Trends in Industry Payments to Dermatologists: A 5-Year Analysis of Open Payments Data (2017-2021).

Financial relationships between dermatologists and industry are prevalent and may have implications for patient care. To analyze reported industry payments made to dermatologists, we performed a retrospective analysis of the Centers for Medicare and Medicaid Services Open Payments database (OPD) from January 1, 2017, to December 31, 2021. During this 5-year period, a total of $278 million in industry payments were made to dermatologists. It is important for all dermatologists to review their public profiles in the OPD to confirm the reported payments are accurate.

Addressing the Marketing Practices of Medicare Advantage Plans.

The Medicare Advantage (MA) Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. Recent investigations conducted by the United States Senate Committee on Finance and Centers for Medicare & Medicaid Services (CMS) have uncovered marketing practices of MA insurance agents that "were not complying with current regulation and unduly pressuring beneficiaries, as well as failing to provide accurate or enough information to assist a beneficiary in making an informed enrollment decision." These findings come at a time in which MA programs are under investigation for denials of prior authorization requests that fall within Medicare guidelines for covered health services. In this Commentary we consider the backdrop for the growing scrutiny of the MA program and the implications thereof to its future trajectory.

The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics.

BACKGROUND: Despite the intense policy focus on reducing health-care-associated conditions, adverse events in health care settings persist. Therefore, evaluating patient safety efforts and related health policy initiatives remains critical. PURPOSE: The aim of this study was to explore the relationship between hospital patient safety culture and hospital performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. METHODOLOGY/APPROACH: A pooled cross-sectional study design was used utilizing three secondary datasets from 2018 and 2021: the Hospital Survey on Patient Safety Culture, the American Hospital Association annual survey, and the Hospital Compare data from CMS. We used two multivariable linear regression models to examine the relationship between organizational patient safety culture and hospital performance. The dependent variables included the overall CMS total performance score (TPS) and the four individual TPS domain scores. Hospital patient safety culture, the independent variable, was operationalized using two measures from the Hospital Survey on Patient Safety Culture: (a) the domain score of overall perceptions of patient safety and (b) the patient safety grade. RESULTS: We observed positive and significant associations between hospital patient safety culture and a hospital's overall TPS and the "patient and community engagement" and "safety" domains. CONCLUSION: Findings suggest that building a strong patient safety culture has the potential to lead health care organizations to achieve high performance on HVBP metrics. PRACTICE IMPLICATIONS: Our findings have important policy implications for both the future of CMS HVBP as a motivator of patient safety and how health care managers integrate culture change into programs to meet external quality metrics.

Impact of Site-Neutral Payments for Commercial and Employer-Sponsored Plans.

Site-neutral payment is a policy created by federal rule making and implemented by the Centers for Medicare and Medicaid Services (CMS) that aims to reduce healthcare costs by aligning payment rates for certain services provided in multiple care settings. Site-neutral payments are intended to eliminate the incentive for providers to acquire facilities, such as physician offices or ambulatory surgical centers (ASCs), that Medicare reimburses at the lower non-facility rate and convert those settings into hospital outpatient departments (HOPDs), where Medicare reimburses at the higher facility rate. Although initiated by Congress to address payment disparities in Medicare, similar payment discrepancies can be seen in the commercial market where individual and employer-sponsored health plans often pay more for certain outpatient services depending on their location. This analysis presents a simulation of the impact of applying site-neutral payments to the commercial market with respect to overall potential savings for consumers, health plans and the federal government. To conduct the analysis, we use an all-payer claims data base generalizable to the United States. The analysis focused on a select group of outpatient services identified by the Medicare Payment Advisory Commission (MedPAC). We mapped the MedPAC identified 68 Ambulatory Payment Classifications (APCs), the codes Medicare uses to reimburse facilities for outpatient services, to the relevant CPT4/HCPCS codes, which the commercial market uses for billing. The potential cost savings of applying the site-neutral payment policy to the commercial insurance market to be $58 billion for year 2022. We estimate the 10-year total (2024-2033) employer market premium reduction ranges from 5.35% to 5.0% and found that those premium reductions would result in employer-sponsored insurance (ESI) tax subsidy savings of $140 billion to the federal government over a 10-year period (2024-2033).

Impact of Tricuspid Regurgitation on Outcomes of Transcatheter Aortic Valve Replacement With Balloon-Expandable Valves.

