Medicare Services Research Articles

Do Post-Surgical Follow-Up Calls Reduce Unplanned 30-day Readmissions in Neurosurgery Patients? A Quality Improvement Project in a University Hospital.

Unplanned 30-day readmissions after surgery are a source of patient dissatisfaction, monitored by the Centers for Medicare and Medicaid Services, have financial penalties for hospitals and are publicly reported. Neurosurgical operations unfortunately have a higher 30-day unplanned readmission rate after the index discharge than other specialties. After a simple initiative for a 48-72-hour post discharge phone call, there was an observed significant drop-in readmission rate from 17% to 8% in 7 months at Thomas Jefferson University. To better understand the role of post operation phone calls for this reduction a retrospective evaluation over a longer period was performed. Assessment of quality improvement initiative using patient records between August 2018 and May 2023. The primary observed subject is the 30-day unplanned readmission rate and secondarily a change in physician communication score. 30-day unplanned readmission rate and physician communication scores before and after the phone call initiative were compared besides checking for difference, variance and correlation. 874 readmissions, average of 28 (95% CI 25.3 - 29.3) per month, 12.9% (95% CI 11.9 - 13.9) before phone call. 673 readmissions, average of 26 (95% CI 23 - 28.8) per month, 12.9% (95% CI 11.6 - 14.1) afterwards. Neither significant difference nor variance of scores or rates, nor correlation of rate with communication score was noted before and after the initiative. Phone calls and peri-discharge efficient communication is needed after neurological surgeries. This approach decreased unplanned readmissions in certain instances while not having a significant impact on neurosurgical patients.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas.

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

In-State Retention Rates of Female Neurosurgery Graduates.

We sought to determine the rate of retaining female neurosurgery graduates in the same states as their medical education and identify medical school and state characteristics associated with high retention rates. Database from the Center for Medicare & Medicaid Services was used to extract female physicians indicating "neurosurgery" as their specialty. The top 25 medical schools with the highest number of female neurosurgery graduates were selected. Descriptive analysis was used to determine the retention rate of female neurosurgery graduates. Univariable and multivariable analyses were used to identify medical school and state characteristics associated with high retention rates. Medical schools with the highest retention rate included the University of California, San Francisco (60%), the University of Alabama (60%), and the University of Pennsylvania (60%). Univariable and multivariable analysis showed the number of female neurosurgery attendings (β = 0.036, CI = 0.003 to 0.070, p= 0.04 and β = 0.036, CI = 0.001 to 0.071, p= 0.04.) and the healthcare employment rate (β = 0.098, CI = 0.011 to 0.186, p= 0.03 and β = 0.117, CI = 0.021 to 0.212, p= 0.02) to be positively associated with the retention rate of female neurosurgery graduates. Retaining female neurosurgery graduates within a state is essential for addressing the physician shortage and gender inequality. To encourage female medical students to practice in the same state, medical schools and states should work collectively to improve the visibility of female neurosurgeons and increase employment opportunities.

Effect of End-Stage Renal Disease Prospective Payment System on Utilization of Peritoneal Dialysis in Patients with Kidney Allograft Failure.

The Center for Medicare and Medicaid Services (CMS) introduced an End Stage Renal Disease (ESRD) Prospective Payment System (PPS) in 2011 to increase the utilization of home dialysis modalities, including peritoneal dialysis (PD). Several studies have shown a significant increase in PD utilization after PPS implementation. However, its impact on patients with kidney allograft failure remains unknown. We conducted an interrupted time series (ITS) analysis using data from the United States Renal Data System (USRDS) that include all adult kidney transplant recipients with allograft failure who started dialysis between 2005 and 2019. We compared the PD utilization in the pre-PPS period (2005-2010) to the fully implemented post-PPS period (2014 - 2019) for early (within 90 days) and late (91-365 days) PD experience. 27507 adult recipients with allograft failure started dialysis during the study period. There was no difference in early PD utilization between the pre-PPS and the post-PPS period in either immediate change (0.3% increase; 95%CI: -1.95%, 2.54%; p=0.79) or rate of change over time (0.28% increase per year; 95%CI: -0.16%, 0.72%; p=0.18). Subgroup analyses revealed a trend toward higher PD utilization post-PPS in for-profit and large-volume dialysis units. There was a significant increase in PD utilization in the post-PPS period in units with low PD experience in the pre-PPS period. Similar findings were seen for the late PD experience. PPS did not significantly increase the overall utilization of PD in patients initiating dialysis after allograft failure.

