Medicare Services Research Articles

Integrating Social Drivers of Health into Hospital Ratings with Application to the 100 Top Hospitals Study.

The objective was to investigate the relationship between social drivers of health (SDOH) and hospital performance within the 100 Top Hospitals study, exploring methods to recognize hospitals serving marginalized communities. Publicly available data sourced from the Centers for Medicare and Medicaid Services and the 2023 100 Top Hospitals study was used. The study employed multivariable hierarchical generalized linear regression models to assess the association between an SDOH composite variable derived using principal component analysis and overall hospital performance measures within the 100 Top Hospitals study. The analysis revealed a statistically significant association between SDOH factors and study ranking results. The SDOH composite variable is a significant predictor of performance within the 100 Top Hospitals study. Accounting for SDOH is essential to recognize high-performing hospitals serving marginalized communities. The findings suggest a need for broader considerations of SDOH in hospital ranking methodologies across various industry programs.

The impact of insurance status on patient placement into inpatient and outpatient orthopaedic surgical centers

BackgroundInnovation has fueled the shift from inpatient to outpatient care for orthopaedic joint arthroplasty. Given this transformation, it becomes imperative to understand what factors help assign care-settings to specific patients for the same procedure. While the comorbidities suffered by patients are important considerations, recent research may point to a more complex determination. Differences in reimbursement structures and patient characteristics across various insurance statuses could potentially influence these decisions.MethodsRetrospective binary logistic and ordinary least square (OLS) regression analyses were employed on de-identified inpatient and outpatient orthopaedic arthroplasty data from Albany Medical Center from 2018 to 2022. Data elements included surgical setting (inpatient vs. outpatient), covariates (age, sex, race, obesity, smoking status), Elixhauser comorbidity indices, and insurance status.ResultsPatients insured by Medicare were significantly more likely to be placed in inpatient care-settings for total hip, knee, and ankle arthroplasty when compared to their privately insured counterparts even after Centers for Medicare and Medicaid Services (CMS) removed each individual surgery from its inpatient-only-list (1.65 (p < 0.05), 1.27 (p < 0.05), and 12.93 (p < 0.05) times more likely respectively). When compared to patients insured by the other payers, Medicare patients did not have the most comorbidities (p < 0.05).ConclusionsMedicare patients were more likely to be placed in inpatient care-settings for hip, knee, and ankle arthroplasty. However, Medicaid patients were shown to have the most comorbidities. It is of value to note Medicare patients billed for outpatient services experience higher coinsurance rates.Level of evidenceIII.

Lower Associated Risk of Revision With All-Polyethylene Tibial Components in Total Knee Arthroplasty: An Analysis of the American Joint Replacement Registry

BackgroundDespite the potential advantage of all-polyethylene tibial components, modular metal-backed component use predominates the market in the United States for total knee arthroplasty (TKA). This is partially driven by concerns about the associated revision risk due to the lack of modularity with all-polyethylene components. This study utilized the American Joint Replacement Registry to compare the associated risk of all-cause revision and revision for infection for all-polyethylene versus modular metal-backed tibial components. MethodsAn analysis of primary TKA cases in patients aged 65 years and older was performed with American Joint Replacement Registry data linked to Centers for Medicare and Medicaid Services data from 2012 to 2019. Analyses compared all-polyethylene to modular metal-backed tibial components. We identified 485,024 primary TKA cases, consisting of 479,465 (98.9%) metal-backed and 5,559 (1.1%) all-polyethylene. Cox proportional hazard regression analyses created hazard ratios (HRs) to evaluate the association of design and the risk of all-cause revision while adjusting for sex, age, and the competing risk of mortality. Event-free survival curves evaluate time to revision. ResultsThe all-polyethylene tibia group demonstrated a decreased risk for all-cause revision (HR = 0.37; 95% confidence interval: 0.24 to 0.55; P < .0001) and revision for infection (HR = 0.41; 95% confidence interval: 0.22 to 0.77, P < .0001). Event-free survival curves demonstrated a decreased risk of all-cause revision that persisted across time points until 8 years post-TKA. ConclusionsIn the United States, all-polyethylene tibial component use for TKA remains low compared to modular metal-backed designs. A decreased associated risk for revision should ease concerns about the use of all-polyethylene components in patients aged 65 years or older, and future investigations should investigate the potential cost and value savings associated with expanded use in this population. Level of EvidenceTherapeutic Level III.

