Total Medicare Costs Research Articles

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.

Abstract 16015: The Effect of the 2019 Reduction in Price of PCSK9 Inhibitors on Total Cost, Out-of-Pocket Cost, and Access Among Medicare Part D Beneficiaries

Introduction: Uptake of Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) among Medicare beneficiaries was initially slow because of coverage restrictions and high out-of-pocket costs. In November 2018, manufacturers announced an unprecedented 60% reduction in the price of PCSK9is. The effect of this price reduction on access and cost has not been previously studied. Hypothesis: Did the large reductions in PCSK9i prices improve coverage and lower out-of-pocket (OOP) costs for Medicare Part D beneficiaries? Methods: Medicare Part D Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information files (2018-2022) were used to evaluate coverage, 30-day OOP and total costs, and formulary restrictions before (2018Q1-2019Q1) and after (2019Q2-2023Q1) the PCSK9i price reduction. Costs were calculated in the coverage phase, not the deductible or coverage gaps. Paired t-tests were used to determine statistical significance with a two-sided alpha of 0.05. Results: We examined Part D plans in the first quarter of each year from 2018 to 2023 (3,127 to 4,543 plans per year, 79% Medicare Advantage plans). Nearly all plans covered at least 1 PCSK9i before and after the price reduction (97% vs 100% of plans). The price reduction was associated with significant reductions in 30-day total costs (from $1,075 to $585; difference = $489; 95% CI $484 - $494; p <0.001) and 30-day out-of-pocket costs ($306 to $75; difference = $231; 95% CI $228 - $233; p<0.001) (Figure 1). The proportion of plans requiring coinsurance as a proportion as opposed to a fixed copayment amount declined from 97% to 15% (p<0.001). Conclusions: The reduction in prices of PCSK9i was associated with significant declines in total Medicare costs and projected OOP costs for Medicare Part D beneficiaries. Nearly all Part D plans cover at least 1 PCSK9i. Future studies should examine the impact of this price reduction on adherence and cost-effectiveness of these therapies.

Impact of remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePRO) on hospitalization, survival, and cost in community oncology practice: The Texas Two-Step study.

569 Background: There is rising interest to integrate electronic patient reported outcomes (ePRO) solutions for symptom monitoring to enhance the quality of care in oncology and to support value-based care (VBC) models. Step 1 of the Texas Two-Step Study demonstrated successful implementation of an ePRO system in >200 sites of service of a large community oncology practice. We now report step 2 of our study which evaluates the impact of ePROs in reducing adverse outcomes and cost of care among cancer patients enrolled in CMS’ Oncology Care Model (OCM) VBC program. Methods: This observational study focused on patients with metastatic cancer enrolled in the OCM program at Texas Oncology between July 2020 to December 2020. Patients who enrolled and completed ≥1 survey via the ePRO tool defined the study arm. Patients were matched and balanced for confounders with propensity score matching (PSM). Data used for this analysis included data collected from OCM claims files and the ePRO vendor database. Adverse events (death (D)/hospitalizations (H)/Emergency Department (ED) visits), average H/ED visits per patient, average length of H, total Medicare cost (i.e. Medicare paid amounts for different services except Part D drugs) were study measures. Mann-Whitney U and Chi-Square tests compared continuous and categorical variables, respectively, and multivariable logistic regression was used to adjust the covariates (age, gender, cancer type, therapy line). Results: Out of 831 metastatic cancer patients, 458 matched patients (229 patients per group) were identified through PSM. In our matched cohort, ~52% of patients were male, with a mean age of 74 years. Mean total adverse events were significantly less (0.98 vs 1.41 p-value: 0.007) in the study group (SG) as compared to control (C). We observed decreased rates of H (20% vs 32.5%; p value: <0.05), ED (38.4% vs 42.3%) and D (11.8% vs 16.6%) in the SC compared to C. After adjusting for covariates, the SG had decreased odds of H (aOR: 0.51; 95% CI 0.33, 0.8; p-value 0.002) compared to C. Similar, but not statistically significant, effects were observed in the case of D and ED visits. Average number of H (0.28 vs 0.52, p-value-0.003) and ED visits (0.51 vs 0.75, p value: 0.01) per patient were also lower in the SG as compared to C. In addition, mean H duration per patient (days) was significantly less in the SG as compared to C (1.9 vs 3.2, p value: 0.03). ePRO engagement also reduced the total cost of care (per member per month) by an average of $1146. Conclusions: RSM with ePROs reduced adverse outcomes and cost of care among patients with metastatic cancer in a large multi-site community oncology practice. Additional studies to include a larger patient population are warranted to strengthen these observations. This work suggests that ePRO use in the community setting does improve patient outcomes and enhance VBC.