Prevalence, Medicaid use and mortality risk of low FEV1 in adults aged 20–35 years old in the USA: evidence from a population-based retrospective cohort study

BackgroundThe prevalence, Medicaid use and mortality risk associated with low forced expiratory volume in 1 s (FEV1) among young adults aged 20–35 years are not well understood, despite its potential...

Verification of Death by Neurologic Criteria: A Survey of 12 Organ Procurement Organizations Across the United States.

The Center for Medicare and Medicaid Services requires Organ Procurement Organizations (OPOs) to verify and document that any potential organ donor has been pronounced dead per applicable legal requirements of local, state, and federal laws. However, OPO practices regarding death by neurologic criteria (DNC) verification are not standardized, and little is known about their DNC verification processes. This study aimed to explore OPO practices regarding DNC verification in the United States. An electronic survey was sent to all 57 OPOs in the United States from June to September 2023 to assess verification of policies and practices versus guidelines, concerns about policies and practices, processes to address concerns about DNC determination, and communication practices. Representatives from 12 OPOs across six US regions completed the entire survey; 8 of 12 reported serving > 50 referral hospitals. Most respondents (11 of 12) reported comparing their referral hospital's DNC policies with the 2010 American Academy of Neurology Practice Parameter and/or other (4 of 12) guidelines. Additionally, most (10 of 12) reported independently reviewing and verifying each DNC determination. Nearly half (5 of 12) reported concerns about guideline-discordant hospital policies, and only 3 of 12 thought all referral hospitals followed the 2010 American Academy of Neurology Practice Parameter in practice. Moreover, 9 of 12 reported concerns about clinician knowledge surrounding DNC determination, and most (10 of 12) reported having received referrals for patients whose DNC declaration was ultimately reversed. All reported experiences in which their OPO requested additional assessments (11 of 12 clinical evaluation, 10 of 12 ancillary testing, 9 of 12 apnea testing) because of concerns about DNC determination validity. Accurate DNC determination is important to maintain public trust. Nearly all OPO respondents reported a process to verify hospital DNC policies and practices with medical society guidelines. Many reported concerns about clinician knowledge surrounding DNC determination and guideline-discordant policies and practices. Educational and regulatory advocacy efforts are needed to facilitate systematic implementation of guideline-concordant practices across the country.

Tennessee hospital noncompliance with price transparency legislation for 8common laboratory tests.

The goal of this study was to assess hospital compliance with federal price transparency mandates and barriers to pricing information in Tennessee. All hospitals websites were queried for gross, cash, and BlueCross BlueShield of Tennessee prices for 8 high-frequency laboratory tests in 2 Centers for Medicare & Medicaid Services-mandated pricing sources: (1) a machine-readable file of all available services and (2) a consumer-friendly display of 300 shoppable services. Barriers, including click counts, data availability, and intrahospital price discrepancies, were noted. Of the 145 Tennessee hospitals assessed, 97.2% were noncompliant with the Centers for Medicare & Medicaid Services final rule. Subanalysis of available machine-readable files, price estimators, and shoppable services files demonstrated 49.6%, 95.1%, and 78.6% noncompliance, respectively. Barriers to pricing information included requiring protected health information (55.9%), missing at least 1 pricing source (7.6%), having no pricing sources available (6.2%), and involving more than 3 clicks to access the cash price in machine-readable files (54.1%) and price estimators (68.6%.) Average intrahospital discrepancy for basic metabolic panel cash prices across pricing sources was $101.30 (range, $0-1012.40). Our study showed high levels of noncompliance with price transparency laws, inconsistent and inaccessible pricing, and continued challenges facing patients in Tennessee.

Preoperative prediction model for risk of readmission after total joint replacement surgery: a random forest approach leveraging NLP and unfairness mitigation for improved patient care and cost-effectiveness