Beyond Brick and Mortar: The Rise of Street Medicine.

In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country's history. This alarming statistic has made homelessness a key issue in the 2024 elections, especially with the White House's goal to reduce homelessness by 25% by 2025. Despite efforts and investments, homelessness remains a persistent public health challenge. The recent inclusion of street medicine services in Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement. This policy change, alongside state-level initiatives, aims to improve healthcare access for the unhoused, particularly older adults. However, challenges remain in establishing adequate fee schedules and integrating care management. Despite these obstacles, the integration of healthcare and housing services is crucial for addressing homelessness effectively, promoting stability, and improving health outcomes for PEH. This manuscript explores the history, practical guidance, and potential impacts of these developments on homelessness and public health.

Editor's Spotlight/Take 5: Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

Editor's Spotlight/Take 5: Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

Patient out-of-pocket costs for guideline-recommended treatments for erectile dysfunction: a medicare cost modeling analysis.

Patient out-of-pocket (OOP) cost represents an access barrier to erectile dysfunction (ED) treatment. We determined OOP cost for men with ED covered by Fee-for-Service Medicare. Coverage policies were obtained from the Medicare Coverage Database for treatments recommended by the 2018 American Urological Association (AUA) guidelines. OOP cost was retrieved from the 2023 Centers for Medicare & Medicaid Services Final Rule. OOP cost for treatments without Medicare coverage were extracted from GoodRx® or literature and inflated to 2022 dollars. Annual prescription costs were calculated using the published estimate of 52.2 yearly instances of sexual intercourse. Medicare has coverage for inflatable penile prostheses (IPP; strong recommendation), non-coverage for vacuum erection devices (VED; moderate recommendation) and phosphodiesterase type-5 inhibitors (PDE5i; strong recommendation), and no policies for intracavernosal injections (ICI; moderate recommendation), intraurethral alprostadil (IA; conditional recommendation), or low-intensity extracorporeal shock wave therapy (ESWT; conditional recommendation). Annual IA prescription is most costly ($4022), followed by ICI prescription ($3947), one ESWT course ($3445), IPP ($1600), PDE5i prescription ($696), and one VED ($213). PDE5i and IPP, both strongly recommended by AUA guidelines, are associated with lower OOP cost. Better understanding of patient financial burden may inform healthcare decision-making.

Hospital Patient Experience: Exploring Hospitals as Shifters and Sustainers Over Time.

Patient experience is a key factor in measuring hospital performance, and the Hospital Consumer Assessment of Healthcare Providers and Systems survey tool is used to assess patient perceptions. Hospitals with positive patient experience tend to have a better quality of clinical care, lower readmission and mortality rates, and an overall shorter inpatient length of stay. Studies have identified several organizational determinants of high- and low-rated patient experiences, including hospital size, type, staffing levels, and patient demographics.This study aims to explore the determinants of consistently high- and low-rated patient experience, as well as factors associated with positive and negative changes in patient experience over time. The 2014 to 2019 American Hospital Association annual survey and the Centers for Medicare and Medicaid Services Hospital Value-Based Purchasing database were used. A total of 2801 acute-care hospitals were included in this study. A series of multivariate logistic regressions were used to model the probability of "1" (being a superior hospital or an inferior hospital). In addition, a generalized linear mixed model for binary responses was used to analyze the change (probability of positive and negative change). The results showed that most hospitals did not sustain superior or inferior performance, and competition decreased the likelihood of a hospital consistently performing well in terms of patient experience. Superior performance was associated with hospital ownership (P <.001), size (P =.026), location (P =.002), teaching status (P =.009), average Herfindahl-Hirschman Index value (P =.005), and Medicaid and Medicare patient population. On the other hand, inferior performance was associated with hospital ownership (P =.003), size (P <.001), teaching status (P =.003), safety net status (P =.020), and Medicaid and Medicare patient population. This study aimed to examine the trends in hospital patient experience performance and the influence of hospital organizational characteristics on those trends. Our findings allow us to question the widely held belief that patient experience is a metric of differentiation and industry competition, suggesting that performance in this domain has not been utilized by most hospitals as a source of sustainable competitive advantage. The findings from this study highlight the importance of considering changes in performance over time and the need for significant organizational efforts to improve hospital performance in terms of patient experience.

