The development of the Community Deprivation Index and its application to accountable care organizations.

There is strong interest among policymakers to adjust for area-level deprivation when making payments to providers because such areas have traditionally been underserved. The Medicare Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model provides higher payments to ACOs serving areas with greater deprivation. Area Deprivation Index (ADI) is the primary component to measure deprivation for ACO REACH.

Health Care Use of ACA Marketplace Enrollees During the COVID-19 Pandemic.

The onset of the COVID-19 pandemic in March 2020 had a sudden and substantial impact on health care utilization for most, if not all, individuals. We study the impact the pandemic had on the population insured in the individual and small group markets under the Patient Protection and Affordable Care Act (ACA) of 2010, using administrative claims data from January 2019 through December 2021. Our results demonstrated how health care utilization differed between the acute phase (i.

Incorporating Prescription Drugs Into Affordable Care Act Risk Adjustment.

Background: The 2010 Patient Protection and Affordable Care Act reformed the individual and small group health insurance markets and established a risk adjustment program to create a level playing field for competition. A new set of predictive models for measuring enrollee risk across plans was developed for the Patient Protection and Affordable Care Act-reformed markets, referred to as the Department of Health and Human Services Hierarchical Condition Category (HHS-HCC) models. Beginning in 2018, selected prescription drug classes were added to the models as risk markers.

A Comparison of Health Risk and Costs Across Private Insurance Markets.

Background: The Patient Protection and Affordable Care Act (PPACA) established new parameters for the individual and small group health insurance markets starting in 2014. We study these 2 reformed markets by comparing health risk and costs to the more mature large employer market.

Study Data: For 2017, claims data for all enrollees in PPACA-compliant individual and small group market plans as well as claims data from a sample of large employer market enrollees.

Underutilization and disparities in access to EGFR testing among Medicare patients with lung cancer from 2010 - 2013.

Background: Tumor testing for mutations in the epidermal growth factor receptor (EGFR) gene is indicated for all newly diagnosed, metastatic lung cancer patients, who may be candidates for first-line treatment with an EGFR tyrosine kinase inhibitor. Few studies have analyzed population-level testing.

Methods: We identified clinical, demographic, and regional predictors of EGFR & KRAS testing among Medicare beneficiaries with a new diagnosis of lung cancer in 2011-2013 claims.

21-Gene recurrence score testing among Medicare beneficiaries with breast cancer in 2010-2013.

Purpose: We evaluated national patient-level utilization of the 21-gene recurrence score (21-gene RS) test among Medicare beneficiaries with breast cancer. We analyzed clinical, demographic, and regional factors that predict testing.

Methods: Using 2010-2013 Medicare claims, we conducted a retrospective study of breast cancer patients.

Utilization of genetic tests: analysis of gene-specific billing in Medicare claims data.

Purpose: We examined the utilization of precision medicine tests among Medicare beneficiaries through analysis of gene-specific tier 1 and 2 billing codes developed by the American Medical Association in 2012.

Methods: We conducted a retrospective cross-sectional study. The primary source of data was 2013 Medicare 100% fee-for-service claims.

Affordable Care Act risk adjustment: overview, context, and challenges.

Beginning in 2014, individuals and small businesses will be able to purchase private health insurance through competitive marketplaces. The Affordable Care Act (ACA) provides for a program of risk adjustment in the individual and small group markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge and the incentive for plans to avoid sicker enrollees.

The HHS-HCC risk adjustment model for individual and small group markets under the Affordable Care Act.

Beginning in 2014, individuals and small businesses are able to purchase private health insurance through competitive Marketplaces. The Affordable Care Act (ACA) provides for a program of risk adjustment in the individual and small group markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge.

Risk transfer formula for individual and small group markets under the Affordable Care Act.

The Affordable Care Act provides for a program of risk adjustment in the individual and small group health insurance markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge. The risk adjustment methodology includes the risk adjustment model and the risk transfer formula.

Financial and quality impacts of the Medicare physician group practice demonstration.

Objective: To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes.

Data Source: Secondary data analysis of 2001-2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups.

Study Design: We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01-12/04) and five demonstration years (4/05-3/10).

Competitive bidding for Medicare Part B clinical laboratory services.

The traditional Medicare fee-for-service program may be able to purchase clinical laboratory test services at a lower cost through competitive bidding. Demonstrations of competitive bidding for clinical laboratory tests have been twice mandated or authorized by Congress but never implemented. This article provides a summary and review of the final design of the laboratory competitive bidding demonstration mandated by the Medicare Modernization Act of 2003.

Improvements in Medicare Part D risk adjustment: beneficiary access and payment accuracy.

Introduction: The continued success of the Medicare Part D program is contingent on appropriate Medicare payment adjustments for the projected drug costs of Part D plan enrollees. This article describes a major revision of these "risk adjustments," intended to more accurately match payments to costs, especially for high-cost, disadvantaged populations.

