Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Concomitant Surgical Ablation in Paroxysmal vs Persistent Atrial Fibrillation During Mitral Surgery.

BACKGROUND: Despite prospective randomized evidence supporting concomitant treatment of Atrial Fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management of AF remains. We sought to assess longitudinal outcomes following surgical treatment of persistent or paroxysmal AF during MV surgery in Medicare Beneficiaries. METHODS: All Medicare beneficiaries with a diagnosis of AF undergoing MV surgery (2018-2020) were evaluated. Patients were stratified by no AF treatment versus Left Atrial Appendage Obliteration (LAAO) alone versus LAAO and Surgical Ablation (SA+LAAO). Doubly robust risk-adjustment and subgroup analysis by persistent or paroxysmal AF were performed. RESULTS: A total of 7,517 patients with preoperative AF underwent MV surgery (32.1% no AF treatment, 23.1% LAAO alone, 44.7% SA+LAAO). After doubly robust risk-adjustment, AF treatment with SA+LAAO or LAAO alone was associated with lower 3-year readmission for stroke or bleeding. However, SA+LAAO was associated with reduced 3-year mortality, and readmission for AF or heart failure, compared to no AF treatment or LAAO alone. Compared to no AF treatment or LAAO alone, SA+LAAO was associated with lower composite endpoint of stroke or death at 3 years (HR 0.75 and HR 0.83, respectively). Subgroup analysis identified similar longitudinal benefits of SA+LAAO in patients with persistent or paroxysmal AF. CONCLUSIONS: In Medicare beneficiaries with AF undergoing MV surgery, SA+LAAO was associated with improved longitudinal outcomes compared to LAAO alone or no AF treatment in patients with paroxysmal or persistent AF. These contemporary real-world data further clarify the benefit of SA+LAAO during mitral valve surgery across all types of AF.

Temporal trends in medication and service use patterns for mental health issues among men with prostate cancer.

OBJECTIVE: Prostate cancer can significantly impact mental wellbeing, creating uncertainty and morbidity. This study described patterns of psychotropic medication and mental health service use, as a proxy measure for mental health problems, 5 years before and 5 years after prostate cancer diagnosis. METHODS: Population-based registry data were linked with Pharmaceutical Benefits Scheme and Medicare Benefits Schedule data for all prostate cancer patients diagnosed in South Australia between 2012 and 2020 (n = 13,693). We estimated the proportion and rates of psychotropic medication and mental health service use before and after diagnosis. Multivariable adjusted interrupted time series analyses (ITSA) were conducted to uncover temporal patterns. RESULTS: Fifteen percent of men commenced psychotropic medications and 6.4% sought out mental health services for the first time after diagnosis. Psychotropic medication use rose from 34.5% 5 years before to 40.3% 5 years after diagnosis, including an increase in use of antidepressants (from 20.7% to 26.0%) and anxiolytics (from 11.3% to 12.8%). Mental health service use increased from 10.2% to 12.1%, with the increase mostly being general practice mental health visits (from 7.8% to 10.6%). Multivariable ITSA indicated a significant rise in medication and service utilisation immediately before and in the first 2 years following prostate cancer diagnosis. CONCLUSION: There is a clear increase in psychotropic medication use and mental health service use around the time of prostate cancer diagnosis. Mental health outcomes of men with prostate cancer may be improved with early mental health screening, particularly during the diagnosis process, to enable early intervention.

Processing and validation of inpatient Medicare Advantage data for use in hospital outcome measures.