BACKGROUND: Tricuspid regurgitation (TR) is highly prevalent in the transcatheter aortic valve replacement (TAVR) population, but clear management guidelines are lacking. OBJECTIVES: The aims of this study were to elucidate the prevalence and consequences of severe TR in patients with aortic stenosis undergoing TAVR and to examine the change in TR post-TAVR, including predictors of improvement and its impact on longer term mortality. METHODS: Using Centers for Medicare and Medicaid Services-linked TVT (Transcatheter Valve Therapy) Registry data, a propensity-matched analysis was performed among patients undergoing TAVR with baseline mild, moderate, or severe TR. Kaplan-Meier estimates were used to assess the impact of TR on 3-year mortality. Multivariable analysis identified predictors of 30-day TR improvement. RESULTS: Of the 312,320 included patients, 84% had mild, 13% moderate, and 3% severe TR. In a propensity-matched cohort, severe baseline TR was associated with higher in-hospital mortality (2.5% vs 2.1% for moderate TR and 1.8% for mild TR; P = 0.009), higher 1-year mortality (24% vs 19.6% for moderate TR and 16.6% for mild TR; P < 0.0001), and 3-year mortality (54.2% vs 48.5% for moderate TR and 43.3% for mild TR; P < 0.0001). Among the patients with severe TR at baseline, 76.4% improved to moderate or less TR 30 days after TAVR. Baseline mitral regurgitation moderate or greater, preserved ejection fraction, higher aortic valve gradient, and better kidney function predicted TR improvement after TAVR. However, severe 30-day residual TR was associated with higher 1-year mortality (27.4% vs 18.7% for moderate TR and 16.8% for mild TR; P < 0.0001). CONCLUSIONS: Severe baseline and 30-day residual TR after TAVR are associated with increased mortality up to 3 years. This analysis identifies a higher risk group that could be evaluated for the recently approved tricuspid interventions.

Continuity Matters: Financial Impact of the G2211 Code in Primary Care.

Family medicine is financially undervalued compared with other medical specialties, and reimbursement fails to recognize the valuable longitudinal care provided to patients. According to one estimate, a primary care physician earns approximately $80,000 less than a subspecialist peer in Medicare reimbursement over a one-year period.1 This gap persists despite primary care physicians addressing higher numbers of medical concerns during office visits. To address continuity, the Centers for Medicare and Medicaid Services created the G2211 code in 2019 to compensate for the "visit complexity inherent to evaluation and management associated with medical care services."2 The G2211 code was implemented in January 2024.

Centers for Medicare and Medicaid Services Coverage of Amyloid PET.

This Viewpoint discusses the ambiguity of amyloid positron emission tomography coverage in the era of anti-amyloid therapeutics and the considerations and consequences of narrow coverage.

Integrating Social Drivers of Health into Hospital Ratings with Application to the 100 Top Hospitals Study.

The objective was to investigate the relationship between social drivers of health (SDOH) and hospital performance within the 100 Top Hospitals study, exploring methods to recognize hospitals serving marginalized communities. Publicly available data sourced from the Centers for Medicare and Medicaid Services and the 2023 100 Top Hospitals study was used. The study employed multivariable hierarchical generalized linear regression models to assess the association between an SDOH composite variable derived using principal component analysis and overall hospital performance measures within the 100 Top Hospitals study. The analysis revealed a statistically significant association between SDOH factors and study ranking results. The SDOH composite variable is a significant predictor of performance within the 100 Top Hospitals study. Accounting for SDOH is essential to recognize high-performing hospitals serving marginalized communities. The findings suggest a need for broader considerations of SDOH in hospital ranking methodologies across various industry programs.

Scaling the CMS Cardiovascular Risk Reduction Model.

This Viewpoint discusses the potential benefits of expanding the Million Hearts Cardiovascular Risk Reduction Model of the US Centers for Medicare & Medicaid Services (CMS).

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.

Business and Corporate Models for Interventional Radiology in the Office Based Lab and Ambulatory Surgical Center Setting.

The landscape of healthcare is shifting towards outpatient settings such as Office-Based Labs (OBLs) and Ambulatory Surgery Centers (ASCs). This transition, driven by the Centers for Medicare & Medicaid Services (CMS), presents various business and corporate models for interventional radiologists seeking to practice outside traditional hospital environments. The role of private equity and management services in facilitating these transitions is highlighted, offering opportunities for growth, efficiency, and enhanced control over practice operations. The document also discusses the financial aspects of establishing an OBL or ASC, the benefits of outpatient procedures, and the adaptability of private equity deals to the specific needs of medical practices. It concludes by emphasizing the potential for long-term wealth creation and the adaptability of these models to individual physician needs.

