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The Centers for Disease Control and Prevention (CDC) estimates that approximately 3.2 million people in the United States are currently living with chronic hepatitis C virus (CHC) infection. Hepatitis C is known to progress to advanced liver disease, cirrhosis and hepatocellular carcinoma (HCC).[2, 3] Furthermore, the rates of these complications have risen over the past years. Kanwal and colleagues recently studied a large cohort of patients from the Veterans Administration diagnosed with CHC and found that the prevalence of cirrhosis and decompensated cirrhosis had more than doubled from 1996 to 2006, and that the prevalence of HCC increased approximately 20-fold. In another recent study, Davis and Roberts have postulated that as the individuals who are currently 50–65 years old (so called ‘baby boomers’) age, complications of CHC such as hepatic failure and hepatocellular carcinoma may become even more prevalent.
The increase in disease progression has already led to a substantial increase in CHC-associated mortality. Using U.S. census and multiple causes of death data, Wise and colleagues found that from 1995 to 2004, hepatitis C mortality rates increased 123% with the highest death rates noted for the time period from 1995 to 1999, among non-Hispanic blacks, males and those aged 55–64 years.
In addition to mortality, patients with CHC suffer from substantial morbidity and poorer health-related quality of life (HRQL) when compared with healthy controls.[7-9] In a systematic review of HRQL, investigators reported that the vitality subscale of the SF-36 was the category most affected by patients living with HCV. In a more recent study using the SF-36, a liver disease-specific instrument (Chronic Liver disease Questionnaire, CLDQ) and a fatigue questionnaire (Chronic Fatigue Screener, CFS) to assess features that may be associated with HRQL, investigators reported that, in fact, the main contributor to HCV patients' reported lower HRQL scores was extreme fatigue-related loss of activity.
The 2008 Dartmouth Atlas of chronic diseases lists chronic liver disease (CLD) as one of the nine chronic diseases that account for the most Medicare dollars spent at the end of one's life. Given that CHC is the most common cause of chronic liver disease, HCV-related complications will remain an important aspect of healthcare resource utilisation. The majority of the Medicare costs were sustained during the end-of-life in-patient care although over 50% of the patients wanted to die at home. Value-based purchasing and reimbursement reduction, the phrases used for Medicare's new reimbursement method which started in October of 2012, links hospital payments to the quality of care that patients receive and penalises hospitals that do not deliver care that is on par with their peers.[11-16] These programmes are structured so that unnecessary care is not rewarded. Given this perspective, it is especially important to gain an understanding of Medicare's resource utilisation trends for patients living with HCV so that as Medicare's new reimbursement system expands, interventions can be developed to control spending and to eliminate unnecessary, inappropriate or duplicate services.[13, 16] The study purpose is to evaluate recent trends (2005–2010) and predictors of Medicare's major resource utilisation parameters including total charges, total payments, Medicare spending and the proportion of patient's responsibility for in-patient and out-patient visits for patients living with CHC.
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The study is the first to assess the impact of CHC on the Medicare population. We found that during the study years (2005–2010), there were approximately 9500–10 800 Medicare beneficiaries seen yearly in the in-patient setting for their CHC, as well as 67 000–80 000 CHC patients who received care in out-patient setting.
While gender and ethnic distribution of Medicare beneficiaries with CHC stayed relatively stable over time, the proportion of Medicare beneficiaries with CHC younger than 65 years old increased substantially. So far, individuals younger than 65 are eligible for Medicare only in case of disability, but as this cohort ages, this may have important implications for Medicare resource utilisation in the near future. Specifically, several reports suggested that as the baby boomers aged, there would be an increase in of HCV in the patient population 65 years old and greater.[5, 19] This supposition was based on the thought that the majority of patients with HCV acquired their infections in the 1970s when they were young adults; therefore, as they aged, there would be a corresponding increase in the complications of HCV-related chronic liver disease.[5, 19] As this group becomes Medicare eligible over the next decade, their impact on Medicare resource utilisation will become enormous.
Analysis of the CHC in-patient hospital costs demonstrated no trending pattern overall. The average total yearly payments stayed the same while the patients' monetary responsibility dropped in 2006, then rose to its highest point in 2008, then dropped again. The one consistent upward trend was the total charges submitted to Medicare from hospitals despite there being no changes in patient length of stay or in the number of in-patient procedures performed during the patient stay.
There was regional variation in the proportion of the patient's responsibility, which was higher in the Midwest and the South. Regional variation is not a new finding. In the Dartmouth Atlas of Chronic Illness project, the investigators determined that there was a wide variation in Medicare spending across the country after matching similar patients. However, they found that only 4% of the variation in Medicare spending was accounted for by regional variation. Instead, the major contributor to the variation was due to the supply of the services deemed necessary for care. Furthermore, the care practitioners changed their practices based on the resources available, so areas with more resources had more procedures incurred and less resources led to fewer procedures. They found as well that more care did not necessarily improve patient outcomes and could actually increase their risk of dying. Razavi, Menzin and Manos et al. also found that hospital stay costs were rapidly rising due to the use of more supplies and devices without necessarily better patient outcomes.[20-22] Menzin and Manos also found that Medicare costs varied by region and the number of comorbidities.[21, 22]
The multivariate analysis results determined that the number of related conditions per claim and the total number of out-patient procedures per year were the major predictors of increased resource utilisation. In addition, the total number of diagnosis per claim and more procedures performed per hospitalisations were associated with higher mortality (OR = 1.446; 95% CI: 1.3444–1.555). All these are not unexpected findings, but do help establish further that it is necessary to continuously review care procedures to determine which ones provide the most value to patients.[20-22]
Unlike in-patient, the number of CHC-related claims submitted to Medicare for patients with HCV who sought care in out-patient setting rose significantly from 49.3% of all out-patient claims in 2005 to 56.9% in 2010. The average number of out-patient claims (2.2–2.3/year) also exceeded the number of in-patient claims (1.5–1.6/year). This suggests that much of the care for the Medicare patient with CHC is being delivered in the out-patient setting.
The study is not free from limitations. Specifically, as the majority of those with CHC are younger than 65 years of age and have multiple disabilities, many of these patients could be considered dual eligible for both Medicare and Medicaid coverage. There have been a few reports that have found that in states with lower Medicaid spending, there was a corresponding higher Medicare spending[23, 24]. This spending pattern may, in fact, be biased due to differences in proportions of those underserved by their states' Medicaid programmes. Furthermore, we had limited access to patients' demographic characteristics and could not link them to respective spending, thus, we were unable highlight the directions for future dynamics of resource utilisation, given the ongoing changes in the U.S. population. Also, the nature of billing data warranted the use of bottom-up approach to estimating the total economic burden on Medicare associated with CHC. However, as a general limitation of this approach, it results in underestimation of that burden, because all costs that are not covered as in-patient or out-patient claims (such as costs of pharmacy, hospice, skilled nursing or other long-term care facility) were not accounted for in this study.
In summary, our study demonstrated that the number of Medicare patients living with HCV and the number of Medicare claims for CHC did not significantly change over the study period. The majority of patients in this cohort remain younger than 65 years and had multiple other disabilities. This indicates that the potential economic impact of CHC on Medicare has not been fully realised. Also, the total charges for managing CHC did significantly increase over time with the patients' payment responsibility increasing through 2008. This report of Medicare data supports efforts directed towards more aggressive identification and treatment of CHC patients who are younger than 65 years who are experiencing other disabilities. In addition, further study should be undertaken to understand why the total charges submitted to Medicare increased for in-patient stays over time without a subsequent increase in length of stay or number of procedures performed.