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Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was −$1,766.2 (95% confidence interval: −$2,576.4 to −$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas. [ABSTRACT FROM AUTHOR]

Low-value care is associated with increased healthcare costs and direct harm to patients. We sought to develop and validate a simple diagnostic intensity index (DII) to quantify hospital-level diagnostic intensity, defined by the prevalence of advanced imaging among patients with selected clinical diagnoses that may not require imaging, and to describe hospital characteristics associated with high diagnostic intensity. We utilized State Inpatient Database data for inpatient hospitalizations with one or more pre-defined discharge diagnoses at acute care hospitals. We measured receipt of advanced imaging for an associated diagnosis. Candidate metrics were defined by the proportion of inpatients at a hospital with a given diagnosis who underwent associated imaging. Candidate metrics exhibiting temporal stability and internal consistency were included in the final DII. Hospitals were stratified according to the DII, and the relationship between hospital characteristics and DII score was described. Multilevel regression was used to externally validate the index using pre-specified Medicare county-level cost measures, a Dartmouth Atlas measure, and a previously developed hospital-level utilization index. This novel DII, comprised of eight metrics, correlated in a dose-dependent fashion with four of these five measures. The strongest relationship was with imaging costs (odds ratio of 3.41 of being in a higher DII tertile when comparing tertiles three and one of imaging costs (95 % CI 2.02–5.75)). A small set of medical conditions and related imaging can be used to draw meaningful inferences more broadly on hospital diagnostic intensity. This could be used to better understand hospital characteristics associated with low-value care. [ABSTRACT FROM AUTHOR]

This study investigates the determinants of average Medicare payments, focusing on the impact of secondary diagnoses, demographic factors, and regional disparities. Our model reveals that major complications and comorbidities (MCCs) significantly increase average Medicare payments compared to less severe complications (CCs), with coefficients of 7674.13 and 1542.67, respectively. Higher percentages of the elderly living in poverty correlate with increased payments, highlighting the influence of social determinants on healthcare costs. Demographic analysis shows that counties with higher populations of Black, Hispanic, Asian, or other races receive higher Medicare payments, indicating potential racial disparities in healthcare access and quality. Political affiliation also plays a role, with Democrat-voting counties incurring higher Medicare costs. Surprisingly, larger populations served correlate with decreased payments, possibly due to cost-containment programs like Medicare's Competitive Bidding. State-level analysis reveals significant regional variations, with states like Oregon and Wyoming showing higher payments, while Mississippi and Georgia have the lowest. Our findings underscore the complexity of Medicare funding and the need for targeted policy interventions to address health disparities and ensure sustainable healthcare delivery. [ABSTRACT FROM AUTHOR]

Background: Although prior research has estimated the overarching cost burden of heart failure (HF), a thorough analysis examining medical expense differences and trends, specifically among commercially insured patients with heart failure, is still lacking. Thus, the study aims to examine historical trends and differences in medical costs for commercially insured heart failure patients in the United States from 2006 to 2021. Methods: A population-based, cross-sectional analysis of medical and pharmacy claims data (IQVIA PharMetrics® Plus for Academic) from 2006 to 2021 was conducted. The cohort included adult patients (age > = 18) who were enrolled in commercial insurance plans and had healthcare encounters with a primary diagnosis of HF. The primary outcome measures were the average total annual payment per patient and per cost categories encompassing hospitalization, surgery, emergency department (ED) visits, outpatient care, post-discharge care, and medications. The sub-group measures included systolic, diastolic, and systolic combined with diastolic, age, gender, comorbidity, regions, states, insurance payment, and self-payment. Results: The study included 422,289 commercially insured heart failure (HF) patients in the U.S. evaluated from 2006 to 2021. The average total annual cost per patient decreased overall from $9,636.99 to $8,201.89, with an average annual percentage change (AAPC) of -1.11% (95% CI: -2% to -0.26%). Hospitalization and medication costs decreased with an AAPC of -1.99% (95% CI: -3.25% to -0.8%) and − 3.1% (95% CI: -6.86–0.69%). On the other hand, post-discharge, outpatient, ED visit, and surgery costs increased by an AAPC of 0.84% (95% CI: 0.12–1.49%), 4.31% (95% CI: 1.03–7.63%), 7.21% (95% CI: 6.44–8.12%), and 9.36% (95% CI: 8.61–10.19%). Conclusions: The study's findings reveal a rising trend in average total annual payments per patient from 2006 to 2015, followed by a subsequent decrease from 2016 to 2021. This decrease was attributed to the decline in average patient costs within the Medicare Cost insurance category after 2016, coinciding with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, expenses related to surgical procedures, emergency department (ED) visits, and outpatient care have shown substantial growth over time. Moreover, significant differences across various variables have been identified. [ABSTRACT FROM AUTHOR]

Purpose: To characterize trends in use of and expenditure for the intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents aflibercept, ranibizumab, and bevacizumab among the population enrolled in Original Medicare from 2014 to 2019. Methods: The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to extract Medicare Part B fee-for-service outpatient injection claims data submitted by ophthalmologists. Multivariable linear regression models were used to evaluate the association between reimbursement, ophthalmologist availability, and agent administration rate. Results: Between 2014 and 2019, 17,588,995 intravitreal injection claims were filed by 4218 US ophthalmologists. Medicare costs for anti-VEGF injections increased from 2.51 B USD in 2014 to 4.02 B USD in 2019. Increased state-level ophthalmologist availability and incremental increases in average reimbursement amounts were found to be significantly associated with a 6.8-fold variation in 2019 overall anti-VEGF injection rates across states. Conclusions: Medicare injection rates and costs for anti-VEGF injections have both increased between 2014 and 2019, largely driven by increased aflibercept use. There is a significant association between ophthalmologist availability and anti-VEGF injection rate on the state level, suggesting access to care may contribute to the observed state-level disparities in intravitreal injection rates. Further characterization of factors contributing to the state-level variation in injection rates of individual anti-VEGF agents may help inform interventions promoting equitable access to and use of these drugs. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between growth in Medicare Advantage (MA) enrollment and changes in finances at skilled nursing facilities (SNFs). Data Source s : Medicare SNF cost reports, LTCFocus.org data, and county MA penetration rates. Study Design: We used ordinary least squares regression with SNF and year fixed effects. Our primary outcomes were SNF revenues, expenses, profits, and occupancy. Our primary independent variable was the yearly county Medicare Advantage penetration. Data Collection/Extraction: We linked facility‐year data from 2012 to 2019 obtained from cost reports and LTCFocus.org to county‐year MA penetration. Principal Findings: A 10 percentage point increase in county MA enrollment was associated with a $213,883.89 (95% Confidence Interval [CI]: −296,869.08, −130,898.71) decrease in revenue, a $132,456.19 (95% CI: −203,852.28, −61,060.10) decrease in expenses, and a 0.59 percentage point (95% CI: −0.97, −0.21) decrease in profit margin. A 10 percentage point increase in county MA enrollment was associated with a decline (−318.93; 95% CI: −468.84, −169.02) in the number of resident‐days (a measure of occupancy) as well as a decline in the revenue per resident day ($4.50; 95% CI: −6.81, −2.20), potentially because of lower prices in MA. There was also a decline in expenses per patient day (−2.35; 95% CI: −4.76, 0.05), though this was only statistically significant at the 10% level. While increased MA enrollment was associated with a substantial decline in the number of Medicare resident days (487.53; 95% CI: −588.70, −386.37), this was partially offset by an increase in other payer (e.g., private pay) resident days (285.91; 95% CI: 128.18, 443.63). Increased MA enrollment was not associated with changes in the number of Medicaid resident days or a decrease in staffing per resident day. Conclusion: SNFs in counties with more MA growth had substantially greater relative declines in revenue, expenses, and profit margins. The continued growth of MA may result in significant changes in the SNF industry. [ABSTRACT FROM AUTHOR]