The Healthcare Cost Burden of Asthma in Children: A Longitudinal Population-Based Study

ObjectivesThis study aimed to investigate the extent of healthcare cost increase at population level due to childhood asthma. We aimed to investigate the cross-sectional relationship between asthma and healthcare costs among children aged 2 to 18 years and, in longitudinal analyses, whether costs increase with an increase in the duration of asthma prevalence. MethodsStudy participants are 4175 and 4482 children of birth and kindergarten cohorts from the nationally representative Longitudinal Study of Australian Children for whom the linked Medicare cost data are available. The children were followed in all waves from the year 2004 to 2018. Generalized linear models were used to estimate the excess healthcare costs associated with asthma. The sum of Medicare Benefits Schedule and Pharmaceutical Benefits Scheme costs constitutes the total healthcare costs. ResultsTotal excess healthcare costs associated with asthma among the 2- to 18-year-old children were A$4316 per child. At the population level, the estimated total excess Medicare costs associated with current asthma treatment among 2- to 18-year-old children were, on average, A$190.6 million per year (2018 population and price). Compared with the non-asthmatic children, peers with persistent asthma morbidity and treatment requirements had excess costs up to A$20 727 for the B cohort children until 14 years of age, whereas excess costs for the K cohort children were A$19 571 until 18 years of age. ConclusionsAsthma in children imposes a significant financial burden on the public health system. Higher excess healthcare costs of all asthmatic children than the costs of nonasthmatic children provide further economic justification for promoting preventive efforts at early ages.

Frequency and implications of coexistent manifestations of serious illness in older adults with dementia.

In older adults, serious illness comprises three manifestations: dementia, activity of daily living (ADL) impairment, and other advanced medical conditions (AMC; e.g., end-stage renal disease). Little is known about how dementia and other manifestations of serious illness co-occur. We aim to describe the prevalence of persons with dementia (PWD) who are living with additional manifestations of serious illness, and the implications on healthcare utilization, Medicare costs, caregiving hours and out-of-pocket expenses. In this cross-sectional study, we use data from the 2016 Health and Retirement Study (HRS) linked to Medicare fee-for-service claims. We limited inclusion to adults >65 years. Dementia was determined using validated methodology that incorporates functional and cognitive test scores from HRS. We classified PWD as having dementia alone, dementia and an AMC (irrespective of ADL impairment) or dementia and ADL impairment (without an AMC). Healthcare utilization and Medicare costs were measured in claims, caregiving hours and out-of-pocket expenses were self-reported. Most PWD (67%) met criteria for another manifestation of serious illness (24% advanced medical condition, 44% ADL impairment). PWD and an AMC had the highest proportion of hospital use and the highest median total Medicare costs ($17,900 vs. $8962 dementia + ADL impairment vs. $4376 dementia alone). Mean total hours of caregiving per month were similar for PWD and an AMC and PWD and ADL impairment (142.9 and 141.9h, respectively), while mean hours were much lower for PWD alone (47.7h). Median out-of-pocket costs were highest for PWD and ADL impairment ($13,261) followed by PWD and an AMC ($10,837) and PWD alone ($7017). PWD commonly face another manifestation of serious illness. Dementia and ADL impairment was associated with the highest costs for PWD and families while dementia and an AMC was associated with the highest costs for Medicare.

Change in a Claims-Based Frailty Index, Mortality, and Health Care Costs in Medicare Beneficiaries.

A claims-based frailty index (CFI) allows measurement of frailty on a population scale. Our objective was to examine the association of changes in CFI over 12months with mortality and Medicare costs. We used a 5% sample of fee-for-service Medicare beneficiaries. We estimated CFI (range: 0–1: nonfrail (<0.25), mildly frail (0.25–0.34), moderately-to-severely frail (≥0.35) on January 1, 2015 and January 1, 2016. Beneficiaries were categorized as having a large decrease (-<0.045), small decrease (-≤0.045-0.015), stable (±0.015), small increase (>0.015-0.045), or large increase (>0.045). We used Cox proportional hazards model to estimate hazard ratio (HR) for mortality adjusting for age, sex, and 2015 CFI value and compared total Medicare costs from January 1, 2016 to December 31, 2016. The study population included 995664 beneficiaries (mean age 77years, 56.8% female). In nonfrail (n=906046), HR (95% confidence interval [CI]) ranged from 0.71 (0.67-0.75) for a large decrease to 2.75 (2.68-2.33) for a large increase. In moderate-to-severely frail beneficiaries (n=16527), the corresponding HR (95% CI) ranged from 0.63 (0.57-0.70) to 1.21 (1.06-1.38). The mean total Medicare cost per member per year (standard deviation) was from $12149 ($83508) in nonfrail beneficiaries to $61155 ($345904) in moderate-to-severely frail beneficiaries. One-year changes in CFI are associated with elevated mortality risk and health care costs across all levels of frailty.

