Jeffrey D. Clough

Implementing MACRA: Implications for Physicians and for Physician Leadership

This Viewpoint discusses the Medicare Access and CHIP Reauthorization Act and the key features of the law and the opportunities it presents to shape the future of payment and medical practice.

ACGME competencies in neurology Web-based objective simulated computerized clinical encounters

Objective: The American Headache Society developed an innovative Web-based neurology resident educational program to 1) meet the objectives of the Accreditation Council for Graduate Medical Education Outcomes Project; 2) provide measurable improvement of a neurology resident’s understanding of headache and the performance within each core competency; 3) assist residents and program directors in identifying knowledge gaps; and, ultimately, 4) improve the quality of patient care through enhanced educational initiatives. Methods: Quantitative analysis focused on pretest and post-test results, level attainment on case-based simulations, competency achievement, and interactions between cases. One of four validated global scores was related to each resident response on all competency learning opportunities and was measured, from one case to another, to determine improvement and understanding. The pretest and post-test each consisted of 50 randomized questions that tested baseline and improvement on specific core competencies and understanding of headache. Results: The pretest mean score was 30.08, and the post-test mean score was 34.79. A paired sample t test analysis showed a significant difference from pretest to post-test scores (M = −4.72, SD = 4.88, t[91] = −9.269, p < 0.001). There was significant improvement in the competencies as the residents moved through the cases as well as in each of the competencies from the pretest to the post-test. Results showed that residents increased their knowledge and performance by synthesizing the content. Conclusions: This outcomes analysis demonstrates the effectiveness of the American Headache Society Neurology Resident’s Program in improving the resident’s knowledge of headache medicine and Accreditation Council for Graduate Medical Education core competencies. ACGME = Accreditation Council for Graduate Medical Education; AHS = American Headache Society; GME = graduate medical education; NS = not significant; OSCCE = objective simulated computerized clinical encounter; PGY = postgraduate year.

Oncology Care Model: Short- and Long-Term Considerations in the Context of Broader Payment Reform.

With the recent announcement of the Center for Medicare and Medicaid Innovation’s Oncology Care Model (OCM), oncology practices must consider the opportunities and risks of participation in light of the complexities of the model, competing ideas for payment reform, and uncertainty surrounding several details of the model and factors needed for success. Thus, the decision to participate is not straightforward, and the challenges and benefits vary among practices. In this article, we discuss key factors to consider that may influence decisions to participate in the OCM, by presenting comparable payment reform efforts outside of oncology. OCM Overview The OCM is a service delivery and payment model that primarily aims to improve cancer care quality while reducing treatment-related costs. In combining typical fee-for-service payments, an additional per-beneficiary-per-month (PBPM) payment, and performance-based payments, the OCM is a hybrid payment model. 1 The PBPM constitutes an addi

Wide Variation In Payments For Medicare Beneficiary Oncology Services Suggests Room For Practice-Level Improvement

In recent years many policy makers have recommended alternative payment models in medical oncology in order to reduce costs and improve patient outcomes. Yet information on how oncology practices differ in their use of key service categories is limited. We measured annual payments for key service categories delivered to fee-for-service Medicare beneficiaries receiving care from 1,534 medical oncology practices in 2011-12. In 2012, differences in payments per beneficiary at the seventy-fifth-percentile practice compared to the twenty-fifth-percentile practice were

Utilization of darbepoetin alfa in relation to cancer patients' hemoglobin levels

3,866 for chemotherapy (including administration and supportive care drugs),

Patterns of care for clinically distinct segments of high cost Medicare beneficiaries.

1,872 for acute medical hospitalizations, and

Outlook for Alternative Payment Models in Fee-for-Service Medicare

439 for advanced imaging. Supportive care drugs, bevacizumab, and positron-emission tomography accounted for the greatest percentage of variation. Average practice payments for service categories were highly correlated across years but not correlated with each other, which suggests that service categories may be affected by different physician practice characteristics. These differences, even when clinical guidelines exist, demonstrate the potential for quality improvement that could be accelerated through alternative payment models.

Practice‐Level Variation in Outpatient Cardiac Care and Association With Outcomes

