Total Medicare Expenditures Research Articles

Medicare expenditures among spouses of persons with dementia.

Spouses of persons living with dementia face intense strains on their well-being compared with similarly aged adults and spouses of partners with no dementia. This strain can impact spouses' health and healthcare needs, and therefore affect their healthcare utilization and expenditures. Using data from the Health and Retirement Study linked with Medicare claims, we matched dyads of spouses and their partners with dementia (SPWD) to a comparison group of similar spouses and their partners with no dementia (SPWND). We then examined Medicare expenditures for spouses in the 5 years following their partner's dementia onset month using a two-part regression model. SPWD cumulative total Medicare expenditures were, on average, $60,043 in the 5 years post dementia onset, compared to $56,068 for SPWND. This difference ($3974, 95% CI = [-$3,199; $11,477]) was not significant. However, there were significant differences in the 5th year's total expenditures (+$2,748 [$321; $5,447]), driven by inpatient expenditures ($1,562 [$22; $3,277]). Despite the differences in partner's dementia status, we found no significant difference in the 5-year cumulative Medicare expenditures between SPWD and SPWND. Compared to previous studies, we likely captured an earlier stage of dementia more consistently for a broader population which may be less straining on spouses. Further research should examine patterns of expenditures in later years and around critical timepoints in caregiving, such as partner transitions to formal long-term care settings and death, to better understand healthcare expenditures for spouses of persons living with dementia.

Racial and ethnic differences in disease course Medicare expenditures for beneficiaries with dementia.

Research on racial and ethnic disparities in costs of care during the course of dementia is sparse. We analyzed Medicare expenditures for beneficiaries with dementia to identify when during the course of care costs are the highest and whether they differ by race and ethnicity. We analyzed data from the 2000-2016 Health and Retirement Study (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four phases: (1) the year before a dementia diagnosis, (2) the first year following a dementia diagnosis, (3) ongoing care for dementia after the first year, and (4) the last year of life. We estimated each patient's phase-specific and disease course Medicare expenditures by using a race-specific survival model and monthly expenditures adjusted for patient characteristics. We investigated healthcare utilization by service type across races/ethnicities and phases of care. Adjusted mean total Medicare expenditures for non-Hispanic (NH) Black ($165,730) and Hispanic beneficiaries with dementia ($160,442) exceeded corresponding expenditures for NH Whites ($136,326). In the year preceding and immediately following initial dementia diagnosis, mean Medicare expenditures for NH Blacks ($26,337 and $20,429) exceeded expenditures for Hispanics and NH Whites ($21,399-23,176 and 17,182-18,244). The last year of life was responsible for the greatest cost contribution: $51,294 (NH Blacks), $47,469 (Hispanics), and $39,499 (NH Whites). These differences were driven by greater use of high-cost services (e.g., emergency department, inpatient and intensive care), especially during the last year of life. NH Black and Hispanic beneficiaries with dementia had higher disease course Medicare expenditures than NH Whites. Expenditures were highest for NH Black beneficiaries in every phase of care. Further research should address mechanisms of such disparities and identify methods to improve communication, shared decision-making, and access to appropriate services for all populations.

Ambulatory Care Fragmentation and Total Health Care Costs.

The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. To determine the association between ambulatory care fragmentation and total health care costs. Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. A total of 13,680 Medicare beneficiaries who are 65 years and older. We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.

Racial and ethnic differences in lifetime Medicare expenditures for dementia patients