Adherence to colorectal cancer screening and healthcare resource utilization: a longitudinal analysis in Medicare beneficiaries aged 66–75 years

Objective In this study, we examined colorectal cancer (CRC) screening adherence in Medicare beneficiaries and associated healthcare resource utilization (HCRU) and Medicare costs. Methods Using 20% Medicare random sample data, the study population included Medicare fee-for-service beneficiaries aged 66–75 years on 1 January 2009, at average risk for CRC and continuously enrolled in Medicare Part A/B from 2008 to 2018. We excluded those who had undergone colonoscopy or flexible sigmoidoscopy during 2007–2008 and assumed everyone was due for screening in 2009; screening patterns were determined for 2009–2018. Based on US Preventive Services Task Force recommendations, individuals were categorized as adherent to screening, inadequately screened or not screened. HCRU and Medicare costs were calculated as mean per patient per year (PPPY). Results Of 895,846 eligible individuals, 13.2% were adherent to screening, 53.4% were inadequately screened, and 33.4% were not screened. Compared with those not screened, adherent or inadequately screened individuals were more likely to be female, White and have comorbidities. These individuals also used more healthcare services, generating higher Medicare costs. For example, physician visits were 14.6, 22.9 and 25.9 PPPY and total Medicare costs were $6102, $8469 and $9102 PPPY for those not screened, inadequately screened and adherent, respectively. Conclusions In Medicare beneficiaries at average risk, adherence to CRC screening was low, although the rate might be underestimated due to lack of early Medicare data. The link between HCRU and screening status suggests that screening initiatives independent of clinical visits may be needed to reach unscreened or inadequately screened individuals.

Out-of-hospital health care costs of childhood food allergy in Australia: A population-based longitudinal study.

Australia has one of the highest prevalence of childhood food allergy in the world, but there are no data on its economic burden in Australia. We used data from the HealthNuts study, a population-based longitudinal study undertaken in Melbourne, Australia. Infants were recruited at age 12 months between Sept 2007 and Aug 2011 with food allergy diagnosed using oral food challenges. Health care costs of out-of-hospital services were collected through data linkage to Australia's universal health insurance scheme Medicare. Two-part model was used to compare costs after controlling for potential confounders. 2919 children were included, and 390 (13.4%) had challenge-confirmed food allergy at age 1year. Compared with children without food allergy, children with food allergy had significantly higher costs for GP visits, specialist visits, tests, and prescriptions in the first four years of life. The total Medicare cost associated with food allergy from age 1 to 4 years was estimated to be AUD$889.7 (95% CI $566.1-$1188.3) or €411.0 (95% CI €261.5-€549.0) per child. This was projected into an annual Medicare cost of AUD$26.1 million (95% CI $20.1-$32.3 million) or €12.1 (95% CI €9.3-€14.9 million) based on population size in 2020. Childhood food allergy causes considerable Medicare costs for out-of-hospital services in the first four years after birth in Australia. These findings can help anticipate the financial impact on the health care system associated with childhood food allergy, act as a useful costing resource for future evaluations, and inform management of childhood food allergy internationally.

Implementing pharmacists' medication safety recommendations is associated with reduced health care resource utilization and mortality in high-risk older Americans

BackgroundA medication safety review (MSR) is a novel, pharmacist-driven, technology-supported intervention that prioritizes adverse drug event risk mitigation. Previous research has shown that Medicare Part D beneficiaries who received MSRs in an enhanced medication therapy management (EMTM) model realized improvements in total Medicare spending, hospitalizations, emergency department (ED) visits, and mortality compared to control. However, it is unknown whether beneficiaries implemented pharmacists’ MSR recommendations. ObjectiveThe objective of the study was to evaluate whether MSR recommendation implementation is associated with improvements in these same outcomes for Part D beneficiaries enrolled in EMTM compared to a control group. MethodsThis retrospective, pre-post, cohort study evaluated outcomes for beneficiaries who were targeted for MSR services in 2018 and 2019. The “validated implementation MSR (viMSR)” cohort included those who received their first-ever MSR in 2018, received another MSR in 2019, and validated implementation of ≥1 recommendation in their 2018 MSR. The “failed to engage” (FTE) cohort included beneficiaries who were targeted for MSR services in both 2018 and 2019 but did not engage in an MSR at any point through the end of 2019. For both cohorts, we calculated the 2018-to-2019 change for each outcome and then determined whether year-over-year changes differed significantly between cohorts. For mortality, we relaxed the requirement for continuous enrollment in 2019, permitting us to compare the proportion of beneficiaries that died in each group in 2019. Analyses were adjusted for baseline multimorbidity. ResultsOf 4384 beneficiaries who completed MSRs, 602 (13.7%) implemented ≥1 recommendation. The viMSR cohort (N = 602) outperformed the FTE cohort (N = 7052) in total Medicare costs ($2162/y lower; P = 0.020), Part A Medicare costs ($1855/y; P = 0.024), hospitalizations (9.1 fewer admissions/100 beneficiaries/y, P = 0.020), ED visits (10.8 fewer visits/100 beneficiaries/y, P = 0.014), and mortality (3.8% fewer died in 2019; P < 0.001). ConclusionImplementing pharmacists’ recommendations in MSRs was associated with improved health care resource utilization and mortality for MSR-eligible beneficiaries.

