Comparing the cost of cirrhosis to other common chronic diseases: A longitudinal study in a large national insurance database.

Background Aims: Cirrhosis prevalence is increasing, yet costs associated with its chronic, complex care are poorly understood. The aim was to characterize the costs of care for patients with cirrhosis and compare them to other chronic diseases such as heart failure (HF) and chronic obstructive pulmonary disease (COPD), for which the public health burden is better recognized.

Approach: Patients enrolled in Medicare Advantage plans from a large national insurer between 2011-2020 with cirrhosis, HF, and COPD were identified by ICD-9/-10 codes.

Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials.

Background: The role of direct oral anticoagulants (DOACs) in the treatment of left ventricular thrombus (LVT) after ST-elevation myocardial infarction (STEMI) remains uncertain.

Aims: We aimed to compare the effect of rivaroxaban versus warfarin in patients with STEMI complicated by LVT.

Methods: Adult patients with STEMI and two-dimensional transthoracic echocardiography showing LVT were assigned to rivaroxaban (15 mg once daily) or warfarin (international normalised ratio goal of 2.

Trends in Cervical Laminoplasty Incidence in the United States: A Comparison of Commercial Insurance, Medicare, and Device Manufacturer Databases.

Study Design: Retrospective database study.

Objective: To leverage a commercial insurance claims database to explore trends in laminoplasty utilization and reimbursement in the United States. Secondarily, volume estimates were compared with data from the industry and from the Centers for Medicare and Medicaid (CMS).

Contributors and Solutions to High Out-of-Pocket Costs for Heart Failure Medications.

As expensive therapeutics rise to the fore of heart failure management, out-of-pocket (OOP) medication costs have become increasingly relevant to patient care. Prescription medication costs influence medical decision-making and affect adherence. Yet, individualized cost estimates are seldom available during clinical encounters when prescription decisions are made.

Association Between Hospital Efficiency and Quality of Care Among Fee-for-Service Medicare Beneficiaries with Prostate Cancer: A Retrospective Cohort Study.

Background: Technical efficiency evaluates a hospital's economic performance and plays an important role in variations in quality of care and outcomes. The study objective was to examine the association between hospital efficiency and quality of care among fee-for-service Medicare beneficiaries with prostate cancer and to assess if race moderates this association.

Design: Retrospective study using Surveillance, Epidemiological, and End Results-Medicare (SEER-Medicare) data from 1998 to 2016 for prostate cancer patients aged ≥ 66.

Disparities in treatment delays among metastatic breast cancer patients: insights from nationwide electronic health records, 2011-2022.

Purpose: While previous research has highlighted treatment delay inequities in early-stage breast cancer and identified potential contributing factors, there is limited research on disparities in treatment delays for metastatic breast cancer (MBC). This study investigates these disparities in MBC treatment initiation, aiming to identify key factors crucial for improving timely access to care.

Method: Nationwide Flatiron Health electronic health records-derived deidentified database, including females aged 18+ diagnosed with either De novo or relapsed MBC in the U.

Assessing Medicare's Coverage With Evidence Development Program.

The Centers for Medicare and Medicaid Services (CMS) coverage with evidence development (CED) program provides coverage for items and services not meeting Medicare's "reasonable and necessary" standard while requiring participation in clinical studies. As additional evidence is available, CMS may reconsider CED decisions. Of twenty-six items and services in the CED program since its 2005 inception, CMS has reconsidered coverage for ten (38 percent).

Medicare Advantage Networks Include Few Black Or Hispanic Physicians, Making Concordant Care Inaccessible For Many.

Black and Hispanic patients who receive care from Black and Hispanic physicians have greater use of preventive care. However, receiving care from racially concordant physicians requires that such physicians are included in private insurance plan networks. Using data from 2019, we examined the extent to which racially concordant physicians are available in the Medicare Advantage (MA) program, which disproportionately enrolls Black and Hispanic Medicare beneficiaries, by linking MA physician networks to physician race and ethnicity to measure the diversity of in-network physicians.

After Risk-Adjustment Change, Dementia Diagnoses Increased In Medicare Advantage Relative To Traditional Medicare.

In 2020, the Centers for Medicare and Medicaid Services reintroduced Alzheimer's disease and related dementias to its risk-adjustment payment model for Medicare Advantage (MA) plans. Using 2017-20 data for 100 percent of community-dwelling beneficiaries enrolled in Medicare, we evaluated how the reintroduction of dementia to the risk-adjustment model affected rates of new (incident) dementia diagnoses among beneficiaries enrolled in MA relative to those enrolled in traditional Medicare. In response to the payment change, annual incident dementia diagnosis rates in MA increased by 11.

Are Fewer Diagnoses Better? Assessing A Proposal To Improve The Medicare Advantage Payment System.

Medicare Advantage (MA) plans report diagnoses more completely than they are reported in traditional Medicare. As a result, payment to MA plans is greater than it would be if coding patterns were identical in the two sectors. The Medicare Payment Advisory Commission estimates that the overpayment to MA attributable to differential coding was $50 billion in 2024.

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.

Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine.

Importance: Monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) or its receptor (anti-CGRP mAbs) offer effective migraine-specific preventive treatment. However, concerns exist about their potential cardiovascular risks due to CGRP blockade.

Objective: To compare the incidence of cardiovascular disease (CVD) between Medicare beneficiaries with migraine who initiated anti-CGRP-mAbs vs onabotulinumtoxinA in the US.

National analysis of health-related social needs among adult injury survivors.

Background: Despite advances in trauma care, the effects of social determinants of health continue to be a barrier to optimal health outcomes. Health-related social needs (HRSNs), now the basis of a Centers for Medicare and Medicaid Services national screening program, may contribute to poor health outcomes, inequities, and low-value care, but the impact of HRSNs among injured patients remains poorly understood at the national level.