Practical Applications and Observational Implications of Time-Based Coding for Workers' Compensation Clinical Encounters-A Follow-up to Best Practices in Documenting and Coding High-Value Care in Workers' Compensation Encounters-ACOEM Guidance Statement.

ABSTRACT: Clinical practices that provide workers' compensation care and other services related to managing work-related illnesses and injuries have long been challenged in receiving appropriate payment for their professional work. The American College of Occupational and Environmental Medicine (ACOEM) has provided excellent guidelines for coding and billing via its various documents that have been provided over the years. However, despite these guidelines, payors have been slow to adopt occupational specific coding guidelines to justify higher professional payment. With the move to a Centers for Medicare & Medicaid Services (CMS)-sponsored time-based coding option in 2011, the occupational and environmental medicine (OEM) clinics have been able to finally not only document but recoup the value of those services that go beyond the simple patient interface, being able to capture those activities that truly provide high value in the management of workers' medical issues.

Price benchmarks of drugs selected for Medicare price negotiation and their therapeutic alternatives.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) are currently negotiating prices with pharmaceutical manufacturers for the first 10 Part D drugs selected for Medicare drug price negotiation. Non-publicly available data, including the net prices of selected drugs and their therapeutic alternatives, will play a central role in the determination of the maximum fair prices (MFPs). OBJECTIVE: To estimate price benchmarks involved in the derivation of the starting point of the CMS initial price offer for the 10 drugs selected for Medicare price negotiation. METHODS: For the 10 drugs selected for negotiation, we reported (1) the list price, (2) the net price after manufacturer discounts, (3) the maximum negotiated price based on the minimum statutory discount, and (4) the ceiling of the MFP, estimated as the lowest of the latter 2. We also estimated net prices for therapeutic alternatives to the selected drugs. Net prices were estimated using peer-reviewed methodology that isolates commercial discounts negotiated between payers and manufacturers from mandatory discounts under government programs. All price benchmarks were estimated at the product level, for 30-day equivalent dosing, using 2021 data. RESULTS: 6 products (apixaban, rivaroxaban, empagliflozin, sacubitril/valsartan, etanercept, and insulin aspart) had therapeutic alternatives with lower net prices, which will be integrated with clinical benefit data in the derivation of initial price offers. The other 4 products (ustekinumab, ibrutinib, sitagliptin, and dapagliflozin) had therapeutic alternatives with higher net prices than the drugs selected for negotiation. For ibrutinib and ustekinumab, prices based on the minimum discounts were considerably lower than the estimated net prices and will likely set the starting point of the initial price offer. For dapagliflozin and sitagliptin, the starting point of the initial price offer will likely resemble their existing net prices. CONCLUSIONS: Our analyses identify different negotiation scenarios for the first 10 drugs selected for Medicare price negotiation, based on key elements involved in the derivation of the initial price offer. Our analyses can help improve transparency in the negotiation process, because the CMS is not required to reveal the information used in the derivation of price offers.

Variation in Postoperative Outcomes Across Federally Designated Hospital Star Ratings.