Comparing costs of renal preservation versus radical nephroureterectomy management among patients with non-metastatic upper tract urothelial carcinoma.

To describe overall and categorical cost components in the management of patients with non-metastatic upper tract urothelial carcinoma (UTUC) according to treatment. We identified 4,114 patients diagnosed with non-metastatic UTUC from 2004 to 2013 in the Survival Epidemiology and End Results-Medicare linked database. Patients were stratified into renal preservation (RP) vs. radical nephroureterectomy (NU) groups. Total Medicare costs within 1 year of diagnosis were compared for patients managed with RP vs. NU using inverse probability of treatment-weighted propensity score models. A total of 1,085 (26%) and 3,029 (74%) patients underwent RP and NU, respectively. Median costs were significantly lower for RP vs. NU at 90 days (median difference -$4,428, Hodges-Lehmann [H-L] 95% confidence interval [CI], -$7,236 to -$1,619) and 365 days (median difference -$7,430, H-L 95% CI, -$13,166 to -$1,695), respectively. Median costs according to categories of services were significantly less for RP vs. NU patients by hospitalization, office visits, emergency room/critical care, consultations, and anesthesia. The only category which was significantly higher for RP vs. NU was inpatient visits ($1,699 vs. $1,532; median difference $152; HL 95% CI, $19-$286). Median costs were significantly lower for RP vs. NU up to 1-year and by hospitalization, office visits, emergency room/critical care, consultations, and anesthesia costs. In appropriately selected patients, such as patients with low-risk disease, these findings suggest the utility of RP as a suitable high-value management option in UTUC.

Long term cost comparisons of radical cystectomy versus trimodal therapy for muscle-invasive bladder cancer.

Earlier studies on the cost of muscle-invasive bladder cancer treatments are limited to short-term costs of care. We determined the 2- and 5-year costs associated with trimodal therapy (TMT) vs. radical cystectomy (RC). We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Total Medicare costs at 2 and 5 years following RC vs. TMT were compared using inverse probability of treatment-weighted propensity score models. A total of 2,537 patients aged 66 to 85 years were diagnosed with clinical stage T2-4a muscle-invasive bladder cancer. Total median costs for patients that received no definitive treatment(s) were $73,780 and $88,275 at 2-and 5-years. Costs were significantly higher for TMT than RC at 2-years ($372,839 vs. $191,363, Median Difference $127,815, Hodges-Lehmann Estimate (H-L) 95% Confidence Interval (CI), $112,663-$142,966) and 5-years ($424,570 vs. $253,651, Median Difference $124,466, H-L 95% CI, $105,711-$143,221). TMT had higher outpatient costs than RC (2-years: $318,221 vs. $100,900; 5-years: $367,092 vs. $146,561) with significantly higher costs with radiology, medications, pathology/laboratory, and other professional services. RC had higher inpatient costs than TMT (2-years: $62,240 vs. $33,631, Median Difference $-29,174, H-L 95% CI, $-32,364-$-25,984; 5-years: $75,499 vs. $45,223, Median Difference $-29,843, H-L 95% CI, $-33,905-$-25,781). The excess spending associated with trimodal therapy vs. radical cystectomy was largely driven by outpatient expenditures. The relatively high long-term trimodal therapy costs are prime targets for cost containment strategies to optimize future value-based care.