AbstractBackgroundResearch on racial and ethnic disparities in lifetime dementia costs is sparse. We analyzed lifetime Medicare expenditures for dementia patients to identify when during the course of care costs are the highest, and whether these costs differ by race and ethnicity.MethodWe analyzed data from the 2000‐2016 Health and Retirement Survey (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four “phases”: 1) the year before dementia diagnosis; 2) the first year following a dementia diagnosis; 3) ongoing care for dementia after the first year; and 4) the last year of life. We then estimated each patient’s phase‐specific and lifetime Medicare expenditures by using a race‐specific survival model and monthly expenditures adjusted for demographics, socio‐economic status, year of dementia diagnosis, nursing home status, functional limitations, cognitive impairment, comorbidities, and Medicaid eligibility status.ResultAdjusted mean lifetime Medicare expenditures for non‐Hispanic Blacks ($166,548) and Hispanics with dementia ($163,425) exceeded corresponding expenditures for non‐Hispanic whites ($135,648) (Figure). In the year preceding and immediately following an initial dementia diagnosis, mean Medicare expenditures for non‐Hispanic Blacks ($26,384 and $20,824) exceeded expenditures for Hispanics and non‐Hispanic whites (ranging $21,340‐23,379 and 17,382‐18,085). Ongoing care costs for non‐Hispanic Blacks with dementia (mean $1,734/month) exceeded costs for Hispanics ($1,538/month) and non‐Hispanic whites ($1,424/month). Of the four phases, the last year of life was responsible for the greatest cost contribution: $52,003 for non‐Hispanic Blacks, $48,377 for Hispanics, and $39,648 for non‐Hispanic whites.ConclusionsTotal mean Medicare expenditures for non‐Hispanic Black and Hispanic beneficiaries with dementia exceeded corresponding expenditures for non‐Hispanic whites. Expenditures were highest for non‐Hispanic Blacks with dementia in every phase of care. Compared to non‐Hispanic whites, Hispanics had lower expenditures in the first year following dementia diagnosis and similar monthly ongoing care expenditures but much higher expenditures during their last year of life. Research should identify factors contributing to the disparities identified here so that policy makers can address problems adversely affecting disadvantaged populations. Figure: Estimated mean lifetime Medicare expenditures for beneficiaries newly diagnosed with dementia, by phase of care and by race and ethnicity (adjusted)

Association of the Range of Outpatient Services Provided by Primary Care Physicians with Subsequent Health Care Costs and Utilization.

Broader primary care practice range of services (ROS), defined as the diversity of professional services delivered, is associated with lower utilization. ROS provided by individual primary care physicians (PCPs) varies considerably with unclear implications for patients. Create a PCP-ROS measure covering six categories of outpatient services, including expanded codes for mental health counseling services and point of care ultrasound (POCUS) technology in physician offices. Determine whether PCP-ROS is associated with total Medicare expenditures, inpatient admissions, acute hospital utilization (AHU), and emergency department (ED) visits. Examine physician and practice characteristics associated with PCP-ROS. Retrospective cohort study. 4,569,711 Medicare fee-for-service beneficiaries and 27,008 PCPs observed during the evaluation of the Comprehensive Primary Care Plus (CPC +) initiative. PCP-ROS, hospitalizations, AHU (includes observation stays as well as inpatient admissions), ED visits, and total Medicare expenditures. Physicians varied substantially in the range of services provided. Broader PCP-ROS was significantly, independently associated with 1 - 3% lower Medicare expenditures (p ≤ 0.01), inpatient admissions (p ≤ 0.027), AHU (p ≤ 0.025), and ED visit rates (p ≤ 0.000). PCP-ROS score was associated with improved patient outcomes, independent of physician provision of procedures (such as laceration repair or skin excisions). Physicians in practice sites affiliated with a hospital or health system had narrower PCP-ROS than independent physicians by 0.3 to 0.4 (p < 0.001). Internal medicine specialty was associated with narrower PCP-ROS than family medicine by 0.3 (p < 0.001). Patients cared for by primary care physicians who provide a broader range of services subsequently experience lower acute care utilization and expenditures than do those cared for by physicians with narrower ROS. Practice leaders and professional associations should consider how best to ensure that primary care physicians efficiently and effectively provide the office-based professional services most needed by their patients.

Costs During the Last Five Years of Life for Patients with Clinical and Pathological Confirmed Diagnosis of Lewy Body Dementia and Alzheimer's Disease.

