Nicole M. Coomer

The impact of hospital-acquired conditions on Medicare program payments.

RESEARCH OBJECTIVEnHospital-acquired conditions, or HACs, often result in additional Medicare payments, generated during the initial hospitalization and in subsequent health care encounters. The purpose of this article is to estimate the incremental cost to Medicare, as measured by Medicare program payments, of six HACs.nnnSTUDY DESIGNnThe researchers used a matched case-control design to determine the incremental increase in Medicare payments attributable to each HAC. For each HAC patient, five comparison patients were matched on diagnosis group, sex, race, and age. Using the matched sample, we estimated a hospital fixed effects log-linear regression on total Medicare payments for the episode of care, further controlling for co-morbid conditions. Care episodes included the initial hospitalization and all inpatient, outpatient, physician, home health, and hospice care that occurred within 90 days of hospital discharge.nnnPOPULATION STUDIEDnAll Medicare fee-for-service patients discharged alive from a hospital between October 2008 and June 2010 with one of six HACs-severe pressure ulcer, fracture, catheter-associated urinary tract infection, vascular catheter-associated infection, surgical site infection following certain orthopedic procedures, or deep vein thrombosis/ pulmonary embolism following certain orthopedic procedures-were included in the sample and matched to five similar patients without the HACs.nnnPRINCIPAL FINDINGSnThe multivariate analysis suggests that Medicare paid an additional

Utilization of genetic tests: analysis of gene-specific billing in Medicare claims data

146 million per year across these HAC care episodes compared with what would have been paid without the HACs.nnnCONCLUSIONSnHACs create a significant financial burden for the Medicare program. We compare the incremental Medicare payments for these six HACs to the current and upcoming Medicare HAC payment penalties.

Impact of hospital-acquired conditions on financial liabilities for Medicare patients

Purpose:We examined the utilization of precision medicine tests among Medicare beneficiaries through analysis of gene-specific tier 1 and 2 billing codes developed by the American Medical Association in 2012.Methods:We conducted a retrospective cross-sectional study. The primary source of data was 2013 Medicare 100% fee-for-service claims. We identified claims billed for each laboratory test, the number of patients tested, expenditures, and the diagnostic codes indicated for testing. We analyzed variations in testing by patient demographics and region of the country.Results:Pharmacogenetic tests were billed most frequently, accounting for 48% of the expenditures for new codes. The most common indications for testing were breast cancer, long-term use of medications, and disorders of lipid metabolism. There was underutilization of guideline-recommended tumor mutation tests (e.g., epidermal growth factor receptor) and substantial overutilization of a test discouraged by guidelines (methylenetetrahydrofolate reductase). Methodology-based tier 2 codes represented 15% of all claims billed with the new codes. The highest rate of testing per beneficiary was in Mississippi and the lowest rate was in Alaska.Conclusions:Gene-specific billing codes significantly improved our ability to conduct population-level research of precision medicine. Analysis of these data in conjunction with clinical records should be conducted to validate findings.Genet Med advance online publication 26 January 2017

Examination of the Accuracy of Coding Hospital-Acquired Pressure Ulcer Stages

BACKGROUNDnHospital-acquired conditions (HACs) can increase the financial liabilities faced by patients when the HACs require additional treatment both in the hospital and in subsequent health care encounters. This article estimates incremental effects of 6 HACs on Medicare beneficiary financial liabilities.nnnMETHODSnDescriptive and multivariate analyses were used to examine the differences in beneficiary liability between care episodes with and without HACs. Episodes included the index hospitalization in which the HAC occurred and all inpatient, outpatient, and physician claims within 90 days of index hospital discharge. Medicare fee-for-service patients discharged from a hospital in fiscal year (FY) 2009 or FY 2010 with severe pressure ulcer, fracture, catheter-associated urinary tract infection, vascular catheter-associated infection, surgical site infection, or deep vein thrombosis or pulmonary embolism after certain orthopedic procedures were matched by diagnosis, sex, race, and age to with patients without HACs.nnnRESULTSnMedicare patients were liable for an additional

21-Gene recurrence score testing among Medicare beneficiaries with breast cancer in 2010–2013

20.5 million per year across the HAC episodes compared with what they would have owed without the HACs. Beneficiaries with HACs were also more likely to exhaust their Part A days in the index hospitalization.nnnCONCLUSIONSnHACs create significant financial burden for Medicare beneficiaries. The incremental financial liabilities are concentrated in the episode of care after the index hospitalization with the HAC. Policies and programs that reduce HAC incidence will improve Medicare beneficiaries physical and financial health.

Underutilization and disparities in access to EGFR testing among Medicare patients with lung cancer from 2010-2013

OBJECTIVEnPressure ulcers (PU) are considered harmful conditions that are reasonably prevented if accepted standards of care are followed. They became subject to the payment adjustment for hospitalacquired conditions (HACs) beginning October 1, 2008. We examined several aspects of the accuracy of coding for pressure ulcers under the Medicare Hospital-Acquired Condition Present on Admission (HAC-POA) Program. We used the 4010 claim format as a basis of reference to show some of the issues of the old format, such as the underreporting of pressure ulcer stages on pressure ulcer claims and how the underreporting varied by hospital characteristics. We then used the rate of Stage III and IV pressure ulcer HACs reported in the Hospital Cost and Utilization Project State Inpatient Databases data to look at the sensitivity of PU HAC-POA coding to the number of diagnosis fields.nnnMETHODSnWe examined Medicare claims data for FYs 2009 and 2010 to examine the degree that the presence of stage codes were underreported on pressure ulcer claims. We selected all claims with a secondary diagnosis code of pressure ulcer site (ICD-9 diagnosis codes 707.00-707.09) that were not reported as POA (POA of N or U). We then created a binary indicator for the presence of any pressure ulcer stage diagnosis code. We examine the percentage of claims with a diagnosis of a pressure ulcer site code with no accompanying pressure ulcer stage code.nnnRESULTSnOur results point to underreporting of PU stages under the 4010 format and that the reporting of stage codes varied across hospital type and location. Further, our results indicate that under the 5010 format, a higher number of pressure ulcer HACs can be expected to be reported and we should expect to encounter a larger percentage of pressure ulcers incorrectly coded as POA under the new format.nnnCONCLUSIONSnThe combination of the capture of 25 diagnosis codes under the new 5010 format and the change from ICD-9 to ICD-10 will likely alleviate the observed underreporting of pressure ulcer HACs. However, as long as coding guidelines direct that Stage III and IV pressure ulcers be coded as POA, if a lower stage pressure ulcer was POA and progressed to a higher stage pressure ulcer during the admission, the acquisition of Stage III and IV pressure ulcers in the hospital will be underreported.