Lessons learned from CMS's National Partnership to Improve Dementia Care: a thematic synthesis of multiple stakeholder-engaged studies.

Antipsychotic prescribing in United States nursing homes (NHs) has decreased since the Center for Medicare & Medicaid Service debuted the National Partnership to Improve Dementia Care in Nursing Homes (NP); however, reductions have stalled. To help explain persistent antipsychotic use despite the NP's reduction efforts, the perspectives of diverse NP stakeholders were qualitatively assessed. This study aimed to re-evaluate these individual perspectives in combined thematic synthesis to discover NP improvement opportunities undetectable in single stakeholder assessments. Thematic synthesis. Through immersive crystallisation, original source coding results were organised into related descriptive themes. Similarities and differences were identified, and descriptive themes were regrouped into new, increasingly abstract, analytical themes. This cycle continued until variances were resolved and analytic themes sufficiently described and explained all initial descriptive themes. Three analytic themes emerged regarding NP improvement opportunities. The NP's positive impacts would be augmented by: (i) a deeper and expanded appreciation of stakeholder perspectives; (ii) more urgent and rapid adaptation to unintended adverse outcomes; and (iii) greater recognition of the contextual and environmental factors influencing decisions to prescribe or not prescribe antipsychotic medications. Stakeholder groups described: perspectives they perceived as inadequately considered by the NP; insufficient NP engagement with the stakeholders capable of creating evidenced, affordable, and available non-pharmacologic therapies for dementia symptoms; recognition that dementia interventions effective for a specific individual at a specific time in a specific community may not generalise; and diverse ongoing undesirable outcomes from NP policies that could be mitigated by NP modifications. The NP has done much to advance dementia care in NHs. Notwithstanding, these results suggest the NP would only be improved through increasingly comprehensive inclusion of stakeholder perspectives, enhanced incorporation of individual contextual factors, and a more decisive mechanism for ongoing and continual adaptation.

Hospital readmissions among adults living with and without HIV in the US: findings from the Nationwide Readmissions Database

Thirty-day hospital readmission measures quality of care, but there are limited data among people with HIV (PWH) and people without HIV (PWoH) in the era of universal recommendation for antiretroviral therapy. We descriptively compared 30-day all-cause, unplanned readmission risk between PWH and PWoH. A retrospective cohort study was conducted using the 2019 Nationwide Readmissions Database (2019/01/01-2019/12/31), an all-payer database that represents all US hospitalizations. Index (initial) admissions and readmissions were determined using US Centers for Medicare & Medicaid Services definitions. Crude and age-adjusted risk ratios (aRR) comparing the 30-day all-cause, unplanned readmission risk between PWH to PWoH were estimated using random effect logistic regressions and predicted marginal estimates. Survey weights were applied to all analyses. We included 24,338,782 index admissions from 18,240,176 individuals. The median age was 52(IQR=40-60) years for PWH and 61(IQR=38-74) years for PWoH. The readmission risk was 20.9% for PWH and 12.2% for PWoH (age-adjusted-RR:1.88 [95%CI=1.84-1.92]). Stratified by age and sex, young female (age 18-29 and30-39 years) PWH had a higher readmission risk than young female PWoH (aRR=3.50 [95%CI=3.11-3.88] and aRR=4.00 [95%CI=3.67-4.32], respectively). While the readmission risk increased with age among PWoH, the readmission risk was persistently high across all age groups among PWH. The readmission risk exceeded 30% for PWH admitted for hypertensive heart disease, heart failure, and chronic kidney disease. PWH have a disproportionately higher risk of readmission than PWoH, which is concerning given the aging profile of PWH. More efforts are needed to address readmissions among PWH. US National Institutes of Health.