ABSTRACT Objective: Previous labeling and guidelines recommended initiating erythropoiesis agents (ESAs) for chemotherapy-induced anemia (CIA) at hemoglobin (Hb) levels < 11 g/dL, maintaining near 12 g/dL, and withholding at ≥ 13 g/dL. This study analyzed adherence with recommendations in administration of darbepoetin (DA) to cancer patients. Design, setting, and participants: Retrospective analysis of Hb levels at which DA was administered using Varian electronic medical records (EMRs). The dataset comprises 141 694 cancer patients from 82 sites across 13 states. The study evaluated DA administrations with respect to recorded Hb for 8988 patients from 1/1/05 to 5/31/07. Main outcome measures: Proportion of DA administrations at Hb ≥ 12 and Hb ≥ 13 g/dL. Hb level was analyzed for all administrations, stratified by year and anemia type (CIA, anemia-of-cancer, and myelodysplastic syndrome). Results: There were 51 111 DA administrations with Hb results. The proportion of administrations at Hb ≥ 12 g/dL was 7.2% and at Hb ≥ 13 g/dL was 0.6%, and for CIA 6.9%/0.6%, anemia of cancer (AOC) 8.8%/0.8%, and myelodysplastic syndrome (MDS) 6.5%/0.6%. The proportion of all DA administrations at Hb ≥ 12 g/dL and ≥ 13 g/dL declined from 8.6% to 5.3% ( p < 0.0001) and from 0.7% to 0.4% ( p < 0.0007), respectively during 1/1/05–5/31/07. Conclusions: In this population, DA administration at Hb ≥ 12 g/dL and Hb ≥ 13 g/dL occurred in 7.2% and 0.6% of administrations, respectively, a ≈ 93% adherence rate with recommendations. Further research is required to understand dose titrations at Hb 12–13 g/dL, and whether similar patterns are observed for other ESAs, and in other practice settings. This study provides context for the debate regarding the utilization, benefits and risks of ESAs in cancer patients.

Association of Practice-Level Hospital Use With End-of-Life Outcomes, Readmission, and Weekend Hospitalization Among Medicare Beneficiaries With Cancer

BACKGROUND Efforts to improve the efficiency of care for the Medicare population commonly target high cost beneficiaries. We describe and evaluate a novel management approach, population segmentation, for identifying and managing high cost beneficiaries. METHODS A retrospective cross-sectional analysis of 6,919,439 Medicare fee-for-service beneficiaries in 2012. We defined and characterized eight distinct clinical population segments, and assessed heterogeneity in managing practitioners. RESULTS The eight segments comprised 9.8% of the population and 47.6% of annual Medicare payments. The eight segments included 61% and 69% of the population in the top decile and top 5% of annual Medicare payments. The positive-predictive values within each segment for meeting thresholds of Medicare payments ranged from 72% to 100%, 30% to 83%, and 14% to 56% for the upper quartile, upper decile, and upper 5% of Medicare payments respectively. Sensitivity and positive-predictive values were substantially improved over predictive algorithms based on historical utilization patterns and comorbidities. The mean [95% confidence interval] number of unique practitioners and practices delivering E&M services ranged from 1.82 [1.79-1.84] to 6.94 [6.91-6.98] and 1.48 [1.46-1.50] to 4.98 [4.95-5.00] respectively. The percentage of cognitive services delivered by primary care practitioners ranged from 23.8% to 67.9% across segments, with significant variability among specialty types. CONCLUSIONS Most high cost Medicare beneficiaries can be identified based on a single clinical reason and are managed by different practitioners. IMPLICATIONS Population segmentation holds potential to improve efficiency in the Medicare population by identifying opportunities to improve care for specific populations and managing clinicians, and forecasting and evaluating the impact of specific interventions.

Sensitive Troponin I Assay in Patients With Suspected Acute Coronary Syndrome

The warnings are now familiar: health care spending for retirees in the United States is unsustainable, the Medicare program is going bankrupt, and the program is in desperate need of reform. The financial burden the Medicare program imposes on the federal budget and the national economy is substantial. Medicare’s total obligations were 3.5% of the gross domestic product in 2013 and are projected to increase to 5.4% by 2035, primarily due to expected growth in enrollment from 52.3 million to 86.8 million beneficiaries, and will substantially strain the economy and the federal budget.1 Alternative payment models (APMs), which are built on the existing fee-for-service foundation but include new payments linked to the effective management of a population or episode of care, have been proposed as potential solutions to restrain costs. In this Viewpoint, we describe the status of the APMs being tested in the Medicare population and the outlook for these models to reduce program expenditures. The Department of Health and Human Services has announced an effort to replace 20% of Medicare fee-for-service payments with APMs in 2015 and has set goals of replacing 30% by the end of 2016 and 50% by 2018.2 Under the Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act (MACRA), beginning in 2019, physicians who receive a substantial proportion of revenues through APMs will receive a global 5% bonus and opt out of the consolidated pay-for-performance program, termed the Merit-Based Incentive Payment System (MIPS). Although the legislation applies to services provided by physicians and other practitioners, physicians play an important role in all APMs, which affect a broad range of Medicare services. Under current law, there are 2 principal avenues by which clinicians and health care entities may participate in APMs: expansion of the Medicare Shared Savings Program or expansion and development of APMs tested through the Center for Medicare & Medicaid Innovation (CMMI). The Medicare Shared Savings Program is a voluntary program in which accountable care organizations (ACOs), which are collections of health care organizations that agree to accept accountability for a population of beneficiaries, enter into a contract with the Centers for Medicare & Medicaid Services (CMS), whereby the ACO is eligible for a shared savings payment if it is able to maintain payments to attributed beneficiaries below a financial benchmark, while simultaneously demonstrating adequate performance for a set of quality measures. CMS anticipates that 404 ACOs will serve 7.3 million beneficiaries in 2015.3 Established by the Affordable Care Act in 2010, the CMMI was funded with approximately