Importance: Despite widespread use to guide patients to hospitals providing the best care, it remains unknown whether Centers for Medicare & Medicaid Services (CMS) hospital star ratings are a reliable measure of hospital surgical quality. Objective: To examine the CMS hospital star ratings and hospital surgical quality measured by 30-day postoperative mortality, serious complications, and readmission rates for Medicare beneficiaries undergoing colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, and incisional hernia repair. Design, Setting, and Participants: This cohort study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals with a CMS hospital star rating for calendar years 2014-2018. Data analysis was performed from January 15, 2022, to April 30, 2023. Participants included fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair with continuous Medicare coverage for 3 months before and 6 months after surgery. Exposure: Centers for Medicare & Medicaid Services hospital star rating. Main Outcomes and Measures: Risk- and reliability-adjusted hospital rates of 30-day postoperative mortality, serious complications, and 30-day readmissions were measured and compared across hospitals and star ratings. Results: A total of 1 898 829 patients underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair at 3240 hospitals with a CMS hospital star rating. Mean (SD) age was 74.8 (7.0) years, 50.6% of the patients were male, and 86.5% identified as White. Risk- and reliability-adjusted 30-day mortality rate decreased in a stepwise fashion from 6.80% (95% CI, 6.79%-6.81%) in 1-star hospitals to 4.93% (95% CI, 4.93%-4.94%) in 5-star hospitals (adjusted odds ratio, 1.86; 95% CI, 1.73-2.00). There was wide variation in the rates of hospital mortality (variation, 1.89%; range, 2.4%-16.2%), serious complications (variation, 1.97%; range, 5.5%-45.1%), and readmission (variation, 1.27%; range, 9.1%-22.5%) across all hospitals. After stratifying hospitals by their star rating, similar patterns of variation were observed within star rating groups for 30-day mortality: 1 star (variation, 1.91%; range, 3.6%-12.0%), 2 star (variation, 1.86%; range, 2.8%-16.2%), 3 star (variation, 1.84%; range, 2.9%-12.3%), 4 star (variation, 1.76%; range, 2.9%-11.5%), and 5 star (variation, 1.79%; range, 2.4%-9.1%). Similar patterns were observed for serious complications and readmissions. Conclusion and Relevance: Although CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.

A Contemporary Evaluation of the Centers for Medicare and Medicaid Services High-risk Indicators for Carotid Endarterectomy.

OBJECTIVE: Compare stroke/death outcomes across carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) using Centers for Medicare and Medicaid Services (CMS) high-risk criterion. BACKGROUND: Existing literature has revealed inconsistencies with CMS risk guidelines. With recent approval for TCAR and TFCAS in standard-risk patients, an updated analysis of guidelines is needed. METHODS: Data from the Vascular Quality Initiative (VQI) (2016-2023) on CEA, TFCAS, or TCAR patients were used. We used inverse probability of treatment weighting to compare in-hospital stroke/death rates across procedures for high-risk criteria: contralateral occlusion (CLO), prior CEA, CAS, radiation, neck surgery, moderate to severe CHF, severe COPD (on home O 2 ), unstable angina, recent MI (<6 mo), and age (≥75 years-old). RESULTS: A total of 199,050 patients were analyzed, of whom 122,737 (62%) patients underwent CEA, 50,095 (25%) TCAR, and 26,218 (13%) TFCAS. TCAR had lower odds of stroke/death compared with CEA in patients with CLO [aOR=0.73 (95% CI: 0.55-0.98], P =0.035] and radiation [aOR=0.44 (95% CI: 0.23-0.82), P =0.010]. Contrary to CMS criteria, CEA patients did not have higher stroke/death in patients with prior CEA, CAS, neck surgery, moderate to severe CHF, severe COPD, unstable angina, recent MI, or age (≥75) compared with TCAR and TFCAS. CONCLUSIONS: While CMS high-risk criteria have traditionally been recognized as contraindications for CEA, our study reveals inconsistencies-with CEA performing similarly to TCAR and significantly better than TFCAS in patients with prior CEA, moderate to severe CHF, recent MI, or age (≥75). As a result, the definition of high-risk criteria may warrant reconsideration.

Lessons learned from CMS's National Partnership to Improve Dementia Care: a thematic synthesis of multiple stakeholder-engaged studies.

BACKGROUND: Antipsychotic prescribing in United States nursing homes (NHs) has decreased since the Center for Medicare & Medicaid Service debuted the National Partnership to Improve Dementia Care in Nursing Homes (NP); however, reductions have stalled. To help explain persistent antipsychotic use despite the NP's reduction efforts, the perspectives of diverse NP stakeholders were qualitatively assessed. This study aimed to re-evaluate these individual perspectives in combined thematic synthesis to discover NP improvement opportunities undetectable in single stakeholder assessments. METHODS: Thematic synthesis. Through immersive crystallisation, original source coding results were organised into related descriptive themes. Similarities and differences were identified, and descriptive themes were regrouped into new, increasingly abstract, analytical themes. This cycle continued until variances were resolved and analytic themes sufficiently described and explained all initial descriptive themes. RESULTS: Three analytic themes emerged regarding NP improvement opportunities. The NP's positive impacts would be augmented by: (i) a deeper and expanded appreciation of stakeholder perspectives; (ii) more urgent and rapid adaptation to unintended adverse outcomes; and (iii) greater recognition of the contextual and environmental factors influencing decisions to prescribe or not prescribe antipsychotic medications. Stakeholder groups described: perspectives they perceived as inadequately considered by the NP; insufficient NP engagement with the stakeholders capable of creating evidenced, affordable, and available non-pharmacologic therapies for dementia symptoms; recognition that dementia interventions effective for a specific individual at a specific time in a specific community may not generalise; and diverse ongoing undesirable outcomes from NP policies that could be mitigated by NP modifications. CONCLUSIONS: The NP has done much to advance dementia care in NHs. Notwithstanding, these results suggest the NP would only be improved through increasingly comprehensive inclusion of stakeholder perspectives, enhanced incorporation of individual contextual factors, and a more decisive mechanism for ongoing and continual adaptation.