Continuous Urine Output-Based Alert Identifies Cardiac Surgery–associated Acute Kidney Injury Earlier Than Serum Creatinine: A Prospective and Retrospective Observational Study

Objective(s)Acute kidney injury (AKI) is defined and staged by reduced urine output (UO) and increased serum creatinine (SCr). UO is typically measured manually and documented in the electronic health record, making early and reliable detection of oliguria-based AKI and electronic data extraction challenging. We investigated the diagnostic performance of continuous UO, enabled by active drain line clearance, based alerts (Accuryn AKI Alert), compared to AKI stage 2 SCr criteria and their association to length of stay (LOS), need for continuous renal replacement therapy (CRRT), and 30-day mortality. DesignProspective and retrospective observational study. SettingNine tertiary centers. ParticipantsCardiac surgery patients. InterventionsNone. Measurements and Main Results522 patients were analyzed. AKI stages 1, 2, and 3 were diagnosed in 32.18%, 30.46%, and 3.64% of patients based on UO compared to 33.72%, 4.60%, and 3.26% of patients using SCr, respectively. Continuous UO-based alerts diagnosed stage ≥1 AKI 33.6 (IQR= [15.43, 95.68]) hours before stage ≥2 identified by SCr. A SCr-based diagnosis of AKI stage ≥2 has been designated a Hospital Harm by the Centers for Medicare & Medicaid Services. Using this criterion as a benchmark, AKI alerts had a discriminative power of 0.78. AKI Alert stage 1 was significantly associated with increased ICU and hospital LOS and CRRT, and stage ≥2 alert with mortality. ConclusionsAKI Alert based on continuous UO, enabled by active drain line clearance, detected AKI stages 1 and 2 before SCr. Early AKI detection allows for early kidney optimization, potentially improving patient outcomes.

A Contemporary Evaluation of the Centers for Medicare and Medicaid Services High-Risk Indicators for Carotid Endarterectomy.

Compare stroke/death outcomes across Carotid Endarterectomy (CEA), Transcarotid Artery Revascularization (TCAR), and Transfemoral Carotid Artery Stenting (TFCAS) using Centers for Medicare & Medicaid Services (CMS) high-risk criterion. Existing literature has revealed inconsistencies with CMS risk guidelines. With recent approval for TCAR and TFCAS in standard risk patients, an updated analysis of guidelines is needed. Data from the Vascular Quality Initiative (VQI) (2016-2023) on CEA, TFCAS, or TCAR patients were used. We used inverse probability of treatment weighting to compare in-hospital stroke/death rates across procedures for high-risk criteria: contralateral occlusion (CLO), prior CEA, CAS, radiation, neck surgery, moderate to severe CHF, severe COPD (on home O2), unstable angina, recent MI (<6mo.), and age (≥75 years-old). A total of 199,050 patients were analyzed, of whom 122,737 (62%) patients underwent CEA, 50,095 (25%) TCAR, and 26,218 (13%) TFCAS. TCAR had lower odds of stroke/death compared to CEA in patients with CLO (aOR=0.73 [95%CI:0.55-0.98], P=0.035) and radiation (aOR=0.44[95%CI:0.23-0.82], P=0.010). Contrary to CMS criteria, CEA patients did not have higher stroke/death in patients with prior CEA, CAS, neck surgery, moderate to severe CHF, severe COPD, unstable angina, recent MI, or age (≥75) compared to TCAR and TFCAS. While CMS high-risk criteria have traditionally been recognized as contraindications for CEA, our study reveals inconsistencies-with CEA performing similarly to TCAR and significantly better than TFCAS in patients with prior CEA, moderate to severe CHF, recent MI, or age (≥75). As a result, the definition of high-risk criteria may warrant reconsideration.

