RESUMO
BACKGROUND: Medicare Part B pharmaceutical spending has increased rapidly, more than doubling in 2006-2017. Yet, it is unclear whether this increase was driven by increased utilization or increased cost per claim. OBJECTIVE: To evaluate the relative impact of changes in drug utilization and cost per claim on changes in Medicare Part B pharmaceutical spending in 2008-2016 overall, by drug type (specialty and nonspecialty) and therapeutic category. METHODS: In this retrospective descriptive study, we extracted all claims in 2008-2016 for separately payable Part B drugs from a 5% random sample of Medicare beneficiaries. Our study included 3 outcomes calculated annually for all included drugs: (1) spending, defined as the sum of total payments; (2) utilization, defined as total number of claims; and (3) cost per claim, defined as spending divided by the number of claims. Estimates of spending and utilization were expressed per beneficiary-year. Spending and cost per claim were adjusted for inflation. For each outcome, we calculated relative changes in 2008-2016. We repeated analyses stratifying by drug type (specialty and nonspecialty) and therapeutic class. RESULTS: Pharmaceutical spending in Medicare Part B increased by 34% from 2008-2016, driven by a 53% increase in the cost per claim. Utilization decreased by 12%. Spending on specialty drugs increased by 56%, driven by a 48% increase in the cost per claim and a 6% utilization increase. Spending on nonspecialty drugs decreased by 32% driven by an 18% reduction in the cost per claim and a 17% reduction in utilization. Spending on ophthalmic preparations increased by 281%, driven by a 238% utilization increase and a 13% increase in the cost per claim. Spending on antiarthritic and immunologic agents increased by 159%, driven by a 117% increase in the cost per claim and a 19% utilization increase. CONCLUSIONS: Medicare Part B pharmaceutical spending grew in recent years, despite decreased utilization, driven by an overall increase in the cost per claim. This was a product of rising drug prices and increased utilization of more expensive specialty drugs. These findings support the development of policies that aim to spur competition and control price growth of provider-administered drugs. DISCLOSURES: The authors acknowledge funding from the Myers Family Foundation. Hernandez was funded by the National Heart, Lung and Blood Institute (grant number K01HL142847). Shrank is an employee of Humana. Good is an employee of the UPMC Health Plan Insurance Services Division. There are no other potential conflicts of interest to disclose.
Assuntos
Custos de Medicamentos , Uso de Medicamentos/economia , Gastos em Saúde/tendências , Medicare Part B/economia , Humanos , Revisão da Utilização de Seguros , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: To examine the impact of the 340B drug discount program on the site of cancer drug administration and cancer care spending in Medicare. DATA SOURCES/STUDY SETTING: 2010-2013 Medicare claims data for a random sample of Medicare Fee-for-Service beneficiaries with cancer. STUDY DESIGN: We identified the 340B effect using variation in the availability of 340B hospitals across markets. We considered beneficiaries from markets that newly gained a 340B hospital during the study period (new 340B markets) as the treatment group. Beneficiaries in markets with no 340B hospital were the control group. We used a difference-in-differences approach with market fixed effects. DATA COLLECTION: Secondary data analysis. PRINCIPAL FINDINGS: The probability of a patient receiving cancer drug administration in hospital outpatient departments (HOPDs) versus physician offices increased 7.8 percentage points more in new 340B markets than in markets with no 340B hospital. Per-patient spending on other cancer care increased $1,162 more in new 340B markets than in markets with no 340B hospital. CONCLUSIONS: The 340B program shifted the site of cancer drug administration to HOPDs and increased spending on other cancer care. As the program expands, continuing assessment of its impact on service utilization and spending would be needed.
Assuntos
Assistência Ambulatorial/economia , Antineoplásicos/economia , Redução de Custos , Economia Hospitalar , Planos de Pagamento por Serviço Prestado/economia , Medicare Part B/economia , Custos e Análise de Custo , Humanos , Estados UnidosRESUMO
We propose a novel and easy-to-implement approach to detect potential overbilling based on the hours worked implied by the service codes which physicians submit to Medicare. Using the Medicare Part B Fee- for-Service (FFS) Physician Utilization and Payment Data in 2012 and 2013 released by the Centers for Medicare and Medicaid Services, we construct estimates for physicians' hours spent on Medicare beneficiaries. We find that about 2,300 physicians, representing about 3 percent of those with 20 or more hours of Medicare Part B FFS services, have billed Medicare over 100 hours per week. We consider these implausibly long hours.
Assuntos
Fraude/prevenção & controle , Reembolso de Seguro de Saúde/economia , Medicare Part B/economia , Planos de Pagamento por Serviço Prestado , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Fatores de Tempo , Estados UnidosRESUMO
The Medicare population remains largely unmanaged despite its increasing cost burden. With a few notable exceptions, health maintenance organizations (HMOs) have historically avoided serving this expensive segment. In many cases, the inability to control costs results from failing to understand the importance of specialist reimbursement mechanisms. This article examines the importance of these mechanisms and describes how to successfully capitate specialty physicians in a Medicare risk program. The article also includes a case study on a successful capitation agreement between an HMO and a specialty group.