Methods: Using data from the nationally representative 2021 Medical Expenditure Panel Survey, injured patients were matched with uninjured controls via coarsened exact matching on age and sex.

Care Fragmentation Following Bariatric Operations: A National Analysis.

Background: Although existing work has evaluated outcomes associated with care fragmentation (CF), these adverse consequences may be accentuated in patients undergoing bariatric operations. This retrospective study examined the association of CF with clinical and financial outcomes among patients receiving bariatric surgery.

Methods: All adult (≥18 years) records for bariatric operations were tabulated from the 2016-2021 Nationwide Readmissions Database.

The Burden of Insurance Prior Authorization on Cancer Care: A Review of Evidence From Radiation Oncology.

Purpose: Despite its high cost-effectiveness, radiation oncology faces the greatest prior authorization (PA) burden of any medical specialty. Insurance denials and resulting treatment delays have been documented across several treatment modalities, including stereotactic body radiation, intensity modulated radiation, and proton therapy. Although insurance companies suggest that PA is intended to control health care spending and ensure the implementation of evidence-based practice, the number of radiation treatment plans reviewed by the PA process that result in changes is quite low.

Navigating performance measures for ambulatory antimicrobial stewardship: a review of HEDIS® and other metrics the steward should know.

Ambulatory antimicrobial stewardship can be challenging due to disparities in resource allocation across the care continuum, competing priorities for ambulatory prescribers, ineffective communication strategies, and lack of incentive to prioritize antimicrobial stewardship program (ASP) initiatives. Efforts to monitor and compare outpatient antibiotic usage metrics have been implemented through quality measures (QM). Healthcare Effectiveness Data and Information Set (HEDIS®) represent standardized measures that examine the quality of antibiotic prescribing by region and across insurance health plans.

Disparities in Utilization of Immune Checkpoint Inhibitor Therapy Among Older Patients With Advanced Non-Small Cell Lung Cancer: A SEER-Medicare Analysis.

Purpose: In the United States, there are disparities in access to care for patients with non-small cell lung cancer (NSCLC) on the basis of socioeconomic and racial/ethnic factors. This study investigates the association between race/ethnicity and the utilization of immune checkpoint inhibitor (ICI) therapy among older patients with advanced NSCLC (aNSCLC).

Methods: This retrospective study used data from the SEER-Medicare-linked database.

Trends in Payments for Ambulatory Surgery Center Facility Fees and Surgeon Professional Fees for Hip and Knee Arthroplasty.

Background: Ambulatory Surgery Centers (ASCs) have been shown to deliver high-quality care to patients at major cost savings to the healthcare system. The objective of this investigation was to examine trends in the Medicare facility and surgeon professional fee payments for hip and knee arthroplasty.

Methods: Publicly available Medicare data was analyzed to determine professional and facility fee payments for unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), and total hip arthroplasty (THA) to ASCs and hospitals between 2018 and 2024.

Hospital Volume and Long-Term Survival Among Medicare Beneficiaries Undergoing Surgical Repair of Acute Type A Aortic Dissection.

Despite guideline recommendations, transfer rates to high-volume aortic centers (high-VACs) for acute type A aortic dissections (TAAD) remain suboptimal; this may be because the benefit of undergoing surgical repair of TAAD at high-VACs remains poorly quantified. Medicare beneficiaries undergoing surgical repair of TAAD from 1999-2019 were identified. Hospital and surgeon annual aortic case volumes in Medicare beneficiaries were determined.

Inpatient Hypoglycemic Rate Reduction Through the Implementation of Prescriber Targeted Decision Support Tools.

Purpose Of Review: Hypoglycemia has been shown to increase mortality and length of hospital stay and is now reportable to the Centers for Medicare and Medicaid Services as a quality measure. The purpose of this article is to review clinical decision support (CDS) tools designed to reduce inpatient hypoglycemic events.

Recent Findings: CDS tools such as order set development, medication alerts, and data visibility have all been shown to be valuable tools in improving glycemic performance.

Influence of referral type and sociodemographic factors on completion of bariatric surgery.

Background: The impact of referral type and socioeconomic status on completion of the bariatric surgery process is not well understood.

Objectives: This study aims to 1) describe how sociodemographic characteristics influence referral type and 2) identify predictors of completion of surgery.

Setting: Large multihospital health care system, including a large academic medical center.

The substance-exposed birthing person-infant/child dyad and health information exchange in the United States.

Objective: Timely access to data is needed to improve care for substance-exposed birthing persons and their infants, a significant public health problem in the United States. We examined the current state of birthing person and infant/child (dyad) data-sharing capabilities supported by health information exchange (HIE) standards and HIE network capabilities for data exchange to inform point-of-care needs assessment for the substance-exposed dyad.

Material And Methods: A cross-map analysis was performed using a set of dyadic data elements focused on pediatric development and longitudinal supportive care for substance-exposed dyads (70 birthing person and 110 infant/child elements).

Racial, Socioeconomic, and Geographic Disparities in Preamputation Vascular Care for Patients With Chronic Limb-Threatening Ischemia.

Background: Black patients, those with low socioeconomic status (SES), and those living in rural areas have elevated rates of major lower extremity amputation, which may be related to a lack of subspecialty chronic limb-threatening ischemia care. We evaluated the association between race, rurality, SES, and preamputation vascular care.

Methods: Among patients aged 66 to 86 years with fee-for-service Medicare who underwent major lower extremity amputation for chronic limb-threatening ischemia from July 2010 to December 2019, we compared the proportion who received vascular care in the 12 months before amputation by race (Black versus White), rurality, and SES (dual eligibility for Medicaid versus no dual eligibility) using multivariable logistic regression adjusting for clinical and demographic covariates.