BACKGROUND Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Until recently, the Centers of Medicare and Medicaid were restricted from negotiating drug cost. We assessed the potential impact of alternative drug sourcing models on Medicare Part D spending. METHODS: Twenty-seven drugs were extracted from 2021 Medicare Part D claims. Drug-specific/total spending was compared against cost at Mark Cuban Cost Plus Drugs Company, Costco Member Prescription Program, and Veterans Health Administration price point. RESULTS: Potential Part D savings were $798.99 million, $573.84 million, and $1.02 billion (Mark Cuban Cost Plus Drugs Company, Costco Member Prescription Program, and Veterans Health Administration, respectively). DISCUSSION: Disproportionate PartDspending likely reflects less competitive acquisition cost. Provider awareness of medications with advantaged price may promote targeted prescribing with potentially tremendous health care savings. [ABSTRACT FROM AUTHOR]

Introduction: Increasing cancer survivorship, in part due to new radiation treatments, has created a larger population at risk for delayed complications of treatment. Radiation cystitis continues to occur despite targeted radiation techniques. Materials and Methods: To investigate value-based care applying hyperbaric oxygen (HBO2) to treat delayed radiation cystitis, we reviewed public-access Medicare data from 3,309 patients from Oct 1, 2014, through Dec 31, 2019. Using novel statistical modeling, we compared cost and clinical effectiveness in a hyperbaric oxygen group to a control group receiving conventional therapies. Results: Treatment in the hyperbaric group provided a 36% reduction in urinary bleeding, a 78% reduced frequency of blood transfusion for hematuria, a 31% reduction in endoscopic procedures, and fewer hospitalizations when study patients were compared to control. There was a 53% reduction in mortality and reduced unadjusted Medicare costs of $5,059 per patient within the first year after completion of HBO2 treatment per patient. When at least 40 treatments were provided, cost savings per patient increased to $11,548 for the HBO2 study group compared to the control group. This represents a 37% reduction in Medicare spending for the HBO2-treated group. We also validate a dose-response curve effect with a complete course of 40 or more HBO2 treatments having better clinical outcomes than those treated with fewer treatments. Conclusion: These data support previous studies that demonstrate clinical benefits now with costeffectiveness when adjunctive HBO2 treatments are added to routine interventions. The methodology provides a comparative group selected without bias. It also provides validation of statistical modeling techniques that may be valuable in future analysis, complementary to more traditional methods. [ABSTRACT FROM AUTHOR]

Objective: To analyze Hyperbaric Oxygen Therapy Registry (HBOTR) data to estimate the Medicare costs of hyperbaric oxygen therapy (HBO2) based on standard treatment protocols and the annual mean number of treatments per patient reported by the registry. Methods: We performed a secondary analysis of deidentified data for all payers from 53 centers registered in the HBOTR from 2013 to 2022. We estimated the mean annual per-patient costs of HBO2 based on Medicare (outpatient facility + physician) reimbursement fees adjusted to 2022 inflation using the Medicare Economic Index. Costs were calculated for the annual average number of treatments patients received each year and for a standard 40-treatment series. We estimated the 2022 costs of standard treatment protocols for HBO2 indications treated in the outpatient setting. Results: Generally, all costs decreased from 2013 to 2022. The facility cost per patient per 40 HBO2 treatments decreased by 10.7% from $21,568.58 in 2013 to $19,488.00 in 2022. The physician cost per patient per 40 treatments substantially decreased by -37.8%, from $5,993.16 to $4,346.40. The total cost per patient per 40 treatments decreased by 15.6% from $27,561.74 to $23,834.40. In 2022, a single HBO2 session cost $595.86. For different indications, estimated costs ranged from $2,383.4-$8,342.04 for crush injuries to $17,875.80-$35,751.60 for diabetic foot ulcers and delayed radiation injuries. Conclusions: This real-world analysis of registry data demonstrates that the actual cost of HBO2 is not nearly as costly as the literature has insinuated, and the per-patient cost to Medicare is decreasing, largely due to decreased physician costs. [ABSTRACT FROM AUTHOR]

To report out-of-pocket costs associated with overactive bladder (OAB) medications among Medicare beneficiaries and the uninsured. We performed a cross-sectional analysis of the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary Data (Q1-2022). FDA-approved medications for OAB were identified. We calculated out-of-pocket costs for Medicare beneficiaries in each Part D prescription benefit phase, average retail price, total yearly costs and discounted prices through cash-pay discount coupons (GoodRx) or online pharmacies like Mark Cuban Cost Plus Drug Company (MCCPDC). We also report plan utilization management requirements. We analyzed 5721 plan formularies for 18 medications. Mirabegron was the only beta-3 agonist (B3). Only Vesicare oral solution (14.3% of plans) and Mirabegron (0.1%) required prior authorization. Many plans required step therapy for selective generic anticholinergics (ACH) (12.4%-43.3%), while the B3 rarely required step therapy (0.6%). Monthly costs varied by coverage phase and averaged $59 for ACHs in the initial coverage phase ($14 in catastrophic; $72 in coverage gap). The monthly cost for the B3 averaged $47 in the initial coverage phase ($26 in catastrophic; $129 in coverage gap). The total yearly cost for generic ACHs ranged from $494 (oxybutynin IR) to $1452 (darifenacin) and the yearly cost for brand-name ACHs ranged from $1175 (Toviaz ER) to $2198 (Oxytrol). The total yearly cost for the B3 was $1283. We evaluated coverage, out-of-pocket costs, total yearly costs, and utilization management for OAB medications to make pricing more transparent. While selective medications may be "covered," coverage does not translate into affordable drug prices. [ABSTRACT FROM AUTHOR]

Introduction: Generic pharmaceuticals account for the majority of the $359 billion US pharmaceutical market, including for cardiology drugs. Amidst a lack of price transparency and administrative inefficiencies, generic drug prices are high, causing an undue burden on patients. Methods: We identified the 50 most used generic cardiology drugs by volume per the 2020 Medicare Part D spending data. We extracted cost per dose of each drug from the Marc Cuban Cost Plus Drug Company (MCCPDC) website and estimated the aggregate cost savings if MCCPDC were employed on a national scale by calculating the difference between this cost and Medicare spending. Results: Medicare spent $7.7 billion on the 50 most used generic cardiology drugs by volume in 2020 according to Medicare Part D data. Pharmacy and shipping costs accounted for a substantial portion of expenditures. Per our most conservative estimate, $1.3 billion (17% of total) savings were available on 16 of 50 drugs. A slightly less conservative estimate suggested $2.9 billion (38%) savings for 35 of 50 drugs. Discussion: There is enormous potential for cost savings in the US market for generic cardiology drugs. By encouraging increased competition, decreasing administrative costs, and advocating for our patients to compare prices between the MCCPDC and other generic pharmaceutical dispensers, we have the potential to improve access to care and corresponding outcomes for cardiology patients. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is a global health challenge affecting nearly 700 million people worldwide. In the United States alone, the Medicare costs for CKD management has reached nearly USD 80 billion per year. While reversing CKD may be possible in the future, current strategies aim to slow its progression. For the most part, current management strategies have focused on employing Renin Angiotensin Aldosterone (RAS) inhibitors and optimizing blood pressure and diabetes mellitus control. Emerging data are showing that a disruption of the gut–kidney axis has a significant impact on delaying CKD progression. Recent investigations have documented promising results in using microbiota-based interventions to better manage CKD. This review will summarize the current evidence and explore future possibilities on the use of probiotics, prebiotics, synbiotics, and fecal microbial transplant to reduce CKD progression. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the extent of healthcare cost increase at population level due to childhood asthma. We aimed to investigate the cross-sectional relationship between asthma and healthcare costs among children aged 2 to 18 years and, in longitudinal analyses, whether costs increase with an increase in the duration of asthma prevalence. Study participants are 4175 and 4482 children of birth and kindergarten cohorts from the nationally representative Longitudinal Study of Australian Children for whom the linked Medicare cost data are available. The children were followed in all waves from the year 2004 to 2018. Generalized linear models were used to estimate the excess healthcare costs associated with asthma. The sum of Medicare Benefits Schedule and Pharmaceutical Benefits Scheme costs constitutes the total healthcare costs. Total excess healthcare costs associated with asthma among the 2- to 18-year-old children were A$4316 per child. At the population level, the estimated total excess Medicare costs associated with current asthma treatment among 2- to 18-year-old children were, on average, A$190.6 million per year (2018 population and price). Compared with the non-asthmatic children, peers with persistent asthma morbidity and treatment requirements had excess costs up to A$20 727 for the B cohort children until 14 years of age, whereas excess costs for the K cohort children were A$19 571 until 18 years of age. Asthma in children imposes a significant financial burden on the public health system. Higher excess healthcare costs of all asthmatic children than the costs of nonasthmatic children provide further economic justification for promoting preventive efforts at early ages. • For children aged 2 to 9 years only, healthcare costs, which are the sum of Medicare and pharmaceutical costs, are known for a few studied pediatric morbidities in the Australian context. • This study is the first to use a nationally representative Longitudinal Study of Australian Children to evaluate the excess healthcare costs of asthmatic children aged 2 to 18 years, age group-wise and longitudinally. • This new knowledge on the pattern of excess healthcare costs associated with asthma would inform healthcare policy makers about the target groups and how to design and implement project interventions. [ABSTRACT FROM AUTHOR]