OBJECTIVE: To determine the feasibility of integrating Medicare Advantage (MA) admissions into the Centers for Medicare & Medicaid Services (CMS) hospital outcome measures through combining Medicare Advantage Organization (MAO) encounter- and hospital-submitted inpatient claims. DATA SOURCES AND STUDY SETTING: Beneficiary enrollment data and inpatient claims from the Integrated Data Repository for 2018 Medicare discharges. STUDY DESIGN: We examined timeliness of MA claims, compared diagnosis and procedure codes for admissions with claims submitted both by the hospital and the MAO (overlapping claims), and compared demographic characteristics and principal diagnosis codes for admissions with overlapping claims versus admissions with a single claim. DATA COLLECTION/EXTRACTION METHODS: We combined hospital- and MAO-submitted claims to capture MA admissions from all hospitals and identified overlapping claims. For admissions with only an MAO-submitted claim, we used provider history data to match the National Provider Identifier on the claim to the CMS Certification Number used for reporting purposes in CMS outcome measures. PRINCIPAL FINDINGS: After removing void and duplicate claims, identifying overlapped claims between the hospital- and MAO-submitted datasets, restricting claims to acute care and critical access hospitals, and bundling same admission claims, we identified 5,078,611 MA admissions. Of these, 76.1% were submitted by both the hospital and MAO, 14.2% were submitted only by MAOs, and 9.7% were submitted only by hospitals. Nearly all (96.6%) hospital-submitted claims were submitted within 3 months after a one-year performance period, versus 85.2% of MAO-submitted claims. Among the 3,864,524 admissions with overlapping claims, 98.9% shared the same principal diagnosis code between the two datasets, and 97.5% shared the same first procedure code. CONCLUSIONS: Inpatient MA data are feasible for use in CMS claims-based hospital outcome measures. We recommend prioritizing hospital-submitted over MAO-submitted claims for analyses. Monitoring, data audits, and ongoing policies to improve the quality of MA data are important approaches to address potential missing data and errors.

Call for Specialty-Specific Benchmarks for Cross-Specialty Quality Measures in the Quality Payment Program.

The introduction of the Quality Payment Program (QPP) by the Centers for Medicare & Medicaid Services (CMS) played a critical role in the process of transitioning U.S. healthcare from a pay-for-service to a pay-for-performance system. Physicians can participate in the QPP through one of three reporting methods: the traditional merit-based incentive payment system (MIPS), MIPS Value Pathways (MVPs), or Advanced Alternative Payment Models (APMs). These reporting methods require physicians to submit data on quality measures, which are averaged to determine a total quality performance score, which is weighted along with other QPP measures related to self-performance to provide an aggregate final performance score. This final score is used to determine either a negative, neutral, or positive percentage modifier for the physician's Medicare reimbursement payments, which applies to the fiscal year two years following the year of reporting. Quality measures are either specialty-specific or cross-specialty, meaning that they are reportable by any physician specialty. No studies have compared performance across physician specialty categories on these measures. Critics argue that CMS has not ensured equitable reporting of cross-specialty quality measures due to the difference in emphasis on aspects of care of different physician specialties, potentially advantaging some. For example, family medicine physicians may score higher on the blood pressure control quality measure due to its relevance in their practice. Significant performance differences could highlight areas of improvement for certain physicians in certain specialties and guide balanced measure development. The QPP currently uses non-specialty-specific historical quality performance scores as benchmarks to determine current-year quality measure scores, likely leading to unfair comparisons. Establishing specialty-specific benchmarks for cross-specialty measures would promote equitable evaluation and fair competition among all participating physicians.

Tiny patients, huge impact: a call to action.

The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.

Trends and Factors Associated With Peripheral Vascular Interventions for the Treatment of Claudication From 2011 to 2022: A National Medicare Cohort Study.

BACKGROUND: Previous cross-sectional studies have identified wide practice pattern variations in the use of peripheral vascular interventions (PVIs) for the treatment of claudication. However, there are limited data on longitudinal practice patterns. We aimed to describe the temporal trends and charges associated with PVI use for claudication over the past 12 years in the United States. METHODS AND RESULTS: We conducted a retrospective analysis using 100% Medicare fee-for-service claims data to identify all patients who underwent a PVI for claudication between January 2011 and December 2022. We evaluated the trends in utilization and Medicare-allowed charges of PVI according to anatomic level, procedure type, and intervention settings using generalized linear models. Multinomial logistic regressions were used to evaluate factors associated with different levels and types of PVI. We identified 599 197 PVIs performed for claudication. The proportional use of tibial PVI increased 1.0% per year, and atherectomy increased by 1.6% per year over the study period. The proportion of PVIs performed in ambulatory surgical centers/office-based laboratories grew at 4% per year from 12.4% in 2011 to 55.7% in 2022. Total Medicare-allowed charges increased by $11 980 035 USD/year. Multinomial logistic regression identified significant associations between race and ethnicity and treatment setting with use of both atherectomy and tibial PVI. CONCLUSIONS: The use of tibial PVI and atherectomy for the treatment of claudication has increased dramatically in in ambulatory surgical center/office-based laboratory settings, non-White patients, and resulting in a significant increase in health care charges. There is a critical need to improve the delivery of value-based care for the treatment of claudication.

Trends in Utilization and Cost of Nonpharmacological Pain Therapies in the United States Under Medicare Part B, 2000-2022.