BackgroundThe Center for Medicare and Medicaid Services (CMS) imposes payment penalties for readmissions following total joint replacement surgeries. This study focuses on total hip, knee, and shoulder arthroplasty procedures as they account for most joint replacement surgeries. Apart from being a burden to healthcare systems, readmissions are also troublesome for patients. There are several studies which only utilized structured data from Electronic Health Records (EHR) without considering any gender and payor bias adjustments.MethodsFor this study, dataset of 38,581 total knee, hip, and shoulder replacement surgeries performed from 2015 to 2021 at Novant Health was gathered. This data was used to train a random forest machine learning model to predict the combined endpoint of emergency department (ED) visit or unplanned readmissions within 30 days of discharge or discharge to Skilled Nursing Facility (SNF) following the surgery. 98 features of laboratory results, diagnoses, vitals, medications, and utilization history were extracted. A natural language processing (NLP) model finetuned from Clinical BERT was used to generate an NLP risk score feature for each patient based on their clinical notes. To address societal biases, a feature bias analysis was performed in conjunction with propensity score matching. A threshold optimization algorithm from the Fairlearn toolkit was used to mitigate gender and payor biases to promote fairness in predictions.ResultsThe model achieved an Area Under the Receiver Operating characteristic Curve (AUROC) of 0.738 (95% confidence interval, 0.724 to 0.754) and an Area Under the Precision-Recall Curve (AUPRC) of 0.406 (95% confidence interval, 0.384 to 0.433). Considering an outcome prevalence of 16%, these metrics indicate the model’s ability to accurately discriminate between readmission and non-readmission cases within the context of total arthroplasty surgeries while adjusting patient scores in the model to mitigate bias based on patient gender and payor.ConclusionThis work culminated in a model that identifies the most predictive and protective features associated with the combined endpoint. This model serves as a tool to empower healthcare providers to proactively intervene based on these influential factors without introducing bias towards protected patient classes, effectively mitigating the risk of negative outcomes and ultimately improving quality of care regardless of socioeconomic factors.

Best Practices in Documenting and Coding High-Value Care in Workers' Compensation Encounters - ACOEM Guidance Statement.

Workers' compensation outpatient care requires attention to causation, functional assessment, work disability prevention and return-to-work planning, elements not usually addressed in other types of outpatient encounters. Because these elements of care deviate from the usual pattern of ambulatory services, providers of workers' compensation care have faced challenges in billing and auditing practices resulting in underpayment when providing high-value care based on evidence-based guidelines. Recent changes in Centers for Medicare and Medicaid Services rules on documentation requirements for coding outpatient evaluation and management encounters offer an opportunity for occupational health clinicians to be paid appropriately for care that follows occupational medicine practice guidelines. There remains a need to define the elements of documentation that should be expected in delivering high-value workers' compensation care. This paper provides guidance for documenting high-value workers' compensation care.

Interpretable (not just posthoc-explainable) medical claims modeling for discharge placement to reduce preventable all-cause readmissions or death

We developed an inherently interpretable multilevel Bayesian framework for representing variation in regression coefficients that mimics the piecewise linearity of ReLU-activated deep neural networks. We used the framework to formulate a survival model for using medical claims to predict hospital readmission and death that focuses on discharge placement, adjusting for confounding in estimating causal local average treatment effects. We trained the model on a 5% sample of Medicare beneficiaries from 2008 and 2011, based on their 2009–2011 inpatient episodes (approximately 1.2 million), and then tested the model on 2012 episodes (approximately 400 thousand). The model scored an out-of-sample AUROC of approximately 0.75 on predicting all-cause readmissions—defined using official Centers for Medicare and Medicaid Services (CMS) methodology—or death within 30-days of discharge, being competitive against XGBoost and a Bayesian deep neural network, demonstrating that one need-not sacrifice interpretability for accuracy. Crucially, as a regression model, it provides what blackboxes cannot—its exact gold-standard global interpretation, explicitly defining how the model performs its internal “reasoning” for mapping the input data features to predictions. In doing so, we identify relative risk factors and quantify the effect of discharge placement. We also show that the posthoc explainer SHAP provides explanations that are inconsistent with the ground truth model reasoning that our model readily admits.

Exercise Therapy for Peripheral Artery Disease.

To summarize evidence regarding exercise treatments for lower extremity peripheral artery disease (PAD). Supervised walking exercise is recommended by practice guidelines for PAD. Supervised treadmill exercise improves treadmill walking distance by approximately 180m and 6-min walk distance by 30-35m, compared to control. The Centers for Medicaid and Medicare Services covers 12weeks of supervised exercise, but most people with PAD do not participate. Home-based walking exercise may be more convenient and accessible than supervised exercise. In randomized clinical trials, home-based walking exercise interventions incorporating behavioral methods, such as accountability to a coach, goal-setting, and self-monitoring, improved 6-min walk distance by 40-54m, compared to control. Arm and leg ergometry also improved walking endurance for people with PAD, but efficacy compared to walking exercise remains unclear. Walking exercise is first-line therapy for PAD-related walking impairment and can be effective in either a supervised or a structured home-based setting.