MP39-14 COMPARING HEALTHCARE UTILIZATION AND COSTS ACCORDING TO RENAL PRESERVATION VERSUS RADICAL NEPHROURETERECTOMY MANAGEMENT FOR PATIENTS WITH NON-METASTATIC UPPER TRACT UROTHELIAL CARCINOMA

You have accessJournal of UrologyCME1 May 2022MP39-14 COMPARING HEALTHCARE UTILIZATION AND COSTS ACCORDING TO RENAL PRESERVATION VERSUS RADICAL NEPHROURETERECTOMY MANAGEMENT FOR PATIENTS WITH NON-METASTATIC UPPER TRACT UROTHELIAL CARCINOMA Kathryn Fero, Yong Shan, Giri Movva, Jacques Baillargeon, Douglas Tyler, Karim Chamie, and Stephen Williams Kathryn FeroKathryn Fero More articles by this author , Yong ShanYong Shan More articles by this author , Giri MovvaGiri Movva More articles by this author , Jacques BaillargeonJacques Baillargeon More articles by this author , Douglas TylerDouglas Tyler More articles by this author , Karim ChamieKarim Chamie More articles by this author , and Stephen WilliamsStephen Williams More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002599.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Non-metastatic upper tract urothelial carcinoma (UTUC) is a heterogeneous disease with many treatment options that may lead to wide variation in costs. METHODS: We identified 4,114 patients diagnosed with non-metastatic UTUC from 2004-2013 in the Survival Epidemiology and End Results-Medicare linked population-based database. Patients were stratified into low- or high-risk disease groups. Total Medicare costs within one year of diagnosis were compared for patients managed with renal preservation (RP) versus radical nephroureterectomy (NU) using inverse probability of treatment-weighted (IPTW) propensity score models. RESULTS: After risk stratification, 1,027 (25%) and 3,087 (75%) patients were classified into low- vs high-risk UTUC groups and 1,085 (26%) and 3,029 (74%) patients underwent RP and NU, respectively. Median total costs were significantly higher by risk (high vs. low: $141,621 vs. $110,878, p <0.001). Median costs according to categories of services were significantly less for RP vs. NU patients by hospitalization ($22,801 vs. $23,211; Median Difference -$1,369, Hodges-Lehmann (H-L) 95% Confidence Interval (CI), -$2,556 to -$181), office visits ($1,616 vs. $1,874; Median Difference -$238, HL 95% CI, -$340 to -$135), emergency room/critical care ($578 vs. $758; Median Difference -$88, HL 95% CI, -$141 to -$34), consultations ($578 vs. $758; Median Difference -$80, HL 95% CI, -$134 to -$25), and anesthesia ($534 vs. $711; Median Difference -$203; HL 95% CI, -$230 to -$176). The only category which was significantly higher for RP vs. NU was inpatient visits ($1,699 vs. $1,532; Median Difference $152; HL 95% CI, $19 to $286). CONCLUSIONS: Healthcare costs of patients with high-risk UTUC are greater than those of low-risk patients. Median costs were significantly less for RP vs. NU by hospitalization, office visits, emergency room/critical care, consultations, and anesthesia costs. In the absence of data demonstrating superiority of NU over RP, especially for patients with low-risk disease, the increased costs may not be substantiated with equivocal outcomes. Source of Funding: This study was conducted with the support of a Department of Defense Peer Reviewed Cancer Research Program (PRCRP) Career Development Award (W81XWH1710576) (SBW). VS is supported by the Veteran’s Affairs Health Services Research and Development Fellowship. KEF is supported by H&H Lee UCLA Surgical Scholars Program. This project was supported by UroGen Pharma © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e671 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathryn Fero More articles by this author Yong Shan More articles by this author Giri Movva More articles by this author Jacques Baillargeon More articles by this author Douglas Tyler More articles by this author Karim Chamie More articles by this author Stephen Williams More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP39-02 LONG TERM COST COMPARISONS OF RADICAL CYSTECTOMY VERSUS TRIMODAL THERAPY FOR MUSCLE-INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 May 2022MP39-02 LONG TERM COST COMPARISONS OF RADICAL CYSTECTOMY VERSUS TRIMODAL THERAPY FOR MUSCLE-INVASIVE BLADDER CANCER Vishnukamal Golla, Yong Shan, Elias Farran, Courtney Stewart, Kevin Vu, Alexander Yu, Ali Raza Khaki, Kirk Keegan, Ashish Kamat, Douglas S. Tyler, Stephen J. Freedland, and Stephen B. Williams Vishnukamal GollaVishnukamal Golla More articles by this author , Yong ShanYong Shan More articles by this author , Elias FarranElias Farran More articles by this author , Courtney StewartCourtney Stewart More articles by this author , Kevin VuKevin Vu More articles by this author , Alexander YuAlexander Yu More articles by this author , Ali Raza KhakiAli Raza Khaki More articles by this author , Kirk KeeganKirk Keegan More articles by this author , Ashish KamatAshish Kamat More articles by this author , Douglas S. TylerDouglas S. Tyler More articles by this author , Stephen J. FreedlandStephen J. Freedland More articles by this author , and Stephen B. WilliamsStephen B. Williams More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002599.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Earlier studies on the cost of muscle-invasive bladder cancer treatments are limited to short-term periods of cost. Our study objective is to compare the 2- and 5-year costs associated with trimodal therapy (TMT) versus radical cystectomy (RC) benchmarked against costs for patients who received no curative treatment. METHODS: This cohort study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Medicare expenditures were summed from inpatient, outpatient, and physician services within 2 and 5 years of diagnosis to determine total costs Total Medicare costs at 2-and 5-years following TMT versus RC were compared using inverse probability of treatment-weighted (IPTW) propensity score models. RESULTS: A total of 2,537 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2009. Total median costs for patients that received no definitive/systemic treatments (RC, TMT, radiotherapy alone, or chemotherapy alone) were $73,780 vs. $88,275 at 2-and 5-years respectively. Total median costs were significantly higher for TMT than RC at 2-years ($372,839 vs. $191,363, p<0.001) and 5-years ($424,570 vs. $253,651, p<0.001), respectively. TMT had higher outpatient median costs than RC (2-yr: $318,221 vs. $100,900; 5-yr: $367,092 vs. $146,561) with significantly higher costs largely associated with radiology, medications, pathology/laboratory, and other professional services. Out-of-pocket prescription drug costs within 5 years of diagnosis were not significantly different for RC vs. TMT (median, $732 vs. $822; H-L Median, $-17; 95% CI, -$213 to $178). CONCLUSIONS: TMT vs. RC was associated with higher long-term costs among patients with muscle-invasive bladder cancer largely driven by outpatient expenditures. Reduction in costs associated with radiology, medications, pathology/laboratory, and other professional services may improve the value of TMT. Source of Funding: DOD PRCRP CDA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e664 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vishnukamal Golla More articles by this author Yong Shan More articles by this author Elias Farran More articles by this author Courtney Stewart More articles by this author Kevin Vu More articles by this author Alexander Yu More articles by this author Ali Raza Khaki More articles by this author Kirk Keegan More articles by this author Ashish Kamat More articles by this author Douglas S. Tyler More articles by this author Stephen J. Freedland More articles by this author Stephen B. Williams More articles by this author Expand All Advertisement PDF DownloadLoading ...

