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Sample records for fr27au10r medicare program

  1. 78 FR 43820 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2013-07-22

    ... and 423 [CMS-4173-CN] RIN 0938-AR69 Medicare Program; Medical Loss Ratio Requirements for the Medicare... number of technical, typographical, and cross-referencing errors that are identified and corrected in the... Minimum Medical Loss Ratio, we made a typographical error in a section number. On page 31311, in Sec. 423...

  2. 76 FR 21372 - Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions...

    Science.gov (United States)

    2011-04-15

    ...] Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions Program... interested parties of an opportunity to apply to participate in the Medicare Community-based Care Transitions.... 111-148, enacted on March 23, 2010) (Affordable Care Act) authorized the Medicare Community-based Care...

  3. Can health promotion programs save Medicare money?

    Directory of Open Access Journals (Sweden)

    Ron Z Goetzel

    2007-04-01

    Full Text Available Ron Z Goetzel1, David Shechter2, Ronald J Ozminkowski1, David C Stapleton3, Pauline J Lapin4, J Michael McGinnis5, Catherine R Gordon6, Lester Breslow71Institute for Health and Productivity Studies, Cornell University, Washington, DC; 2Health and Productivity Research, Thomson Medstat, Santa Barbara, CA; 3Cornell Institute for Policy Research, Cornell University, Washington, DC; 4Office of Research, Development, and Information, Centers for Medicare and Medicaid Services, Baltimore, MD; 5National Academy of Sciences, Institute of Medicine, The National Academies, Washington, DC; 6Office of the Director, Centers for Disease Control and Prevention, Washington, DC; 7UCLA School of Public Health, Dept. of Health Services, Los Angeles, CA, USAAbstract: The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program.Keywords: health promotion, return on investment, Medicare, financial

  4. Can health promotion programs save Medicare money?

    Science.gov (United States)

    Goetzel, Ron Z; Shechter, David; Ozminkowski, Ronald J; Stapleton, David C; Lapin, Pauline J; McGinnis, J Michael; Gordon, Catherine R; Breslow, Lester

    2007-01-01

    The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program. PMID:18044084

  5. 77 FR 29647 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    Science.gov (United States)

    2012-05-18

    ...] Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education Demonstration... participate in the Medicare Graduate Nurse Education (GNE) Demonstration. DATES: Proposals will be considered...--(A) 1 or more applicable schools of nursing; and (B) 2 or more applicable non- hospital community...

  6. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Science.gov (United States)

    2011-04-07

    ...). Under these provisions, providers of services and suppliers can continue to receive traditional Medicare... Plans and Integration of Community Resources 11. ACO Marketing Guidelines 12. Program Integrity... the Institute of Medicine report: Safety, effectiveness, patient-centeredness, timeliness, efficiency...

  7. Medicare Beneficiary Knowledge of the Part D Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare Beneficiary Knowledge of the Part D Program and Its Relationship with Voluntary Enrollment According to findings appearing in Medicare Beneficiary Knowledge...

  8. 76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative

    Science.gov (United States)

    2011-10-03

    ...] Medicare Program; Comprehensive Primary Care Initiative AGENCY: Centers for Medicare & Medicaid Services... organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to... the Comprehensive Primary Care initiative or the application process. SUPPLEMENTARY INFORMATION: I...

  9. Medicare

    Science.gov (United States)

    ... get about Medicare Lost/incorrect Medicare card Report fraud & abuse File a complaint Identity theft: protect yourself ... the U.S. Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore, MD 21244 Sign Up / Change Plans ...

  10. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    Science.gov (United States)

    2013-03-18

    ... policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council... issued by the ALJs and the Medicare Appeals Council do not establish Medicare payment policy, we are... Council decisions previously described, this Ruling establishes a policy that revises the current policy...

  11. Evaluation of Medicare Health Support chronic disease pilot program.

    Science.gov (United States)

    Cromwell, Jerry; McCall, Nancy; Burton, Joe

    2008-01-01

    The Medicare Program is conducting a randomized trial of care management services among fee-for-service (FFS) beneficiaries called the Medicare Health Support (MHS) pilot program. Eight disease management (DM) companies have contracted with CMS to improve clinical quality, increase beneficiary and provider satisfaction, and achieve targeted savings for chronically ill Medicare FFS beneficiaries. In this article, we present 6-month intervention results on beneficiary selection and participation rates, mortality rates, trends in hospitalizations, and success in achieving Medicare cost savings. Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization.

  12. 77 FR 16841 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    Science.gov (United States)

    2012-03-22

    ...] Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education Demonstration... Education (GNE) Demonstration. The primary goal of the GNE Demonstration is to increase the number of... schools of nursing; and (B) 2 or more applicable non-hospital community-based care settings. The written...

  13. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    Science.gov (United States)

    2013-12-11

    ... [CMS-6061-ANPRM] RIN 0938-AR88 Medicare Program; Medicare Secondary Payer and Certain Civil Money... practices for which civil money penalties (CMPs) may or may not be imposed for failure to comply with...-3951. I. Background A. Imposition of Civil Money Penalties (CMPs) In 1981, the Congress added section...