Variation in Postoperative Outcomes Across Federally Designated Hospital Star Ratings

Despite widespread use to guide patients to hospitals providing the best care, it remains unknown whether Centers for Medicare & Medicaid Services (CMS) hospital star ratings are a reliable measure of hospital surgical quality. To examine the CMS hospital star ratings and hospital surgical quality measured by 30-day postoperative mortality, serious complications, and readmission rates for Medicare beneficiaries undergoing colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, and incisional hernia repair. This cohort study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals with a CMS hospital star rating for calendar years 2014-2018. Data analysis was performed from January 15, 2022, to April 30, 2023. Participants included fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair with continuous Medicare coverage for 3 months before and 6 months after surgery. Centers for Medicare & Medicaid Services hospital star rating. Risk- and reliability-adjusted hospital rates of 30-day postoperative mortality, serious complications, and 30-day readmissions were measured and compared across hospitals and star ratings. A total of 1 898 829 patients underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair at 3240 hospitals with a CMS hospital star rating. Mean (SD) age was 74.8 (7.0) years, 50.6% of the patients were male, and 86.5% identified as White. Risk- and reliability-adjusted 30-day mortality rate decreased in a stepwise fashion from 6.80% (95% CI, 6.79%-6.81%) in 1-star hospitals to 4.93% (95% CI, 4.93%-4.94%) in 5-star hospitals (adjusted odds ratio, 1.86; 95% CI, 1.73-2.00). There was wide variation in the rates of hospital mortality (variation, 1.89%; range, 2.4%-16.2%), serious complications (variation, 1.97%; range, 5.5%-45.1%), and readmission (variation, 1.27%; range, 9.1%-22.5%) across all hospitals. After stratifying hospitals by their star rating, similar patterns of variation were observed within star rating groups for 30-day mortality: 1 star (variation, 1.91%; range, 3.6%-12.0%), 2 star (variation, 1.86%; range, 2.8%-16.2%), 3 star (variation, 1.84%; range, 2.9%-12.3%), 4 star (variation, 1.76%; range, 2.9%-11.5%), and 5 star (variation, 1.79%; range, 2.4%-9.1%). Similar patterns were observed for serious complications and readmissions. Although CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.

Is Preoperative Weight Reduction in Patients Who Have Body Mass Index ≥ 40 Associated With Lower Complication Rates After Primary Total Hip Arthroplasty?

BackgroundGiven the heightened risk of postoperative complications associated with obesity, delaying total hip arthroplasty (THA) in patients who have a body mass index (BMI) > 40 to maximize preoperative weight loss has been advocated by professional societies and orthopaedic surgeons. While the benefits of this strategy are not well-understood, previous studies have suggested that a 5% reduction in weight or BMI may be associated with reduced complications after THA. MethodsWe identified 613 patients who underwent primary THA in a single institution during a 7-year period and who had a BMI >40 recorded from 9 to 12 months prior to surgery. Subjects were stratified into 3 cohorts based on whether their baseline BMI decreased by >5% (147 patients, 24%), was unchanged ( ± 5%) (336 patients, 55%), or increased by >5% (130 patients, 21%) on the day of surgery. The frequency of 90-days Hip Society and Centers for Medicare & Medicaid Services complications was compared between these cohorts. There were significant baseline differences between the cohorts with respect to baseline American Society of Anesthesiologists class (P < .001) and hemoglobin A1C (P = .011), which were accounted for in a multivariate regression analysis. ResultsIn univariate analysis, there was a lower incidence of readmission (P = .025) and total complications (P = .005) in the increased BMI cohort. The overall complication rate was 18.4% in the decreased BMI cohort, 17.6% in the unchanged cohort, and 6.2% in the increased cohort. However, multivariable regression analysis controlling for potential confounders did not find that preoperative change in BMI was associated with differences in 90-days complications between cohorts (P > .05). ConclusionsPatients who have a BMI >40 and achieved a clinically significant (>5%) BMI reduction prior to THA did not have a lower risk of 90-days complications or readmissions. Thus, delaying THA in these patients to encourage weight loss may result in restricting access to a beneficial surgery without an appreciable safety benefit.