Little is known regarding healthcare expenditures for patients with dementia with Lewy bodies (DLB) during the end of life. This study estimated Medicare expenditures during the last 5 years of life in a decedent sample of patients who were clinically diagnosed with Alzheimer's disease (AD) or DLB and had autopsy confirmed diagnosis. The study included 58 participants clinically diagnosed with mild dementia at study entry (AD: n = 44, DLB: n = 14) and also had autopsy-confirmed diagnoses of pure AD (n = 32), mixed AD+Lewy body (LB) (n = 5), or pure LB (n = 11). Total Medicare expenditures were compared by clinical and pathology confirmed diagnosis, adjusting for sex, age at death, and patient's cognition, function, comorbidities, and psychiatric and extrapyramidal symptoms. When pathology diagnoses were not considered, predicted annualized total Medicare expenditures during the last 5 years of life were similar between clinically diagnosed AD ($7,465±1,098) and DLB ($7,783±1,803). When clinical diagnoses were not considered, predicted expenditures were substantially higher in patients with pathology confirmed mixed AD+LB ($12,005±2,455) than either pure AD ($6,173±941) or pure LB ($4,629±1,968) cases. Considering clinical and pathology diagnosis together, expenditures for patients with clinical DLB and pathology mixed AD+LB ($23,592±3,679) dwarfed other groups. Medicare expenditures during the last 5 years of life were substantially higher in patients with mixed AD+LB pathology compared to those with pure-AD and pure-LB pathologies, particularly in those clinically diagnosed with DLB. Results highlight the importance of having both clinical and pathology diagnoses in examining healthcare costs.

Use Trends and Recent Expenditures for Cervical Cancer Screening–Associated Services in Medicare Fee-for-Service Beneficiaries Older Than 65 Years

Since 1996, the US Preventive Services Task Force has recommended against cervical cancer screening in average-risk women 65 years or older with adequate prior screening. Little is known about the use of cervical cancer screening-associated services in this age group. To examine annual use trends in cervical cancer screening-associated services, specifically cytology and human papillomavirus (HPV) tests, colposcopy, and cervical procedures (loop electrosurgical excision procedure, cone biopsy, and ablation) in Medicare fee-for-service beneficiaries during January 1, 1999, to December 31, 2019, and estimate expenditures for services performed in 2019. This population-based, cross-sectional analysis included health service use data across 21 years for women aged 65 to 114 years with Medicare fee-for-service coverage (15-16 million women per year). Data analysis was conducted between July 2021 and April 2022. Proportion of testing modalities (cytology alone, cytology plus HPV testing [cotesting], HPV testing alone); annual use rate per 100 000 women of cytology and HPV testing, colposcopy, and cervical procedures from 1999 to 2019; Medicare expenditure for these services in 2019. There were 15 323 635 women 65 years and older with Medicare fee-for-service coverage in 1999 and 15 298 656 in 2019. In 2019, the mean (SD) age of study population was 76.2 (8.1) years, 5.1% were Hispanic, 0.5% were non-Hispanic American Indian/Alaska Native, 3.0% were non-Hispanic Asian/Pacific Islander, 7.4% were non-Hispanic Black, and 82.0% were non-Hispanic White. From 1999 to 2019, the percentage of women who received at least 1 cytology or HPV test decreased from 18.9% (2.9 million women) in 1999 to 8.5% (1.3 million women) in 2019, a reduction of 55.3%; use rates of colposcopy and cervical procedures decreased 43.2% and 64.4%, respectively. Trend analyses showed a 4.6% average annual reduction in use of cytology or HPV testing during 1999 to 2019 (P < .001). Use rates of colposcopy and cervical procedures decreased before 2015 then plateaued during 2015 to 2019. The total Medicare expenditure for all services rendered in 2019 was about $83.5 million. About 3% of women older than 80 years received at least 1 service at a cost of $7.4 million in 2019. The results of this cross-sectional study suggest that while annual use of cervical cancer screening-associated services in the Medicare fee-for-service population older than 65 years has decreased during the last 2 decades, more than 1.3 million women received these services in 2019 at substantial costs.

