Person:

Newhouse, Joseph

Medicare continues to implement payment reforms that shift reimbursement from fee-for-service towards episode-based payment, affecting average and marginal reimbursement. We contrast the effects of two reforms for home health agencies. The Home Health Interim Payment System in 1997 lowered both types of reimbursement; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The Home Health Prospective Payment System in 2000 raised average but lowered marginal reimbursement with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality.

BACKGROUND: Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees’ socioeconomic background is controversial.

METHODS: We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008–2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees’ socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds.

RESULTS: Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees.

CONCLUSIONS: Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.

The Family Smoking Prevention and Tobacco Control Act of 2009 gave the Food and Drug Administration (FDA) regulatory authority over cigarettes and smokeless tobacco products and authorised it to assert jurisdiction over other tobacco products. As with other Federal agencies, FDA is required to assess the costs and benefits of its significant regulatory actions. To date, FDA has issued economic impact analyses of one proposed and one final rule requiring graphic warning labels (GWLs) on cigarette packaging and, most recently, of a proposed rule that would assert FDA’s authority over tobacco products other than cigarettes and smokeless tobacco. Given the controversy over the FDA's approach to assessing net economic benefits in its proposed and final rules on GWLs and the importance of having economic impact analyses prepared in accordance with sound economic analysis, a group of prominent economists met in early 2014 to review that approach and, where indicated, to offer suggestions for an improved analysis. We concluded that the analysis of the impact of GWLs on smoking substantially underestimated the benefits and overestimated the costs, leading the FDA to substantially underestimate the net benefits of the GWLs. We hope that the FDA will find our evaluation useful in subsequent analyses, not only of GWLs but also of other regulations regarding tobacco products. Most of what we discuss applies to all instances of evaluating the costs and benefits of tobacco product regulation and, we believe, should be considered in FDA's future analyses of proposed rules.

BACKGROUND/OBJECTIVES: No data exist regarding the validity of International Classification of Disease (ICD)-10 dementia diagnoses within Medicare claims data. We examined the accuracy of claims-based diagnoses with respect to expert clinician adjudication using a novel database with individual-level linkages between electronic health record (EHR) and claims. DESIGN: In this retrospective observational study, two neurologists and two psychiatrists performed a standardized review of patients’ medical records from January-2016 to December-2018, and adjudicated dementia status. We measured the accuracy of three claims-based definitions of dementia against the reference standard. SETTING: Mass-General-Brigham Healthcare (MGB), Massachusetts, USA. PARTICIPANTS: From an eligible population of 40,690 fee-for-service (FFS) Medicare beneficiaries, aged 65-years and older, within the MGB Accountable Care Organization (ACO), we generated a random sample of 1,002 patients, stratified by the pretest likelihood of dementia using administrative surrogates. INTERVENTION: None. MEASUREMENTS: We evaluated the accuracy (area-under-receiver-operating-curve [AUROC]) and calibration (calibration-in-the-large [CITL] and calibration slope) of three ICD-10 claims-based definitions of dementia against clinician-adjudicated standards. We applied inverse probability weighting to reconstruct the eligible population and reported the mean and 95% confidence interval (95% CI) for all performance characteristics, using 10-fold cross-validation (CV). RESULTS: Beneficiaries had an average age of 75.3-years and were predominately female (59%) and non-Hispanic white (93%). The adjudicated prevalence of dementia in the eligible population was 7%. The best performing definition demonstrated excellent accuracy (CV-AUC 0.94; 95% CI 0.92-0.96) and was well-calibrated to the reference standard of clinician-adjudicated dementia (CV-CITL <0.001, CV-slope 0.97). CONCLUSION: This study is the first to validate ICD-10 diagnostic codes against a robust and replicable approach to dementia ascertainment using a real-world clinical reference standard. The best performing definition includes diagnostic codes with strong face validity and outperforms an updated version of a previously validated ICD-9 definition of dementia.

We investigated labor force and health outcomes in cities experiencing fiscal difficulties to assess how those difficulties might impact their employees. We matched 23 cities with bond downgrades and 31 cities with stable bond ratings to sampling units in the Medical Expenditure Panel Survey. Starting the year before the downgrade and for the four subsequent years, the rate of separation from local public employment fell in the cities with downgrades relative to the comparison group. Self-reported health may have worsened, but there were no statistically significant effects on health care use or spending.

Objectives: To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost‐sharing. Data Sources: Twenty percent random sample of fee‐for‐service (FFS) Medicare claims, 2000‐2012. Study Design: Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference‐in‐differences analysis to estimate the effects of eliminating cost‐sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA. Findings: Model‐based algorithms have higher sensitivity (0.53‐0.99) than expert‐based algorithms (0.35‐0.39), but lower specificity (0.43‐0.65 vs 0.79‐0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24‐93/10 000) and the 2011 cost‐sharing change (range: 1.1‐34/10 000). Difference‐in‐difference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm. Conclusions: Screening colonoscopy rates increased after eliminating cost‐sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.

Purpose: To examine indications for, duration of use, and rate of adverse drug events (ADE) attributable to anticonvulsant initiation, as adjudicated by expert review of electronic health records (EHR) of older adults. Methods: We identified a cohort of community-dwelling Medicare beneficiaries with linked EHR (aged 65+, continuously enrolled with a large health system/until death between 2012-2014, n=20,945) and drew a stratified EHR review sample (n=1,534). An expert reviewed all records to adjudicate anticonvulsant use, years of use, indication for use, and evidence of ADEs attributable to anticonvulsant initiation. After excluding patients with insufficient EHR data (n=37; 2%), we reconstructed the cohort using inverse probability weights to resemble the original cohort of eligible beneficiaries (n=20,380). Among incident users of a single anticonvulsant, we estimated the rate of ADEs and described the type and severity of ADEs. Results: Overall, 12% (n=2,469) of eligible beneficiaries used at least one anticonvulsant in the 2012-2014 period (4% [n=757] incident users, 8% [n=1,712] prevalent users). Incident users were most frequently prescribed gabapentin (n=461/757, 61%), benzodiazepines (n=122/757, 16%), and levetiracetam (n=74/757, 10%); the most common indication was pain relief (n=214; 28%) followed by epilepsy (n=53; 7%). Among incident users, the overall ADE rate was 10/100 person-years (95% CI 4-20/100 person-years), of which 29% (n=28/97) were life-threatening (e.g., somnolence). Most ADEs among incident monotherapy users were nervous-system related (68%, n=66/97). Conclusions: Many older adult community-dwelling Traditional Medicare beneficiaries had clinically significant ADEs likely attributable to the initiation of anticonvulsant therapy, which was begun for a range of indications.