Time for physicians to prepare for impending appropriate use mandate

Within a year, the Centers for Medicare & Medicaid Services (CMS) will implement a provision in the Protecting Access to Medicare Act (PAMA) that requires physicians to consult appropriate use criteria (AUC) using CMS-approved computer-based clinical decision support mechanisms when ordering advanced imaging procedures. Under PAMA, providers will have to submit proof that applicable AUC were consulted to have their claims processed. After the CMS collects 2 years of data, “outlier” physicians will subject to prior authorization, thus possibly limiting patients’ and physicians’ access to advanced imaging procedures. Because coronary artery disease evaluation is a priority clinical area, most cardiac imaging procedures will be subject to the initial rollout of the mandate.

Once PAMA is implemented, the burden of reducing inappropriate use will move largely from payers to providers. In preparation for this shift, physicians will need to be educated about expectations under PAMA, which should include increasing their understanding of appropriate use. This will require close collaboration between professional societies representing referring providers and imaging specialists and involvement of all stakeholders.

Article: Promoting Appropriate Use of Cardiac Imaging: No Longer an Academic Exercise, Rami Doukky, MD, MSc; Gretchen Diemer, MD; Andria Medina, MD, PhD; David E. Winchester, MD, MS; Venkatesh L. Murthy, MD, PhD; Lawrence M. Phillips, MD; Kathleen Flood, BS; Linda Giering, PhD; Georgia Hearn, JD; Ronald G. Schwartz, MD, MS; Raymond Russell, MD, PhD; David Wolinsky, MD, Annals of Internal Medicine, published 28 February 2017.

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This entry was posted on March 1, 2017, in Main.

Trump's policies set to damage health and science, warns The BMJ

The BMJ warns that Trump’s administration “is acting in ways that will suppress research and limit communication on scientific topics that it deems politically inconvenient.”

Early policies “risk head-on collision with the scientific and health communities” say editors Jose Merino, Elizabeth Loder and Kamran Abbasi, and Harvard professor of health policy, Ashish Jha. “Trump’s policies in other areas also have the potential to damage health,” they add.

For example, they point to communications restrictions on several environmental protection and public health agencies, while scientific information on government websites “is being removed and becoming inaccessible.”

And they warn that proposals to reform the Food and Drug Administration “will scale back the agency’s ability to ensure the safety and efficacy of approved drugs, harming not only people in America but those in other countries that often follow the FDA’s lead.”

Instant repeal of the Affordable Care Act, without a viable alternative, will surely prove damaging, they write. While Trump’s immigration policy “will disrupt the flow of scientific ideas and knowledge, hinder recruitment of scientists to American institutions, limit training opportunities for international physicians, and worsen national shortages of healthcare workers.”

Of course, Trump isn’t the first politician to flout scientific principles or favour “alternative facts,” but this situation seems different and more worrisome, they say.

They point out that the United States is a powerful nation with a profound influence on the health of the world’s population. “That power and influence, if misdirected, will damage efforts to create a healthier, stronger world, one that supports women’s health, condemns torture and other human rights abuses, treats refugees and migrants with dignity and hospitality, and ensures that all people, especially the most vulnerable, have access to high quality healthcare.”

The BMJ’s solution is to “reaffirm our commitment to fostering and applying the best evidence for policy and practice, to be an open forum for rigorous debate that challenges the status quo and holds us all to account, to speak truth to power and support others who do the same, and to actively campaign for a better world, based on our values of transparency, independence, and scientific and journalistic integrity,” they explain.

“Whichever way Trump turns, the scientific and healthcare communities must commit to serving the best interests of patients and the public,” they say. “By arming ourselves with the fruits of science, being guided by facts and evidence, we can create a healthier planet, not just for Americans but for all the peoples of our world.”

Editorial: Standing up for science in the era of Trump, Jose G Merino, Ashish Jha KT Li, Elizabeth Loder and Kamran Abbasi, The BMJ, doi: 10.1136/bmj.j775 , published 21 February 2017.

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This entry was posted on February 22, 2017, in Main.

Many cancer survivors change their prescription drug use for financial reasons

A new analysis indicates that many cancer survivors change their prescription drug use (including skipping doses or requesting cheaper medications) for financial reasons. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the study provides important information on the financial burden experienced by cancer survivors, suggesting non-elderly cancer survivors are particularly vulnerable to this phenomenon.

