Use Of Patient Health Survey Data For Risk Adjustment To Limit Distortionary Coding Incentives In Medicare.

A core problem with the current risk-adjustment system in Medicare Advantage and accountable care organization (ACO) programs-the Hierarchical Condition Categories (HCC) model-is that the inputs (coded diagnoses) can be influenced for gain by risk-bearing plans or providers. Using existing survey data on health status (which provide less manipulable inputs), we found that the use of a hybrid risk score drawing from survey data and a scaled-back set of HCCs would, in addition to mitigating coding incentives, modestly lessen risk-selection incentives, strengthen payment incentives to deliver efficient care, allocate payment across ACOs more efficiently according to markers of population health that are not as affected by practice patterns or coding efforts, and redistribute payment in a manner that supports equity goals. Although sampling error and survey nonresponse present challenges, analyses suggest that these should not be prohibitive.

Strengths And Weaknesses Of Introducing An Inflation Factor Into The Medicare Physician Fee Schedule.

Unlike most other Medicare fee schedules, the Medicare Physician Fee Schedule does not include an automatic inflation update. We describe the history of Physician Fee Schedule update systems and present paradigms for evaluating the merits of adding an inflation-based adjustment factor to the schedule's updating formulas. We adopt an incentive paradigm, which emphasizes how access to care and the consolidation of health care facilities are affected by fees.

Promoting Access To Hospital Care In Rural Areas: Current Approaches And Ongoing Challenges.

Financial distress among rural hospitals is a significant concern for policy makers. Poor financial performance increases the likelihood of hospital closure and merger, and it can limit hospitals' ability to invest in quality improvements. In response to these challenges, policy makers are actively seeking ways to ensure access to affordable, high-quality care for rural communities.

Medicare Advantage: National Carriers Expand Market Share While Regional Carriers Without Affiliation Decline, 2012-23.

This study examined the evolving landscape of insurer competition in the Medicare Advantage (MA) program from both national and local perspectives. Data from the Centers for Medicare and Medicaid Services revealed that the MA market has become more concentrated. National carriers expanded their national market share significantly from 2012 to 2023, whereas the collective market share of regional carriers without affiliation to Blue Cross and Blue Shield organizations declined because of acquisitions.

Lack Of Persistent Coding In Traditional Medicare May Widen The Risk-Score Gap With Medicare Advantage.

Payments to Medicare Advantage (MA) plans are adjusted by a risk-score model that is calibrated on diagnostic and demographic data from traditional Medicare beneficiaries and then applied to MA beneficiaries. If MA plans capture more diagnostic codes than traditional Medicare, they receive payment that is higher than the amount that would be spent in traditional Medicare. Although most previous research has focused on the coding practices of MA plans, less attention has been paid to the completeness of coding in traditional Medicare.

Hospital-Skilled Nursing Facility Integration and Participation in a Bundled Payment Initiative.

Importance: Reduced institutional postacute care has been associated with savings in alternative payment models. However, organizations may avoid voluntary participation if participation could threaten their own revenues.

Objective: To characterize the association between hospital-skilled nursing facility (SNF) integration and participation in Medicare's Bundled Payments for Care Improvement Advanced (BPCI-A) program.

Reduced Cost Sharing and Medication Management Services for COPD: A Randomized Clinical Trial.

Importance: High out-of-pocket costs and improper use of maintenance inhalers contribute to poor outcomes among patients with chronic obstructive pulmonary disease (COPD). There is limited evidence for how addressing these barriers could improve adherence and affect COPD exacerbations, spending, or racial disparities in these outcomes.

Objective: To examine the effect of a national program to reduce beneficiary cost sharing for COPD maintenance inhalers and provide medication management services that included education on proper technique for inhaler use.

Artificial intelligence in Medicare: utilization, spending, and access to AI-enabled clinical software.

Objectives: In 2018, CMS established reimbursement for the first Medicare-covered artificial intelligence (AI)-enabled clinical software: CT fractional flow reserve (FFRCT) to assist in the diagnosis of coronary artery disease. This study quantified Medicare utilization of and spending on FFRCT from 2018 through 2022 and characterized adopting hospitals, clinicians, and patients.

