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https://www.readbyqxmd.com/read/28930892/costs-and-trends-in-utilization-of-low-value-services-among-older-adults-with-commercial-insurance-or-medicare-advantage
#1
Elizabeth A Carter, Pamela E Morin, Keith D Lind
BACKGROUND: Overutilization of low-value services (unnecessary or minimally beneficial tests or procedures) has been cited as a large contributor to the high costs of health care in the United States. OBJECTIVES: To analyze trends in utilization of low-value services from 2009 to 2014 among commercial and Medicare Advantage (MA) enrollees 50 and older. RESEARCH DESIGN: A retrospective analysis of deidentified claims obtained from the OptumLab Data Warehouse...
September 19, 2017: Medical Care
https://www.readbyqxmd.com/read/28874941/predictors-of-return-visits-among-insured-emergency-department-mental-health-and-substance-abuse-patients-2005-2013
#2
Sangil Lee, Jeph Herrin, William V Bobo, Ryan Johnson, Lindsey R Sangaralingham, Ronna L Campbell
INTRODUCTION: Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States. METHODS: We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSA between 2005 and 2013 who were discharged home...
August 2017: Western Journal of Emergency Medicine
https://www.readbyqxmd.com/read/28874935/increased-computed-tomography-utilization-in-the-emergency-department-and-its-association-with-hospital-admission
#3
M Fernanda Bellolio, Herbert C Heien, Lindsey R Sangaralingham, Molly M Jeffery, Ronna L Campbell, Daniel Cabrera, Nilay D Shah, Erik P Hess
INTRODUCTION: Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization. METHODS: We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization...
August 2017: Western Journal of Emergency Medicine
https://www.readbyqxmd.com/read/28874484/regulated-medicare-advantage-and-marketplace-individual-health-insurance-markets-rely-on-insurer-competition
#4
Richard G Frank, Thomas G McGuire
Two important individual health insurance markets-Medicare Advantage and the Marketplaces-are tightly regulated but rely on competition among insurers to supply and price health insurance products. Many local health insurance markets have little competition, which increases prices to consumers. Furthermore, both markets are highly subsidized in ways that can exacerbate the impact of market power-that is, the ability to set price above cost-on health insurance prices. Policy makers need to foster robust competition in both sectors and avoid designing subsidies that make the market-power problem worse...
September 1, 2017: Health Affairs
https://www.readbyqxmd.com/read/28873324/proportion-and-patterns-of-hospice-discharges-in-medicare-advantage-compared-to-medicare-fee-for-service
#5
Joan M Teno, Thomas J Christian, Pedro Gozalo, Michael Plotzke
BACKGROUND: When Medicare Advantage (MA) patients elect hospice, all covered services are reimbursed under the Medicare fee-for-service (FFS) program. This financial arrangement may incentivize MA plans to refer persons to hospice near end of life when costs of care typically rise. OBJECTIVE: To characterize hospice discharge patterns for MA versus FFS patients and examine whether patterns differ by MA concentration across hospital referral regions (HRRs). DESIGN AND MEASUREMENT: The rate and pattern of live discharges and length of stay (LOS) between FFS and MA patients were examined...
September 5, 2017: Journal of Palliative Medicine
https://www.readbyqxmd.com/read/28851435/first-dollar-cost-sharing-for-skilled-nursing-facility-care-in-medicare-advantage-plans
#6
Laura M Keohane, Regina C Grebla, Momotazur Rahman, Dana B Mukamel, Yoojin Lee, Vincent Mor, Amal Trivedi
BACKGROUND: The initial days of a Medicare-covered skilled nursing facility (SNF) stay may have no cost-sharing or daily copayments depending on beneficiaries' enrollment in traditional Medicare or Medicare Advantage. Some policymakers have advocated imposing first-dollar cost-sharing to reduce post-acute expenditures. We examined the relationship between first-dollar cost-sharing for a SNF stay and use of inpatient and SNF services. METHODS: We identified seven Medicare Advantage plans that introduced daily SNF copayments of $25-$150 in 2009 or 2010...
August 29, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/28846618/the-collaborative-payer-provider-model-enhances-primary-care-producing-triple-aim-plus-one-outcomes-a-cohort-study
#7
Thomas Doerr, Lisa Olsen, Deborah Zimmerman
Rising health care costs are threatening the fiscal solvency of patients, employers, payers, and governments. The Collaborative Payer Provider Model (CPPM) addresses this challenge by reinventing the role of the payer into a full-service collaborative ally of the physician. From 2010 through 2014, a Medicare Advantage plan prospectively deployed the CPPM, averaging 30,561 members with costs that were 73.6% of fee-for-service (FFS) Medicare (p < 0.001). The health plan was not part of an integrated delivery system...