Objective: To test whether differences in hospital interoperability are related to the extent to which hospitals treat groups that have been economically and socially marginalized. Data Sources and Study Setting: Data on 2393 non‐federal acute care hospitals in the United States from the American Hospital Association Information Technology Supplement fielded in 2021, the 2019 Medicare Cost Report, and the 2019 Social Deprivation Index. Study Design: Cross‐sectional analysis. Data Collection/Extraction Methods: We identified five proxy measures related to marginalization and assessed the relationship between those measures and the likelihood that hospitals engaged in all four domains of interoperable information exchange and participated in national interoperability networks in cross‐sectional analysis. Principal Findings: In unadjusted analysis, hospitals that treated patients from zip codes with high social deprivation were 33% less likely to engage in interoperable exchange (Relative Risk = 0.67, 95% CI: 0.58–0.76) and 24% less likely to participate in a national network than all other hospitals (RR = 0.76; 95% CI: 0.66–0.87). Critical Access Hospitals (CAH) were 24 percent less likely to engage in interoperable exchange (RR = 0.76; 95% CI: 0.69–0.83) but not less likely to participate in a national network (RR = 0.97; 95% CI: 0.88–1.06). No difference was detected for 2 measures (high Disproportionate Share Hospital percentage and Medicaid case mix) while 1 was associated with a greater likelihood to engage (high uncompensated care burden). The association between social deprivation and interoperable exchange persisted in an analysis examining metropolitan and rural areas separately and in adjusted analyses accounting for hospital characteristics. Conclusions: Hospitals that treat patients from areas with high social deprivation were less likely to engage in interoperable exchange than other hospitals, but other measures were not associated with lower interoperability. The use of area deprivation data may be important to monitor and address hospital clinical data interoperability disparities to avoid related health care disparities. [ABSTRACT FROM AUTHOR]

IMPORTANCE: With an aging population, it is necessary to systematically examine variation in costs and use of Medicare services by dementia subtype. We provide the first national estimates for dementia by subtype, and the respective Medicare costs and use. METHODS: We analyzed Medicare fee‐for‐service (FFS) claims from 2017 through 2019. The sample included 41 million beneficiaries: 727,700 beneficiaries with a new dementia diagnosis in 2017. We calculated descriptive statistics and conducted generalized linear regression models by subtype of dementia. RESULTS: Annual Medicare costs for beneficiaries with dementia ranged from $22,840 for frontotemporal dementia to $44,896 for vascular dementia compared to $9,034 for beneficiaries without dementia. Comparing beneficiaries across dementia subtypes, the greatest differences were in the use of home health and hospice care. CONCLUSIONS: These analyses demonstrate substantial heterogeneity across dementia subtypes, which will be important in developing models of care that improve value for people with dementia. [ABSTRACT FROM AUTHOR]

Background A claims-based frailty index (CFI) allows measurement of frailty on a population scale. Our objective was to examine the association of changes in CFI over 12 months with mortality and Medicare costs. Methods We used a 5% sample of fee-for-service Medicare beneficiaries. We estimated CFI (range: 0–1; nonfrail [<0.20], mildly frail [0.20–0.29], moderately-to-severely frail [≥0.35]) on January 1, 2015 and January 1, 2016. Beneficiaries were categorized as having a large decrease (−<0.045), small decrease (−≤0.045–0.015), stable (±0.015), small increase (>0.015–0.045), or large increase (>0.045). We used Cox proportional hazards model to estimate hazard ratio (HR) for mortality adjusting for age, sex, and 2015 CFI value and compared total Medicare costs from January 1, 2016 to December 31, 2016. Results The study population included 995 664 beneficiaries (mean age 77 years, 56.8% female). In nonfrail (n  = 906 046), HR (95% confidence interval [CI]) ranged from 0.71 (0.67–0.75) for a large decrease to 2.75 (2.68–2.33) for a large increase. In moderate-to-severely frail beneficiaries (n  = 16 527), the corresponding HR (95% CI) ranged from 0.63 (0.57–0.70) to 1.21 (1.06–1.38). The mean total Medicare cost per member per year (standard deviation) was from $12 149 ($83 508) in nonfrail beneficiaries to $61 155 ($345 904) in moderate-to-severely frail beneficiaries. Conclusions One-year changes in CFI are associated with elevated mortality risk and health care costs across all levels of frailty. [ABSTRACT FROM AUTHOR]

This article examines the growth in the cost of biologic medications for Medicare beneficiaries from 2017 to 2019. The study focuses on 11 biologics approved by the FDA for psoriasis treatment. The findings reveal significant price increases for some biologics, such as ustekinumab, while others experienced price decreases. Rheumatologists were the most frequent prescribers of biologics, followed by dermatologists. The study also highlights the impact of rising costs on family medicine physicians, nurse practitioners, and physician assistants. The limitations of the study include its restriction to Medicare Part D enrollees and the lack of consideration for manufacturer rebates and discounts. [Extracted from the article]

