Cardiovascular event costs in patients with Type 2 diabetes mellitus

OBJECTIVE

To quantify the cost of acute major adverse cardiac events (MACE; myocardial infarction [MI] and stroke) stratified by cardiovascular disease (CVD) risk factors in commercially, Medicare Supplemental-, and Medicaid-insured patients with type 2 diabetes mellitus (T2DM).

METHODS

US administrative claims data were used to identify patients with T2DM aged ≥18 and continuously enrolled with insurance benefits from July 1, 2009-June 30, 2010 (baseline). Patients were classified into three baseline CVD risk groups (highest, medium, and lowest) and followed from July 1, 2010 until 1 year or censoring (follow-up) to measure per-patient per-month (PPPM) all-cause healthcare costs. Multivariable regression compared costs between patients with/without MACE during follow-up. Patients with MACE were further followed for up to 1 year after initial event to quantify longitudinal event costs.

RESULTS

Sample comprised 1,415,598 T2DM patients. Over average follow-up ranging from 301-343 days across CVD risk groups, 10,399 patients experienced MACE. Expected multivariable-adjusted mean PPPM costs of MACE per 100 covered patients within each CVD risk group varied by payer and generally increased with CVD risk (range = $1555 in lowest-risk commercially insured patients to $18,727 in highest-risk Medicaid-insured patients). Longitudinal costs of MACE were lowest among Medicare Supplemental-insured patients with stroke ($22,657 initial event, $2488 PPPM up-to 1-year follow-up care) and highest among Medicaid-insured patients with MI ($41,505 initial event, $4799 PPPM up to 1-year follow-up care).

CONCLUSIONS

These results illustrate the potential clinical and economic importance of considering patients' CVD risk and medications' cardiovascular safety profile when treating T2DM patients.

Medicare program; revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015. Final rule with comment period

This major final rule with comment period addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. See the Table of Contents for a listing of the specific issues addressed in this rule.

Incident user cohorts for assessing medication cost-offsets

OBJECTIVE

To develop and test incident drug user designs for assessing cost savings from statin use in diabetics.

DATA SOURCE

Random 5 percent sample of Medicare beneficiaries, 2006-2008.

STUDY DESIGN

Seven-step incident user design to assess impact of statin initiation on subsequent Medicare spending: (1) unadjusted pre/post initiation test; (2) unadjusted difference-in-difference (DID) with comparison series; (3) adjusted DID; (4) propensity score (PS)-matched DID with static and dynamic baseline covariates; (5) PS-matched DID by drug adherence strata; (6) PS-matched DID for high adherers controlling for healthy adherer bias; and (7) replication for ACE-inhibitor/ARB initiators.

DATA COLLECTION/EXTRACTION METHODS

Subjects with prevalent diabetes and no statin use (January-June 2006) and statin initiation (July 2006-January 2008) compared to nonusers with a random "potential-initiation" month. Monthly Medicare spending tracked 24 months pre- and post-initiation.

PRINCIPAL FINDINGS

Statistically significant savings in Medicare spending were observed beginning 7 months post-initiation for statins and 13 months post-initiation for ACEIs/ARBs. However, these savings were only observed for adherent patients in steps 5 and 6.

CONCLUSIONS

Drug initiator designs are more robust to confounding than prevalent user designs in assessing cost-offsets from drug use but still require other adjustments and sensitivity analysis to ensure proper inference.

Medicare program; prospective payment system for federally qualified health centers; changes to contracting policies for rural health clinics; and changes to Clinical Laboratory Improvement Amendments of 1988 enforcement actions for proficiency testing referral. Final rule with comment period

This final rule with comment period implements methodology and payment rates for a prospective payment system (PPS) for federally qualified health center (FQHC) services under Medicare Part B beginning on October 1, 2014, in compliance with the statutory requirement of the Affordable Care Act. In addition, it establishes a policy which allows rural health clinics (RHCs) to contract with nonphysician practitioners when statutory requirements for employment of nurse practitioners and physician assistants are met, and makes other technical and conforming changes to the RHC and FQHC regulations. Finally, this final rule with comment period implements changes to the Clinical Laboratory Improvement Amendments (CLIA) regulations regarding enforcement actions for proficiency testing (PT) referrals.

Medicare determinations and income-related monthly adjustment amounts to Medicare Part B premiums; conforming changes to regulations. Final rule

This final rule adopts, without change, the interim final rule with request for comments we published in the Federal Register on September 18, 2013. The interim final rule modified our rules regarding Medicare Part B income-related monthly adjustment amounts to conform to changes made to the Social Security Act (Act) and Internal Revenue Code by the Affordable Care Act. We also removed provisions that phased in income-related monthly adjustment amounts between 2007 and 2009 and updated a citation to reflect the transfer of authority for hearing appeals under title XVIII of the Act from the Social Security Administration to the Department of Health and Human Services.

Medicare program; revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to Part B for CY 2014. Final rule with comment period

This major final rule with comment period addresses changes to the physician fee schedule, clinical laboratory fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule with comment period also includes a discussion in the Supplementary Information regarding various programs. (See the Table of Contents for a listing of the specific issues addressed in the final rule with comment period.)

Medicare determinations and income-related monthly adjustment amounts to Medicare Part B premiums; conforming changes to regulations. Interim final rule with request for comments

We are modifying our regulations regarding Medicare Part B income-related monthly adjustment amounts (IRMAA) in order to conform to changes made to the Social Security Act (Act) by the Affordable Care Act. This rule freezes the modified adjusted gross income threshold and ranges from 2011 through 2019 and removes the requirement that beneficiaries consent to our release of Internal Revenue Service (IRS) information to the U.S. Department of Health and Human Services (HHS) for the purpose of adjudicating any appeal of an IRMAA to the Part B premium subsidy. We are also removing provisions that phased in IRMAA between 2007 and 2009 and updating a citation to reflect the transfer of authority for hearing appeals under Title XVIII of the Act from the Social Security Administration to HHS.

