Searching for the policy-relevant treatment effect in Medicare's ACO evaluations.

Objectives: To explain key challenges to evaluating Center for Medicare and Medicaid Innovation (CMMI) accountable care organization (ACO) models and ways to address those challenges.

Study Design: We enumerate the challenges, beginning with the conception of the alternative payment model and extending through the decision to scale up the model should the initial evaluation suggest that the model is successful. The challenges include churn at the provider and ACO levels, beneficiary leakage and spillover, participation in prior payment models, and determinants of shared savings and penalties.

Resource Use and Care Quality Differences Among Medicare Beneficiaries Undergoing Chemotherapy.

Importance: Medicare Advantage (MA) has grown significantly over the last decade; however, MA's performance for patients with serious conditions, such as cancer, remains unclear.

Objective: To compare resource use and care quality between MA and traditional Medicare (TM) beneficiaries undergoing cancer chemotherapy.

Design, Setting, And Participants: This cohort study used TM claims and MA encounter records from January 2015 to December 2019.

The Effect Of Next Generation Accountable Care Organizations On Medicare Expenditures.

The Next Generation Accountable Care Organization (NGACO) model (active during 2016-21) tested the effects of high financial risk, payment mechanisms, and flexible care delivery on health care spending and value for fee-for-service Medicare beneficiaries. We used quasi-experimental methods to examine the model's effects on Medicare Parts A and B spending. Sixty-two ACOs with more than 4.

Gaps In Quality Of Care Not Consistent Between Traditional Medicare, Medicare Advantage For Racial And Ethnic Groups.

The quality of care experienced by members of racial and ethnic minority groups in Medicare Advantage, which is an increasingly important source of Medicare coverage for these groups, has critical implications for health equity. Comparing gaps in Medicare Advantage and traditional Medicare for three quality-of-care outcomes, measured by adverse health events, between minority and non-Hispanic White populations, we found that the relative magnitude of the gaps varied both by racial and ethnic minority group and by quality measure. Hispanic versus non-Hispanic White gaps were smaller in Medicare Advantage than in traditional Medicare for all outcomes: avoidable emergency department use, preventable hospitalizations, and thirty-day hospital readmissions.

The mechanics of risk adjustment and incentives for coding intensity in Medicare.

Objective: To study diagnosis coding intensity across Medicare programs, and to examine the impacts of changes in the risk model adopted by the Centers for Medicare and Medicaid Services (CMS) for 2024.

Data Sources And Study Setting: Claims and encounter data from the CMS data warehouse for Traditional Medicare (TM) beneficiaries and Medicare Advantage (MA) enrollees.

Study Design: We created cohorts of MA enrollees, TM beneficiaries attributed to Accountable Care Organizations (ACOs), and TM non-ACO beneficiaries.

Wide Variation In Differences In Resource Use Seen Across Conditions Between Medicare Advantage, Traditional Medicare.

Medicare Advantage (MA) is a rapidly growing source of coverage for Medicare beneficiaries. Examining how MA performs compared with traditional Medicare is an important policy issue. We analyzed national MA encounter data and found that the adjusted differences in resource use between MA and traditional Medicare varied widely across medical conditions in 2019.

Coding Intensity Through Health Risk Assessments and Chart Reviews in Medicare Advantage: Does It Explain Resource Use?

Medicare Advantage (MA) plans increase their risk-adjusted payments through intensive coding in health risk assessments (HRAs) and chart reviews. Whether the additional diagnoses from HRAs and chart reviews are associated with increased resource use is not known. Using national MA encounter data (2016-2019), we examine the relative contributions of three health risk scores to MA resource use: the risk score that excludes diagnoses from HRAs and chart reviews; the score added to the base score from diagnoses in HRAs; and the score added from diagnoses in chart reviews.

Understanding factors associated with increases in Medicare Advantage enrollment, 2007-2018.

Objectives: Private managed care plans in the Medicare Advantage (MA) program have been gaining market share relative to traditional fee-for-service Medicare (TM), yet there are no obvious structural changes to Medicare that would explain this growth. Our goal is to explain the growth in MA market share during a period when it increased dramatically.

Study Design: Data are drawn from a representative sample of the Medicare population from 2007 to 2018.

Implementation of resource use measures in Medicare Advantage.

Objective: To complement the previously illustrated method to measure resource use in Medicare Advantage (MA) using Encounter data and provide technical details and SAS code to validate Encounter data and implement resource use measures in MA.

Data Sources: 2015-2018 MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and Traditional Medicare (TM) claims data.

Study Design: Secondary data analysis.

Disparities in the quality of care for chronic hepatitis C among Medicare beneficiaries.

Purpose: Chronic hepatitis C virus (HCV) infection is an important public health concern. Limited information exists on disparities in the quality of HCV care. We examine disparities in genotype or quantitative HCV ribonucleic acid testing before and after starting HCV treatment, and screening for hepatocellular carcinoma (HCC) in HCV patients with cirrhosis.

Measuring resource use in Medicare Advantage using Encounter data.

Objective: To check the completeness of Medicare Advantage (MA) Encounter data and to illustrate a process to measure resource use among MA enrollees using Encounter data.

Data Sources: 2015 Preliminary MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and 2013 Traditional Medicare (TM) claims data.

Study Design: Secondary data analysis.

Association of the Extension for Community Healthcare Outcomes Project With Use of Direct-Acting Antiviral Treatment Among US Adults With Hepatitis C.