Study Design: Analysis, using 100% Medicare fee-for-service claims data, of the hospitals, clinicians, and patients who performed or received coronary CT angiography with or without FFRCT.

Role of prices in driving the variation in spending across medical groups.

Objective: To understand the relative role of prices versus utilization in the variation in total spending per patient across medical groups.

Data Sources: We conducted a cross-sectional analysis of medical claims for commercially insured adults from a large national insurer in 2018.

Study Design: After assigning patients to a medical group based on primary care visits in 2018, we calculated total medical spending for each patient in that year.

Benchmarking Changes And Selective Participation In The Medicare Shared Savings Program.

In 2017 the Medicare Shared Savings Program (MSSP) began incorporating regional spending into accountable care organization (ACO) benchmarks, thus favoring the participation of ACOs and practices with lower baseline spending than their region. To characterize providers' responses to these incentives, we isolated changes in spending due to changes in the mix of ACOs and practices participating in the MSSP. In contrast to earlier participation patterns, the composition of the MSSP after 2017 increasingly shifted to providers with lower preexisting levels of spending relative to their region, consistent with a selection response.

Hospital Survival In Rural Markets: Closures, Mergers, And Profitability.

Financial distress among rural hospitals in the US has increased in recent years. Using national hospital data, we investigated how the decline in profitability has affected hospital survival, either independently or with a merger. The answer has direct implications for access to care and competition in rural markets.

Reducing Medicare Advantage Benchmarks Will Decrease Plan Generosity, But Those Effects Will Likely Be Modest.

Concerns that Medicare Advantage (MA) plans are overpaid have motivated calls to reduce MA benchmarks-the dollar amounts set by the Centers for Medicare and Medicaid Services (CMS) against which MA plans bid to set premiums and fund extra benefits. However, cutting benchmarks may lead to higher MA enrollee premiums and decreased plan generosity. We assessed the relationships between MA benchmarks and plan generosity and benefits.

Association of Evaluation and Management Payment Policy Changes With Medicare Payment to Physicians by Specialty.

Importance: US primary care physicians (PCPs) have lower mean incomes than specialists, likely contributing to workforce shortages. In 2021, the Centers for Medicare & Medicaid Services increased payment for evaluation and management (E/M) services and relaxed documentation requirements. These changes may have reduced the gap between primary care and specialist payment.

Organization and Performance of US Health Systems.

Importance: Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.

Objective: To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.

Evidence Review: Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region.

Changes in use of low-value services during the COVID-19 pandemic.

The COVID-19 pandemic led to a significant disruption, then recovery, of health care services use. Prior research has not examined the relative rates of resumption of high-value and low-value care. We examined the use of 6 common low-value services that received a D grade from the US Preventive Services Task Force compared with clinically comparable high-value services in a large commercially insured population nationwide from before the pandemic to April 1, 2021.

How Emerging Telehealth Models Challenge Policymaking.

Policy Points Current telehealth policy discussions are focused on synchronous video and audio telehealth visits delivered by traditional providers and have neglected the growing number of alternative telehealth offerings. These alternative telehealth offerings range from simply supporting traditional brick-and-mortar providers to telehealth-only companies that directly compete with them. We describe policy challenges across this range of alternative telehealth offerings in terms of using the appropriate payment model, determining the payment amount, and ensuring the quality of care.

The Contribution of Price Growth to Pharmaceutical Revenue Growth in the United States: Evidence from Medicines Sold in Retail Pharmacies.

Context: To what extent does pharmaceutical revenue growth depend on new medicines versus increasing prices for existing medicines? Moreover, does using list prices, as is commonly done, instead of prices net of confidential rebates offered by manufacturers, which are harder to observe, change the relative importance of the sources of revenue growth?

Methods: This study uses data from SSR Health LLC to address these research questions using decomposition methods that analyze list prices, prices net of rebates, and sales for branded pharmaceutical products sold primarily through retail pharmacies.

Findings: From 2009 to 2019, retail pharmaceutical revenue growth was primarily driven by new products rather than by price increases on existing products. Failing to account for confidential rebates creates a more prominent role for price increases in explaining revenue growth, because list price inflation during this period was 10.

The merits of administrative benchmarks for population-based payment programs.

The different approaches to setting benchmarks for population-based payment models (empirical, bidding based, and administratively set) have unique advantages and challenges.