Although research has shown that cancer drugs can represent considerable costs for cancer patients and their families, there is limited information about changes in prescription drug use for financial reasons among cancer survivors. To further investigate this, researchers from the American Cancer Society, the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health used 2011-2014 data from the National Health Interview Survey, an annual household interview survey conducted by the CDC. This nationally representative survey included 8931 cancer survivors and 126,287 individuals without a cancer history.

Among non-elderly adults, 31.6 percent of those who had been recently diagnosed and 27.9 percent of those who had been previously diagnosed (at least two years earlier) reported a change in prescription drug use for financial reasons, compared with 21.4 percent of adults without a history of cancer. “Specifically, non-elderly cancer survivors were more likely to skip medication, delay filling a prescription, ask their doctor for lower-cost medication, and use alternative therapies for financial reasons compared with non-elderly individuals without a cancer history,” said the American Cancer Society’s Ahmedin Jemal, DVM, PhD, a senior author of the paper. The study also showed that among privately insured non-elderly cancer survivors, one-third of survivors enrolled in high-deductible plans asked their doctor for lower-cost medications compared with less than one-fifth of survivors enrolled in low-deductible plans.

Changes in prescription drug use for financial reasons were generally similar between elderly cancer survivors and elderly individuals without a cancer history. This is likely because of uniform healthcare coverage through Medicare.

The findings may have significant policy implications. “Healthcare reforms addressing the financial burden of cancer among survivors, including the escalating cost of prescription drugs, should consider multiple comorbid conditions and high-deductible health plans, and the working poor,” said Dr. Jemal. “Our findings also have implications for doctor and patient communication about the financial burden of cancer when making treatment decisions, especially on the use of certain drugs that cost hundreds of thousands of dollars but with very small benefit compared with alternative and more affordable drugs.”

In an accompanying editorial addressing the financial toxicity of cancer, Daniel Goldstein, MD, of the Rabin Medical Center in Israel and Emory University, stressed the need to avoid unnecessary testing and treatments. He added that “when two different treatments exist with equivalent efficacy and safety, the cheaper treatment should always be chosen.”

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This entry was posted on February 21, 2017, in Main.

Insurance status impacts complication rates after shoulder replacement surgery

Patients undergoing shoulder replacement surgery who have Medicaid, Medicare or no health insurance, had higher complication rates as compared to patients who had private insurance.

The findings, which appear in the Journal of Shoulder and Elbow Surgery, demonstrate disparities in acute postoperative outcomes for shoulder replacement surgery based on insurance status.

Shoulder replacements (arthroplasties) are recommended for patients suffering from various conditions, including shoulder arthritis, irreparable rotator cuff tears and fractures. The primary goal of the procedure is pain relief, with a secondary benefit of restoring motion, strength, function and returning patients to an activity level as near to normal as possible.

Using a large, national administrative database (The Healthcare Cost and Utilization Project Nationwide Inpatient Sample), the researchers analyzed more than 100,000 cases (68,578 Medicare; 27,159 private insurance; 3,544 Medicaid/uninsured and 4,009 other) of patients undergoing shoulder arthroplasty (partial or hemi, total, and reverse) procedures. Overall, the perioperative medical and surgical complication rate was 17.2 percent and the mortality rate was 0.20 percent. However, they found that there was a significantly higher rate of medical, surgical and overall complications among Medicare (20.3 percent) and Medicaid/uninsured (16.9 percent) patients compared with privately insured (10.5 percent) patients. When the data was matched and analyzed, the researchers found no differences in the complication rates between Medicaid/uninsured and Medicare patients. However, both the Medicaid/Uninsured and Medicare patients had significantly more medical and surgical complications when compared to the privately insured patients.

According to the researchers, this discrepancy in the complication rates may be the result of a lack of access to both preoperative and postoperative care due to poor socioeconomic status or education level for patients that have government sponsored insurance. Additionally, patients with Medicaid or no insurance may lack access to high volume shoulder surgeons, which may also contribute to the higher complication rates. The authors also found that patients with private insurance are likely to go to higher volume hospitals to have their elective shoulder replacement surgery done.

“Studies in the literature have shown that patients with Medicaid or no insurance have a higher mortality rate after penetrating trauma compared to private insured patients. Patients with Medicaid also have higher medical complication rates after spine surgery. We report similar findings that patients with government-sponsored insurance are more likely to have medical and surgical complications compared to privately insured patients after shoulder replacement surgery. Thus, insurance status should be considered an independent risk factor for medical and surgical complications in patients undergoing shoulder replacement surgery.” said corresponding and first author Xinning Li, MD, assistant professor of orthopaedic surgery at Boston University School of Medicine.

