Medicare Risk Adjustment: Goals, Reform Proposals, And New Frontiers.

Risk adjustment modifies payments to health insurers based on enrollee characteristics that are predictive of higher or lower medical spending. Risk-adjustment policy is a key ingredient for the success of regulated individual insurance markets in Medicare and beyond. Researchers have identified shortcomings of Medicare's current risk-adjustment system, illustrated the limits of coarse fixes, and proposed new strategies that improve the data and calculations used to generate beneficiary risk scores.

Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members.

Purpose: The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program.

Patients And Methods: This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices.

Use and Cost of Low-Value Services Among Veterans Dually Enrolled in VA and Medicare.

Background: Over half of veterans enrolled in the Veterans Health Administration (VA) are also enrolled in Medicare, potentially increasing their opportunity to receive low-value health services within and outside VA.

Objectives: To characterize the use and cost of low-value services delivered to dually enrolled veterans from VA and Medicare.

Design: Retrospective cross-sectional.

Care cascades following low-value cervical cancer screening in dually enrolled Veterans.

Background: Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare.

Methods: This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019.

Trends in low-value cancer care during the COVID-19 pandemic.

Objective: To assess the association between the onset of the COVID-19 pandemic and change in low-value cancer services.

Study Design: In this retrospective cohort study, we used administrative claims from the HealthCore Integrated Research Environment, a repository of medical and pharmacy data from US health plans representing more than 80 million members, between January 1, 2016, and March 31, 2021.

Methods: We used linear probability models to investigate the relation between the onset of the COVID-19 pandemic and 4 guideline-based metrics of low-value cancer care: (1) conventional fractionation radiotherapy instead of hypofractionated radiotherapy for early-stage breast cancer; (2) non-guideline-based antiemetic use for minimal-, low-, or moderate- to high-risk chemotherapies; (3) off-pathway systemic therapy; and (4) aggressive end-of-life care.

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage.

Objective: To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories.

Design: Cross sectional analysis.

Setting: PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.

Growth of Medicare Advantage After Plan Payment Reductions.

Importance: Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program.

Objective: To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth.

Variation in Low-Value Service Use Across Veterans Affairs Facilities.

Background: It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA).

Objective: To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use.

Design: In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year.

Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems.

Importance: Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades.

Objective: To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services.

Design, Setting, And Participants: This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018.

Health Care Utilization and Spending in Medicare Advantage vs Traditional Medicare: A Difference-in-Differences Analysis.

Importance: Medicare Advantage (MA) has entailed a major expansion of government-financed, privately administered health insurance in the US. As policy makers consider options to expand Medicare further, it is informative to compare the performance of traditional Medicare (TM) and MA.

Objective: To assess whether MA is associated with differential changes in health care utilization and spending for beneficiaries entering Medicare from commercial insurance compared with beneficiaries entering TM.

Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration.

Background: Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA).

Objective: To examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery.

Design: Retrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not.

Coverage Denials: Government And Private Insurer Policies For Medical Necessity In Medicare.

Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their key features, using Medicare Advantage claims for a large insurer from the period 2014-19. In this setting, claims could be denied because of traditional Medicare's coverage rules or additional Medicare Advantage private insurer rules.

Association of Low-Value Care Exposure With Health Care Experience Ratings Among Patient Panels.

Importance: Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices.

Objective: To assess associations between rates of low-value service provision to a primary care professional (PCP) patient panel and patients' ratings of their health care experiences.

Measuring the Scope of Prior Authorization Policies: Applying Private Insurer Rules to Medicare Part B.

Importance: Health insurers use prior authorization to evaluate the medical necessity of planned medical services. Data challenges have precluded measuring the frequency with which medical services can require prior authorization, the spending on these services, the types of services and clinician specialties affected, and differences in the scope of prior authorization policies between government-administered and privately administered insurance.

Objectives: To measure the extent of prior authorization requirements for medical services and to describe the services and clinician specialties affected by them using novel data on private insurer coverage policies.

Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims.

Importance: Overuse of health care services exposes patients to unnecessary risk of harm and costs. Distinguishing patterns of overuse among hospitals requires hospital-level measures across multiple services.

Objective: To describe characteristics of hospitals associated with overuse of health care services in the US.

Differences in the Receipt of Low-Value Services Between Publicly and Privately Insured Children.

Background: Children frequently receive low-value services that do not improve health, but it is unknown whether the receipt of these services differs between publicly and privately insured children.

Methods: We analyzed 2013-2014 Medicaid Analytic eXtract and IBM MarketScan Commercial Claims and Encounters databases. Using 20 measures of low-value care (6 diagnostic testing measures, 5 imaging measures, and 9 prescription drug measures), we compared the proportion of publicly and privately insured children in 12 states who received low-value services at least once or twice in 2014; the proportion of publicly and privately insured children who received low-value diagnostic tests, imaging tests, and prescription drugs at least once; and the proportion of publicly and privately insured children eligible for each measure who received the service at least once.