• BMP use in spinal fusions decreased from 2006 to 2015 for Medicare patients. • There was significant state and region-level geographic variation in BMP use. • BMP use was associated with increased hospital costs but similar Medicare payments. Bone morphogenic protein (BMP) promotes bony fusion but increases costs. Recent trends in BMP use among Medicare patients have not been well-characterized. To assess utilization trends, complication, payments, and costs associated with BMP use in spinal fusion in a Medicare-insured population. Retrospective cohort study. Total of 316,070 patients who underwent spinal fusion in a 20% sample of Medicare-insured patients, 2006 to 2015. Utilization trends across time and geography, complications, payments, and costs. Patients were stratified by fusion type and diagnosis. Multivariable logistic and linear regression were used to adjust for the effect of baseline characteristics on complications and total payments or cost, respectively. BMP was used in 60,249 cases (19.1%). BMP utilization rates decreased from 23.1% in 2006 to 12.0% in 2015, most significantly in anterior cervical (7.5%–3.1%), posterior cervical (17.0%–8.3%), and posterior lumbar fusions (31.5%–15.8%). There are significant state- and region-level geographic differences in BMP utilization. Across all years, states with the highest BMP use were Indiana (28.5%), Colorado (26.6%), and Nevada (25.7%). States with the lowest BMP use were Maine (2.3%), Vermont (8.2%), and Mississippi (10.4%). After multivariate risk adjustment, BMP use was associated with decreased overall complications in thoracic (odds ratios [OR] [95% confidence intervals [CI]): 0.89 [0.81–0.99]) and anterior lumbar fusions (OR [95% CI]: 0.89 [0.84–0.95]), as well as increased reoperation rates in anterior cervical (OR [95% CI]: 1.11 [1.04–1.19]), posterior cervical (OR (95% CI): 1.14 (1.04–1.25)), thoracic (OR (95% CI): 1.32 (1.23–1.41)), and posterior lumbar fusions (OR (95% CI): 1.11 (1.06–1.16)). BMP use was also associated with greater total costs, independent of fusion type, after multivariate risk adjustment (p<.0001). Payments, however, were comparable between groups in anterior and posterior cervical fusion with or without BMP. BMP use was associated with greater total payments in thoracic, anterior lumbar, and posterior lumbar fusions. Notably, the difference in payments was smaller than the associated cost increase in all fusion types. BMP use has declined across all fusion types over the last decade, after a peak in 2007. While BMP is associated with greater costs, reimbursement does not increase proportionally with BMP cost. [ABSTRACT FROM AUTHOR]

High out-of-pocket costs can impede access to guideline-directed cardiovascular drugs. The 2022 Inflation Reduction Act (IRA) will eliminate catastrophic coinsurance and cap annual out-of-pocket costs for Medicare Part D patients by 2025. This study sought to estimate the IRA's impact on out-of-pocket costs for Part D beneficiaries with cardiovascular disease. The investigators chose 4 cardiovascular conditions that frequently require high-cost guideline-recommended drugs: severe hypercholesterolemia; heart failure with reduced ejection fraction (HFrEF); HFrEF with atrial fibrillation (AF); and cardiac transthyretin amyloidosis. This study included 4,137 Part D plans nationwide and compared projected annual out-of-pocket drug costs for each condition in 2022 (baseline), 2023 (rollout), 2024 (5% catastrophic coinsurance eliminated), and 2025 ($2,000 cap on out-of-pocket costs). In 2022, mean projected annual out-of-pocket costs were $1,629 for severe hypercholesterolemia, $2,758 for HFrEF, $3,259 for HFrEF with AF, and $14,978 for amyloidosis. In 2023, the initial IRA rollout will not significantly change out-of-pocket costs for the 4 conditions. In 2024, elimination of 5% catastrophic coinsurance will lower out-of-pocket costs for the 2 costliest conditions: HFrEF with AF ($2,855, 12% reduction) and amyloidosis ($3,468, 77% reduction). By 2025, the $2,000 cap will lower out-of-pocket costs for all 4 conditions to $1,491 for hypercholesterolemia (8% reduction), $1,954 for HFrEF (29% reduction), $2,000 for HFrEF with AF (39% reduction), and $2,000 for cardiac transthyretin amyloidosis (87% reduction). The IRA will reduce Medicare beneficiaries' out-of-pocket drug costs for the selected cardiovascular conditions by 8% to 87%. Future studies should assess the IRA's impact on adherence to guideline-directed cardiovascular therapies and health outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This systematic review sought to assess quantitative evidence on health outcomes, health services use, and health care costs among uninsured migrant populations in Canada. Methods: OVID MEDLINE, Embase, Global Health, EconLit, and grey literature were searched to identify relevant literature published up until March 2021. The Cochrane Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) tool was used to assess the quality of studies. Results: Ten studies were included. Data showed that there are differences among insured and uninsured groups in reported health outcomes and health services use. No quantitative studies on economic costs were captured. Conclusions: Our findings indicate a need to review policies regarding accessible and affordable health care for migrants. Increasing funding to community health centers may improve service utilization and health outcomes among this population. [ABSTRACT FROM AUTHOR]

To evaluate whether a prognosis-tailored triage of ART for couples with idiopathic infertility by using the Hunault prognostic model can decrease the cost of treatment without compromising the chance of live birth. This is a retrospective study conducted in an Australian fertility clinic. Couples seeking infertility consultation who were subsequently found to have idiopathic infertility after evaluation were included. We compared the costs per conception leading to live birth of the prognosis-tailored strategy with the immediate ART strategy, which generally reflects the current practice in Australian fertility clinics, over a 24-month period. In the prognosis-tailored strategy, for each couple, the prognosis for natural conception was assessed using the well-established Hunault model. Total cost of treatments were calculated as the sum of typical out-of-pocket and Australian Medicare cost (Australian national insurance scheme). We studied 261 couples. In the prognosis-tailored strategy, the total cost was $2,766,781 and the live birth rate was 63.9%. In contrast, the immediate ART strategy yielded a live birth rate of 64.4% with a total cost of $3,176,845. Implementing the prognosis-tailored strategy using the Hunault model saved $410,064 in total and $1,571 per couple. The incremental cost-effectiveness ratio (ICER) was $341,720 per live birth. In couples with idiopathic infertility, assessment of prognosis for natural conception using the Hunault model and delaying ART for 12 months in couples with favourable prognoses can considerably reduce costs without significantly compromising live birth rates. [ABSTRACT FROM AUTHOR]

Objective: To investigate competing explanations for why Medicare Fee for Service (FFS) and private sector payments lead to hospital cost variations in Californian counties. Data sources: Ratios of private to Medicare hospital costs were obtained from state-based all-payer claims databases. Demographics were estimated from the U.S. Census Bureau and the California Health Interview Survey. Medicaid and Medicare spending was obtained from Kaiser Family Foundation. Medicare Advantage enrollment was obtained from the California Department of Health Care Services and market consolidation was estimated using the Herfindahl–Hirschman Index (HHI). Study design: Per capita costs, demographics, Medicaid and Medicare spending, Medicare Advantage enrollment, and HHI scores were compared for San Francisco (SF), Sacramento, Los Angeles (LA), and San Diego (SD). Principal findings: LA hospitals had the lowest per capita private insurer costs, but the highest Medicare FFS costs. The findings might be explained by a lower HHI for LA, indicating a more competitive market, than SD, SF, and Sacramento. Conclusions: Medicare FFS hospital costs do not provide an accurate representation of health care spending in Californian counties. In more competitive markets, private insurance companies can negotiate lower prices, while oversupply may allow facilities to increase volume in Medicare FFS. [ABSTRACT FROM AUTHOR]

High out-of-pocket prescription drug costs contribute to financial toxicity, medication nonadherence, and adverse cardiovascular (CV) outcomes. Policymakers recently passed the Inflation Reduction Act, which will cap Medicare out-of-pocket drug costs at $2,000/year and expand full low-income subsidies (LIS). It is unclear how these provisions will affect Medicare beneficiaries with CV risk factors and/or conditions. The authors sought to characterize the population of Medicare beneficiaries with CV risk factors/conditions experiencing out-of-pocket prescription drug costs >$2,000/year and estimate their potential savings under the Inflation Reduction Act's spending cap; identify sociodemographic characteristics associated with out-of-pocket costs >$2,000/year; and characterize beneficiaries newly eligible for LIS under the Inflation Reduction Act. This was a cross-sectional study of Medicare beneficiaries aged ≥65 years with ≥1 CV risk factor/condition from 2016 to 2019. An annual estimated 34,056,335 ± 855,653 Medicare beneficiaries (mean ± SE) had ≥1 CV risk factor/condition, of whom 1,020,484 ± 77,055 experienced out-of-pocket drug costs >$2,000/year. The likelihood of experiencing out-of-pocket drug costs >$2,000/year was lower among adults ≥75 years vs 65 to 74 years (adjusted OR: 0.67; 95% CI: 0.49-0.93) and for low-income vs higher-income adults. Among beneficiaries currently spending >$2,000/year, estimated median out-of-pocket drug savings would be $855/year and total annual savings $1,723,031,307 ± $91,150,609 under the Inflation Reduction Act. An estimated 1,289,861 beneficiaries would also become newly eligible for LIS. More than 1 million older adults with CV risk factors and/or conditions spend >$2,000/year out-of-pocket on prescription drugs and will likely benefit from the Inflation Reduction Act's cap, with estimated total out-of-pocket savings of $1.7 billion/year, while another 1.3 million will also become newly eligible for LIS. [Display omitted] [ABSTRACT FROM AUTHOR]