A comprehensive analysis of clinical, quality of life, and cost-effectiveness outcomes of key treatment options for benign prostatic hyperplasia.

Treatment options for men with moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) have variable efficacy, safety, and retreatment profiles, contributing to variations in patient quality of life and healthcare costs. This study examined the long-term cost-effectiveness of generic combination therapy (CT), prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), photoselective vaporization of the prostate (PVP), and transurethral resection of the prostate (TURP) for the treatment of BPH. A systematic literature review was performed to identify clinical trials of CT, PUL, WVTT, PVP, and TURP that reported change in International Prostate Symptom Score (IPSS) for men with BPH and a prostate volume ≤80 cm3. A random-effects network meta-analysis was used to account for the differences in patient baseline clinical characteristics between trials. An Excel-based Markov model was developed with a cohort of males with a mean age of 63 and an average IPSS of 22 to assess the cost-effectiveness of these treatment options at 1 and 5 years from a US Medicare perspective. Procedural and adverse event (AE)-related costs were based on 2021 Medicare reimbursement rates. Total Medicare costs at 5 years were highest for PUL ($9,580), followed by generic CT ($8,223), TURP ($6,328), PVP ($6,152), and WVTT ($2,655). The total cost of PUL was driven by procedural ($7,258) and retreatment ($1,168) costs. At 5 years, CT and PUL were associated with fewer quality-adjusted life years (QALYs) than WVTT, PVP, and TURP. Compared to WVTT, the incremental cost-effectiveness ratios (ICERs) for both TURP and PVP were above a willingness-to-pay threshold of $50,000/QALY (TURP: $64,409/QALY; PVP: $87,483/QALY). This study provides long-term cost-effectiveness evidence for several common treatment options for men with BPH. WVTT is an effective and economically viable treatment in resource-constrained environments.

Long-term cost comparisons of radical cystectomy versus trimodal therapy for muscle-invasive bladder cancer.

455 Background: Earlier studies on the cost of muscle-invasive bladder cancer treatments are limited to short-term periods of cost. Our study objective is to compare the 2- and 5-year costs associated with trimodal therapy (TMT) versus radical cystectomy (RC) benchmarked against costs for patients who received no curative treatment. Methods: This cohort study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Medicare expenditures were summed from inpatient, outpatient, and physician services within 2 and 5 years of diagnosis to determine total costs Total Medicare costs at 2-and 5-years following TMT versus RC were compared using inverse probability of treatment-weighted (IPTW) propensity score models. Results: A total of 2,537 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2009. Total median costs for patients that received no definitive/systemic treatments (RC, TMT, radiotherapy alone, or chemotherapy alone) were $73,780 vs. $88,275 at 2-and 5-years respectively. Total median costs were significantly higher for TMT than RC at 2-years ($372,839 vs. $191,363, p&lt;0.001) and 5-years ($424,570 vs. $253,651, p&lt;0.001), respectively. TMT had higher outpatient median costs than RC (2-yr: $318,221 vs. $100,900; 5-yr: $367,092 vs. $146,561) with significantly higher costs largely associated with radiology, medications, pathology/laboratory, and other professional services. Conclusions: TMT vs. RC was associated with higher long-term costs among patients with muscle-invasive bladder cancer largely driven by outpatient expenditures. Reduction in costs associated with radiology, medications, pathology/laboratory, and other professional services may improve the value of TMT.[Table: see text]

