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BACKGROUND: Cardiovascular disease and stroke are common and costly, and their prevalence is rising. Forecasts on the prevalence of risk factors and clinical events are crucial. METHODS: Using the 2015 to March 2020 National Health and Nutrition Examination Survey and 2015 to 2019 Medical Expenditure Panel Survey, we estimated trends in prevalence for cardiovascular risk factors based on adverse levels of Life's Essential 8 and clinical cardiovascular disease and stroke. We projected through 2050, overall and by age and race and ethnicity, accounting for changes in disease prevalence and demographics. RESULTS: We estimate that among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050. Diabetes (16.3% to 26.8%) and obesity (43.1% to 60.6%) will increase, whereas hypercholesterolemia will decline (45.8% to 24.0%). The prevalences of poor diet, inadequate physical activity, and smoking are estimated to improve over time, whereas inadequate sleep will worsen. Prevalences of coronary disease (7.8% to 9.2%), heart failure (2.7% to 3.8%), stroke (3.9% to 6.4%), atrial fibrillation (1.7% to 2.4%), and total cardiovascular disease (11.3% to 15.0%) will rise. Clinical CVD will affect 45 million adults, and CVD including hypertension will affect more than 184 million adults by 2050 (>61%). Similar trends are projected in children. Most adverse trends are projected to be worse among people identifying as American Indian/Alaska Native or multiracial, Black, or Hispanic. CONCLUSIONS: The prevalence of many cardiovascular risk factors and most established diseases will increase over the next 30 years. Clinical and public health interventions are needed to effectively manage, stem, and even reverse these adverse trends. [ABSTRACT FROM AUTHOR]

The article discusses the health economics of cardiovascular disease (CVD) in the United States. CVD is the leading cause of morbidity and mortality in the country, resulting in significant direct medical spending and indirect costs. The economic burden of CVD is felt at various levels, including society, clinicians, and individual patients or families. Factors such as obesity, hypertension, and the increasing cost of cardiovascular medications and procedures contribute to the rising medical spending and indirect costs associated with CVD. Demographic shifts, including the aging and diversification of the population, are projected to drive cost growth and the need for cardiovascular services. Structural and systemic racism and other inequities contribute to the disproportionate burden of CVD borne by Black, Hispanic, and Native American individuals. The tension between the price and speed of innovation and health economics is also discussed, with high-priced but highly effective drugs facing challenges in uptake due to their unaffordability. The article emphasizes the need for policy interventions to address these issues, including reducing the unit costs of high-priced treatments, increasing access to innovative care, and reducing health care spending through prevention and addressing high prices. The economic trends facing clinicians, such as consolidation, corporatization, and private equity ownership, are also highlighted, along with the financial burdens faced by individuals and families affected by CVD. The article concludes by emphasizing the importance of prioritizing access, quality, and prevention to maximize cardiovascular health for all individuals in the United States. [Extracted from the article]

Despite higher per-capita health care spending than any other country, the United States lags far behind in health outcomes. Additionally, there are significant health inequities by race, ethnicity, socioeconomic position, and rurality. One set of potential solutions to improve these outcomes and reduce inequities is through health policy. Policy focused on improving access to care through insurance coverage, such as the Affordable Care Act's Medicaid expansion, has led to better health and reduced mortality. Policy aimed at improving health care delivery, including value-based payment and alternative payment models, has improved quality of care but has had little impact on population health outcomes. Policies that influence broader issues of economic opportunity likely have a strong influence on health, but lack the evidence base of more targeted interventions. To advance health outcomes and equity, further policy change is crucial. [ABSTRACT FROM AUTHOR]