Background: Many clinical practice guidelines for management of pain disorders now favor first-line use of nonpharmacological therapies (NPT). However, Medicare coverage of NPT is limited. Methods: Using a serial cross-sectional design, we examined temporal trends in the utilization and cost of NPT procedures commonly used to treat pain under Medicare. Results: Utilization and costs for physical therapy increased while those for spinal and osteopathic manipulation declined. Discussion: Future research on NPT under Medicare should focus on equity of patient access and comparative outcomes.

Use of chronic care management service among Medicare beneficiaries in 2015-2019.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics. METHODS: We used 2014-2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics. RESULTS: The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2-5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service. CONCLUSION: We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.

Medicare expenditures among spouses of persons with dementia.

BACKGROUND: Spouses of persons living with dementia face intense strains on their well-being compared with similarly aged adults and spouses of partners with no dementia. This strain can impact spouses' health and healthcare needs, and therefore affect their healthcare utilization and expenditures. METHODS: Using data from the Health and Retirement Study linked with Medicare claims, we matched dyads of spouses and their partners with dementia (SPWD) to a comparison group of similar spouses and their partners with no dementia (SPWND). We then examined Medicare expenditures for spouses in the 5 years following their partner's dementia onset month using a two-part regression model. RESULTS: SPWD cumulative total Medicare expenditures were, on average, $60,043 in the 5 years post dementia onset, compared to $56,068 for SPWND. This difference ($3974, 95% CI = [-$3,199; $11,477]) was not significant. However, there were significant differences in the 5th year's total expenditures (+$2,748 [$321; $5,447]), driven by inpatient expenditures ($1,562 [$22; $3,277]). CONCLUSIONS: Despite the differences in partner's dementia status, we found no significant difference in the 5-year cumulative Medicare expenditures between SPWD and SPWND. Compared to previous studies, we likely captured an earlier stage of dementia more consistently for a broader population which may be less straining on spouses. Further research should examine patterns of expenditures in later years and around critical timepoints in caregiving, such as partner transitions to formal long-term care settings and death, to better understand healthcare expenditures for spouses of persons living with dementia.

Controlled CMS Data Demonstrates a Cost and Clinical Advantage for Hyperbaric Oxygen for Radiation Cystitis.

Introduction: Increasing cancer survivorship, in part due to new radiation treatments, has created a larger population at risk for delayed complications of treatment. Radiation cystitis continues to occur despite targeted radiation techniques. Materials and Methods: To investigate value-based care applying hyperbaric oxygen (HBO2) to treat delayed radiation cystitis, we reviewed public-access Medicare data from 3,309 patients from Oct 1, 2014, through Dec 31, 2019. Using novel statistical modeling, we compared cost and clinical effectiveness in a hyperbaric oxygen group to a control group receiving conventional therapies. Results: Treatment in the hyperbaric group provided a 36% reduction in urinary bleeding, a 78% reduced frequency of blood transfusion for hematuria, a 31% reduction in endoscopic procedures, and fewer hospitalizations when study patients were compared to control. There was a 53% reduction in mortality and reduced unadjusted Medicare costs of $5,059 per patient within the first year after completion of HBO2 treatment per patient. When at least 40 treatments were provided, cost savings per patient increased to $11,548 for the HBO2 study group compared to the control group. This represents a 37% reduction in Medicare spending for the HBO2-treated group. We also validate a dose-response curve effect with a complete course of 40 or more HBO2 treatments having better clinical outcomes than those treated with fewer treatments. Conclusion: These data support previous studies that demonstrate clinical benefits now with cost- effectiveness when adjunctive HBO2 treatments are added to routine interventions. The methodology provides a comparative group selected without bias. It also provides validation of statistical modeling techniques that may be valuable in future analysis, complementary to more traditional methods.

Caught Between a ROCR and a Hard Place: Improving Proposed Radiation Oncology Alternative Payment Models.