Risk Factors of Failure to Discharge Before “Two Midnights” in Outpatient-Designated Total Hip Arthroplasty

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days. Methods: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS < 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days. Results: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P < 0.01); were more likely to have body mass index (BMI) > 35 (24.0 vs. 17.8%; P < 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P < 0.01), diabetes (15.4% vs. 9.9%; P < 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P < 0.01), and hypertension (57.6% vs. 49.2%; P < 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection (P < 0.01), hospital readmission (P < 0.01), and revision surgery (P < 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days. Conclusion: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization.

Abstract PO5-10-10: Disparities in Work RVUs for Breast and Prostate Cancer Operations

Abstract Introduction: In a vast array of different methods used to quantify healthcare processes, the Relative Value Unit (RVUs) has become the federal precedent set by the Centers for Medicare and Medicaid Services (CMS) to assign value to different procedures and processes. The current RVU conversion factor in 2023 is $33.06 per unit. Physician work RVUs, malpractice RVUs (MP RVUs) and practice expense RVUs (PE RVUs) were first implemented in 1992 as a system for assigning payment to physicians while providing administrative budgeting based on clinical and liability expenditures. These values are subject to reevaluation every 5 years at minimum, or as new services become available. The CMS updates it’s RVU model by consulting the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), which controversially sets higher values in certain fields of medicine than others. This article will objectively analyze the RVUs provided by the CMS to surgical oncologists treating breast cancer and compare them to the RVUs compensated to urologists treating prostate cancer, across multiple modalities. Methods: Work RVUs, practice expense RVUs, and malpractice RVUs were obtained from the CMS 2023 physician fee schedule, using the HCPCS codes to identify the services from their database. Estimated pre-evaluation times, intra-procedure times, immediate post service times, and total procedural times were gathered from the CY 2023 Final Rule Physician Work Time database provided by CMS. The HCPCS codes used for mastectomy variations were 19301 for partial mastectomy, 19302 for partial mastectomy with lymph node removal, 19303 for a simple complete mastectomy, 19305 for a radical mastectomy, 19306 for an urban type radical mastectomy, and 19307 for a modified radical mastectomy. The HCPCS codes used for armpit lymph nodes were 38740 and 38745 for axillary lymph node dissections. The HCPCS codes used for prostatectomy variations were 55810 and 55812 for a radical perineal prostatectomy, 55840 and 55845 for a radical retropubic prostatectomy, and 55866 for a laparoscopic retropubic radical prostatectomy. The HCPCS codes used for pelvic lymph nodes were 38571-38573 for laparoscopic lymphadenectomies. Work RVUs were compared between mastectomy and prostatectomy procedures, and axillary node procedures were compared to those of pelvic lymph nodes. To further asses any true disparities in the values assigned to the operations, a second analysis of work RVUs divided by total operation times were compared between their surgical counterparts. Conclusion: Values collected from CMS indicate 59% more RVUs are provided to urologists for prostatectomies than breast surgeons for mastectomies per procedure, and 12% more per hour of total procedure time. Additionally, the CMS indicates on average 29% more work RVUs are provided to urologists for pelvic lymph node removals than breast surgeons for axillary lymph node removals, and 3.4% more per hour of total procedure time (appendix 1). Breast cancer and prostate cancer have similar incidence and mortality rates, but one affects mostly women and the other only men. The decision by the Center of Medicare and Medicaid Services to place a higher value in prostate cancer management is unknown, and elicits future analysis with surveyed procedural data across the nation for statistical significance determination. Appendix 1 allocated work RVUs, practice expense RVUs, malpractice RVUs, and median operative times for prostate cancer and breast cancer operations. Citation Format: Noah Khosrowzadeh, Kyle Chambers, Matthew Gompels, Cyrus Washington, Jessica Meshman. Disparities in Work RVUs for Breast and Prostate Cancer Operations [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-10-10.

Performance of health care service area definitions for capturing variation in inpatient care and social determinants of health.

