. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality. ResultsUnadjusted reimbursement to radiologists per beneficiary increased 4.2% between 2005 and 2021, but when adjusted for inflation, it declined 24.9%. Over this period, the conversion factor declined 7.9%. Without this decline, the reimbursement per beneficiary would have been 9 percentage points higher in 2021 compared with actual. RVUs per beneficiary performed by radiologists increased 13.1%. Keeping RVUs per beneficiary at 2005 levels, reimbursement per beneficiary would have been 12.1 percentage points lower than observed in 2021. ConclusionsGiven budget neutrality, a substantial decline has occurred in inflation-adjusted reimbursement to radiologists per Medicare beneficiary. Decreases due to both inflation and the decline in conversion factor are only partially offset by increased RVUs per beneficiary, meaning more services per patient with less overall pay, an equation likely to heighten access challenges for Medicare beneficiaries and shortages of radiologists.

Participation in a Medicare advanced primary care model and the delivery of high-value services.

To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services. Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare. We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year. Secondary data are linked at the provider level. We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening. CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.

Epidemiology and treatment of proximal femoral fractures in the elderly U.S. population

Proximal femoral fractures are a serious complication, especially for elderly patients. Detailed epidemiological analyzes provide a valuable resource for stakeholders in the health care system in order to foresee future development possibly influenceable by adaption of therapeutic procedures and prevention strategies. This work aimed at answering the following research questions: (1) What are the incidence rates of proximal femoral fractures in the elderly U.S. population? (2) What is the preferred treatment procedure for these fractures? Proximal femoral fractures occurred between January 1, 2009 and December 31, 2019 in patients ≥ 65 years were identified from the Medicare Physician Service Records Data Base. The 5% sample of Medicare beneficiaries, equivalent to the records from approximately 2.5 million enrollees formed the basis of this study. Fractures were grouped into head/neck, intertrochanteric, and subtrochanteric fractures. The overall incidence rate, age and sex specific incidence rates as well as incidence rate ratios were calculated. Common Procedural Terminology (CPT) codes were used to identify procedures and operations. In 2019, a total number of 7982 femoral head/neck fractures was recorded. In comparison to 9588 cases in 2009, the incidence substantially decreased by 26.6% from 666.7/100,000 inhabitants to 489.3/100,000 inhabitants (z = − 5.197, p < 0.001). Also, in intertrochanteric fractures, a significant decline in the incidence by 17.3% was evident over the years from 367.7/100,000 inhabitants in 2009 to 304.0 cases per 100,000 inhabitants in 2019 (z = − 2.454, p = 0.014). A similar picture was observable for subtrochanteric fractures, which decreased by 29.6% (51.0 cases per 100,000 to 35.9 cases per 100,000) over the time period (z = − 1.612, p = 0.107). Head/neck fractures were mainly treated with an arthroplasty (n = 36,301, 40.0%). The majority of intertrochanteric fractures and subtrochanteric fractures received treatment with an intramedullary device (n = 34,630, 65.5% and n = 5870, 77.1%, respectively). The analysis indicated that the incidence of all types of proximal femoral neck fractures decreased for the population of elderly patients in the U.S. within the last decade. Treatment of head and neck fractures was mainly conducted through arthroplasty, while intertrochanteric and subtrochanteric fractures predominantly received an intramedullary nailing.

Attrition From the US Emergency Medicine Workforce During Early Stages of the COVID-19 Pandemic.

Attrition From the US Emergency Medicine Workforce During Early Stages of the COVID-19 Pandemic.

A Medicare Physician Fee Schedule Analysis of Reimbursement Trends in Laryngology from 2000 to 2021.

The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades. This analysis used CMS' Physician Fee Schedule (PFS) Look-Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office-based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non-facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization. Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office-based procedures was -2.0%, for airway procedures was -2.2%, for voice disorders procedures was -1.4%, and for dysphagia procedures was -1.7%. In non-facilities, the weighted average CAGR for office-based procedures was -0.9%. The procedures in the other procedure groups did not have a corresponding non-facility reimbursement rate. Like other otolaryngology subspecialties, inflation-adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care. NA Laryngoscope, 134:247-256, 2024.

Two Decades of Declining Medicare Reimbursement in Cardiac Surgery

BackgroundGiven the uncertainty of US health care finances, an understanding of reimbursement trends has become increasingly important in the field of cardiac surgery. We aimed to assess Medicare reimbursement trends for common cardiac surgical procedures from 2000 to 2022. MethodsReimbursement data were extracted from the Centers for Medicare and Medicaid Services Physician Fee Schedule Look-Up Tool during the study period for 6 common cardiac operations: aortic valve replacement, mitral valve repair and replacement, tricuspid valve replacement, Bentall procedure, and coronary artery bypass grafting. Reimbursement rates were adjusted for inflation to 2022 US dollars using the Consumer Price Index. Total percentage change and compound annual growth rate were calculated. A split-time analysis was performed to assess trends before and after 2015. Least squares and linear regressions were performed. The R2 value was calculated for each procedure, and slope was used to determine change in reimbursements over time. ResultsInflation-adjusted reimbursement decreased by 34.1% during the study period. The overall compound annual growth rate was −1.8%. Reimbursement trends differed by procedure (P < .001), with all reimbursements trending down (R2 > 0.62), except for mitral valve replacement (P = .21) and tricuspid valve replacement (P = .43). Coronary artery bypass grafting decreased the most (−44.4%), followed by aortic valve replacement (−40.1%), mitral valve repair (−38.5%), mitral valve replacement (−29.8%), Bentall procedure (−28.5%), and tricuspid valve replacement (−25.3%). In split-time analysis, reimbursement rates did not significantly change from 2000 to 2015 (P = .24) but decreased significantly from 2016 to 2022 (P = .001). ConclusionsMedicare reimbursement significantly decreased for most cardiac surgical procedures. These trends justify further advocacy by The Society of Thoracic Surgeons to maintain access to quality cardiac surgical care.