PT10 Utility of the ISPOR Presentations Database to Support the Centers for Medicare and Medicaid Services (CMS) Drug Price Negotiation (DPN): An Apixaban and Rivaroxaban Case Study

PT10 Utility of the ISPOR Presentations Database to Support the Centers for Medicare and Medicaid Services (CMS) Drug Price Negotiation (DPN): An Apixaban and Rivaroxaban Case Study

Spanish-Speaking Caregiver Preferences for Social Determinants of Health Screening.

Equitable social determinants of health (SDOH) screening has been recommended by the Centers for Medicare & Medicaid Services and the Joint Commission; however, little is known about Spanish-speaking caregiver preferences on how they would like to be screened. We conducted a cross-sectional study at 3 pediatric clinics (October-December 2019). Caregivers completed (in English or Spanish) an SDOH screening preferences survey. Three hundred eighty-two of 443 caregivers approached (response rate = 86.2%) completed the survey. Most were female, preferred Spanish, and completed only high school. Spanish-speaking caregivers had greater odds of preferring verbal SDOH screening (odds ratio: 4.1; 95% confidence interval, 1.8-9.2) than English-speaking caregivers. Verbal SDOH screening should be a consideration in families who speak Spanish. Future studies should utilize qualitative methods to further explore Spanish-speaking caregiver preferences for SDOH screening.

Implementing primary care follow-up for high-risk vascular surgery patients

Background: The Centers for Medicare and Medicaid Services consider the 30-day hospital readmission rate an outcome of care measure; a high rate is associated with high-cost and bed utilization. Purpose: The Division of Vascular Surgery at a large academic medical center implemented a 15-week quality improvement project in the fall of 2022 to reduce readmissions among patients deemed high-risk for readmission and discharged to home. Methods: The discharging provider utilized the “HOSPITAL Score for Readmission” tool to identify patients at high-risk for unplanned 30-day readmission to receive the intervention, which included follow-up with a primary care provider (PCP) within two weeks of hospital discharge to address non-surgical medical conditions that may have been exacerbated during the hospital stay. A hospital based transitional care clinic bridged medical care for identified patients without an established PCP or whose PCP could not accommodate an appointment until PCP assumption of care. Discharging providers included 11 nurse practitioners and 2 surgery residents; each received a one-on-one educational teaching session and a weekly reminder e-mail through week 9. Results: A total of 158 vascular surgery patients (low and high-risk) were discharged home over 15 weeks with 30 patients (19%) having an unplanned readmission within 30-days from discharge. Adherence issues with the intervention among staff allowed for the high-risk group to be divided into those who did not receive the intervention versus those who did. The high-risk patients who did not receive the intervention had a higher readmission rate (30.4%) than the high-risk patients who did receive the intervention (21.4%). Conclusions: Numerous acute and chronic medical problems were treated at the PCP/transitional care clinic visits, which may have contributed to the reduction in rate of readmissions occurring within 30-days for those patients. Increased usage of the transitional care clinic identified a gap that patients continue to require assistance with establishing care with a PCP and further process change in the future is needed to ensure successful transition for all patients.

Experiences and Interest in Value‐Based Payment Arrangements for Medical Products Among Medicaid Agencies: An Exploratory Analysis