Medicare Advantage coverage restrictions for the costliest physician-administered drugs.

To examine the use of step therapy, prior authorization, and Part D formulary exclusion by 4 large Medicare Advantage (MA) insurers to manage 20 physician-administered drugs with the highest total Medicare expenditures (top 20 drugs). We collected data for United Healthcare, CVS/Aetna, Humana, and Kaiser plans to create a database of 2020 Part B coverage restrictions and conducted a retrospective analysis of 2018-2020 Part D formularies. For each insurer, we calculated the number of top 20 physician-administered drugs subject to prior authorization and step therapy. For physician-administered drugs for which there were no similar or interchangeable alternatives, we examined which insurers required prior authorization or step therapy. Finally, we examined whether insurers restricted access to physician-administered drugs by reducing coverage on Part D formularies. Of the top 20 physician-administered drugs, 17 were subject to prior authorization and 10 were subject to step therapy by at least 1 insurer. For 5 physician-administered drugs without a similar or interchangeable alternative, none were subject to step therapy and all were subject to prior authorization by at least 1 insurer. Across the 4 insurers, 16 physician-administered drugs were covered on all or some of the Part D formularies in 2018, which decreased to 6 in 2020. Four large MA insurers managed access to expensive physician-administered drugs with a combination of prior authorization, step therapy, and Part D formulary design. When a low-cost alternative exists, these tools can help reduce wasteful spending, but the administrative barriers may also reduce access.

Trends in Medicare Part B Payments and Utilization for Imaging Services Between 2009 and 2019

BackgroundIn 2019, the total National Healthcare Expenditure (NHE) reached $3.8 trillion, or nearly 20% of the total Gross Domestic Product. This represents a 4-fold increase in its Gross Domestic Product share since 1960. Given the magnitude and growth of such expenditures, healthcare cost containment is central to the country's financial sustainability. Moreover, as Medicare represents nearly 20% of the total NHE, it is a primary target for piloting, implementing and scaling initiatives that reduce expenditures. ObjectiveTo assess trends in Medicare Physician Fee Schedule for Service (Part B) payments and utilization for Imaging relative to other services from 2009 through 2019. Materials and methodsWe conducted a retrospective observational study of annual expenditures and utilization of imaging services using data from Centers for Medicare and Medicaid Services Medicare Part B. Data was grouped according to the Berenson-Eggers Type of Service Classification. The values were adjusted for inflation and we calculated the annual changes and the compound annual growth rates and the price elasticity of supply. ResultsFor the 10-year period, Imaging represented on average 8% of the total Medicare Part B expenditures, an equivalent of 1.4% of total Medicare expenditures or 0.05% of the NHE. While NHE, overall Medicare and overall Part B had positive growth rates of total expenditures, Imaging did not. Moreover, Imaging had the most negative CAGR compared to all other categories, including Drugs, Procedures, Evaluation and Management and Durable Medical Equipment. ConclusionImaging did not contribute to the increase in Medicare Part B expenditures, and it might have been disproportionately affected by cost containment policies.

Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure.

The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI. Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures. We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs. The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.

Practice-site-level measures of primary care comprehensiveness and their associations with patient outcomes.

To develop two practice-site-level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician-level measures. Medicare fee-for-service claims. We calculated practice-site-level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices' attributed beneficiaries' 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs' comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice-site and PCP-level measures with outcomes. The measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P<.01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P<.05); 8.84 (3.0%) fewer hospitalizations (P<.001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P<.01). PCP comprehensiveness varied more within than between practices. More comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice-site level comprehensiveness measures had strong construct and predictive validity; PCP-level measures were more precise.

The Cost of a Fall Among Older Adults Requiring Emergency Services.

The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures. Retrospective cohort analysis. Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. We included 2,494 community-dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage. The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates. The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189). Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs.