An Investigation of the Historical Black Wage Premium in Nursing

Purpose:We evaluated national patient-level utilization of the 21-gene recurrence score (21-gene RS) test among Medicare beneficiaries with breast cancer. We analyzed clinical, demographic, and regional factors that predict testing.Methods:Using 2010–2013 Medicare claims, we conducted a retrospective study of breast cancer patients. The outcome variable was whether the patient underwent testing. Independent variables expected to predict testing were age, gender, race, Medicaid status, clinical characteristics, and hospital referral region (HRR).Results:From 2010 to 2013, the number of test orders increased by 23.0%. Of the 256,818 patients identified in 2011–2012 claims, 25,352 (9.9%) underwent the 21-gene RS test. Estrogen receptor–positive status was the strongest positive predictor of testing (odds ratio (OR) 2.58, 95% confidence interval (CI) 2.48–2.69). White patients were more likely to be tested than minorities (OR 1.46, 95% CI 1.39–1.52). Secondary cancer was the strongest negative predictor. Medicaid recipients were less likely to be tested (OR 0.74, 95% CI 0.71–0.78). The likelihood of testing decreased with increasing age and comorbidities.Conclusions:Despite widespread implementation of the 21-gene RS test, minorities and Medicaid recipients had less access to testing. Many patients with serious comorbidities or advanced age were tested even though the risk algorithm may not have been applicable to them.Genet Med advance online publication 23 March 2017

Children's public health insurance and scholastic success

BackgroundTumor testing for mutations in the epidermal growth factor receptor (EGFR) gene is indicated for all newly diagnosed, metastatic lung cancer patients, who may be candidates for first-line treatment with an EGFR tyrosine kinase inhibitor. Few studies have analyzed population-level testing.MethodsWe identified clinical, demographic, and regional predictors of EGFR & KRAS testing among Medicare beneficiaries with a new diagnosis of lung cancer in 2011–2013 claims. The outcome variable was whether the patient underwent molecular, EGFR and KRAS testing. Independent variables included: patient demographics, Medicaid status, clinical characteristics, and region where the patient lived. We performed multivariate logistic regression to identify factors that predicted testing.ResultsFrom 2011 to 2013, there was a 19.7% increase in the rate of EGFR testing. Patient zip code had the greatest impact on odds to undergo testing; for example, patients who lived in the Boston, Massachusetts hospital referral region were the most likely to be tested (odds ratio (OR) of 4.94, with a 95% confidence interval (CI) of 1.67–14.62). Patient demographics also impacted odds to be tested. Asian/Pacific Islanders were most likely to be tested (OR 1.63, CI 1.53–1.79). Minorities and Medicaid patients were less likely to be tested. Medicaid recipients had an OR of 0.74 (CI 0.72–0.77). Hispanics and Blacks were also less likely to be tested (OR 0.97, CI 0.78–0.99 and 0.95, CI 0.92–0.99), respectively. Clinical procedures were also correlated with testing. Patients who underwent transcatheter biopsies were 2.54 times more likely to be tested (CI 2.49–2.60) than those who did not undergo this type of biopsy.ConclusionsDespite an overall increase in EGFR testing, there is widespread underutilization of guideline-recommended testing. We observed racial, income, and regional disparities in testing. Precision medicine has increased the complexity of cancer diagnosis and treatment. Targeted interventions and clinical decision support tools are needed to ensure that all patients are benefitting from advances in precision medicine. Without such interventions, precision medicine may exacerbate racial disparities in cancer care and health outcomes.

Historical data indicates a wage premium for black registered nurses.

This paper builds off of prior work analyzing the historical wage premium paid to black registered nurses (RNs) (Coomer, Nurs Econ 31(5):254–259, 2013). The average observed wages of black RNs was higher than that of white RNs in the National Sample Survey of Registered Nurses (NSSRN) over more than two decades from 1984 to 2008. This study examines the wage differential between black and white nurses that remains after controlling for factors likely to affect wages in addition to race, such as experience, education, employer type, and specialty. The differential is decomposed, following Blinder (1973) and Oaxaca (1973), revealing a large unexplained portion. Four possible explanations are examined and support is found for self-selection, experience, shift work, and demand effects.

The Effect of the Minimum Wage on Covered Teenage Employment

There are currently two public health insurance options available to United States children, Medicaid and the State Children’s Health Insurance Program (SCHIP). The programmes are similar in that they both target improvements in children’s health through increased access to medical care. A well-developed body of literature has examined the effect these programmes have on a child’s health and to a large extent has found that the programmes perform as desired. This article uses data from the Early Childhood Longitudinal Study–Kindergarten Cohort to determine whether access to public health insurance translates to an improvement in a child’s academic performance.