To quantify the degree to which health care service area (HCSA) definitions captured hospitalizations and heterogeneity in social determinants of health (SDOH). Geospatial data from the Centers for Medicare and Medicaid Services, the Census Bureau, and the Dartmouth Institute. Drive-time isochrones from MapBox. Area Deprivation Index (ADI) data. 2017 inpatient discharge data from Arizona, Florida, Iowa, Maryland, Nebraska, New Jersey, New York, and Wisconsin, State Emergency Department Databases and State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; and Fee-For-Service Medicare data in 48 states. Cross-sectional, descriptive analysis. The capture rate was the percentage of inpatient discharges occurring in the same HCSA as the hospital. We compared capture rates for each HCSA definition for different populations and by hospital type. We measured SDOH heterogeneity using the coefficient of variation of the ADI among ZIP codes within each HCSA. HCSA definitions captured a wide range of inpatient discharges, ranging from 20% to 50% for Public Use Microdata Areas (PUMAs) to 93%-97% for Metropolitan Statistical Areas (MSAs). Three-quarters of inpatient discharges were from facilities within the same county as the patient's residential ZIP code, while nearly two-thirds were within the same Hospital Service Area. From the hospital perspective, 74.7% of inpatient discharges originated from within a 30-min drive and 90.1% within a 60-min drive. Capture rates were the lowest for teaching hospitals. PUMAs and drive-time-based HCSAs encompassed more homogenous populations while MSAs, Commuting Zones, and Hospital Referral Regions captured the most variation. The proportion of hospital discharges captured by each HCSA varied, with MSAs capturing the highest proportion of discharges and PUMAs capturing the lowest. Additionally, researchers face a trade-off between capture rate and population homogeneity when deciding which HCSA to use.

Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents

Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Race and ethnicity of NH residents. Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.

Most Major Hospitals Fail to Comply with Federal Price Transparency Regulations

PurposeThis study aims to present hospital compliance with federal price transparency regulations for sports medicine procedures. MethodsOnline price estimator and machine-readable files were recovered for U.S. News and World Report’s (USNWR) top 100 orthopedic hospitals. From June to November 2023, compliance and monetary values were recorded for each of Centers for Medicare and Medicaid Services (CMS) price transparency regulations. Price estimator data was assessed based on hospital placement in the bottom and top 50 of the 100 institutions under review, as well as by region (Northeast, South, Midwest, West). Statistical analyses included two-sample t-tests and Kruskal Wallis tests. Results95% of hospitals had a price estimator tool for both subacromial decompression (Current Procedural Terminology (CPT): 29826) and meniscectomy (CPT: 29881). Only 38% were compliant with all regulations for subacromial decompression and 39% for meniscectomy; the remaining did not list minimum or maximum procedure charges. Higher ranked hospitals were significantly more likely to charge a higher cash price for subacromial decompression and meniscectomy (p = 0.040 and p = 0.009 respectively). Compliance with machine-readable file reporting was poor with less than 20% meeting requirements for each CPT code. Reported prices varied greatly by hospital. ConclusionsThis study demonstrates that USNWR top 100 orthopedic hospitals exhibit poor overall compliance with federal price transparency regulations for sports medicine procedures. Most often they lack full compliance by not reporting minimum or maximum charges as part of their price estimator tool or do not report procedure prices in their machine-readable files. Hospitals also exhibit wide variation in prices reported for specific procedures. Clinical RelevanceConsumer price transparency continues to be an important goal in healthcare as it allows patients to make informed decisions when selecting appropriate treatment options and providers. To realize the full benefits of price transparency hospitals should address areas of improvement.

Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050.

Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States. Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index. Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932). The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice.

Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied. To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services. This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024. Live hospice discharge. Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death. This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions. This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program

BackgroundBundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. MethodsData was obtained from the CMS QPP for total knee (TKA) and total hip (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. ResultsThere were four TKA and three THA surgeons who were cost-efficiency outliers within our area. Outliers and non-outlier surgeons had patients who had similar BMI, ASA, and age-adjusted CCI scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < 0.001; 0.94 versus 1.15, P < 0.001) and lower out-of-pocket costs ($86.10 versus $135.46, P < 0.001; $116.10 versus $177.40, P < 0.001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). ConclusionThe CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.

Physician Group Practices Accrued Large Bonuses Under Medicare's Bundled Payment Model, 2018-20.

The Bundled Payments for Care Improvement Advanced Model (BPCI-A), a voluntary Alternative Payment Model for Medicare, incentivizes hospitals and physician group practices to reduce spending for patient care episodes below preset target prices. The experience of physician groups in BPCI-A is not well understood. We found that physician groups earned $421million in incentive payments during BPCI-A's first four performance periods (2018-20). Target prices were positively associated with bonuses, with a mean reconciliation payment of $139 per episode in the lowest decile of target prices and $2,775 in the highest decile. In the first year of the COVID-19 pandemic, mean bonuses increased from $815 per episode to $2,736 per episode. These findings suggest that further policy changes, such as improving target price accuracy and refining participation rules, will be important as the Centers for Medicare and Medicaid Services continues to expand BPCI-A and develop other bundled payment models.