Policy Points State Medicaid experience with value‐based payment (VBP) arrangements for medical products is still relatively limited, and states face a number of challenges in designing and implementing such arrangements, particularly because of the resource‐intensive nature of arrangements and data needed to support measurement of desired outcomes. A number of success factors and opportunities to support VBP arrangement efforts were identified through this study, including leveraging established venues or processes for collaboration with manufacturers, engaging external and internal partners in VBP efforts to bolster capabilities, acquiring access to new data sources, and utilizing annual renegotiation of contracts to allow for adjustments. ContextTo date, uptake of value‐based payment (VBP) arrangements for medical products and knowledge of their design and impact have been mainly concentrated among private payers. Interest and activity are expanding to Medicaid; however, their experiences and approaches to VBP arrangements for medical products are not well characterized.MethodsThis study sought to characterize the use of VBP arrangements for medical products among state Medicaid agencies through the use of a two‐staged, mixed‐methods approach. A survey and semistructured interviews were conducted to gain an understanding of state experiences with VBP arrangements for medical products. The survey and interviews were directed at senior leaders from nine states through the survey, with respondents from seven of these states additionally participating in the semistructured interviews.FindingsAlthough experience with VBP arrangements for medical products among states varied, there were similarities across their motivations and general processes or phases employed in their design and implementation. States collectively identified a number of significant challenges to VBP arrangements, such as manufacturer engagement, outcomes measurement, and the time, expertise, and resources required to design and implement them. We outline a range of strategies to help address these gaps and make it easier for states to pursue VBP arrangements, including more direct engagement from the Center for Medicare and Medicaid Services, state‐to‐state peer learning and collaboration, data infrastructure and sharing, and additional research to inform fit‐for‐purpose VBP arrangement approaches.ConclusionsFindings from this study suggest that it may be easier for states to pursue VBP arrangements for medical products if there is greater clarity on processes employed that support design and implementation as well as effective strategies to address common challenges associated with contract negotiations. As states gain more experience, it will be important to monitor the design and implementation of common VBP arrangements to assess impact on the Medicaid program and the populations it serves.

Gender based disparities in Medicare physician reimbursement persist across years and specialty.

The gender pay gap is wide in medicine but the extent of this disparity across specialties and over time have not been elucidated. Here we evaluate differences in Medicare reimbursement between men and women physicians over time and by specialty, controlling for physician and practice characteristics. The Centers for Medicare & Medicaid Services Payment Data was used to determine total reimbursements and number of services submitted by physicians practicing in the US between 2013 and 2019. Data from the American Community Survey (ACS) were used to determine average income, unemployment rates, poverty rates, income, and educational attainment levels by zip code for each physician's practice location. Among the 3,831,504 physicians included in this analysis from 2013-2019, 2,712,545 (70.8%) were men and 1,118,859 (29.2%) were women. Overall, men received more in Medicare reimbursements ($58,815 ± $104,772 vs. $32,205 ± $60,556, p<0.001) and billed more services (864 ± 1,780 vs. 505 ± 1,007, p<0.001) compared to women. The median Medicare reimbursement for men decreased from 2013 to 2019 from $59,710 to $57,874, while the median Medicare reimbursement for women increased from $30,575 to $33,456. Men were reimbursed more than women across all specialties with the greatest disparity in procedure-heavy specialties. The specialties with the highest difference in median Medicare reimbursement between men and women were ophthalmology ($99,452), dermatology ($84,844), cardiology ($64,112), nephrology ($62,352), and pulmonary medicine ($47,399). In linear regression models controlling for calendar year, years of experience, total number of services, and ACS zip-code-level variables, men received a higher amount of Medicare reimbursement in all specialties, as compared to women (p<0.01 for all). The percentage of top earning men (range: 65.0%-99.5%) surpassed the proportion of men in each specialty (range: 46.1%-94.6%), except public health and preventive medicine. Women physicians continue to receive lower total Medicare reimbursements than men physicians, particularly in procedure-heavy specialties. Lower clinical volume and fewer procedural services among women physicians partially contribute to the disparities in reimbursement.

