A 4-Year Retrospective Claims Analysis of Oral Corticosteroid Use and Health Conditions in Newly Diagnosed Medicare FFS Patients with COPD.

Purpose: We analyzed population-level administrative claims data for Medicare fee-for-service (FFS) beneficiaries to provide insights on systemic oral corticosteroid (OCS) use patterns and associated health conditions and acute events among patients newly diagnosed with chronic obstructive pulmonary disease (COPD). Background: COPD is a progressive inflammatory disease of the lungs, characterized by acute exacerbations that may lead to increased mortality. Short courses of systemic corticosteroids (SCS) are recommended to reduce recovery time from exacerbations, although SCS use has been associated with increased risk of adverse events. Methods: This study used 2013-2019 Medicare 100% FFS research identifiable files, which contain all Medicare Parts A, B, and D paid claims incurred by 100% of Medicare FFS beneficiaries. Descriptive statistics for patients newly diagnosed with COPD were analyzed, including OCS use, select health conditions and acute events, and COPD exacerbations. Statistical models were used to analyze the relationship between the incidence of select health conditions and events and cumulative OCS dosage. Results: Of Medicare FFS patients newly diagnosed with COPD, 36% received OCS in the 48 months following diagnosis, and 38% of OCS episodes lasted longer than the recommended 5-7 days. Patients had a variety of health conditions or acute events in the 24-month period prior to new COPD diagnosis, such as hypertension, depression/anxiety, type 2 diabetes, or osteoporosis, that could heighten the risks of OCS use. Patients treated with >1000 mg of prednisolone equivalent OCS in the 48 months following COPD diagnosis had a higher incidence of new conditions or events, including cardiovascular disease, heart failure, hypertension, obesity, dyspepsia, infections, and depression/anxiety, than patients with no OCS use. Conclusion: These results highlight the potential risks of OCS in COPD treatment, including prolonged use among complex Medicare patients, and reinforce the importance of preventive treatment strategies and therapy optimization early in the disease course.

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients.

BACKGROUND: A recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings. OBJECTIVES: To examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals. METHODS: The primary source for this retrospective observational study was the MarketScan® 2013-2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated. RESULTS: Of the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year. CONCLUSIONS: The majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

Design Challenges of an Episode-Based Payment Model in Oncology: The Centers for Medicare & Medicaid Services Oncology Care Model.

The Centers for Medicare & Medicaid Services developed the Oncology Care Model as an episode-based payment model to encourage participating practitioners to provide higher-quality, better-coordinated care at a lower cost to the nearly three-quarter million fee-for-service Medicare beneficiaries with cancer who receive chemotherapy each year. Episode payment models can be complex. They combine into a single benchmark price all payments for services during an episode of illness, many of which may be delivered at different times by different providers in different locations. Policy and technical decisions include the definition of the episode, including its initiation, duration, and included services; the identification of beneficiaries included in the model; and beneficiary attribution to practitioners with overall responsibility for managing their care. In addition, the calculation and risk adjustment of benchmark episode prices for the bundle of services must reflect geographic cost variations and diverse patient populations, including varying disease subtypes, medical comorbidities, changes in standards of care over time, the adoption of expensive new drugs (especially in oncology), as well as diverse practice patterns. Other steps include timely monitoring and intervention as needed to avoid shifting the attribution of beneficiaries on the basis of their expected episode expenditures as well as to ensure the provision of necessary medical services and the development of a meaningful link to quality measurement and improvement through the episode-based payment methodology. The complex and diverse nature of oncology business relationships and the specific rules and requirements of Medicare payment systems for different types of providers intensify these issues. The Centers for Medicare & Medicaid Services believes that by sharing its approach to addressing these decisions and challenges, it may facilitate greater understanding of the model within the oncology community and provide insight to others considering the development of episode-based payment models in the commercial or government sectors.

Centers for medicare and medicaid services: using an episode-based payment model to improve oncology care.

PURPOSE: Cancer is a medically complex and expensive disease with costs projected to rise further as new treatment options increase and the United States population ages. Studies showing significant regional variation in oncology quality and costs and model tests demonstrating cost savings without adverse outcomes suggest there are opportunities to create a system of oncology care in the US that delivers higher quality care at lower cost. DESIGN: The Centers for Medicare and Medicaid Services (CMS) have designed an episode-based payment model centered around 6 month periods of chemotherapy treatment. Monthly per-patient care management payments will be made to practices to support practice transformation, including additional patient services and specific infrastructure enhancements. Quarterly reporting of quality metrics will drive continuous quality improvement and the adoption of best practices among participants. Practices achieving cost savings will also be eligible for performance-based payments. Savings are expected through improved care coordination and appropriately aligned payment incentives, resulting in decreased avoidable emergency department visits and hospitalizations and more efficient and evidence-based use of imaging, laboratory tests, and therapeutic agents, as well as improved end of life care. CONCLUSION: New therapies and better supportive care have significantly improved cancer survival in recent decades. This has come at a high cost, with cancer therapy consuming $124 billion in 2010. CMS has designed an episode-based model of oncology care that incorporates elements from several successful model tests. By providing care management and performance based payments in conjunction with quality metrics and a rapid learning environment, it is hoped that this model will demonstrate how oncology care in the US can transform into a high value, high quality system.

The Undergraduate Medical Education for the 21st Century (UME-21) project: the Federal Government perspective.

The Undergraduate Medical Education for the 21st Century (UME-21) project was implemented by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration (HRSA) to encourage medical schools to collaborate with managed care organizations and others. The purpose of the collaboration was to ensure that medical students are prepared to provide quality patient care and manage that care in an integrated health care system in which the cost of care and use of empirically justified care are important elements. The UME-21 project represents a continuation of HRSA's interest in the managed care arena. The UME-21 project involved the collaboration of eight partner schools and 10 associate partner schools, together with 50 external partners, to develop innovative curricula that integrated UME-21 content from nine special areas as learning objectives. This project demonstrated that concerted efforts by the leadership in medical education can bring about innovative change in medical school curricula. It ís also demonstrated that faculty of the three primary care disciplines of family medicine, general internal medicine, and general pediatrics were able to cooperate to accomplish such change by working together to allocate clerkship time and content. An important lesson learned in this project was that significant innovations in medical school curricula could be accomplished with a broadbased commitment and involvement of both faculties across the three primary care disciplines and top administrative officials of the medical school. It is uncertain, however, if the innovations achieved will produce further changes or if those changes achieved can be sustained without continued funding.