BACKGROUND: Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive CR (ICR) which incorporates greater lifestyle education through 72 sessions (versus 36 in CR). Our objective was to determine whether ICR is associated with a mortality and cardiovascular benefit compared with CR. METHODS: Retrospective cohort study of Medicare Fee-For-Service beneficiaries in a 100% sample, claims data set. Qualifying events were captured from May 1, 2016 to December 31, 2019 and ICR/CR utilization captured from May 1, 2016 to December 31, 2020. Among patients attending at least 1 day of either CR or ICR, Cox proportional hazards models using a 1 to 5 propensity score match were used to compare utilization and the association of ICR versus CR participation with (1) all-cause mortality and (2) cardiovascular-related hospitalizations or nonfatal cardiac events. Dose-response was assessed by the number of days attended. RESULTS: From 2016 to 2019, 1 277 358 unique patients met at least one qualifying indication for ICR/CR from 2016 to 2019. Of these, 262 579 (20.6%) and 4452 (0.4%) attended at least one session of CR or ICR, respectively (mean [SD] age, 73.2 [7.8] years; 32.3% female). In the matched sample, including 26 659 total patients (median, 2.4-year follow-up), ICR was associated with 12% lower all-cause mortality (multivariable adjusted hazard ratio, 0.88 [95% CI, 0.78--0.99]; P=0.036) compared with CR but no significant difference for cardiovascular-related hospitalization or nonfatal cardiac events. The mortality benefit was seen for both ICR and CR per day strata, with each modality demonstrating a clear dose-response benefit. CONCLUSIONS: ICR is associated with lower mortality than traditional CR among Medicare beneficiaries but no difference in cardiovascular-related hospitalization or nonfatal cardiac events. Moreover, ICR and CR demonstrate a dose-response relationship for mortality. Additional studies are needed to confirm these observations and to better understand the mechanisms by which ICR may lead to a reduction in mortality. [ABSTRACT FROM AUTHOR]

A study published in the European Heart Journal analyzed trends in cardiovascular hospitalizations and in-hospital mortality among young and middle-aged adults in the USA between 2008 and 2019. The study found that hospitalizations for acute myocardial infarction, heart failure, and ischemic stroke increased during this period, while in-hospital mortality rates for these conditions slightly declined. The burden of comorbidities, particularly diabetes, kidney disease, and obesity, also increased among hospitalized patients. The study highlighted disparities in hospitalization rates and mortality based on income and insurance status, with low-income individuals and people identifying as Black or Hispanic being disproportionately affected. The authors suggested that a multifaceted approach is needed to address the increasing rates of hospitalizations and disparities in cardiovascular health, including raising awareness of disparities, improving access to care, and implementing interventions that address social determinants of health. [Extracted from the article]

Background: The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments.Methods: We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals). The primary outcomes were the differences in changes in quarterly trends in 90-day per-episode Medicare payments and the percentage of patients with readmission within 90 days after discharge. Secondary outcomes were mortality, volume, and case mix.Results: A total of 826 BPCI-A participant hospitals were compared with 2016 nonjoining hospitals and 334 late-joining hospitals. Among BPCI-A hospitals, the mean baseline 90-day per-episode Medicare payment was $27,315; the change in the quarterly trends in the intervention period as compared with baseline was -$78 per quarter. Among nonjoining hospitals, the mean baseline 90-day per-episode Medicare payment was $25,994; the change in quarterly trends as compared with baseline was -$26 per quarter (difference between nonjoining hospitals and BPCI-A hospitals, $52 [95% confidence interval {CI}, 34 to 70] per quarter; P<0.001; 0.2% of the baseline payment). Among late-joining hospitals, the mean baseline 90-day per-episode Medicare payment was $26,807; the change in the quarterly trends as compared with baseline was $4 per quarter (difference between late-joining hospitals and BPCI-A hospitals, $82 [95% CI, 41 to 122] per quarter; P<0.001; 0.3% of the baseline payment). There were no meaningful differences in the changes with regard to readmission, mortality, volume, or case mix.Conclusions: The BPCI-A program was associated with small reductions in Medicare payments among participating hospitals as compared with control hospitals. (Funded by the National Heart, Lung, and Blood Institute.). [ABSTRACT FROM AUTHOR]

Over the past two decades, Medicare and other payers have been looking at ways to base payment for cardiovascular care on the quality and outcomes of care delivered. Public reporting of hospital performance on a series of quality measures began in 2004 with basic processes of care such as aspirin use and influenza vaccination, and it expanded in later years to include outcomes such as mortality and readmission rates. Following the passage of the Affordable Care Act in March 2010, Medicare and other payers moved forward with payfor- performance programs, more commonly referred to as value-based purchasing (VBP) programs. These programs are largely based on an underlying fee-for-service payment infrastructure and give hospitals and clinicians bonuses or penalties based on their performance. Another new payment mechanism, called alternative payment models (APMs), aims to move towards episode-based or global payments to improve quality and efficiency. The two most relevant APMs for cardiovascular care include Accountable Care Organizations and bundled payments. Both VBP programs and APMs have challenges related to program efficacy, accuracy, and equity. In fact, despite over a decade of progress in measuring and incentivizing high-quality care delivery within cardiology, major limitations remain. Many of the programs have had little benefit in terms of clinical outcomes yet have led to marked administrative burden for participants. However, there are several encouraging prospects to aid the successful implementation of value-based high-quality cardiovascular care, such as more sophisticated data science to improve risk adjustment and flexible electronic health records to decrease administrative burden. Furthermore, payment models designed specifically for cardiovascular care could incentivize innovative care delivery models that could improve quality and outcomes for patients. This review provides an overview of current efforts, largely at the federal level, to pay for high-quality cardiovascular care and discusses the challenges and prospects related to doing so. [ABSTRACT FROM AUTHOR]