PURPOSE: The Radiation Oncology Case Rate (ROCR) aims to shift radiation reimbursement from fee-for-service (FFS) to bundled payments, which would decouple fractionation from reimbursement in the United States. This study compares historical reimbursement rates from three large centers and a national Medicare sample with proposed base rates from ROCR. It also tests the impact of methodological inclusion of treatment and disease characteristics to determine if any variables are associated with greater rate differences that may lead to inequitable reimbursement. METHODS: Using XXXX electronic medical record data from 2017-2020 and Part B claims from the Medicare 5% research identifiable files (RIF), episodic 90-day historical reimbursement rates for 15 cancer types were calculated per the ROCR payment methodology. XXXX reimbursement rates were stratified by disease and treatment characteristics and multiple linear regression was performed to assess the association of these variables on historical episode reimbursement rates. RESULTS: From XXXX, 3,498 patient episodes were included and 480,526 from the RIF. From both datasets, 25% of brain metastases and 13% of bone metastases episodes included ≥2 treatment courses with an average of 51 days between courses. Accounting for all 15 cancer types, ROCR base rates resulted in an average -2.4% and -2.9% reduction in rates for XXXX and the RIF respectively compared to historical reimbursement. On multivariate analysis of XXXX data, treatment intent (curative vs. palliative) was associated with higher historical reimbursement (+$477 to +$7,417; p ≤ 0.05) for 12 out of 12 applicable cancer types. Stage (3-4 vs. 1-2) was associated with higher historical reimbursement (+$1,169 to +$3,917; p ≤ 0.05) for 8 out of 12 applicable cancer types. CONCLUSION: Our data suggest ROCR base rates introduce an average ≤3% reimbursement rate decrease compared to historical FFS reimbursement per cancer type, which could produce the Medicare savings required for congressional approval of ROCR. Estimating comparisons with future FFS reimbursement would require consideration of additional factors such as the increased utilization of hypofractionation, proposed FFS rate cuts, and inflationary updates. A distinct rate and shortened episode duration (≤ 30 days) should be considered for palliative episodes. Applying a base rate modifier per cancer stage may mitigate disproportionate reductions in reimbursement for facilities with a higher volume of curative advanced stage patients such as freestanding centers in rural settings.

Adverse event costs of systemic therapies for metastatic colorectal cancer previously treated with fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy and biologics in the US.

Aim: The objective of this study was to compare adverse event (AE) management costs for fruquintinib, regorafenib, trifluridine/tipiracil (T/T) and trifluridine/tipiracil+bevacizumab (T/T+bev) for patients with metastatic colorectal cancer (mCRC) previously treated with at least two prior lines of therapy from the US commercial and Medicare payer perspectives. Materials & methods: A cost-consequence model was developed to calculate the per-patient and per-patient-per-month (PPPM) AE costs using rates of grade 3/4 AEs with incidence ≥5% in clinical trials, event-specific management costs and duration treatment. Anchored comparisons of AE costs were calculated using a difference-in-differences approach with best supportive care (BSC) as a common reference. AE rates and treatment duration were obtained from clinical trials: FRESCO and FRESCO-2 (fruquintinib), RECOURSE (T/T), CORRECT (regorafenib) and SUNLIGHT (T/T, T/T+bev). AE management costs for the commercial and Medicare perspectives were obtained from publicly available sources. Results: From the commercial perspective, the AE costs (presented as per-patient, PPPM) were: $4015, $1091 for fruquintinib (FRESCO); $4253, $1390 for fruquintinib (FRESCO-2); $17,110, $11,104 for T/T (RECOURSE); $9851, $4691 for T/T (SUNLIGHT); $8199, $4823 for regorafenib; and $11,620, $2324 for T/T+bev. These results were consistent in anchored comparisons: the difference-in-difference for fruquintinib based on FRESCO was -$1929 versus regorafenib and -$11,427 versus T/T; for fruquintinib based on FRESCO-2 was -$2257 versus regorafenib and -$11,756 versus T/T. Across all analyses, results were consistent from the Medicare perspective. Conclusion: Fruquintinib was associated with lower AE management costs compared with regorafenib, T/T and T/T+bev for patients with previously treated mCRC. This evidence has direct implications for treatment, formulary and pathways decision-making in this patient population.

Partial Hepatectomy and Ablation for Survival of Early-Stage Hepatocellular Carcinoma Patients: A Bayesian Emulation Analysis.