August 27, 2017: Healthcare (Basel, Switzerland)
https://www.readbyqxmd.com/read/28817299/how-do-medicare-advantage-beneficiary-payments-vary-with-tenure
#8
Paul D Jacobs, Eamon Molloy
OBJECTIVES: To compare how premiums and expected out-of-pocket medical costs (OOPC) vary with the length of time Medicare Advantage (MA) beneficiaries have been enrolled in their plans. STUDY DESIGN: Descriptive and fixed effects regression analyses. METHODS: Using linked administrative enrollment and plan data, we compared the costs of the MA plans that beneficiaries chose with the costs of other plans available to them. We show predicted values adjusted for age, gender, race/ethnicity, disability, individual health risk, presence of mental health diagnoses, health plan quality, relative size of the plan's provider network, and the number of years continuously enrolled in the same plan...
June 2017: American Journal of Managed Care
https://www.readbyqxmd.com/read/28795870/positive-predictive-value-between-medical-chart-body-mass-index-category-and-obesity-versus-codes-in-a-claims-data-warehouse
#9
Eleanor O Caplan, Pravin S Kamble, Raymond A Harvey, B Gabriel Smolarz, Andrew Renda, Jonathan R Bouchard, Joanna C Huang
OBJECTIVE: To evaluate the positive predictive value of claims-based V85 codes for identifying individuals with varying degrees of BMI relative to their measured BMI obtained from medical record abstraction. METHODS: This was a retrospective validation study utilizing administrative claims and medical chart data from 1/1/2009 to 8/31/2015. Randomly selected samples of patients enrolled in a Medicare Advantage Prescription Drug (MAPD) or commercial health plan and with a V85 claim were identified...
August 10, 2017: Current Medical Research and Opinion
https://www.readbyqxmd.com/read/28760001/association-of-obesity-with-healthcare-utilization-and-costs-in-a-medicare-population
#10
Brandon T Suehs, Pravin Kamble, Joanna Huang, Mette Hammer, Jonathan Bouchard, Mary E Costantino, Andrew Renda
OBJECTIVES: To examine the association of obesity on healthcare resource utilization and costs in a Medicare population. METHODS: This study was a retrospective cohort study using Humana Medicare Advantage (MA) claims data. Body mass index (BMI) was assessed using ICD-9-CM status codes (V85 hierarchy) that have been validated in the data source to classify patients into BMI categories: Normal (N), Overweight (Ow), Obese class I (ObI), Obese class II (ObII), and Obese class III (ObIII)...
August 1, 2017: Current Medical Research and Opinion
https://www.readbyqxmd.com/read/28751176/the-effect-of-interactive-reminders-on-medication-adherence-a-randomized-trial
#11
Hengchen Dai, David Mao, Kevin G Volpp, Heather E Pearce, Michael J Relish, Victor F Lawnicki, Katherine L Milkman
Expanding on evidence that interventions to improve health are more effective when informed by behavioral science, we explore whether reminders designed to harness behavioral science principles can improve medication adherence. We conducted a randomized controlled trial with 46,581 U.S. participants with commercial or Medicare Advantage insurance from Humana. Participants were randomly assigned to one of four experimental conditions. Participants in the usual care condition only received standard mailings that the insurer usually sends...
July 24, 2017: Preventive Medicine
https://www.readbyqxmd.com/read/28749776/comorbid-arthritis-is-associated-with-lower-health-related-quality-of-life-in-older-adults-with-other-chronic-conditions-united-states-2013-2014
#12
Eric Havens, S Lane Slabaugh, Charles G Helmick, Tristan Cordier, Matthew Zack, Vipin Gopal, Todd Prewitt
INTRODUCTION: Arthritis is related to poor health-related quality of life (HRQoL) in adults aged 18 years or older. We sought to determine whether this relationship persisted in an older population using claims-based arthritis diagnoses and whether people who also had arthritis and at least 1 of 5 other chronic conditions had lower HRQoL. METHODS: We identified adults aged 65 years or older with Medicare Advantage coverage in November or December 2014 who responded to an HRQoL survey (Healthy Days)...
July 27, 2017: Preventing Chronic Disease
https://www.readbyqxmd.com/read/28737985/evaluation-of-patient-migration-patterns-and-related-health-care-costs-within-a-national-medicare-advantage-prescription-drug-plan-after-implementation-of-an-oxycodone-hcl-extended-release-access-restriction
#13
Chi-Chang Chen, Ajita P De, Brian Sweet, Rolin L Wade
BACKGROUND: Health plans use formulary restrictions (e.g., prior authorization, step therapy, tier change, nonformulary status) in an effort to control cost and promote quality, safety, and appropriate prescription utilization. Some Medicare payers perceive that the inclusion of certain agents, such as branded oxycodone HCl extended-release tablets (OERs), on their formularies is associated with attracting high-cost members to the plan. OBJECTIVE: To evaluate disenrollment rates, patient migration, and subsequent health care costs among OER users who disenrolled from a national Medicare Advantage Prescription Drug plan (study-MAPD) in the plan year following OER nonformulary restriction...