Background: In 2015, there were approximately 40,000 new HIV diagnoses in the United States. Pre-exposure prophylaxis (PrEP) is an effective strategy that reduces the risk of HIV acquisition; however, uptake among those who can benefit from it has lagged. In this study, we 1) compared the characteristics of patients who were prescribed PrEP with individuals newly diagnosed with HIV infection, 2) identified the specialties of practitioners prescribing PrEP, 3) identified metropolitan statistical areas (MSAs) within the US where there is relatively low uptake of PrEP, and 4) reported median amounts paid by patients and third-party payors for PrEP.Methods and Findings: We analyzed prescription drug claims for individuals prescribed PrEP in the Integrated Dataverse (IDV) from Symphony Health for the period of September 2015 to August 2016 to describe PrEP patients, prescribers, relative uptake, and payment methods in the US. Data were available for 75,839 individuals prescribed PrEP, and findings were extrapolated to approximately 101,000 individuals, which is less than 10% of the 1.1 million adults for whom PrEP was indicated. Compared to individuals with newly diagnosed HIV infection, PrEP patients were more likely to be non-Hispanic white (45% versus 26.2%), older (25% versus 19% at ages 35-44), male (94% versus 81%), and not reside in the South (30% versus 52% reside in the South).Using a ratio of the number of PrEP patients within an MSA to the number of newly diagnosed individuals with HIV infection, we found MSAs with relatively low uptake of PrEP were concentrated in the South. Of the approximately 24,000 providers who prescribed PrEP, two-thirds reported primary care as their specialty. Compared to the types of payment methods that people living with diagnosed HIV (PLWH) used to pay for their antiretroviral treatment in 2015 to 2016 reported in the Centers for Disease Control and Prevention (CDC) HIV Surveillance Special Report, PrEP patients were more likely to have used commercial health insurance (80% versus 35%) and less likely to have used public healthcare coverage or a publicly sponsored assistance program to pay for PrEP (12% versus 45% for Medicaid). Third-party payors covered 95% of the costs of PrEP. Overall, we estimated the median annual per patient out-of-pocket spending on PrEP was approximately US$72. Limitations of this study include missing information on prescription claims of patients not included in the database, and for those included, some patients were missing information on patient diagnosis, race/ethnicity, educational attainment, and income (34%-36%).Conclusions: Our findings indicate that in 2015-2016, many individuals in the US who could benefit from being on PrEP were not receiving this HIV prevention medication, and those prescribed PrEP had a significantly different distribution of characteristics from the broader population that is at risk for acquiring HIV. PrEP patients were more likely to pay for PrEP using commercial or private insurance, whereas PLWH were more likely to pay for their antiretroviral treatment using publicly sponsored programs. Addressing the affordability of PrEP and otherwise promoting its use among those with indications for PrEP represents an important opportunity to help end the HIV epidemic. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In 2018, CMS established reimbursement for the first Medicare-covered artificial intelligence (AI)--enabled clinical software: CT fractional flow reserve (FFRCT) to assist in the diagnosis of coronary artery disease. This study quantified Medicare utilization of and spending on FFRCT from 2018 through 2022 and characterized adopting hospitals, clinicians, and patients. STUDY DESIGN: Analysis, using 100% Medicare fee-for-service claims data, of the hospitals, clinicians, and patients who performed or received coronary CT angiography with or without FFRCT. METHODS: We measured annual trends in utilization of and spending on FFRCT among hospitals and clinicians from 2018 through 2022. Characteristics of FFRCT-adopting and nonadopting hospitals and clinicians were compared, as well as the characteristics of patients who received FFRCT vs those who did not. RESULTS: From 2018 to 2022, FFRCT billing volume in Medicare increased more than 11-fold (from 1083 to 12,363 claims). Compared with nonbilling hospitals, FFRCT-billing hospitals were more likely to be larger, part of a health system, nonprofit, and financially profitable. FFRCT-billing clinicians worked in larger group practices and were more likely to be cardiac specialists. FFRCT-receiving patients were more likely to be male and White and less likely to be dually enrolled in Medicaid or receiving disability benefits. CONCLUSIONS: In the initial 5 years of Medicare reimbursement for FFRCT, growth was concentrated among well-resourced hospitals and clinicians. As Medicare begins to reimburse clinicians for the use of AI-enabled clinical software such as FFRCT, it is crucial to monitor the diffusion of these services to ensure equal access. [ABSTRACT FROM AUTHOR]