Methods: For the first time actual Part D data are used to calibrate risk adjustment.

The national market for Medicare clinical laboratory testing: implications for payment reform.

Current Medicare payment policy for outpatient laboratory services is outdated. Future reforms, such as competitive bidding, should consider the characteristics of the laboratory market. To inform payment policy, we analyzed the structure of the national market for Medicare Part B clinical laboratory testing, using a 5-percent sample of 2006 Medicare claims data.

Minimum savings requirements in shared savings provider payment.

Payer (insurer) sharing of savings is a way of motivating providers of medical services to reduce cost growth. A Medicare shared savings program is established for accountable care organizations in the 2010 Patient Protection and Affordable Care Act. However, savings created by providers cannot be distinguished from the normal (random) variation in medical claims costs, setting up a classic principal-agent problem.

Profiling efficiency and quality of physician organizations in Medicare.

This article presents a methodology for profiling the cost efficiency and quality of care of physician organizations (POs). The method is implemented for the Boston metropolitan area using 2002 Medicare claims. After adjustments for case mix and other factors, 4 of 30 organizations are identified with different than average efficiency Twenty-one of 30 organizations are identified with a different composite quality of care than average.

Medicare physician group practice demonstration design: quality and efficiency pay-for-performance.

The Medicare Physician Group Practice (PGP) demonstration is Medicare's first physician pay-for-performance (P4P) initiative. The demonstration, which is legislatively mandated, establishes incentives for quality improvement (QI) and cost efficiency at the level of the PGP Ten large physician groups are participating in the demonstration, which started on April 1, 2005, and will run for 3 years. In this article the authors provide an overview of the PGP demonstration's key design elements, including the selection process for PGP participants; beneficiary assignment; comparison population; measurement of demonstration savings; performance payments; and quality measurement and reporting.

Impact of multitiered copayments on the use and cost of prescription drugs among Medicare beneficiaries.

Objectives: To assess the impact of multitiered copayments on the cost and use of prescription drugs among Medicare beneficiaries.

Data Sources: Marketscan 2002 Medicare Supplemental and Coordination of Benefits database and Plan Benefit Design database.

Study Design: The study uses cross-sectional variation in copayment structures among firms with a self-insured retiree health plan to measure the impact of number of copayment tiers on total and enrollee drug payments, number of prescriptions filled, and generic substitution.

Medicare risk adjustment for the frail elderly.

CMS has had a continuing interest in exploring ways to incorporate frailty adjustment into the CMS Hierarchical Condition Categories (CMS-HCC) risk adjustment methodology for Medicare Advantage and other Medicare private organizations. In this article we present research results for Medicare risk adjustment of the frail elderly since the adoption of frailty adjustment for Program of All-Inclusive Care for the Elderly (PACE) organizations in 2004. In particular, we present results on the revised frailty adjuster that is being phased in for PACE organizations between 2008 and 2012.

Consumer response to dual incentives under multitiered prescription drug formularies.

Objective: To decompose the overall effect of multitiered formularies on drug utilization and spending into the following 2 observed effects on consumer behavior: first, higher copayments on drug equivalents create an incentive to reduce the number of prescriptions, and, second, wider differential copayments between drug equivalents create an incentive to use a greater proportion of generics.

Study Design: We merged drug claims for 352,760 retired Medicare enrollees having employer-sponsored health insurance with benefit information. Our unit of analysis was the enrollee.

Impact of nonresponse on Medicare Current Beneficiary Survey estimates.

The Medicare Current Beneficiary Survey (MCBS) has been used by policymakers and research analysts to provide information on a wide array of topics about the Medicare Program. Nonresponse bias is potentially one of the most important threats to the validity of the estimates from the MCBS. In this article we present results of our methodological study that analyzes the impact of nonresponse on MCBS estimates, including initial round unit nonresponse, panel attrition, and item nonresponse.

Medicare preferred provider organization demonstration: plan offerings and beneficiary enrollment.

As preferred provider organizations (PPOs) become the dominant model of managed health care in the private sector, policymakers have increasingly viewed PPOs as an attractive option for Medicare. In part to understand how PPOs might operate under the Medicare Program, CMS launched the Medicare PPO demonstration in January 2003. In this article, we examine how PPOs have operated so far under the demonstration, including PPO availability and market entry; premiums, benefits, and beneficiary cost sharing; and enrollment, market share, enrollee characteristics, and disenrollment to date.

Risk adjustment of Medicare capitation payments using the CMS-HCC model.

This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.

CMS Frailty Adjustment Model.

The authors document the development of the CMS frailty adjustment model, a Medicare payment approach that adjusts payments to a Medicare managed care organization (MCO) according to the functional impairment of its community-residing enrollees. Beginning in 2004, this approach is being applied to certain organizations, such as Program of All-Inclusive Care for the Elderly (PACE), that specialize in providing care to the community-residing frail elderly. In the future, frailty adjustment could be extended to more Medicare managed care organizations.