Patient Characteristics and Treatment Patterns among Medicare Beneficiaries Initiating PCSK9 Inhibitor Therapy.

There is limited real-world evidence around use of proprotein convertase subtilisin-kexin type 9 inhibitors (PCSK9i) among US older adults. This study examined baseline characteristics of fee-for-service (FFS) Medicare beneficiaries newly initiating PCSK9i therapy during the period immediately following market availability. This cross-sectional study used Medicare claims (2013-2016) to identify 5051 FFS Medicare beneficiaries who filled ≥ 1 PCSK9i prescription between August 2015 and December 2016. We analyzed patient demographics, clinical characteristics, and baseline healthcare expenditures in the 12-month period prior to PCSK9i initiation, for these beneficiaries. Most beneficiaries initiating PCSK9i were female (57%), < 75years of age (61%), white (89%), and lived in metropolitan areas (83%). At baseline, these PCSK9i initiators had 6 chronic conditions on average, with conditions such as hyperlipidemia, hypertension, and ischemic heart disease being most prevalent. Approximately 88% had a diagnosis of atherosclerotic cardiovascular disease (ASCVD), and 14% experienced acute cardiovascular events during the 12-month baseline period. Use of any statin and/or ezetimibe ranged from 54 to 76% in the 6-month and 24-month baseline period. Their total annual Medicare expenditures averaged US$17,552, of which most were attributable to ambulatory care and prescription use, in the 12-month baseline period. High burden of cardiovascular conditions and prescription expenditures at baseline were common among FFS beneficiaries initiating PCSK9i therapy. These findings suggest that physicians prescribe PCSK9i to elderly patients at high risk for adverse cardiovascular events. Considering the evolving treatment landscape, PCSK9i utilization might increase in Medicare.

PND117 IDENTIFYING PREDICTORS OF HIGH-COST MULTIPLE SCLEROSIS PATIENTS: A MACHINE LEARNING APPROACH

Multiple sclerosis (MS) is the leading cause of non-traumatic neurological disability in young adults. High healthcare resource utilization in MS patients is linked to relapses and disease progression. The goal of this study is to identify predictors of future high-cost MS patients through machine learning (ML) methods. Newly diagnosed MS patients were identified using ICD-9/10 codes in Medicare Part A/B claims (5% sample) between 2011Q1-2015Q1. The total Medicare expenditures during 12 months after the index diagnosis were summed, with the highest decile of average monthly spending defined as “high cost”. Data were partitioned using a 60%/25%/15% split to train, validate and test performance on unseen data. A traditional logistic regression model was estimated as a reference model. Random forest (RF), XGBoost and support vector machine (SVM) models were developed and the best model was selected through assessment of the area under the ROC curve (AUC). Accuracy, recall, precision and F1 scores were also reported. Features that were consistently important for prediction based on model specific importance metrics across all models were noted. The study population included 5,863 MS patients (mean age=63.1 years; females=67%). All ML methods (AUC RF: 78.1%, SVM: 77.4%, XGBoost: 74.6%) outperformed the logistic regression model (AUC: 64.4%). The best performing ML model was RF, which had accuracy: 70.4%; recall: 72.7%; precision: 21.3% and F1: 0.33. The top 15 features identified as positively associated with high-cost patients across all ML methods were being male, selected medication use (epoetin alfa, heparins, insulin), limitations of mobility, musculoskeletal deformities, indicators of past inpatient service utilization, stroke, and comorbidities including chronic kidney disease, hypertension, and pulmonary diseases. In predicting high-cost patients, ML methods provided a significant improvement over the logistic regression model. Our findings can be used to guide further research to proactively manage care and reduce healthcare spending.

Going Home: Access for Home Modalities.

