Steven A. Farmer

Geographic variation in cardiovascular procedure use among medicare fee-for-service vs medicare advantage beneficiaries

IMPORTANCE Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures. OBJECTIVE To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states. MAIN OUTCOMES AND MEASURES Rates of coronary angiography, PCI, and CABG surgery. RESULTS We evaluated a total of 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates. CONCLUSIONS AND RELEVANCE Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.

Tension Between Quality Measurement, Public Quality Reporting, and Pay for Performance

ACCURATE MEASURES OF OUTCOMES ARE NECESSARY TO improve the quality of US health care and address geographic, socioeconomic, and racial/ethnic variations in care quality. However, 2 major initiatives that seek to improve quality—public reporting of outcomes and pay for performance (P4P)—have the potential to reduce the reliabilityof theadministrativedataonwhich theyareoften based and generate spurious estimates of performance.

Demographic, Psychosocial, and Behavioral Factors Associated With Survival After Heart Transplantation

BACKGROUND Heart transplantation requires substantial personal, financial, and psychosocial resources. Using an existing multisite data set, we examined predictors of mortality at 5 to 10 years after heart transplantation. METHODS All 555 participants completed a self-report quality of life instrument. Of these patients, 55 (10%) died 5 to 10 years after heart transplantation. Statistical analyses included frequencies, means, Pearson correlation coefficients, and Cox proportional hazard modeling. RESULTS Educational level and higher levels of social and economic satisfaction were predictive of improved survival. Conversely, married status, more cumulative infections, the presence of hematologic disorders, higher New York Heart Association (NYHA) class, and poor adherence to medical care predicted worse survival. CONCLUSIONS Demographic, clinical, psychosocial, and behavioral factors were important predictors of long-term survival after heart transplantation. These findings have important implications for patient selection for heart transplantation, as well as for posttransplantation care.

Existing and Emerging Payment and Delivery Reforms in Cardiology

Importance Recent health care reforms aim to increase patient access, reduce costs, and improve health care quality as payers turn to payment reform for greater value. Cardiologists need to understand emerging payment models to succeed in the evolving payment landscape. We review existing payment and delivery reforms that affect cardiologists, present 4 emerging examples, and consider their implications for clinical practice. Observations Public and commercial payers have recently implemented payment reforms and new models are evolving. Most cardiology models are modified fee-for-service or address procedural or episodic care, but population models are also emerging. Although there is widespread agreement that payment reform is needed, existing programs have significant limitations and the adoption of new programs has been slow. New payment reforms address some of these problems, but many details remain undefined. Conclusions and Relevance Early payment reforms were voluntary and cardiologists’ participation is variable. However, conventional fee-for-service will become less viable, and enrollment in new payment models will be unavoidable. Early participation in new payment models will allow clinicians to develop expertise in new care pathways during a period of relatively lower risk.

Patient, Caregiver, and Physician Work in Heart Failure Disease Management: A Qualitative Study of Issues That Undermine Wellness

OBJECTIVE To identify factors underlying heart failure hospitalization. METHODS Between January 1, 2012, and May 31, 2012, we combined medical record reviews and cross-sectional qualitative interviews of multiple patients with heart failure, their clinicians, and their caregivers from a large academic medical center in the Midwestern United States. The interview data were analyzed using a 3-step grounded theory-informed process and constant comparative methods. Qualitative data were compared and contrasted with results from the medical record review. RESULTS Patient nonadherence to the care plan was the most important contributor to hospital admission; however, reasons for nonadherence were complex and multifactorial. The data highlight the importance of patient education for the purposes of condition management, timeliness of care, and effective communication between providers and patients. CONCLUSION To improve the consistency and quality of care for patients with heart failure, more effective relationships among patients, providers, and caregivers are needed. Providers must be pragmatic when educating patients and their caregivers about heart failure, its treatment, and its prognosis.

Fully Capitated Payment Breakeven Rate for a Mid-Size Pediatric Practice

BACKGROUND AND OBJECTIVES: Payers are implementing alternative payment models that attempt to align payment with high-value care. This study calculates the breakeven capitated payment rate for a midsize pediatric practice and explores how several different staffing scenarios affect the rate. METHODS: We supplemented a literature review and data from >200 practices with interviews of practice administrators, physicians, and payers to construct an income statement for a hypothetical, independent, midsize pediatric practice in fee-for-service. The practice was transitioned to full capitation to calculate the breakeven capitated rate, holding all practice parameters constant. Panel size, overhead, physician salary, and staffing ratios were varied to assess their impact on the breakeven per-member per-month (PMPM) rate. Finally, payment rates from an existing health plan were applied to the practice. RESULTS: The calculated breakeven PMPM was

Implications of the PEGASUS-TIMI 54 trial for US clinical practice

24.10. When an economic simulation allowed core practice parameters to vary across a broad range, 80% of practices broke even with a PMPM of

Payment Reform to Enhance Collaboration of Primary Care and Cardiology: A Review

35.00. The breakeven PMPM increased by 12% (

The Maryland Medicare waiver and emergency care: mixed experiences deserve close scrutiny.

3.00) when the staffing ratio increased by 25% and increased by 23% (

Association of Medical Liability Reform With Clinician Approach to Coronary Artery Disease Management

5.50) when the staffing ratio increased by 38%. The practice was viable, even with primary care medical home staffing ratios, when rates from a real-world payer were applied. CONCLUSIONS: Practices are more likely to succeed in capitated models if pediatricians understand how these models alter practice finances. Staffing changes that are common in patient-centered medical home models increased the breakeven capitated rate. The degree to which team-based care will increase panel size and offset increased cost is unknown.