INTRODUCTION: Medicare patients in the United States may face high out-of-pocket (OOP) costs for specialty inflammatory bowel disease (IBD) medications. METHODS: We conducted a study of Medicare OOP costs for specialty IBD medications between 2020 and 2022 and compared them to incomes of typical Medicare beneficiaries. RESULTS: In 2022, median OOP costs ranged from 6.4% to 59.2%of annual income for a Medicare patient with approximately median income. Inflation-adjusted OOP costs for most medications increased between 2020 and 2022 though decreased for infliximab and its biosimilars. DISCUSSION: OOP costs may limit many Medicare beneficiaries' access to specialty IBD medications. [ABSTRACT FROM AUTHOR]

Objective: To determine if increases in hospital discharge prices are associated with improvements in clinical quality or patient experience. Data Sources: This study used Medicare cost report data and publicly available Medicare.gov Care Compare quality measures for approximately 3000 short‐term care general hospitals between 2011 and 2018. Study Design: We separately regressed quality measure scores on a lag of case mix adjusted discharge price, hospital fixed effects, and year indicators. Clinical quality measures included 30‐day readmission rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, hip and knee replacement, and pneumonia; risk‐adjusted 30‐day mortality rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, and stroke; and 90‐day complication rate for hip and knee replacement. Patient experience measures included the summary star rating and 10 domain measures reported through the Hospital Consumer Assessment of Healthcare Providers and Systems survey. We tested for heterogeneous effects by hospital ownership, number of beds, the commercial share of overall discharges, and market concentration. Data Collection/Extraction Methods: We linked hospitals identified in Medicare cost reports to Medicare.gov Care Compare quality measures. We excluded hospitals for which we could not identify a discharge price or that had an unrealistic price. Principal Findings: There was no positive association between lagged discharge price and any clinical quality measure. For patient experience measures, a 2% increase in discharge price was not associated with overall patient satisfaction but was associated with small, statistically significant increases ranging from 0.01% to 0.02% (relative to mean scores) for seven of ten domain measures. There was a positive association for five of ten patient experience measures in competitive markets and one measure in both moderately concentrated and heavily concentrated markets. Conclusions: We found no evidence that hospitals use higher prices to make investments in clinical quality; patient experience improved, but only negligibly. [ABSTRACT FROM AUTHOR]

Study Design.: Retrospective analysis of prospectively collected data. Objective.: Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. Summary of Background Data.: Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. Materials and Methods.: A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. Results.: Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. Conclusion.: Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting. [ABSTRACT FROM AUTHOR]

Objective: To compare the cost-effectiveness of surgical interventions for BPH.Methods: Using a Markov model, a cost-utility analysis was performed comparing HoLEP, B-TURP, WVTT, and PUL for prostate size <80cc (index patient 1) and HoLEP and SP for prostate size >80cc (index patient 2). Model probabilities and utility values were drawn from the literature. Analysis was performed at a 5-year time horizon with extrapolation to a lifetime horizon. Primary outcomes included quality-adjusted life years (QALYs), 2021 Medicare costs, and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed.Results: At 5 years, costs per patient for index patient 1 were $3292 (WVTT), $6532 (HoLEP), $6670 (B-TURP), and $10,257 (PUL). HoLEP resulted in the highest QALYs (4.66), followed by B-TURP (4.60), PUL (4.38), and WVTT (4.38). This translated to HoLEP being most cost-effective (ICER $11,847). For index patient 2, HoLEP was less costly ($6,585 vs $15,404) and more effective (4.654 vs 4.650) relative to SP. On sensitivity analysis for index patient 1, B-TURP became most cost-effective if cost of HoLEP increased two-fold or chronic stress incontinence following HoLEP increased ten-fold. When follow-up time was varied, WVTT was preferred at very short follow up (<1 year), and HoLEP became more strongly preferred with longer follow up.Conclusion: At 5 years follow up, HoLEP is a cost-effective surgical treatment for BPH- independent of gland size. [ABSTRACT FROM AUTHOR]

Background: A medication safety review (MSR) is a novel, pharmacist-driven, technologysupported intervention that prioritizes adverse drug event risk mitigation. Previous research has shown that Medicare Part D beneficiaries who received MSRs in an enhanced medication therapy management (EMTM) model realized improvements in total Medicare spending, hospitalizations, emergency department (ED) visits, and mortality compared to control. However, it is unknown whether beneficiaries implemented pharmacists’ MSR recommendations. Objective: The objective of the study was to evaluate whether MSR recommendation implementation is associated with improvements in these same outcomes for Part D beneficiaries enrolled in EMTM compared to a control group. Methods: This retrospective, pre-post, cohort study evaluated outcomes for beneficiaries who were targeted for MSR services in 2018 and 2019. The “validated implementation MSR (viMSR)” cohort included those who received their first-ever MSR in 2018, received another MSR in 2019, and validated implementation of ≥ 1 recommendation in their 2018 MSR. The “failed to engage” (FTE) cohort included beneficiaries who were targeted for MSR services in both 2018 and 2019 but did not engage in an MSR at any point through the end of 2019. For both cohorts, we calculated the 2018-to-2019 change for each outcome and then determined whether year-over-year changes differed significantly between cohorts. For mortality, we relaxed the requirement for continuous enrollment in 2019, permitting us to compare the proportion of beneficiaries that died in each group in 2019. Analyses were adjusted for baseline multimorbidity. Results: Of 4384 beneficiaries who completed MSRs, 602 (13.7%) implemented ≥ 1 recommendation. The viMSR cohort (N = 602) outperformed the FTE cohort (N = 7052) in total Medicare costs ($2162/y lower; P = 0.020), Part A Medicare costs ($1855/y; P = 0.024), hospitalizations (9.1 fewer admissions/100 beneficiaries/y, P = 0.020), ED visits (10.8 fewer visits/ 100 beneficiaries/y, P = 0.014), and mortality (3.8% fewer died in 2019; P < 0.001). Conclusion: Implementing pharmacists’ recommendations in MSRs was associated with improved health care resource utilization and mortality for MSR-eligible beneficiaries. [ABSTRACT FROM AUTHOR]

