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Administrative claims risk-standardized payments

Nicholas A Bedard, Andrew J Pugely, Michael McHugh, Nathan Lux, Jesse E Otero, Kevin J Bozic, Yubo Gao, John J Callaghan
BACKGROUND: Use of large clinical and administrative databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and varies in their methodology of data acquisition, which makes it possible that similar research questions posed to different databases might result in answers that differ in important ways. QUESTIONS/PURPOSES: (1) What are the differences in reported demographics, comorbidities, and complications for patients undergoing primary TKA among four databases commonly used in orthopaedic research? (2) How does the difference in reported complication rates vary depending on whether only inpatient data or 30-day postoperative data are analyzed? METHODS: Patients who underwent primary TKA during 2010 to 2012 were identified within the National Surgical Quality Improvement Programs (NSQIP), the Nationwide Inpatient Sample (NIS), the Medicare Standard Analytic Files (MED), and the Humana Administrative Claims database (HAC)...
January 2018: Clinical Orthopaedics and related Research
Eric T Roberts, Alan M Zaslavsky, J Michael McWilliams
Background: When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average. Objective: To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients...
February 20, 2018: Annals of Internal Medicine
Nicholas A Bedard, Andrew J Pugely, Michael A McHugh, Nathan R Lux, Kevin J Bozic, John J Callaghan
BACKGROUND: Use of large databases for orthopedic research has become extremely popular in recent years. Each database varies in the methods used to capture data and the population it represents. The purpose of this study was to evaluate how these databases differed in reported demographics, comorbidities, and postoperative complications for primary total hip arthroplasty (THA) patients. METHODS: Primary THA patients were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED), and Humana administrative claims database (HAC)...
January 2018: Journal of Arthroplasty
Joseph A Goble, Brian Ung, Sascha van Boemmel-Wegmann, Robert P Navarro, Andrew Parece
BACKGROUND: As a result of global concern about rising drug costs, many U.S. payers and European agencies such as the National Health Service have partnered with pharmaceutical companies in performance-based risk-sharing arrangements (PBRSAs) by which manufacturers share financial risk with health care purchasing entities and authorities. However, PBRSAs present many administrative and legal challenges that have minimized successful contract experiences in the United States. OBJECTIVE: To (a) identify drug and disease characteristics and contract components that contribute to successful PBRSA experiences and the primary barriers to PBRSA execution and (b) explore solutions to facilitate contract negotiation and execution...
October 2017: Journal of Managed Care & Specialty Pharmacy
Jason C Pradarelli, Mark A Healy, Nicholas H Osborne, Amir A Ghaferi, Justin B Dimick, Hari Nathan
Importance: Treating surgical complications presents a major challenge for hospitals striving to deliver high-quality care while reducing costs. Costs associated with rescuing patients from perioperative complications are poorly characterized. Objective: To evaluate differences across hospitals in the costs of care for patients surviving perioperative complications after major inpatient surgery. Design, Setting, and Participants: Retrospective cohort study using claims data from the Medicare Provider Analysis and Review files...
December 21, 2016: JAMA Surgery
Karl Y Bilimoria, Min-Woong Sohn, Jeanette W Chung, Christina A Minami, Elissa H Oh, Emily S Pavey, Jane L Holl, Bernard S Black, Michelle M Mello, David J Bentrem
CONTEXT: The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability. OBJECTIVE: To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery. DESIGN, SETTING, AND PATIENTS: Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure...
June 2016: Annals of Surgery
Megan C Roberts, Stacie B Dusetzina
PURPOSE: Tumor gene expression profiling (GEP) can be used to predict recurrence risk and the potential benefit of breast cancer treatment. Adoption of GEP among privately insured patients has not been well studied. Our objectives were to characterize trends in GEP use and to evaluate per-use patient and health plan payments from 2006 to 2012. METHODS: We used Truven Health Analytics MarketScan administrative claims database to examine GEP testing among women with breast cancer from 2006 to 2012 (N = 154,883)...
July 2015: Journal of Oncology Practice
Nancy Kim, Susannah M Bernheim, Lesli S Ott, Lein Han, Steven B Spivack, Xiao Xu, Mark Volpe, Alex Liu, Harlan M Krumholz
BACKGROUND: Understanding both cost and quality across institutions is a critical first step to illuminating the value of care purchased by Medicare. Under contract with the Centers for Medicare and Medicaid Services, we developed a method for profiling hospitals by 30-day episode-of-care costs (payments for Medicare beneficiaries) for acute myocardial infarction (AMI). METHODS: We developed a hierarchical generalized linear regression model to calculate hospital risk-standardized payment (RSP) for a 30-day episode for AMI...
June 2015: Medical Care
Michael E Stokes, Catherine E Muehlenbein, Martin D Marciniak, Douglas E Faries, Saeed Motabar, Theresa W Gillespie, Joseph Lipscomb, Kevin B Knopf, Don P Buesching
BACKGROUND: Neutropenia is a major adverse event often associated with chemotherapy administration. Neutropenia-related complications often lead to increased use of costly health care including inpatient and outpatient services. Monitoring and treatment of neutropenia thus place an economic burden on the health care system. OBJECTIVES: To evaluate (a) costs and medical resource use for chemotherapy- related afebrile and febrile neutropenia in an elderly population with Stage IIIB or Stage IV non-small cell lung cancer (NSCLC), and (b) costs unrelated to neutropenia and total all-cause health care costs during first-line chemotherapy...
October 2009: Journal of Managed Care Pharmacy: JMCP
(no author information available yet)
The Medicaid Integrity Program (the Program) provides that the Secretary promote the integrity of the Medicaid program by entering into contracts with contractors that will review the actions of individuals or entities furnishing items or services (whether fee-for-service, risk, or other basis) for which payment may be made under an approved State plan and/or any waiver of the plan approved under section 1115 of the Social Security Act; audit claims for payment of items or services furnished, or administrative services furnished, under a State plan; identify overpayments of individuals or entities receiving Federal funds; and educate providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care...
November 30, 2007: Federal Register
John A Morris, Ysela Carrillo, Judith M Jenkins, Philip W Smith, Sandy Bledsoe, James Pichert, Andrew White
OBJECTIVE: To review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events. SUMMARY BACKGROUND DATA: Little data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process...
June 2003: Annals of Surgery
F R Curtiss
The structure, features, and evolution of pharmacy preferred-provider organizations (PPOs) are described. Pharmacy PPOs may be sponsored by insurers, employers, providers, or independents (wherein the PPO functions as a third-party administrator); insurer and provider sponsorship are the most common. The advantages and disadvantages of these four types of sponsorship are described. Ways that pharmacy PPOs contain costs include the following: using drug product selection formularies (wherein providers are paid at prospective prices for generic products, regardless of the product dispensed or prescribed), reducing drug use by employing use-review mechanisms, and eliminating fraud and abuse through audits...
August 1987: American Journal of Hospital Pharmacy
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