Quantifying Industry Spending on Promotional Events Using Open Payments Data.

Importance: Sponsorship of promotional events for health professionals is a key facet of marketing campaigns for pharmaceuticals and medical devices; however, there appears to be limited transparency regarding the scope and scale of this spending. Objective: To develop a novel method for describing the scope and quantifying the spending by US pharmaceutical and medical companies on industry-sponsored promotional events for particular products. Design and Setting: This was a cross-sectional study using records from the Centers for Medicare & Medicaid's Open Payments database on payments made to prescribing clinicians from January 1 to December 21, 2022. Main Outcomes and Measures: An event-centric approach was used to define sponsored events as groupings of payment records with matching variables. Events were characterized by value (coffee, lunch, dinner, or banquet) and number of attendees (small vs large). To test the method, the number of and total spending for each type of event across professional groups were calculated and used to identify the top 10 products related to dinner events. To validate the method, we extracted all event details advertised on the websites of 4 state-level nurse practitioner associations that regularly hosted industry-sponsored dinner events during 2022 and compared these with events identified in the Open Payments database. Results: A total of 1 154 806 events sponsored by pharmaceutical and medical device companies were identified for 2022. Of these, 1 151 351 (99.7%) had fewer than 20 attendees, and 922 214 (80.0%) were considered to be a lunch ($10-$30 per person). Seven companies sponsored 16 031 dinners for the top 10 products. Of the 227 sponsored in-person dinner events hosted by the 4 state-level nurse practitioner associations, 168 (74.0%) matched events constructed from the Open Payments dataset. Conclusions and Relevance: These findings indicate that an event-centric analysis of Open Payments data is a valid method to understand the scope and quantify spending by pharmaceutical and medical device companies on industry-sponsored promotional events attended by prescribers. Expanding and enforcing the reporting requirements to cover all payments to all registered health professionals would improve the accuracy of estimates of the true extent of all sponsored events and their impact on clinical practice.

Discordance in Published 30-Day Readmission Rates Following Primary Total Hip and Total Knee Arthroplasty: Centers for Medicare and Medicaid Services (CMS) Versus the National Surgical Quality Improvement Program (NSQIP).

Background: 30-day readmission is an important quality metric evaluated following primary total joint arthroplasty (TJA) that has implications for hospital performance and reimbursement. Differences in how 30-day readmissions are defined between Centers for Medicare and Medicaid Services (CMS) and other quality improvement programs (i.e., National Surgical Quality Improvement Program [NSQIP]) may create discordance in published 30-day readmission rates. The purpose of this study was to evaluate 30-day readmission rates following primary TJA using two different temporal definitions. Methods: Patients undergoing primary total hip and primary total knee arthroplasty at a single academic institution from 2015-2020 were identified via common procedural terminology (CPT) codes in the electronic medical record (EMR) and institutional NSQIP data. Readmissions that occurred within 30 days of surgery (consistent with definition of 30-day readmission in NSQIP) and readmissions that occurred within 30 days of hospital discharge (consistent with definition of 30-day readmission from CMS) were identified. Rates of 30-day readmission and the prevalence of readmission during immortal time were calculated. Results: In total, 4,202 primary TJA were included. The mean hospital length of stay (LOS) was 1.79 days. 91% of patients were discharged to home. 30-day readmission rate using the CMS definition was 3.1% (130/4,202). 30-day readmission rate using the NSQIP definition was 2.7% (113/4,202). Eight readmissions captured by the CMS definition (6.1%) occurred during immortal time. Conclusion: Differences in temporal definitions of 30-day readmission following primary TJA between CMS and NSQIP results in discordant rates of 30-day readmission. Level of Evidence: III.