The effects of physician retirement on patient outcomes: Anticipation and disruption

The physician retirement rate in the United States is increasing as the population ages. I use an event study model allowing for anticipation to evaluate the effects of primary care physician (PCP) retirement on elderly adults’ health care utilization and quality of care. I find that, despite moderate anticipatory effects, PCP retirement results in an approximately $572 increase in total Medicare costs per beneficiary in the first 1.5 years post-retirement and an over 10% increase in detection of new chronic conditions. Heterogeneity analyses show that the increase in costs is disproportionately driven by the retirement of solo practitioners; Medicare beneficiaries with a retired PCP practicing in states with mandatory physician departure notice experience less disruption in care; and beneficiaries living in primary care health professional shortage areas experience greater disruption in care.

Impact of Spousal Death on Healthcare Costs and Use Among Medicare Beneficiaries: NHATS 2011-2017.

Spousal death is associated with elevated mortality in the surviving partner; less is known about how healthcare costs and use change following spousal death. To examine the causal impact of spousal death on Medicare costs and use over time. Longitudinal cohort study with an event study design. National Health and Aging Trends Study (NHATS) with linked Medicare claims. Respondents from 2011-2017 who reported spousal death the prior year, limited to those with traditional Medicare (n=491 with 9,766 respondent-quarters). Total Medicare costs; binary indicators for acute hospitalization; emergency department; sub-acute care (including skilled nursing, rehabilitation, and long-term care); and number of outpatient management visits on a quarterly basis 3 years before and after spousal death. During the first year post-death, quarterly Medicare costs for the surviving spouse were $1,092 higher than pre-death; probability of hospitalization, emergency department, and sub-acute care were 3.3%, 2.8%, and 2.2% higher, respectively; and there were 0.3 more outpatient visits (p<.01 for all). Several outcomes continued to be elevated during the second year, including costs ($1,174 higher per quarter), hospitalization (3.2% higher), and sub-acute care (2.9% higher; p<.01 for all). By the third year, costs returned to pre-death level but hospitalization and sub-acute care (2.9% and 3.1% higher per quarter; p<.05 for both) remained elevated. Cost increases in the first and second years post-death were larger if the deceased spouse was a caregiver ($1,588 and $1,853 per quarter) or female (i.e., among bereaved males; $1,457 and $1,632 per quarter; p<.05 for all). Spousal death increased total Medicare costs and use of all healthcare categories among the surviving partner; elevations in hospitalization and sub-acute care persisted through the third year. Clinicians and payors may want to target surviving partners as a high-risk population.

S239 Adherence to Colorectal Cancer Screening and Associated Healthcare Resource Utilization, a Longitudinal Analysis in US Medicare Population with Ten Years Follow-up