Beyond demonstrations: implementing a primary care hybrid payment model in Medicare.

The National Academies of Sciences, Engineering, and Medicine's (NASEM's) 2021 report on primary care called for a hybrid payment approach-a mix of fee-for-service and population-based payment-with performance accountability to strike the proper balance for desired practice transformation and to support primary care's important and expanding role. The NASEM report also proposed substantial increases to primary care payment and reforms to the Medicare Physician Fee Schedule. This paper addresses pragmatic ways to implement these recommendations, describing and proposing solutions to the main implementation challenges. The urgent need for primary care payment reform calls for adopting a hybrid model within the Medicare fee schedule rather than engaging in another round of demonstrations, despite legal and practical obstacles to adoption. The paper explores reasons for adopting a roughly 50:50 blend of fee-for-service and population-based payment and addresses other design features, presenting reasons why spending accountability should rely on utilization measures under primary care control rather than performance on total cost of care, and proposes a fresh approach to quality, emphasizing that quality measures should be parsimonious, focused on important outcomes with demonstrated quality improvement.

Optimal Care for Kidney Health: Development of a Merit-based Incentive Payment System (MIPS) Value Pathway.

The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney Health MVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies.

Trends in costs, reimbursements, and surgeon payments for cervical disc arthroplasty cost of care from 2009 to 2019.

The use of cervical disc arthroplasty (CDA) continues to increase in the Medicare population. As healthcare costs continue to rise, payors have begun to implement bundled payment structures for spine surgery. While Medicare has steadily decreased reimbursements for cervical fusions, Medicare reimbursements for CDA have not been studied. The purpose of this study was to assess trends in 1) hospital costs and reimbursement, 2) physician reimbursement, and 3) potential cost drivers for CDA in a Medicare population. This is a retrospective longitudinal study of CDA in Medicare patients. The Medicare Provider Analysis and Review Limited Data Sets for 2009, 2014, and 2019 were used for this study. Patients undergoing elective CDA were included. Corresponding Inpatient Prospective Payment System files were used to calculate cost through cost-to-charge ratios. Physician fees were obtained from the Medicare Physician Fee Schedule Look-Up Tool. All financial data were adjusted for inflation to 2019 values based on the Consumer Price Index for All Urban Consumers. Demographic, comorbidity, surgical, and hospital trends were assessed. Trends in revenue center-level charges were also assessed. Adjusted for inflation, from 2009 to 2019, mean total hospital charges for elective CDA increased from $64,609 ± $45,787 to $111,874 ± $78,611 (73% increase, p < 0.001) and the mean total cost for index hospital admission increased from $19,665 ± $13,414 to $24,682 ± $13,818 (26% increase, p < 0.001). Over the same period, Medicare reimbursement increased from a mean of $11,154 ± $11,684 to $12,879 ± $13,613 (15% increase, p = 0.003), while total reimbursement increased from a mean of $15,005 ± $15,684 to $15,547 ± $15,829 (4% increase, p = 0.040). The mean hospital profit decreased from -$4076 ± $14,041 to -$9023 ± $16,084 (-121%, p < 0.001). Surgeon reimbursement for CDA decreased from a mean of $1850 ± $165 (2009) to $1722 ± $138 (2019) (7% decrease, p < 0.001). On multivariate analysis, increasing year of surgery (p < 0.001), increasing age (p = 0.001), increasing length of stay (p < 0.001), rural hospital setting (p = 0.027), and hospital geography (p < 0.001) were independently associated with cost of care. Medical/surgical supplies and operating room charges increased 71.6% (p < 0.001) and 98.5% (p < 0.001) and accounted for 41.1%-42.5% and 30.6%-35.1% of total charges, respectively. From 2009 to 2019, costs of care for elective inpatient CDA increased disproportionately to reimbursement. Hospitals operated at increasing losses and surgeon reimbursement decreased. Cost of care was independently associated with year of surgery, increasing age, length of stay, hospital setting, and hospital geography. The main charge drivers were medical/surgical supplies and operating room charges. These results may have implications for the future financial feasibility of inpatient CDA for Medicare patients and targets to improve the value of CDA. Further study is necessary to provide fair reimbursement for CDA in Medicare patients and prevent financially based bias against use of CDA in Medicare patients.

Medicare Physician Payment in Need of Major Repair

This Viewpoint examines Medicare physician payment flaws and needed reforms, including changes implemented by Congress, CMS, commercial payers, and physician employers.

The Medicare Physician Fee Schedule and Unethical Behavior

This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.