New Supplemental Benefits and Plan Ratings Among Medicare Advantage Enrollees

In 2018, the US Congress gave Medicare Advantage (MA) historic flexibility to address members' social needs with a set of Special Supplemental Benefits for the Chronically Ill (SSBCIs). In response, the Centers for Medicare & Medicaid Services expanded the definition of primarily health-related benefits (PHRBs) to include nonmedical services in 2019. Uptake has been modest; MA plans cited a lack of evidence as a limiting factor. To evaluate the association between adopting the expanded supplemental benefits designed to address MA enrollees' nonmedical and social needs and enrollees' plan ratings. This cohort study compared the plan ratings of MA enrollees in plans that adopted an expanded PHRB, SSBCI, or both using difference-in-differences estimators with MA Consumer Assessment of Health Care Providers and Systems survey data from March to June 2017, 2018, 2019, and 2021 linked to Medicare administrative claims and publicly available benefits and enrollment data. Data analysis was performed between April 2023 and March 2024. Enrollees in MA plans that adopted a PHRB and/or SSBCI in 2021. Enrollee plan rating on a 0- to 10-point scale, with 0 indicating the worst health plan possible and 10 indicating the best health plan possible. The study sample included 388 356 responses representing 467 MA contracts and 2558 plans in 2021. Within the weighted population of responders, the mean (SD) age was 74.6 (8.7) years, 57.2% were female, 8.9% were fully Medicare-Medicaid dual eligible, 74.6% had at least 1 chronic medical condition, 13.7% had not graduated high school, 9.7% were helped by a proxy, 45.1% reported fair or poor physical health, and 15.6% were entitled to Medicare due to disability. Adopting both a new PHRB and SSBCI benefit in 2021 was associated with an increase of 0.22 out of 10 points (95% CI, 0.4-4.0 points) in mean enrollee plan ratings. There was no association between adoption of only a PHRB (adjusted difference, -0.12 points; 95% CI, -0.26 to 0.02 points) or SSBCI (adjusted difference, 0.09 points; 95% CI, -0.03 to 0.21 points) and plan rating. Medicare Advantage plans that adopted both benefits saw modest increases in mean enrollee plan ratings. This evidence suggests that more investments in supplemental benefits were associated with improved plan experiences, which could contribute to improved plan quality ratings.

Incorporating Medicare Advantage Admissions Into the CMS Hospital-Wide Readmission Measure

Medicare Advantage (MA) enrollment is rapidly expanding, yet Centers for Medicare & Medicaid Services (CMS) claims-based hospital outcome measures, including readmission rates, have historically included only fee-for-service (FFS) beneficiaries. To assess the outcomes of incorporating MA data into the CMS claims-based FFS Hospital-Wide All-Cause Unplanned Readmission (HWR) measure. This cohort study assessed differences in 30-day unadjusted readmission rates and demographic and risk adjustment variables for MA vs FFS admissions. Inpatient FFS and MA administrative claims data were extracted from the Integrated Data Repository for all admissions for Medicare beneficiaries from July 1, 2018, to June 30, 2019. Measure reliability and risk-standardized readmission rates were calculated for the FFS and MA cohort vs the FFS-only cohort, overall and within specialty subgroups (cardiorespiratory, cardiovascular, medicine, surgery, neurology), then changes in hospital performance quintiles were assessed after adding MA admissions. Risk-standardized readmission rates. The cohort included 11 029 470 admissions (4 077 633 [37.0%] MA; 6 044 060 [54.8%] female; mean [SD] age, 77.7 [8.2] years). Unadjusted readmission rates were slightly higher for MA vs FFS admissions (15.7% vs 15.4%), yet comorbidities were generally lower among MA beneficiaries. Test-retest reliability for the FFS and MA cohort was higher than for the FFS-only cohort (0.78 vs 0.73) and signal-to-noise reliability increased in each specialty subgroup. Mean hospital risk-standardized readmission rates were similar for the FFS and MA cohort and FFS-only cohorts (15.5% vs 15.3%); this trend was consistent across the 5 specialty subgroups. After adding MA admissions to the FFS-only HWR measure, 1489 hospitals (33.1%) had their performance quintile ranking changed. As their proportion of MA admissions increased, more hospitals experienced a change in their performance quintile ranking (147 hospitals [16.3%] in the lowest quintile of percentage MA admissions; 408 [45.3%] in the highest). The combined cohort added 63 hospitals eligible for public reporting and more than 4 million admissions to the measure. In this cohort study, adding MA admissions to the HWR measure was associated with improved measure reliability and precision and enabled the inclusion of more hospitals and beneficiaries. After MA admissions were included, 1 in 3 hospitals had their performance quintile changed, with the greatest shifts among hospitals with a high percentage of MA admissions.