Introduction: There is growing evidence that prehabilitation programmes effectively improve the physical and psychological conditions of cancer patients awaiting treatment. During the pandemic, people with cancer were classed as vulnerable. To reduce risk to this population Kent and Medway Prehabilitation service transformed into a TeleHealth format. The aim of this study is to assess the impact on health-related quality of life (HRQoL) and the costs of a digital multimodal prehabilitation programme. Methods: HRQoL was measured with the EQ-5D and quality-adjusted life years (QALYs) were calculated. Costs of the prehabilitation service and inpatient care were calculated. Comparisons were made between different levels of prehabilitation received. Results: A sample of 192 individuals was included in the study Mean HRQoL improved from 69.53 at baseline to 85.71 post-rehabilitation, a 23% increase. For each additional week of prehabilitation care in cancer patients, the model predicts that the total QALYS increase by 0.02, when baseline utility is held constant. Conclusions: Prehabilitation is associated with improved HRQoL and QALYs. Our model of a multimodal digital prehabilitation program can be beneficial for patients and reduce costs for healthcare facilities even when the patients attend only a few sessions. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of Enhanced Recovery After Surgery (ERAS) with and without liposomal bupivacaine (LB) on opioid use, hospital length of stay (LOS), costs, and morbidity of women undergoing sacrocolpopexy. Methods: Retrospective cohort of women who underwent abdominal sacrocolpopexy between April 1, 2009 and November 30, 2017. Costs for relevant healthcare services were determined by assigning 2017 charges multiplied by 2017 Medicare Cost Report's cost to charge ratios. Outcomes were compared among periods with multivariable regression models adjusted for age, American Society of Anesthesiologists score, and concurrent hysterectomy and posterior repair. Results: Patients were subdivided into pre‐ERAS (G1, n = 128), post‐ERAS (G2, n = 83), and post‐ERAS plus LB (G3, n = 91). The proportion of patients needing opioids during postoperative days 0–2 was significantly less for G3 (75.8%) compared with G1 (97.7%) and G2 (92.8%); P < 0.001). The median morphine equivalent units (MEU) with interquartile ranges, mean LOS, and adjusted mean standardized costs were significantly lower in G3 compared with the other two groups (35 [20–75] vs. 67 [31–109], and 60 [30–122] MEUs; 1.8 vs. 2.3 vs. 2.9 days; and $2391, $2975, and $3844, for G3, G2, and G1, respectively; P < 0.001). Conclusion: Implementation of an ERAS pathway led to significant decreases in opioid use, LOS, and costs. Supplementation with LB further improved these measures. Synopsis: Patients undergoing abdominal sacrocolpopexy following enhanced recovery implementation had decreased opioid use, length of stay, and costs; liposomal bupivacaine infiltration further improved these measures. [ABSTRACT FROM AUTHOR]

In this study, we examined colorectal cancer (CRC) screening adherence in Medicare beneficiaries and associated healthcare resource utilization (HCRU) and Medicare costs. Using 20% Medicare random sample data, the study population included Medicare fee-for-service beneficiaries aged 66–75 years on 1 January 2009, at average risk for CRC and continuously enrolled in Medicare Part A/B from 2008 to 2018. We excluded those who had undergone colonoscopy or flexible sigmoidoscopy during 2007–2008 and assumed everyone was due for screening in 2009; screening patterns were determined for 2009–2018. Based on US Preventive Services Task Force recommendations, individuals were categorized as adherent to screening, inadequately screened or not screened. HCRU and Medicare costs were calculated as mean per patient per year (PPPY). Of 895,846 eligible individuals, 13.2% were adherent to screening, 53.4% were inadequately screened, and 33.4% were not screened. Compared with those not screened, adherent or inadequately screened individuals were more likely to be female, White and have comorbidities. These individuals also used more healthcare services, generating higher Medicare costs. For example, physician visits were 14.6, 22.9 and 25.9 PPPY and total Medicare costs were $6102, $8469 and $9102 PPPY for those not screened, inadequately screened and adherent, respectively. In Medicare beneficiaries at average risk, adherence to CRC screening was low, although the rate might be underestimated due to lack of early Medicare data. The link between HCRU and screening status suggests that screening initiatives independent of clinical visits may be needed to reach unscreened or inadequately screened individuals. [ABSTRACT FROM AUTHOR]

Medicare does not pay for a skilled nursing facility (SNF) unless a fee-for-service patient has stayed in the hospital for at least three days. This Medicare reimbursement rule, or the "three-day rule," provides full coverage for the first 20 days and partial coverage for days 21–100 for skilled nursing care provided at any Centers for Medicare and Medicaid Services-approved SNF. In this paper, we study how this Medicare reimbursement rule affects patient routing to SNFs and whether an SNF discharge reduces patients' 30-day hospital readmission rates. Data analysis shows that Medicare patients are more likely to be discharged to an SNF rather than home after the three-day cutoff, and SNF discharges increase hospital readmission rates for Medicare day 3 patients. This perverse effect is driven by infection-related readmissions and is more likely to occur when local SNFs have lower occupancy rates and higher deficiency citations than the median SNF of the same state-year. Back-of-the-envelope calculation suggests that the three-day rule may have generated an extra Medicare cost of $71 million to $345 million per year due to the overuse of SNFs and the subsequent rise in hospital readmissions. Replacing the three-day rule with a machine-learning algorithm mimicking private insurers would help. This paper was accepted by Stefan Scholtes, healthcare management. Supplemental Material: The online appendix and data are available at https://doi.org/10.1287/mnsc.2022.4316. [ABSTRACT FROM AUTHOR]

Purpose: Total knee arthroplasty (TKA) is widely recognized as an effective treatment for end-stage knee osteoarthritis (OA). Compared with conventional TKA, robotic-arm assisted TKA may improve patients' functionality and resulting quality of life by more accurate and precise component placement. Currently, the literature on cost-effectiveness of robotic-arm assisted TKA in the US is limited. The objective of this study was to assess the cost-effectiveness of robotic-arm assisted TKA relative to TKA in the Medicare-aged population including exploring the impact of hospital volume on cost-effectiveness outcomes. Methods: We developed a decision-analytic model to evaluate the costs, health outcomes, and incremental cost-effectiveness ratio (ICER) of robotic-arm assisted TKA vs TKA in Medicare population with OA. We evaluated cost-effectiveness at a willingness-to-pay (WTP) threshold of $50,000 per quality-adjusted life-year (QALY). We sourced costs from the literature including episode-of-care (EOC) costs from a Medicare study. We assessed cost-effectiveness of robotic-arm assisted TKA by hospital procedure volume and conducted deterministic (DSA) and probabilistic sensitivity analysis (PSA). Results: For the average patient treated in a hospital with an annual volume of 50 procedures, robotic-arm assisted TKA resulted in a total QALY of 6.18 relative to 6.17 under conventional TKA. Total discounted costs per patient were $32,535 and $31,917 for robotic-arm assisted TKA and conventional TKA, respectively. Robotic-arm assisted TKA was cost-effective in the base case with an ICER of $41,331/QALY. In univariate DSA, cost-effectiveness outcomes were most sensitive to the annual hospital procedure volume. Robotic-arm assisted TKA was cost-effective at a WTP of $50,000/QALY only when hospital volume exceeded 49 procedures per year. In PSA, robotic-arm assisted TKA was cost-effective at a $50,000/QALY WTP threshold in 50.4% of 10,000 simulations. Conclusions: Despite high robotic purchase costs, robotic-arm assisted TKA is likely to be cost-effective relative to TKA in the Medicare population with knee OA in high-volume hospitals through lowering revision rates and decreasing post-acute care costs. Higher-volume hospitals may deliver higher value in performing in robotic-arm assisted TKA. [ABSTRACT FROM AUTHOR]

Purpose: We investigated the relationship between measures of self-reported health and well-being and concurrent and prospective healthcare utilization and costs to assess the added value of these self-reported measures in understanding utilization and cost. Methods: Kaiser Permanente members (N = 6752) completed a 9-item survey measuring life evaluation, financial situation, social support, meaning and purpose, physical health, and mental health. Responses were linked to medical record information during the period 12 months before and after the survey. Results: Correlations between health and well-being measures and healthcare utilization and cost variables were generally weak, with stronger correlations for future life evaluation and selected health measures (ρ =.20–.33, ps <.001). Better overall life evaluation had a significant but weak association with lower total cost and hospital days in the following year after controlling for age, sex, and race/ethnicity (p <.001). Full multivariate models, adjusting for age, sex, race/ethnicity, prior utilization, and relative risk models, showed weak associations between health and well-being measures and following year total healthcare cost and utilization, though the associations were relatively stronger for the health variables than the well-being variables. Conclusion: Overall, the health and well-being variables added little to no predictive utility for future utilization and cost beyond prior utilization and cost and the inclusion of predictive models based on clinical information. Perceptions of well-being may be associated with factors beyond healthcare utilization. When information about prior use is unavailable, self-reported health items have some predictive utility. [ABSTRACT FROM AUTHOR]