Partial hepatectomy and ablation therapy are two widely used surgical procedures for localized early-stage hepatocellular carcinoma (HCC) patients. This article aimed to evaluate their relative effectiveness in terms of overall survival. An emulation analysis approach was first developed based on the Bayesian technique. We estimated propensity scores via Bayesian logistic regression and adopted a weighted Bayesian Weibull accelerated failure time (AFT) model incorporating prior information contained in the published literature. With the Surveillance, Epidemiology, and End Results (SEER)-Medicare data, an emulated target trial with rigorously defined inclusion/exclusion criteria and treatment regimens for early-stage HCC patients over 66 years old was developed. For the main cohort with tumor size less than or equal to 5 cm, a total of 1146 patients were enrolled in the emulated trial, with 301 and 845 in the partial hepatectomy and ablation arms, respectively. The analysis suggested ablation to be significantly associated with inferior overall survival (hazard ratio [HR] = 1.35; 95% credible interval [CrI]: 1.14, 1.60). For the subgroup with tumor size less than or equal to 3 cm, there was no significant difference in overall survival between the two arms (HR = 1.15; 95% CrI: 0.88, 1.52). Overall, the comparative treatment effect of ablation and partial hepatectomy on survival remains inconclusive. This finding may provide further insight into HCC clinical treatment.

Access to treatment before and after Medicare coverage of opioid treatment programs.

Since January 2020, Medicare has covered opioid use disorder (OUD) treatment services at opioid treatment programs (OTPs), the only outpatient settings allowed to dispense methadone for treating OUD. This study examined policy-associated changes in Medicare acceptance and the availability of four OUD treatment services (ongoing buprenorphine, HIV/AIDS education, employment services, and comprehensive mental health assessment), by for-profit status, and county-level changes in Medicare-accepting-OTPs access, by sociodemographic characteristics (racial composition, poverty rate, and rurality). Using data from the 2019-2022 National Directory of Drug and Alcohol Abuse Treatment Facilities, we found Medicare acceptance increased from 21.31% in 2018 to 80.76% in 2021. The availability of the four treatment services increased, but no increases were significantly associated with Medicare coverage. While county-level OTP access significantly improved, counties with higher rates of non-White residents experienced an additional average increase of 0.86 Medicare-accepting-OTPs (95% CI, 0.05-1.67) compared to those without higher rates of non-White populations. Overall, Medicare coverage was associated with improved OTP access, not ancillary services.

Medicare Utilization and Cost Trends for CAR T Cell Therapies Across Settings of Care in the Treatment of Diffuse Large B-Cell Lymphoma.

INTRODUCTION: Chimeric antigen receptor T-cell (CAR T) therapies have transformed diffuse large B-cell lymphoma (DLBCL) treatment. It is important to better understand their use in Medicare Fee-for-Service (FFS) patients, who often differ from commercially insured populations in important ways. METHODS: We analyzed Medicare FFS claims data, focusing on the utilization patterns across three CAR T products-lisocabtagene maraleucel (liso-cel), tisagenlecleucel (tisa-cel), and axicabtagene autoleucel (axi-cel)-which are indicated for the treatment of DLBCL. Our investigation covered the period from 2021 through 2022. This analysis spanned a 180-day period prior to CAR T procedure and extended to a 90-day post-CAR T. Utilization of healthcare services, healthcare spending, and comorbidities were assessed in the pre- and post-periods. Clinical trial and PPS-exempt center claims were removed from the analysis. Statistical comparisons between inpatient and outpatient cohorts were made using Wilcoxon's rank-sum tests for continuous variables and Chi-square tests or Fisher's exact tests for categorical variables. RESULTS: Among the total 391 CAR T claims assessed, most of the CAR T therapies were administered in the inpatient setting (79%) compared to outpatient (21%). CAR T therapy in the inpatient setting received an average Medicare cost of US$498,723 ($276,138-$1,066,524), while the average Medicare cost for outpatient CAR T claims was $414,393 ($276,980-$849,878). There was a higher 3-month average post-period cost for those hospitals utilizing CAR T in the outpatient setting than the inpatient setting ($15,794 vs. $10,244). Despite the higher post-period cost, when looking at the CAR T procedure and pre- and post-periods as a single episode, beneficiaries receiving outpatient CAR T had less cost for the total episode of care ($587,908 vs. $529,188). Follow-up inpatient claims were also assessed post-CAR T procedure for 30 days. The rate of post-CAR T inpatient re-admission was significantly lower for beneficiaries receiving the index CAR T in the inpatient setting (21%) compared to outpatient CAR T (59%). Days between index CAR T discharge and IP admission were also significantly shorter for OP CAR T compared to IP CAR T (8.0 vs. 14.1 days, p < 0.0001). Additionally, IP CAR T had a longer ALOS on the admission claim (6.9 vs. 6.2 days). CONCLUSION: CAR T therapy for the treatment of LBCL has become more common within the Medicare population, primarily in the inpatient setting. This study helps understand providers' cost and associated patient care around CAR T administration. The data show that the average cost received by hospitals encompasses the expenses related to both the CAR T drug and the medical services delivered to patients.