Importance: Direct-acting antiviral (DAA) medications are highly effective in treating hepatitis C virus (HCV) infection. However, use of DAAs in rural and underserved areas is low owing to limited access to specialist physicians with experience in care of HCV infection. Project ECHO (Extension for Community Healthcare Outcomes) is a distance education model that trains primary care physicians to improve access to care for underserved populations with complex diseases such as HCV infection.

Use of Direct-Acting Antiviral Agents and Survival Among Medicare Beneficiaries with Dementia and Chronic Hepatitis C.

Background: Many patients with Alzheimer's disease and related dementia (ADRD) have chronic hepatitis C due to the high prevalence of both conditions among elderly populations. Direct-acting antivirals (DAAs) are effective in treating hepatitis C virus (HCV). However, the complexity of ADRD care may affect DAA use and outcomes among patients with HCV and ADRD.

Association of Direct-Acting Antiviral Treatment With Mortality Among Medicare Beneficiaries With Hepatitis C.

Importance: Direct-acting antiviral (DAA) drugs are highly effective in curing hepatitis C virus (HCV) infection. Previous simulations showed extended life as a key health advantage of DAA drugs, but real-world evidence on the association between DAA treatment and reduced mortality is limited.

Objectives: To examine the association of DAA treatment with mortality among Medicare beneficiaries with hepatitis C.

Association of Direct-Acting Antiviral Therapy for Hepatitis C With After-Treatment Costs Among Medicare Beneficiaries.

Importance: Direct-acting antiviral (DAA) therapy for hepatitis C is highly effective but expensive. Evidence is scarce on whether DAA therapy reduces downstream medical costs.

Objective: To examine the association of DAA therapy with posttreatment medical costs among Medicare beneficiaries.

Switching Costs in Medicare Advantage.

This paper estimates the magnitude of switching costs in the Medicare Advantage program. Consumers are generally assumed to pick plans that provide the combination of benefits and premiums that maximize their individual utility. However, the plan choice literature has generally omitted prior choices from choice models.

Discontinuation of new hepatitis C drugs among Medicare patients.

Objectives: To examine factors associated with discontinuation of new hepatitis C drugs-second-generation direct-acting antivirals (DAAs)-among Medicare beneficiaries with chronic hepatitis C.

Study Design: A retrospective analysis using 2014-2016 Medicare claims.

Methods: The study population was patients with chronic hepatitis C in fee-for-service Medicare with Part D who initiated a DAA therapy between January 1, 2014, and September 1, 2016.

Racial/Ethnic and Socioeconomic Disparities in Use of Direct-Acting Antivirals Among Medicare Beneficiaries with Chronic Hepatitis C, 2014-2016.

Background: New hepatitis C virus (HCV) drugs-direct-acting antivirals (DAAs)-are highly effective but costly, which raises a concern about limited access to DAAs by vulnerable populations. Previous studies of disparities in DAA use across patient groups showed mixed results, but their generalizability was limited due to using data from commercial insurers or from 2014 only-the first year DAAs were available. Disparities in DAA use in a national cohort in the years when more DAAs were available is unknown.

The impact of integration on outpatient chemotherapy use and spending in Medicare.

Hospital-physician integration has substantially grown in the United States for the past decade, particularly in certain medical specialties, such as oncology. Yet evidence is scarce on the relation between integration and outpatient specialty care use and spending. We analyzed the impact of oncologist integration on outpatient provider-administered chemotherapy use and spending in Medicare, where prices do not depend on providers' integration status or negotiating power.

The authors respond and stand behind their findings.

Our study provides the first evidence on site-specific Medicare spending on chemotherapy adjusting for patient comorbid illnesses, cancer type, and other cancer-related risks.

Differences in spending on provider-administered chemotherapy by site of care in Medicare.

Objectives: To compare Medicare spending on provider-administered chemotherapy in hospital outpatient departments (HOPDs) and physician offices after controlling for cancer type.

Study Design: Secondary data analysis.

Methods: We used 2010-2013 claims data for a random sample of Medicare fee-for-service beneficiaries who had cancer and received chemotherapy services either in physician offices or in HOPDs.

The Relationships Between Cold Ischemia Time, Kidney Transplant Length of Stay, and Transplant-related Costs.

Background: Recent changes in policies guiding allocation of transplant kidneys are predicted to increase sharing between distant geographic regions. The potential exists for an increase in cold ischemia time (CIT) with resulting increases in delayed graft function (DGF) and transplant-related costs (TRC). We sought to explore the impact of CIT on metrics that may influence TRC.

Growing Reinsurance Payments Weaken Competitive Bidding in Medicare Part D.

Objectives: To examine variation in risk-adjusted reinsurance payments across Part D plans, analyze its implications for the program, and explore options to reduce reinsurance payments.

Data/study Design: 2007-2015 Part D Plan Payment and Premium data; 2010-2013 Part D Prescription Drug Event data; and 2013 Part D Plan Formulary Files.

Principal Findings: Risk-adjusted reinsurance payments varied widely across plans at a given out-of-pocket (OOP) premium.

The Price Elasticity of Specialty Drug Use: Evidence from Cancer Patients in Medicare Part D.

Specialty drugs can bring substantial benefits to patients with debilitating conditions, such as cancer, but their costs are very high. Insurers/payers have increased patient cost-sharing for specialty drugs to manage specialty drug spending. We utilized Medicare Part D plan formulary data to create the (cost-sharing in the initial coverage phase in Part D), and estimated the total demand (both on- and off-label uses) for specialty cancer drugs among elderly Medicare Part D enrollees with no low-income subsidies (non-LIS) as a function of the initial price.