Background: Australia has one of the highest prevalence of childhood food allergy in the world, but there are no data on its economic burden in Australia. Methods: We used data from the HealthNuts study, a population‐based longitudinal study undertaken in Melbourne, Australia. Infants were recruited at age 12 months between Sept 2007 and Aug 2011 with food allergy diagnosed using oral food challenges. Health care costs of out‐of‐hospital services were collected through data linkage to Australia's universal health insurance scheme Medicare. Two‐part model was used to compare costs after controlling for potential confounders. Results: 2919 children were included, and 390 (13.4%) had challenge‐confirmed food allergy at age 1 year. Compared with children without food allergy, children with food allergy had significantly higher costs for GP visits, specialist visits, tests, and prescriptions in the first four years of life. The total Medicare cost associated with food allergy from age 1 to 4 years was estimated to be AUD$889.7 (95% CI $566.1–$1188.3) or €411.0 (95% CI €261.5–€549.0) per child. This was projected into an annual Medicare cost of AUD$26.1 million (95% CI $20.1–$32.3 million) or €12.1 (95% CI €9.3–€14.9 million) based on population size in 2020. Conclusions: Childhood food allergy causes considerable Medicare costs for out‐of‐hospital services in the first four years after birth in Australia. These findings can help anticipate the financial impact on the health care system associated with childhood food allergy, act as a useful costing resource for future evaluations, and inform management of childhood food allergy internationally. [ABSTRACT FROM AUTHOR]

Home health agencies (HHAs) provide important care within the U.S. healthcare system. This cross-sectional observational study aims to examine the possible association between HHA financial performance on Home Health Compare (HHC) Patient star ratings in the 2018 to 2019 fiscal years. This study included approximately 4700 HHAs per each fiscal year. Utilizing the Home Health Consumer Assessment of Healthcare Provider and Systems (CAHPS) survey, Medicare Cost Reports, and US Census Bureau County data, we denoted financial performance as negative operating margins for HHAs (i.e., HHAs that lose money). The quality outcome was HHC quality star ratings. Employing Poisson regression, we found HHAs with negative operating margins associated with an 8-percentage point decrease in average mean HHC star ratings (AME = −0.08; 95% CI = −0.12, −0.04; p < .001). For-profit ownership (AME = −0.07; 95% CI = −0.12, −0.03; p < .001) and urban status (AME = −0.31; 95% CI = −0.35, −0.26; p < .001) both had lower mean HHC ratings. Chain affiliation was associated with higher HHC ratings and a 15-percentage point increase in its average mean HHC ratings (AME = 0.15; 95% CI = 0.11, 0.18; p < .001). Earning a positive operating margin may not necessarily equate to high quality, yet establishing quality ratings is a key initiative for HHAs. Medicare Payment Advisory Committee (MEDPAC) recommends an overall reduction in reimbursement payments starting in 2024. Consequently, given the importance of quality ratings for HHAs, and the possible change in reimbursement rates, HHAs need to be aware of how their financial performance associates with quality. [ABSTRACT FROM AUTHOR]

Changes in the Use of Brand Name and Generic Medications and Total Prescription Cost Among Medicare Beneficiaries With Epilepsy Terman SW, Lin CC, Kerr WT, DeLott LB, Callaghan BC, Burke JF. Neurology. 2022;99(8):e751-e761. doi:10.1212/WNL.0000000000200779 Background and Objective: To characterize trends in antiseizure medication (ASM) fills and total prescription costs in people with epilepsy. Methods: This was a retrospective cohort study of beneficiaries with epilepsy (ASM, plus ICD codes) in a 20% random Medicare sample, with continuous Fee-For-Service coverage (Parts A, B, and D) in 2008–2018. We summed the number of pill days and costs (adjusted to 2018 dollars) per person-year for each ASM. ASMs were categorized into brand versus generic, first versus newer generation, and enzyme inducers versus noninducers. Results: There were 77,000–133,000 beneficiaries with epilepsy per year. The most common ASM was phenytoin in 2008, which shifted to levetiracetam in 2018 (2008: phenytoin 25%, levetiracetam 14%; 2018: phenytoin 9%, levetiracetam 27%). Brand name (2008: 56%; 2018: 14%), first-generation (2008: 55%; 2018: 32%), and enzyme-inducing ASMs (2008: 44%; 2018: 24%) each decreased over time as a proportion of pill days. The number of brand pill days per person-year initially decreased (e.g., 2008: 250; 2009: 121; 2010: 96) but then plateaued (2013–2018: between 66 and 69) given a notable increase in lacosamide pill days per person (2008: 0; 2018: 20). Total brand name costs per year initially decreased 2008–2010 (2008: $150 million; 2010: $72 million) but then increased after 2010 (2018: $256 million). In 2018, brand name ASMs represented 79% of costs despite representing only 14% of pill days, a 1-year pill supply became 277% more expensive for brand name medications but 42% less expensive for generic medications over time (2008: brand ∼$2,800 versus generic ∼$800; 2018: brand ∼$10,700 versus generic ∼$460), and many common brand name ASMs cost approximately 10-fold more per pill day than their generic equivalents. Discussion: First-generation and enzyme-inducing ASMs waned from 2008 to 2018. Although brand name ASMs initially waned translating into lower costs and potentially higher value care, after 2010, brand name costs markedly increased because of increasing use of lacosamide plus a 277% increase in per-pill cost of brand name ASMs. Brand name ASMs represented a minority of prescriptions, but the majority of costs. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures. Methods: Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined. Results: Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476. Conclusions: Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure. [ABSTRACT FROM AUTHOR]

Hospitals acquire and maintain long-term operating assets such as land, buildings, and equipment. In this study, we analyzed hospitals' long-term assets acquisitions data extracted from the Medicare Cost Report, a mandatory annual filing for all Medicare-certified hospitals. The first objective of this study is to examine the time trend of land, buildings, and equipment acquisitions of all general acute care hospitals in the U.S. from 2005 to 2019 to understand the relative magnitude and temporal changes for the operating assets. The second objective is to examine the 15-year accumulated acquisitions of land, buildings, and equipment per capita in each state to understand the variations of potential access to hospital operating resources across states. To understand the longitudinal changes in acquisitions of operating assets for each year from 2005 to 2019, we calculated the total acquisition amounts across all hospitals for land, buildings, and equipment, respectively, and adjusted the amounts to 2019 dollars based on the consumer price index (CPI). For each state (including Washington D.C.) and the whole nation, the 15-year accumulated CPI-adjusted acquisition amounts per capita for land, buildings, and equipment were also calculated, respectively. The nationwide acquisitions of those operating assets grew rapidly from 2005 to 2008 followed by a negative overall growth from 2008 to 2014 and since 2015, started increasing steadily again. In 2019, U.S. general acute care hospitals acquired $3.0 billion of land, $44.6 billion of buildings, and $33.9 billion of equipment. Huge geographical variation in per capita cumulative total asset investment were also found with the first place North Dakota having a per capita investment that is almost four times higher than that in the lowest ranked state of Alabama. [ABSTRACT FROM AUTHOR]