Introduction: Adherence to screening guidelines is critical for prevention and early detection of colorectal cancer (CRC). This study examined CRC screening adherence in Medicare beneficiaries and associated long-term healthcare resource utilization (HCRU) and Medicare costs. Methods: Using 20% Medicare random sample data, the study population included Medicare fee-for-service beneficiaries aged 66-75 years on 1/1/2009, at average-risk for CRC (no history of CRC, polyps, inflammatory bowel disease, or hereditary CRC syndrome), and continuously enrolled in Medicare part A/B from 2008 through 2018. The baseline year (2008) was used to define comorbidities and high-risk events. We excluded those who had a colonoscopy or flexible sigmoidoscopy (flex sig) during 2007-2008 and assumed everyone was due for screening in 2009; screening patterns were determined in the 10-year period, 2009-2018. Subjects were categorized as “adherent to screening” based on the USPSTF guidelines: colonoscopy every 10 years, flex sig every 5 years, multi-target stool DNA test every 3 years, or at least 8 fecal immunochemical or guaiac-based fecal occult blood tests in the 10-year period. Subjects were categorized as “not screened” if there were no tests observed; and “inadequately screened” if testing occurred but not enough to qualify as adherent. The long-term HCRU and inflation adjusted Medicare costs in the 10 years were calculated as mean per patient per year (PPPY). Results: In total, 895,846 eligible individuals were in the final sample. Of these, 13.2% were adherent to screening, 53.4% were inadequately screened, and 33.4% were not screened. Differences in baseline characteristics are presented in Table 1. Compared to those not screened, adherent or inadequately screened individuals were more likely to be female, of white race, and have comorbidities (Table 1). These individuals also used more healthcare services and therefore had higher Medicare costs (Figure 1). For example, physician visits were 14.6, 22.9, and 25.9 PPPY; total Medicare costs were $6,102, $8,469, and $9,102 PPPY for those not screened, inadequately screened, and adherent to screening, respectively. Conclusion: In Medicare beneficiaries at average-risk, adherence rate to CRC screening was low although the rate might be underestimated due to lack of early Medicare data. The link between HCRU and screened status suggests that screening initiatives not dependent on clinical visits may be needed to reach those who are unscreened or inadequately screened.Figure 1.: (a) Healthcare resource utilization measured as number of IP admissions, number of IP stay in days, or number of visits per patient per year (PPPY). (b) Mean Medicare cost measured as Medicare paid amount in 2018 US $PPPY. IP, inpatient; OP, outpatient; ED, emergency department; SNF, skilled nursing facility; HH, home health; DME, durable medical equipment; Part D, Medicare prescription drug.Table 1.: Table.Patient characteristic distribution by CRC screening patterns and odds ratio of adherence to or inadequately screened

Cost implications of patient spending on heart failure medications in the US Medicare program

Abstract Objectives The aim of this study was to model the associations between patient spending on heart failure (HF) medications and Medicare and all-payer expenditures on health care services for participants in the Medicare prescription drug (Part D) program. Methods Correlational analysis of pooled 2011–12 data from the Medicare Current Beneficiary Survey. Analysis was restricted to community-dwelling beneficiaries with self-reported HF at baseline, continuous Part D coverage, and no Low-Income Subsidy (LIS). The main predictor was mean patient expenditure on a HF-related prescription per 30-day supply. The outcomes were all-payer and Medicare-specific payments for inpatient and total health care services during the observation year. Key findings Mean patient drug expenditure was not statistically associated with Medicare or all-payer inpatient payments or (after covariate adjustment) with total health care payments. However, patient expenditure was statistically associated with total Medicare payments, eγ = 1.022, 95% CI [1.004 to 1.041]. Marginal effects analysis predicted an average rise in total Medicare payments of $190.32, 95% CI [$40.54 to $341.10], for each additional $1 of patient spending per prescription, P = 0.013. Given an average 2.4 HF-indicated drug classes per participant and assuming 12.2 copays per year, a hypothetical $1 increase in prescription copay predicted a net loss to Medicare of $160.90 per participant. Conclusion Prescription drug spending by Medicare beneficiaries with HF was not associated with higher inpatient or all-payer costs. A modest association between patient drug spending and total Medicare costs was observed, but longitudinal and cost-effectiveness analyses are needed to support causal inference.

Comparing Costs of Radical Versus Partial Cystectomy for Patients Diagnosed with Localized Muscle-Invasive Bladder Cancer: Understanding the Value of Surgical Care

Prior studies noted substantial costs associated with radical cystectomy, however, they lack surgical comparison to a less costly partial cystectomy. We compared costs associated with radical versus partial cystectomy. A total of 2,305 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2011 were included. Total Medicare costs within one year of diagnosis following radical versus partial cystectomy were compared using inverse probability of treatment-weighted propensity score models. Cox regression and competing risks analysis were used to determine overall and cancer-specific survival, respectively. Median total costs were not significantly different for radical than partial cystectomy in 90 days ($73,907 vs. $65,721; median difference $16,796, 95% CI $10,038 to $23,558), 180 days ($113,288 vs. $82,840; median difference $36,369, 95% CI $25,744 to $47,392), and 365 days ($143,831 vs. $107,359; median difference $34,628, 95% CI $17,819 to $53,558), respectively. Hospitalization, surgery, pathology/laboratory, pharmacy, and skilled nursing facility costs contributed largely to costs associated with either treatment. Patients who underwent partial cystectomy had similar overall survival but had worse cancer-specific survival (Hazard Ratio (HR) 1.45, 95% Confidence Interval (CI), 1.34-1.58, p<0.001) than patients who underwent radical cystectomy. While treatments for bladder cancer are associated with substantial costs, we showed radical cystectomy had similar total costs when compared to partial cystectomy among patients with muscle-invasive bladder cancer. However, partial cystectomy resulted in worse cancer-specific survival further supporting radical cystectomy as a high-value surgical procedure for muscle-invasive bladder cancer.