Li believes future research should focus on both clinical and socioeconomic factors to determine the reason for possible differences in the postoperative complications and outcomes in patients after shoulder replacement surgery between government sponsored and private insurance.

“Understanding that disparities in patient care exist is an important first step. Patients with no insurance or Medicaid/Medicare insurance do not have the same access to care compared to someone with private insurance. The next logical question to ask is why these disparities exist, and subsequently, what can be done to eliminate its occurrence to improve patient care while minimizing postoperative complication,” added Li, an orthopedic surgeon that specializes in sports medicine and shoulder reconstructive surgery at Boston Medical Center.

This study was done in collaboration with researchers from the University of Wisconsin School of Medicine (Dr. Paul Yi), University of California San Francisco School of Medicine (David Sing, B.S.), New England Baptist Hospital (Dr. Andrew Jawa), Medical University of South Carolina (Dr. Josef Eichinger), and the University of Michigan School of Medicine (Dr. Joel Gagnier and Dr. Asheesh Bedi). David Veltre, M.D. is a resident in Orthopaedic Surgery and Antonio Cusano, B.S. is a medical student at the Boston University School of Medicine.

Article: Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty, Xinning Li, MD, David R. Veltre, MD, Antonio Cusano, BS, Paul Yi, MD, David Sing, BS, Joel J. Gagnier, ND, MSc, PhD, Josef K. Eichinger, MD, Andrew Jawa, MD, Asheesh Bedi, MD, Journal of Shoulder and Elbow Surgery, doi: 10.1016/j.jse.2016.12.071, published online 10 February 2017.

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This entry was posted on February 15, 2017, in Main.

Examining different accountable care organization payment models

Two new studies published online by JAMA Internal Medicine take a look at different accountable care organization (ACO) payment models.

The first study by J. Michael McWilliams, M.D., Ph.D., of Harvard Medical School, Boston, and coauthors used a sample of fee-for-service Medicare claims to examine changes in postacute care spending and the use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program. The 20 percent sample of beneficiaries included more than 8.3 million hospital admissions and more than 1.5 million stays in skilled nursing facilities (SNFs).

Excessive use of postacute SNF care is thought to be a major source of wasteful spending and a target for health care professionals who participate in new payment models, such as Medicare ACO programs.

The authors report that entrance into the Medicare Shared Savings Program (MSSP) in 2012 for ACOs was associated with a 9 percent differential reduction in postacute spending by 2014 – driven by reductions in discharges to facilities, length of facility stays and acute inpatient care. Reductions were smaller for later program entrants and similar for ACOs with and without financial ties to hospitals, according to the article.

The study’s limitations include that the MSSP is a voluntary program and ACOs likely differ from providers who don’t participate.

“Participation in the MSSP has been associated with significant reductions in postacute care spending without ostensible changes in quality, suggesting gains in the value of health care. Postacute care spending reductions were more consistent with efforts by clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs. Understanding such early successes can support regulatory policy that enhances rather than inhibits the effectiveness of payment and delivery system reform,” the article concludes.

A second study by K. John McConnell, Ph.D., of the Oregon Health & Science University, Portland, examined early performance in Medicaid ACOs in Oregon and Colorado.

With a $1.9 billion investment from the federal government, Oregon started to transform Medicaid in 2012 by moving enrollees into 16 Coordinated Care Organizations so care was managed within a global budget. In 2011, Colorado began its Medicaid Accountable Care Collaborative by creating seven regional care collaborative organizations that were funded to coordinate care and connect Medicaid enrollees with community services, according to the article.

The authors report standardized expenditures, which have common codes across states, for selected services decreased in both states from 2010 to 2014 with no difference between the states. The Oregon model also was associated with improvements in some utilization, access and quality measures.

The study notes important limitations, including that the analysis did not include prescription drug expenditures, which is a growing portion of Medicaid spending.

“These results should be considered in the context of overall promising trends in both states. Continued evaluation of Medicaid reforms and payment models can inform the most effective approaches to improving and sustaining the value of this growing public program,” the article concludes.

Articles: Changes in Postacute Care in the Medicare Shared Savings Program, J. Michael McWilliams, MD, PhD; Lauren G. Gilstrap, MD; David G. Stevenson, PhD et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9115, published online 13 February 2017.

Early Performance in Medicaid Accountable Care Organizations A Comparison of Oregon and Colorado, K. John McConnell, PhD; Stephanie Renfro, MS; Benjamin K. S. Chan, MS et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9098, published online 13 February 2017.

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This entry was posted on February 14, 2017, in Main.