Introduction: Targeted DMARD (tDMARD) use in patients with rheumatoid arthritis (RA) and type 2 diabetes mellitus (T2DM) may increase whole-body insulin sensitivity. Evidence comparing the T2DM-related clinical and economic impact of abatacept versus other tDMARDs is limited. This study compared differences in T2DM-related healthcare resource utilization (HCRU) and costs in patients with RA and T2DM. Methods: This retrospective study used 100% Medicare Fee-for-Service claims (parts A/B/D) to identify patients ≥ 65 age, diagnosed with RA and T2DM, and were either TNFi-experienced (switched from a TNFi to another tDMARD) or tDMARD-naïve, initiating their first tDMARD (abatacept, TNFi, or non-TNFi) between 2010 and 2017. Abatacept users were propensity-score (PS) matched to TNFi and other non-TNFi users separately on baseline demographics, comorbidities, medications, T2DM-related HCRU, and costs. Post-index follow-up: until discontinuation of index treatment, disenrollment, death, or end of study period, whichever occurred first. T2DM-related complications and HCRU were assessed. Costs were normalized to per-patient-per-month (PPPM) and inflated to 2019 US$. Results: The TNFi-experienced group included 2169 abatacept/TNFi and 2118 abatacept/other non-TNFi PS-matched pairs; the tDMARD-naïve group included 2667 abatacept/TNFi and 2247 abatacept/other non-TNFi PS-matched pairs. For TNFi-experienced patients, T2DM-related complication rates for inpatient settings PPPM trended lower for abatacept than TNFi (21 vs. 24, p = 0.046) and other non-TNFi groups (21 vs. 26; p < 0.0001). T2DM-related total costs PPPM for TNFi-experienced patients demonstrated lower trends for abatacept than TNFi ($489 vs. $594, p = 0.016) and other non-TNFi users ($493 vs. $606, p = 0.012). Conclusions: Medicare beneficiaries with RA and T2DM who switch to/initiate abatacept as their first tDMARD have directionally lower rates and costs of T2DM-related complications compared with patients switching to/initiating other tDMARDs. Abatacept treatment may help reduce clinical and economic burdens associated with T2DM in patients with RA. [ABSTRACT FROM AUTHOR]

Background: Spousal death is associated with elevated mortality in the surviving partner; less is known about how healthcare costs and use change following spousal death. Objectives: To examine the causal impact of spousal death on Medicare costs and use over time. Design: Longitudinal cohort study with an event study design. Setting: National Health and Aging Trends Study (NHATS) with linked Medicare claims. Participants: Respondents from 2011–2017 who reported spousal death the prior year, limited to those with traditional Medicare (n=491 with 9,766 respondent-quarters). Main Measures: Total Medicare costs; binary indicators for acute hospitalization; emergency department; sub-acute care (including skilled nursing, rehabilitation, and long-term care); and number of outpatient management visits on a quarterly basis 3 years before and after spousal death. Key Results: During the first year post-death, quarterly Medicare costs for the surviving spouse were $1,092 higher than pre-death; probability of hospitalization, emergency department, and sub-acute care were 3.3%, 2.8%, and 2.2% higher, respectively; and there were 0.3 more outpatient visits (p<.01 for all). Several outcomes continued to be elevated during the second year, including costs ($1,174 higher per quarter), hospitalization (3.2% higher), and sub-acute care (2.9% higher; p<.01 for all). By the third year, costs returned to pre-death level but hospitalization and sub-acute care (2.9% and 3.1% higher per quarter; p<.05 for both) remained elevated. Cost increases in the first and second years post-death were larger if the deceased spouse was a caregiver ($1,588 and $1,853 per quarter) or female (i.e., among bereaved males; $1,457 and $1,632 per quarter; p<.05 for all). Conclusions: Spousal death increased total Medicare costs and use of all healthcare categories among the surviving partner; elevations in hospitalization and sub-acute care persisted through the third year. Clinicians and payors may want to target surviving partners as a high-risk population. [ABSTRACT FROM AUTHOR]

The upper echelons perspective states that the backgrounds and experiences of strategic managers, especially CEOs, influence organization performance. This study seeks to determine if there is a corresponding variety in the demographic and experiential backgrounds of hospital CEOs relates to hospital profit status, rurality, and competition. Multivariable logistic regression is used to examine a sample of 407 hospital-CEO dyads, created by merging a nationally representative random sample of hospital CEOs (2009-2011), the American Hospital Association database (2013), and Medicare Cost Report Database (2009-2011). The results show significant differences between For-profit (FP) and Not-for-profit (NFP) hospital CEOs, as NFP CEOs are more likely to be older and to have longer tenures within their organizations than their FP counterparts. These results hold even as hospital's organizational and environmental contexts become similar in terms of rurality and levels of competition. Given the finding that there are differences between hospital CEO backgrounds based on organizational and environmental contexts, future scholarship should examine the degree to which these differences influence hospital performance and care quality outcomes so that hospital governing boards might consider the degree to which executives' demographic backgrounds and professional experiences align with the hospital's strategic mission, vision, and goals. [ABSTRACT FROM AUTHOR]

Background: Guidelines in 2013 and 2014 recommended Epidermal Growth Factor Receptor (EGFR) testing for metastatic lung adenocarcinoma patients as the efficacy of targeted therapies depends on the mutations. However, adherence to these guidelines and the corresponding costs have not been well-studied.Methods: We identified 2362 patients at least 65 years old newly diagnosed with metastatic lung adenocarcinoma from January 2013 to December 2015 using the SEER-Medicare database. We examined the utilization patterns of EGFR testing and targeted therapies including erlotinib and afatinib. We further examined the costs of both EGFR testing and targeted therapy in terms of Medicare costs and patient out-of-pocket (OOP) costs.Results: The EGFR testing rate increased from 38% in 2013 to 51% and 49% in 2014 and 2015 respectively. The testing rate was 54% among the 394 patients who received erlotinib, and 52% among the 42 patients who received afatinib. The median Medicare and OOP costs for testing were $1483 and $293. In contrast, the costs for targeted therapy were substantially higher with median 30-day costs at $6114 and $240 for erlotinib and $6239 and $471 for afatinib.Conclusion: This population-based study suggests that testing guidelines improved the use of EGFR testing, although there was still a large proportion of patients receiving targeted therapy without testing. The costs of targeted therapy were substantially higher than the testing costs, highlighting the need to improve adherence to testing guidelines in order to improve clinical outcomes while reducing the economic burden for both Medicare and patients. [ABSTRACT FROM AUTHOR]

Objective: We examined the characteristics of non‐profit hospitals providing more community benefits and charity care than value of their tax exemptions and how this relationship changed between 2011 and 2018. Data sources Primary dataset was schedule H Form IRS 990 data. This data was merged with the American Hospital Association, Medicare Hospital Cost Report, and the America Community Survey. Study design We measured six categories of tax benefits and 17 types of community benefits. Subtracting the average value of community benefits provided by for‐profit hospitals, we computed incremental community benefit and charity care provided by each non‐profit hospital. Extraction methods: A nationally representative sample was created of 11 776 non‐profit hospital‐year observations from 1472 unique hospitals over the 2011 to 2018 period was created. Descriptive analyses and random effect logistic regression were used to show associations between hospital characteristics and difference between incremental net community benefits and the value of tax‐exemption. Principal findings: After adjusting for community benefits provided by for‐profits hospitals, on average, non‐profit hospitals spent 5.9% (CI: 5.8%‐6.0%) of their total expenses on community benefits; 1.3% (CI: 1.2%‐1.3%) on charity care; and received 4.3% (CI: 4.2%‐4.4%) of total expenses in tax exemptions. A total of 38.5% of non‐profit hospitals did not provide more community benefit and 86% did not provide more charity care than the value of their tax exemption. Hospitals with fewer beds, providing residency education and located in high poverty communities were more likely to provide more incremental community benefits and charity care than the value of their tax exemption, while system affiliation had a negative association. Conclusion: The amount of community benefits and charity care provided by non‐profits varied substantially across non‐profit hospitals. Establishing minimum requirements for non‐profit hospitals or publicly ranking hospitals based on their community benefit or charity care contributions, could encourage greater community benefits and charity care. [ABSTRACT FROM AUTHOR]