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Concept: Medicare


Risk sharing arrangements between hospitals and payers together with penalties imposed by the Centers for Medicare and Medicaid (CMS) are driving an interest in decreasing early readmissions. There are a number of published risk models predicting 30 day readmissions for particular patient populations, however they often exhibit poor predictive performance and would be unsuitable for use in a clinical setting. In this work we describe and compare several predictive models, some of which have never been applied to this task and which outperform the regression methods that are typically applied in the healthcare literature. In addition, we apply methods from deep learning to the five conditions CMS is using to penalize hospitals, and offer a simple framework for determining which conditions are most cost effective to target.

Concepts: Prediction, Medicaid, Scientific method, Medicare, Hospital, Centers for Medicare and Medicaid Services, Health insurance, Regression analysis


Opioid-related mortality increased by 15.6% from 2014 to 2015 and increased almost 320% between 2000 and 2015. Recent research finds that the use of all pain medications (opioid and nonopioid collectively) decreases in Medicare Part D and Medicaid populations when states approve medical cannabis laws (MCLs). The association between MCLs and opioid prescriptions is not well understood.

Concepts: Medicare Part D, Cannabis, U.S. state, Pharmacology, Health insurance in the United States, Medicare


To examine national changes in rates of cost-related prescription nonadherence (CRN) by age group, we used data from the 1999-2015 Sample Adult and Sample Child National Health Interview Surveys (n = 768 781). In a logistic regression analysis of 2015 data, we identified subgroups at risk for cost-related nonadherence. The proportion of all Americans who did not fill a prescription in the previous 12 months because they could not afford it grew from 1999 to 2009, peaking at 8.3% at the height of the Great Recession and dropping to 5.2% by 2015. CRN among seniors, however, peaked in 2004 at 5.4% and dropped to 3.6% after implementation of Medicare Part D in 2006. CRN is responsive to improved access related to implementation of Medicare Part D and the Affordable Care Act. (Am J Public Health. Published online ahead of print August 23, 2016: e1-e4. doi:10.2105/AJPH.2016.303269).

Concepts: Medicare Prescription Drug, Improvement, and Modernization Act, Health care, Medicare Part D, Medicare, Regression analysis, Late-2000s recession, Pharmacology, Logistic regression



Health spending growth in the United States for 2015-25 is projected to average 5.8 percent-1.3 percentage points faster than growth in the gross domestic product-and to represent 20.1 percent of the total economy by 2025. As the initial impacts associated with the Affordable Care Act’s coverage expansions fade, growth in health spending is expected to be influenced by changes in economic growth, faster growth in medical prices, and population aging. Projected national health spending growth, though faster than observed in the recent history, is slower than in the two decades before the recent Great Recession, in part because of trends such as increasing cost sharing in private health insurance plans and various Medicare payment update provisions. In addition, the share of total health expenditures paid for by federal, state, and local governments is projected to increase to 47 percent by 2025.

Concepts: Medicare, Price, Canada Health Act, Health care, United States, Cost, Health insurance, Economics


On January 10, 2014, the Centers for Medicare and Medicaid Services (CMS) and the State of Maryland jointly announced the launch of a statewide model that will transform Maryland’s health care delivery system. Although some aspects of the new approach may be unique to Maryland and not applicable elsewhere, both the principles of this model and the process that led to its development may serve as a guide for future federal-state partnership efforts aiming to improve health care and to lower costs through an all-payer approach. Since the late 1970s, Maryland has operated what is now the country’s only all-payer . . .

Concepts: Medicine, Health, Medicare, Medical ethics, Health care, Massachusetts, Health insurance, Centers for Medicare and Medicaid Services


Background From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. Methods We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period. Results Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences. Conclusions Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).

Concepts: The Higher, Health insurance, Health insurance in the United States, Better, Medicare and Medicaid, Medicaid, Medicare, Centers for Medicare and Medicaid Services


Nonadherence to taking prescribed antihypertensive medication (antihypertensive) regimens has been identified as a leading cause of poor blood pressure control among persons with hypertension and an important risk factor for adverse cardiovascular disease outcomes. CDC and the Centers for Medicare and Medicaid Services analyzed geographic, racial-ethnic, and other disparities in nonadherence to antihypertensives among Medicare Part D beneficiaries in 2014.

Concepts: Medicare Prescription Drug, Improvement, and Modernization Act, Medicare Part D, Vital signs, Medicare and Medicaid, Health insurance in the United States, Centers for Medicare and Medicaid Services, Medicare, Blood pressure


A bipartisan, bicameral proposal from the Senate Finance Committee and House Ways and Means Committee to repeal and replace the Medicare sustainable growth rate formula (SGR) for physician payment would begin to reform provider payment to reward high-value care.(1) It calls for replacement of the SGR with a 10-year freeze on physician payment levels and, beginning in 2016-2017, would provide a 5% bonus to physicians who receive a substantial portion of their revenue through an alternative payment model, such as a patient-centered medical home (PCMH), an accountable care organization, or a bundled-payment system. The Senate Finance-House Ways and Means proposal . . .

Concepts: Medicine, Medicare, United States House Committee on Ways and Means, United States Senate Committee on Finance


IMPORTANCE Hypertension control for large populations remains a major challenge. OBJECTIVE To describe a large-scale hypertension program in Northern California and to compare rates of hypertension control in that program with statewide and national estimates. DESIGN, SETTING, AND PATIENTS The Kaiser Permanente Northern California (KPNC) hypertension program included a multifaceted approach to blood pressure control. Patients identified as having hypertension within an integrated health care delivery system in Northern California from 2001-2009 were included. The comparison group comprised insured patients in California between 2006-2009 who were included in the Healthcare Effectiveness Data and Information Set (HEDIS) commercial measurement by California health insurance plans participating in the National Committee for Quality Assurance (NCQA) quality measure reporting process. A secondary comparison group was included to obtain the reported national mean NCQA HEDIS commercial rates of hypertension control between 2001-2009 from health plans that participated in the NCQA HEDIS quality measure reporting process. MAIN OUTCOMES AND MEASURES Hypertension control as defined by NCQA HEDIS. RESULTS The KPNC hypertension registry included 349 937 patients when established in 2001 and increased to 652 763 by 2009. The NCQA HEDIS commercial measurement for hypertension control within KPNC increased from 43.6% (95% CI, 39.4%-48.6%) to 80.4% (95% CI, 75.6%-84.4%) during the study period (P < .001 for trend). In contrast, the national mean NCQA HEDIS commercial measurement increased from 55.4% to 64.1%. California mean NCQA HEDIS commercial rates of hypertension were similar to those reported nationally from 2006-2009 (63.4% to 69.4%). CONCLUSIONS AND RELEVANCE Among adults diagnosed with hypertension, implementation of a large-scale hypertension program was associated with a significant increase in hypertension control compared with state and national control rates. Key elements of the program included a comprehensive hypertension registry, development and sharing of performance metrics, evidence-based guidelines, medical assistant visits for blood pressure measurement, and single-pill combination pharmacotherapy.

Concepts: Medicine, Medicare, National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, Blood pressure, Health insurance, Health care provider, Health care