Standardizing Medicare payment information to support examining geographic variation in costs

OBJECTIVES

Examination of efficiency in health care requires that cost information be normalized. Medicare payments include both geographic and policy-based facility type differentials (e.g., wage index and disproportionate share hospital), which can bias cost comparisons of hospitals and averages across geographic areas. Standardizing payment information to remove the area- and policy-based payment differentials should normalize much of the observed geographic variability in payments, allowing for a more accurate comparison of resource use between providers and across geographic regions. Use of standardized payments will ensure that observed payment variation is due to differences in practice patterns and service use, rather than Medicare payment differences over which the providers have no control. This paper describes a method for standardizing claim payments, and demonstrates the difference in actual versus standardized payments by geographic region.

STUDY DESIGN AND METHODS

We used a nationwide cohort of Medicare patients hospitalized with an acute myocardial infarction (AMI) in 2007, then limited our study to those with Medicare Part A and Part B fee-for-service (FFS), and Part D coverage (n = 143,123). Standardized payment amounts were calculated for each Part A and Part B claim; standardized and actual payments were summed for all services for each patient beginning with the index hospitalization through 12 months post discharge.

PRINCIPAL FINDINGS

Without standardization of payments, certain areas of the country are mischaracterized as either high or low healthcare resource-consuming areas. The difference between actual and standardized payments varies by care setting.

CONCLUSIONS

Standardized payment amounts should be calculated when comparing Medicare resource use across geographic areas.

Non-assigned Medicare payment increases practice revenue & lowers Medicare costs

Private practice physicians can increase practice revenue and also save Medicare money. What seems like a paradox is instead a choice. The non-assigned Medicare payment option allows physicians to bill 8% more for their services. This also decreases Medicare payment 5%. Selecting the non-assigned payment method does not require permission from Medicare or any Medicare contractor. This is a physician decision and for 2014 must be made between mid-November and year end 2013.

Know your HINNs and when to deliver them

Hospital-Issued Notices of Noncoverage (HINN) inform patients that they will be responsible for the bill if they choose to stay in the hospital when the care they are receiving or about to receive will not be covered by Medicare. If hospitals don't give a HINN when services aren't covered by Medicare, they can't bill patients for services later on. CMS gives hospitals the option of using Condition Code 44 to change a patient's status from inpatient to outpatient to correct an unnecessary admission, then collect payment from Medicare for Medicare Part B services. All HINNs must be signed by the patient and a copy included in their file. If the patient refuses to sign, a copy should be placed in the file with a notation of the refusal to sign.

Medicare payments: how much do chronic conditions matter?

OBJECTIVE

Analyze differences in Medicare Fee-for-Service utilization (i.e., program payments) by beneficiary characteristics, such as gender, age, and prevalence of chronic conditions.

METHODS

Using the 2008 and 2010 Chronic Conditions Public Use Files, we conduct a descriptive analysis of enrollment and program payments by gender, age categories, and eleven chronic conditions.

RESULTS

We find that the effect of chronic conditions on Medicare payments is dramatic. Average Medicare payments increase significantly with the number of chronic conditions. Finally, we quantify the effect of individual conditions and find that "Stroke / Transient Ischemic Attack" and "Chronic Kidney Disease" are the costliest chronic conditions for Part A, and "Cancer" and "Chronic Kidney Disease" are the costliest for Part B.

Part A to part B rebilling: understanding the rules in a changing environment

Under a recent CMS ruling, hospitals that have been denied payment for Medicare Part A services have the option to submit follow-up claims to Medicare Part B for some of these denied services. A CMS proposed rule threatens to remove that option by imposing barriers to the rebilling of claims denied under Part Afor payment under Part B. By commenting on the rule, hospitals may be able to persuade CMS to reject the proposed rule and, instead, adopt a policy similar to that in the ruling. Should CMS decide to finalize the rule, hospitals can use their comments in efforts either to convince Congress to enact statutory changes that would mandate expanded Part B rebilling or to challenge the final rule in litigation.

Medicare program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B). Notice of CMS ruling

This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register, we published a proposed rule entitled, "Medicare Program; Part B Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis.

Geographic variation in Medicare spending and mortality for diabetic patients with foot ulcers and amputations

AIMS

The purpose of this study was to identify the presence or absence of geographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers (DFU) and lower extremity amputations (LEA).

METHODS

Diabetic beneficiaries with foot ulcers (n=682,887) and lower extremity amputations (n=151,752) were enrolled in Medicare Parts A and B during the calendar year 2007. We used ordinary least squares (OLS) regression to explain geographic variation in per capita Medicare spending and one-year mortality rates.

RESULTS

Health care spending and mortality rates varied considerably across the nation for our two patient cohorts. However, higher spending was not associated with a statistically significant reduction in one-year patient mortality (P=.12 for DFU, P=.20 for LEA). Macrovascular complications for amputees were more common in parts of the country with higher mortality rates (P<.001), but this association was not observed for our foot ulcer cohort (P=.12). In contrast, macrovascular complications were associated with increased per capita spending for beneficiaries with foot ulcers (P=.01). Rates of hospital admission were also associated with higher per capita spending and increased mortality rates for individuals with foot ulcers (P<.001 for health spending and mortality) and lower extremity amputations (P<.001 for health spending, P=.01 for mortality).

CONCLUSIONS

Geographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers and amputations is associated with regional differences in the utilization of inpatient services and the prevalence of macrovascular complications.