The cost and health burden of ESRD continues to increase globally. Total Medicare expenditure on dialysis has increased from 229 million USD in 1973 to 35.4 billion USD in 2016. Dialysis access can represent almost a tenth of these costs. Central venous catheters have been recognized as a significant factor driving costs and mortality in this population. Home dialysis, which includes peritoneal dialysis and home hemodialysis, is an effective way of reducing costs related to renal replacement therapy, reducing central venous catheter usage and in many cases improving the clinical and psychosocial aspects of patients' health. Addressing access-related issues for peritoneal dialysis, urgent-start peritoneal dialysis and home hemodialysis can have impact on the success of home dialysis. This article reviews issues related to dialysis access for home therapies.

Payer effects of personalized preventive care for patients with diabetes.

To examine the effects of MD-Value in Prevention (MDVIP) enrollment on Medicare expenditures and utilization among fee-for-service (FFS) beneficiaries with diabetes over a 5-year period. We obtained participating physician and beneficiary enrollment lists from MDVIP and Medicare FFS claims data through the Virtual Research Data Center to compare changes in outcomes, before and after enrollment dates, with those of nonenrolled beneficiaries receiving primary care in the same local market. We employed propensity score matching to identify comparison beneficiaries similar in observed characteristics and preenrollment trends. Individual fixed effects were used to control for time-consistent differences between treatment and comparison populations. We found that enrollment is statistically associated with reductions in outpatient expenditures, Medicare expenditures in year 5, emergency department (ED) utilization, and unplanned inpatient admissions, accompanied by significant increases in evaluation and management visits and expenditures. Total Medicare expenditures over the 5-year period, as well as all inpatient admissions, were not statistically different between the MDVIP and comparison groups. Our finding of reduced unplanned inpatient admissions and ED utilization supports the previous findings regarding MDVIP enrollees. We did not find significant changes in overall third-party expenditures, although savings were estimated in year 5, the last year of observation, and may occur later. Our approach, however, strengthens controls for baseline characteristics of the population and uses a comparison population drawn from the same markets who do not experience the loss of their primary care physician at the time of enrollment.

Disease-Specific Plan Switching Between Traditional Medicare and Medicare Advantage.

Previous research has reported switching from traditional Medicare (TM) to Medicare Advantage (MA) plans increased from 2006 to 2011 at the aggregate level, and switching from MA plans to TM also increased. However, little is known about switching behavior among individuals with specific chronic diseases. To examine disease-specific switching patterns between TM and MA to understand the impact on MA plans. Using the 2006 to 2012 Medicare Current Beneficiary Survey, we examined disease-specific switching rates between TM and MA and disease-specific ratios of mean baseline total Medicare expenditures of beneficiaries remaining in the same plan (stayers) vs those switching to another plan (switchers), respectively. We focused on beneficiaries with 1 or more of 10 incident diagnoses. Beneficiaries with a new diagnosis of Alzheimer disease and related dementias, hypertension, and psychiatric disorders had relatively high rates of switching into MA plans and low rates of switching out of MA plans. Among those with new diagnoses of psychiatric disorders and diabetes, more costly beneficiaries (those with higher costs) switched into MA plans. For cancer, more costly beneficiaries remained in MA plans. Together, these results suggest that MA plans may have not only higher caseloads but also a more costly case mix of beneficiaries with certain diseases than historically was the case. Our findings can help inform MA plans to understand their beneficiaries' disease burden and prepare for provision of relevant services.

Characterizing and Assessing the Impact of Surgery on Healthcare Spending Among Medicare Enrolled Preoperative Super-utilizers.