Background: The Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. A subsequent study showed that the initiative was associated with reductions in Medicare payments for total joint replacement, but little is known about the effect of BPCI on medical conditions.Methods: We used Medicare claims from 2013 through 2015 to identify admissions for the five most commonly selected medical conditions in BPCI: congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD), sepsis, and acute myocardial infarction (AMI). We used difference-in-differences analyses to assess changes in standardized Medicare payments per episode of care (defined as the hospitalization plus 90 days after discharge) for these conditions at BPCI hospitals and matched control hospitals.Results: A total of 125 hospitals participated in BPCI for CHF, 105 hospitals for pneumonia, 101 hospitals for COPD, 88 hospitals for sepsis, and 73 hospitals for AMI. At baseline, the average Medicare payment per episode of care across the five conditions at BPCI hospitals was $24,280, which decreased to $23,993 during the intervention period (difference, -$286; P=0.41). Control hospitals had an average payment for all episodes of $23,901, which decreased to $23,503 during the intervention period (difference, -$398; P=0.08; difference in differences, $112; P=0.79). Changes from baseline to the intervention period in clinical complexity, length of stay, emergency department use or readmission within 30 or 90 days after hospital discharge, or death within 30 or 90 days after admission did not differ significantly between the intervention and control hospitals.Conclusions: Hospital participation in five common medical bundles under BPCI was not associated with significant changes in Medicare payments, clinical complexity, length of stay, emergency department use, hospital readmission, or mortality. (Funded by the Commonwealth Fund.). [ABSTRACT FROM AUTHOR]

Health services researchers now have enhanced opportunities for overcoming past obstacles to their work being relevant and useful for policy makers. Understanding the policy process itself is essential to taking advantage of these opportunities. Public policy making can be a complex process, and even the highest-quality evidence is only one of many factors considered and balanced during deliberations. We use a recent research report focused on social risk factors and provider performance as an example of the role evidence plays in policy deliberations. The report addressed the question of whether Medicare's value-based purchasing programs should be adjusted for patients' social risk factors. Despite high-quality and consistent results about the relationship between performance and social risk factors, policy deliberations did not result in a simple recommendation about making adjustments. Thus, the report offers a window into the role of research evidence in the development of policy. [ABSTRACT FROM AUTHOR]

Background: Recent policy efforts have focused on improving the value of acute myocardial infarction (AMI) care. Medicare payment programs, for example, increasingly evaluate hospital performance based on spending, as determined by payments made to institutions and providers, and outcome measures for a longitudinal episode of AMI care. Little is known about the relationship between total 30-day payments-both in the inpatient and immediate postdischarge timeframe-and outcomes after an admission for AMI.Methods and Results: Using Medicare claims data, we identified Medicare fee-for-service beneficiaries ≥65 years of age who were hospitalized at an acute-care hospital for AMI between July 1, 2011, and June 30, 2014, and examined the association between hospital-level 30-day payments for an episode of AMI care and patient 30-day mortality using mixed regression models with a logit link function and random hospital intercepts. Our cohort included 642 105 index hospitalizations for AMI at 2319 acute-care hospitals. Overall mean 30-day episode payments per beneficiary were $22 128 (SD, $1750). The observed 30-day mortality rate was 12.9%. Higher 30-day payments were associated with lower 30-day mortality after adjustment for patient characteristics and comorbidities (adjusted odds ratio for additional $1000 payments, 0.986; 95% confidence interval, 0.979-0.992; P<0.001). Additional adjustment for potential mediating factors, including hospital characteristics, coronary revascularization rates, and discharge disposition, did not significantly attenuate the relationship (adjusted odds ratio for additional $1000 payments, 0.987; 95% confidence interval, 0.980-0.994; P<0.001).Conclusions: Higher hospital-level 30-day payments-both inpatient and in multiple settings after discharge-for AMI care were associated with lower 30-day mortality among beneficiaries. This may have implications for payment programs that incent reduction in payments without considering value. [ABSTRACT FROM AUTHOR]