Capturing and harvesting in Medicare Advantage plan design.

Consumers in health insurance markets have inertia stemming from the desire to maintain relationships with providers and other frictions involved in switching plans. In other markets that feature inertia, suppliers respond with pricing strategies that vary by market share: lowering markups to capture consumers when market shares are low and raising markups to harvest profits once market share has been established. I tested for this behavior in the Medicare Advantage (MA) market by examining how MA plan sponsors changed the financial terms of their plans in response to changes in market share from 2007 to 2021 using a first-difference model with fixed effects. I found evidence that plans increase premiums, copays, and out-of-pocket limits when market shares increase. The results imply that for every 1% increase in market share, plan sponsors subsequently increase out-of-pocket costs by 1% in the following year.

Using machine learning to improve anaphylaxis case identification in medical claims data.

Objectives: Anaphylaxis is a severe life-threatening allergic reaction, and its accurate identification in healthcare databases can harness the potential of "Big Data" for healthcare or public health purposes. Materials and methods: This study used claims data obtained between October 1, 2015 and February 28, 2019 from the CMS database to examine the utility of machine learning in identifying incident anaphylaxis cases. We created a feature selection pipeline to identify critical features between different datasets. Then a variety of unsupervised and supervised methods were used (eg, Sammon mapping and eXtreme Gradient Boosting) to train models on datasets of differing data quality, which reflects the varying availability and potential rarity of ground truth data in medical databases. Results: Resulting machine learning model accuracies ranged from 47.7% to 94.4% when tested on ground truth data. Finally, we found new features to help experts enhance existing case-finding algorithms. Discussion: Developing precise algorithms to detect medical outcomes in claims can be a laborious and expensive process, particularly for conditions presented and coded diversely. We found it beneficial to filter out highly potent codes used for data curation to identify underlying patterns and features. To improve rule-based algorithms where necessary, researchers could use model explainers to determine noteworthy features, which could then be shared with experts and included in the algorithm. Conclusion: Our work suggests machine learning models can perform at similar levels as a previously published expert case-finding algorithm, while also having the potential to improve performance or streamline algorithm construction processes by identifying new relevant features for algorithm construction.

Medicare billing and utilization trends in vascular surgery.

OBJECTIVE: Within the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a result, hospitals may increase service charges to offset losses in revenue, which may disproportionately affect underinsured patients. Our analysis aimed to characterize Medicare billing and utilization trends across common vascular surgical procedures. METHODS: The 2017 to 2021 Medicare Physician and Other Practitioners by Provider and Service dataset was queried for Current Procedural Terminology (CPT) codes for common vascular surgery procedures. The average charges, reimbursements, charge-to-reimbursement ratios, and service counts were calculated for the most common interventions performed by vascular surgeons. Data was stratified by care setting, facility (inpatient and outpatient hospital) vs non-facility locations. All monetary values were adjusted to the 2021 United States dollars to account for inflation. RESULTS: For facility settings, the mean charge billed to Medicare Part B increased from $3708 to $3952 (6.6%) from 2017 to 2021, with the average charge-to-reimbursement ratio increasing from 7.2 to 8.6. There were 17 of the 19 facility procedures that had a decline in reimbursements, decreasing from an average of $558 to $499 (-10.4%). Stab phlebectomy had the largest individual decrease in facility reimbursement (-53.5%), followed by above-knee amputation (-11.3%) and below-knee amputation (-11.0%). Both non-facility charges (-10.8%) and reimbursements (-12.2%) declined over the study period. Procedural utilization remained stable from 2017 to 2019. Tibial and femoral-popliteal atherectomy had increases of 45.9% and 33.7%, respectively, in overall procedural utilization when performed in non-facility settings from 2017 to 2019. CONCLUSIONS: Our analysis of vascular surgery procedures billed to Medicare Part B from 2017 to 2021 demonstrates an increase in charges, a decline in reimbursements, and a resultant increase in charge-to-reimbursement ratios for facility care settings. In contrast, non-facility charges have decreased in the face of declining reimbursements. These markups in submitted charges in facility locations may serve as an additional barrier to accessing care for patients who are underinsured.