Physical Therapy Mandates by Medicare Administrative Contractors: Effective or Wasteful?

Documentation of medical necessity for arthroplasty has come under scrutiny by Medicare. In some jurisdictions three months of physical therapy prior to arthroplasty has been mandated. The purpose of this study was to determine the efficacy and cost of this policy to treat advanced osteoarthritis. A systematic review was performed to assimilate efficacy data for physical therapy in patients with advanced osteoarthritis. The number of arthroplasties performed annually was obtained to calculate cost. Evidence-based studies documenting the efficacy of physical therapy in treating advanced arthritis are lacking with a potential cost of 36–68 million dollars. Physical therapy mandates by administrative contractors are not only ineffective but are costly without patient benefit. Medical necessity documentation should be driven by orthopedists not retroactively by Medicare contractors.     

Variation of Medicare Payments for Total Knee Arthroplasty

We analyzed the 2009 Medicare inpatient claims data and other databases to estimate Medicare payments for primary or revision total knee arthroplasty (TKA). The average Medicare hospital payment per procedure was $13,464 for primary TKA (n = 227,587) and $17,331 for revision TKA (n = 18,677). For both primary and revision TKAs Medicare payments varied substantially across patients, hospitals and healthcare markets. Less than one percent of primary TKA cases but seven percent of revision TKA cases triggered Medicare “outlier” payments, which were $10,000 or higher per case beyond regular diagnosis-related-group payments. Urban and major teaching hospitals were more likely to treat these unusually expensive cases. Hospitals in the Northeast and West regions tended to receive higher Medicare payments than hospitals in the Midwest.     

Associations of depression diagnosis and antidepressant treatment with mortality among young and disabled Medicare beneficiaries with COPD

Objective

Depression is prevalent in chronic obstructive pulmonary disease (COPD) patients and a risk factor for COPD exacerbation and death. The objective of this study was to determine the associations of depression diagnosis and antidepressant treatment with mortality among Social Security Disability Insurance (SSDI)-eligible (age < 65 years who had permanent physical or mental disabilities) Medicare beneficiaries with COPD.

Method

This retrospective cohort study used a 5% random sample of SSDI-eligible Medicare beneficiaries with COPD in stand-alone Part D plans during 2006–2008 (n= 17,320). COPD and depression diagnoses were assessed during 2006. Evidence of antidepressant treatment was measured in 2006–2008. All-cause mortality was measured in 2007–2008. Cox proportional hazards models were used to examine the associations of depression diagnosis with mortality and, among depressed beneficiaries, antidepressant treatment (time dependent) with mortality after controlling for covariates.

Results

More than one third (37.3%) of SSDI-eligible beneficiaries with COPD had a baseline depression diagnosis; of those, 86.8% had evidence of antidepressant treatment. Baseline depression diagnosis was an independent risk factor for 2-year mortality [hazard ratio (HR)=1.21; 99% confidence interval (CI)=1.07–1.37]. Among depressed beneficiaries, receiving antidepressant treatment was associated with significantly lower mortality (HR=0.55; 99% CI=0.44–0.68).

Conclusion

Proactive antidepressant treatment should be considered as an intervention to reduce mortality for this young and disabled Medicare population.     

Differential risks for adverse outcomes 3 years after kidney transplantation based on initial immunosuppression regimen: a national study

We examined integrated national transplant registry, pharmacy fill, and medical claims data for Medicare‐insured kidney transplant recipients in 2000–2011 (n = 45 164) from the United States Renal Data System to assess the efficacy and safety endpoints associated with seven early (first 90 days) immunosuppression (ISx) regimens. Risks of clinical complications over 3 years according to IS regimens were assessed with multivariate regression analysis, including the adjustment for covariates and propensity for receipt of a nonreference ISx regimen. Compared with the reference ISx (thymoglobulin induction with tacrolimus, mycophenolate, and prednisone maintenance), sirolimus‐based ISx was associated with significantly higher three‐year risks of pneumonia (adjusted hazard ratio, aHR 1.45; P < 0.0001), sepsis (aHR 1.40; P < 0.0001), diabetes (aHR 1.21; P < 0.0001), acute rejection (AR; adjusted odds ratio, aOR 1.33; P < 0.0001), graft failure (aHR 1.78; P < 0.0001), and patient death (aHR 1.40; P < 0.0001), but reduced skin cancer risk (aHR 0.71; P < 0.001). Cyclosporine‐based IS was associated with increased risks of pneumonia (aHR 1.17; P < 0.001), sepsis (aHR 1.16; P < 0.001), AR (aOR 1.43; P < 0.001), and graft failure (aHR 1.39; P < 0.001), but less diabetes (aHR 0.83; P < 0.001). Steroid‐free ISx was associated with the reduced risk of pneumonia (aHR 0.89; P = 0.002), sepsis (aHR 0.80; P < 0.001), and diabetes (aHR 0.77; P < 0.001), but higher graft failure (aHR 1.35; P < 0.001). Impacts of ISx over time warrant further study to better guide ISx tailoring to balance the efficacy and morbidity.