August 2017: Journal of Managed Care & Specialty Pharmacy
https://www.readbyqxmd.com/read/28717900/elements-of-program-design-in-medicare-s-value-based-and-alternative-payment-models-a-narrative-review
#14
Karen E Joynt Maddox, Aditi P Sen, Lok Wong Samson, Rachael B Zuckerman, Nancy DeLew, Arnold M Epstein
Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around program scope (broad vs. narrow); selecting absolute or relative performance targets; rewarding improvement, achievement, or both; and offering penalties, rewards, or both. We examined and classified current Medicare payment models-the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing Program (HVBP), Hospital-Acquired Conditions Reduction Program (HACRP), Medicare Advantage Quality Star Rating program, Physician Value-Based Payment Modifier (VM) and its successor, the Merit-Based Incentive Payment System (MIPS), and the Medicare Shared Savings Program (MSSP) on these elements of program design and reviewed the literature to place findings in context...
July 17, 2017: Journal of General Internal Medicine
https://www.readbyqxmd.com/read/28708876/presentation-at-computed-tomography-ct-scan-of-the-thorax-and-first-year-diagnostic-and-treatment-utilization-among-patients-diagnosed-with-lung-cancer
#15
Adam C Powell, Amin J Mirhadi, Bryan A Loy, Laura E Happe, James W Long, Erin M Kren, Amit K Gupta
BACKGROUND: As Medicare expands the use of computed tomography (CT) for diagnosing lung cancer, there is increased opportunity to diagnose lung cancer in asymptomatic patients. This descriptive study characterizes the disease-specific diagnostic and treatment services that patients with a positive diagnosis following CT received, stratified by presentation at CT. METHODS: Patients who were diagnosed with lung cancer following CT in 2013, had no history of lung cancer, survived at least 1 year, were aged 55-80 years, and had Medicare Advantage insurance were included...
2017: PloS One
https://www.readbyqxmd.com/read/28707284/fixed-dose-versus-off-label-combination-of-isosorbide-dinitrate-plus-hydralazine-hydrochloride-retrospective-propensity-matched-analysis-in-black-medicare-patients-with-heart-failure
#16
Elizabeth Ofili, Inder Anand, Richard Allen Williams, Ola Akinboboye, Liou Xu, Gary Puckrein
INTRODUCTION: Based upon the findings of the African-American Heart Failure Trial, the US Food and Drug Administration approved the fixed-dose combination of isosorbide dinitrate (ISDN) and hydralazine hydrochloride (HYD) (FDC-ISDN/HYD) as a new drug for treatment of heart failure (HF) in self-identified African Americans. According to the FDA, FDC-ISDN/HYD has no therapeutic equivalent. However, off-label combinations of the separate generic drugs ISDN and HYD (OLC-ISDN+HYD) or isosorbide mononitrate (ISMN) and HYD (OLC-ISMN+HYD) are routinely substituted without any supporting outcome data...
July 13, 2017: Advances in Therapy
https://www.readbyqxmd.com/read/28692718/physician-reimbursement-in-medicare-advantage-compared-with-traditional-medicare-and-commercial-health-insurance
#17
Erin Trish, Paul Ginsburg, Laura Gascue, Geoffrey Joyce
Importance: Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear. Objective: To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans...
September 1, 2017: JAMA Internal Medicine
https://www.readbyqxmd.com/read/28692717/medicare-advantage-reimbursement-to-physicians
#18
James C Robinson
No abstract text is available yet for this article.
September 1, 2017: JAMA Internal Medicine
https://www.readbyqxmd.com/read/28685482/hospital-readmissions-among-commercially-insured-and-medicare-advantage-beneficiaries-with-diabetes-and-the-impact-of-severe-hypoglycemic-and-hyperglycemic-events
#19
Rozalina G McCoy, Kasia J Lipska, Jeph Herrin, Molly M Jeffery, Harlan M Krumholz, Nilay D Shah
BACKGROUND: Hospital readmission is common among patients with diabetes. Some readmissions, particularly for hypoglycemia and hyperglycemia, may be avoidable with better care transitions and post-discharge management. OBJECTIVE: To ascertain the most common reasons and risk factors for readmission among adults with diabetes, with specific consideration of severe dysglycemia. DESIGN: Retrospective analysis of data from the OptumLabs Data Warehouse, an administrative data set of commercially insured and Medicare Advantage beneficiaries across the U...
July 6, 2017: Journal of General Internal Medicine
https://www.readbyqxmd.com/read/28677020/treatment-discontinuation-adherence-and-real-world-effectiveness-among-patients-treated-with-ledipasvir-sofosbuvir-in-the-united-states
#20
Amy Puenpatom, Michael Hull, Jeffrey McPheeters, Kay Schwebke
INTRODUCTION: Ledipasvir/sofosbuvir (LDV/SOF) for hepatitis C virus (HCV) treatment provides an oral interferon-free treatment regimen with high rates of sustained virologic response (SVR). This study assessed treatment discontinuation, factors associated with treatment completion, and real-world effectiveness. METHODS: Patients with HCV treated with LDV/SOF between October 2014 and June 2015 and enrolled in a large US health plan were identified. Expected treatment duration was calculated based on IDSA/AASLD treatment guidelines and US labels using data for genotype, initial treatment regimen, baseline cirrhosis, and prior treatments...
July 4, 2017: Infectious Diseases and Therapy
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