The aim of this study was to characterize preoperative super-utilizers and examine the effect of surgery on service utilization among patients undergoing major elective surgery. Rising healthcare costs are becoming increasingly burdensome for Medicare. Super-utilizers have been increasingly identified and studied as this subset of patients consume a disproportionate amount of healthcare services compared with the majority of the population. Patients aged 65 or older who underwent any of the following general elective surgeries: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), colectomy, or hip replacement were identified using 100% Medicare Inpatient and Outpatient Standard Analytic Files (SAFs) from years 2012 to 2016. Medicare inpatient and outpatient expenditures the year before surgery, around the time of surgery, and the year after surgery were examined. Among 603,105 Medicare beneficiaries, 32,145 patients (5.3%) were categorized as super-utilizers. Compared with low-utilizers, super-utilizers were more likely to be male (low-utilizer vs super-utilizer: 47.9% vs 54.2%) and African American (4.0% vs 7.2%), whereas 58.8% (n = 208,080) of low-utilizers presented without any comorbidity [Charlson Comorbidity Index (CCI) = 0] and 49.8% (n = 16,007) of super-utilizers presented with a CCI score of ≥3. Total preoperative spending among super-utilizers was approximately $1.7 billion with a median of $3,159 [interquartile range (IQR): $554-$15,181] per beneficiary. Spending among super-utilizers accounted for 39.6% of total spending for all Medicare beneficiaries versus only 8.4% among low-utilizers. Although the median spending per Medicare beneficiary in the year after surgery was higher for super-utilizers compared with low-utilizers [$1,837 (IQR: $341-$11,390) vs $18,223 (IQR: $3,466-$43,356)], super-utilizers accounted for 13.5% of total postoperative spending. The reduction in adjusted average annual Medicare expenditure ranged from >$15,000 per year for patients undergoing CABG to approximately $30,000 per year for patients undergoing a hip replacement. Although super-utilizers accounted for only 5.3% of patients, these patients accounted for 39.6% of total Medicare expenditures in the year before surgery. Among a subset of super-utilizers, surgical intervention was associated with a reduction in annual Medicare expenditure in the year after surgery.

Maryland's Global Hospital Budgets: Impacts on Medicare Cost and Utilization for the First 3 Years.

Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014. To evaluate the effect of hospital global budgets on health care utilization and expenditures. Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group. Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas. Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses. Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group. This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.

PUK7 THE EFFECT OF PRETRANSPLANT DIALYSIS MODALITIES ON POSTTRANSPLANT HEALTH SERVICES UTILIZATION AND MEDICARE REIMBURSEMENT: A PROPENSITY-MATCHED COMPARISON

Medicare total expenditure on End-stage renal disease (ESRD) in 2015 was estimated to be $33.9 billion accounting for more than 7% of total Medicare expenditure. To our knowledge, no previous propensity score-matched study was conducted to compare the effect of pretransplant dialysis modalities no posttransplant healthcare services utilization and Medicare expenditure. To compare post-TX healthcare services utilization and Medicare reimbursement between pretransplant peritoneal and hemodialysis for adults with ESRD in the US. A propensity-matched retrospective study of renal recipients between January 2007 and December 2011, following ≥60 days of maintenance dialysis. All the data were obtained from the USRDS for the period 2006 to 2012. Adults who received either kidney or kidney/pancreas, with ≥6 months of pre-TX history were included. Patients with other organ transplants, two or more prior renal TXs, and missing data were excluded. Per-person-per-year (PPPY) and mean differences (M-Diff.) were calculated using multivariate regression analyses models. All the dollar values were adjusted to the 2018 inflation rate. A total of 19,612 renal recipients (9,806 pairs) were included. No difference in follow-up (HD=36.51 vs PD=36.08 months, p-value =0.0807). Nearly, 50% of recipients had 2-18 months of pretransplant dialysis. The 6-year total Medicare reimbursement for healthcare services use was $1.728 billion. Inpatient services accounted for 42%; physician fees, 30%; prescription medications, 12%; outpatient visits, 10%; and dialysis sessions, around 4%. Patients in the HD group had significantly higher PPPY number of and reimbursement on medications, inpatient events, and number of and reimbursement on home health visits. The PPPY total Medicare expenditure indicated that each HD recipient imposes a significantly higher total expenditure (M-Diff. =$1,134.50, p-value <.0001) compared to PD recipients. Our findings indicated that hemodialysis recipients’ utilization of and reimbursement on healthcare services impose a significant expense to Medicare compare to peritoneal dialysis patients.