Critical access hospitals are important providers of care for rural and other underserved communities, but they face staffing and quality challenges while operating with low margins. Medicaid expansion has been found to improve hospital finances broadly and therefore may have permitted sustained investments in staffing and quality improvement at these vulnerable hospitals. In this difference-in-differences analysis, we found that critical access hospitals in Medicaid expansion states did not have statistically significant postexpansion increases in operating margins relative to hospitals in nonexpansion states. Nor did we see evidence of statistically significant differential improvement at critical access hospitals in expansion versus nonexpansion states on either staffing measures (physicians and registered nurses per 1,000 patient days) or quality measures (percentage-point changes in readmissions and mortality within thirty days of admission for pneumonia or heart failure). These findings suggest that critical access hospitals may need to take additional measures to bolster finances to provide continued support for the delivery of high-quality care to rural and other underserved communities. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the ambulatory care access and emergency department use of Medicare beneficiaries with or without disabilities in the U.S. The study employed the 2015-2017 national Medicare Current Beneficiary Survey related to claims and administrative data. Also cited is the introduction by the Centers for Medicare and Medicaid Services (CMS) of the Medicare Quality Payment Program in 2017.

The article explores how policymakers identify safety-net hospitals, which has been a challenging but critical issue in U.S. health policy during Covid-19 pandemic. Topics include the U.S. Department of Health and Human Services (HHS) have struggled to operationalize a strategy for distributing Covid-19 relief funds to the hospitals; and how National Academy of Medicine has defined safety-net providers with insurance coverage, financial circumstances, or immigration status.

The article offers information on the Hospital Readmissions Reduction Program (HRRP) was established by the Centers for Medicare and Medicaid Services (CMS) in 2010 with a goal of reducing preventable hospitalizations by imposing financial penalties on hospitals with higher than-expected 30-day readmission rates. It also mentions that current risk-adjustment models also omit social risk factors that are strongly related to readmissions, such as poverty.

OBJECTIVES: We aimed to describe the experience of a state Medicaid agency incentivizing reduction of racial and ethnic disparities in a hospital quality incentive program (QIP). STUDY DESIGN: Retrospective review of a decade of experience implementing a hospital health disparity (HD) composite measure. METHODS: Observational analysis of programwide trends in missed opportunity rates and between-group variance (BGV) for the HD composite from 2011 to 2020 and subanalysis of 16 metrics included in the HD composite for at least 4 years over the decade. RESULTS: Programwide missed opportunity rates and BGV fluctuated widely from 2011 to 2020, likely due to variation in measures included in the HD composite. When the 16 measures that were included in the HD composite for at least 4 years were collapsed into a hypothetical 4-year period, missed opportunity rates decreased across the 4 consecutive years, from 47% in year 1 to 20% in year 4. Differences among racial and ethnic subgroups also decreased across the 4-year period, as reflected in the BGV decrease from 7.85 x 10-4 in year 1 to 5.10 x 10-4 in year 4. CONCLUSIONS: Construction of a composite measure, use of a summary disparity statistic, and measure selection are key considerations in the design and interpretation of equity-focused payment programs. This analysis revealed improved aggregate quality performance and a modest reduction in racial and ethnic disparities for measures included in the HD composite for at least 4 years. Further research is needed to evaluate the association between equity-oriented incentives and health disparities. [ABSTRACT FROM AUTHOR]

Prior studies suggest that the COVID-19 pandemic was associated with decreases in emergency department (ED) volumes, but it is not known whether these decreases varied by visit acuity or by demographic and socioeconomic risk factors. In this study of more than one million non-COVID-19 visits to thirteen EDs in a large St. Louis, Missouri, health system, we observed an overall 35 percent decline in ED visits. The decrease in medical and surgical visits ranged from 40 percent to 52 percent across acuity levels, with no statistically significant differences between higher and lower-acuity visits after correction for multiple comparisons. Mental health visits saw a smaller decrease (-32 percent), and there was no decrease for visits due to substance use. Medicare patients had the smallest decrease in visits (-31 percent) of the insurance groups; privately insured (-46 percent) and Medicaid (-44 percent) patients saw larger drops. There were no observable differences in ED visit decreases by race. These findings can help inform interventions to ensure that people requiring timely ED care continue to seek it and to improve access to lowerrisk alternative settings of care where appropriate. [ABSTRACT FROM AUTHOR]

Background: In 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge).Methods: We conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as "treatment" areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post-acute care facilities), rates of postsurgical complications, and the percentage of "high-risk" patients (i.e., patients for whom there was an elevated risk of spending - a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures.Results: From 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], -$812, or a -3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post-acute care facilities. The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81).Conclusions: In the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.). [ABSTRACT FROM AUTHOR]