  14. 76 FR 67801 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    Science.gov (United States)

    2011-11-02

    ... Furnished by Non-Physician Practitioners in the Assignment Process c. Assignment of Beneficiaries to ACOs... Insurance Program CMP Civil Monetary Penalties CMS Centers for Medicare & Medicaid Services CNM Certified... the current payment system by rewarding providers for delivering high quality, efficient clinical care...

  15. 77 FR 22071 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Science.gov (United States)

    2012-04-12

    ... Outcome Survey HPMS Health Plan Management System ICD-9-CM Internal Classification of Disease, 9th..., Improvement, and Modernization Act of 2003 (Pub. L. 108-173) MS-DRG Medicare Severity Diagnosis Related Group...

  16. Medicare program; clarification of Medicare's accrual basis of accounting policy--HCFA. Final rule.

    Science.gov (United States)

    1995-06-27

    This final rule revises the Medicare regulations to clarify the concept of "accrual basis of accounting" to indicate that expenses must be incurred by a provider of health care services before Medicare will pay its share of those expenses. This rule does not signify a change in policy but, rather, incorporates into the regulations Medicare's longstanding policy regarding the circumstances under which we recognize, for the purposes of program payment, a provider's claim for costs for which it has not actually expended funds during the current cost reporting period.

  17. 77 FR 23193 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2; Corrections

    Science.gov (United States)

    2012-04-18

    ..., 413, and 495 [CMS-0044-CN] RIN 0938-AQ84 Medicare and Medicaid Programs; Electronic Health Record... proposed rule entitled ``Medicare and Medicaid Programs; Electronic Health Record Incentive Program--Stage... (77 FR 13698), the proposed rule entitled ``Medicare and Medicaid Programs; Electronic Health Record...

  18. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. Final rule.

    Science.gov (United States)

    2016-11-15

    This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies, such as changes to the Value Modifier, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also includes changes related to the Medicare Shared Savings Program, requirements for Medicare Advantage Provider Networks, and provides for the release of certain pricing data from Medicare Advantage bids and of data from medical loss ratio reports submitted by Medicare health and drug plans. In addition, this final rule expands the Medicare Diabetes Prevention Program model.

  19. 78 FR 72089 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    Science.gov (United States)

    2013-12-02

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-6051-N] Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee Amount... period entitled ``Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening...

  20. Medicare program; Medicare depreciation, useful life guidelines--HCFA. Final rule.

    Science.gov (United States)

    1983-08-18

    These final rules amend Medicare regulations to clarify which useful life guidelines may be used by providers of health care services to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize the Departmental useful life guidelines or, if none have been published by the Department, either the American Hospital Association (AHA) useful life guidelines of 1973 of IRS guidelines. We are eliminating the reference to IRS guidelines because these are now outdated for Medicare purposes since they have been rendered obsolete either by the IRS or by statutory change. We are also deleting the specific reference to the 1973 AHA guidelines since these guidelines are updated by the AHA periodically. In addition, we are clarifying that certain tax legislation on accelerated depreciation, passed by Congress, does not apply to the Medicare program.

  1. 76 FR 48563 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2011...

    Science.gov (United States)

    2011-08-08

    ... Medicare and Medicaid Services Medicare and Medicaid Programs; Quarterly Listing of Program Issuances... Centers for Medicare & Medicaid Services [CMS-9066-NC] Medicare and Medicaid Programs; Quarterly Listing... Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with comment period. SUMMARY: This quarterly notice...

  2. 76 FR 68011 - Medicare Program; Advanced Payment Model

    Science.gov (United States)

    2011-11-02

    ...This notice announces the testing of the Advance Payment Model for certain accountable care organizations participating in the Medicare Shared Savings Program scheduled to begin in 2012, and provides information about the model and application process.

  3. Medicare

    Science.gov (United States)

    ... Mariana Islands, Guam, American Samoa, or the U.S. Virgin Islands, we’ll automatically enroll you in Medicare ... enrollment period for people covered under an employer group health plan If you’re 65 or older ...

  4. 75 FR 58405 - Medicare Program; Meeting of the Advisory Panel on Medicare Education, October 13, 2010

    Science.gov (United States)

    2010-09-24

    ... are imposed by section 1804 of the Social Security Act (the Act), requiring the Secretary to provide... President, Social Mission Programs, Independence Blue Cross; Richard C. Frank, M.D., Director, Cancer... Committee Work Summary. Medicare Outreach and Education Strategies. Public Comment. Listening Session with...

  5. 75 FR 3742 - Medicare Program; Meeting of the Advisory Panel on Medicare Education; Cancellation of the...

    Science.gov (United States)

    2010-01-22

    ... the Social Security Act (the Act), requiring the Secretary to provide informational materials to..., National Hispanic Council on Aging; Stephen L. Fera, Vice President, Social Mission Programs, Independence.... Medicare Outreach and Education Strategies. Public Comment. Listening Session with CMS Leadership. Next...

  6. Identifying the Transgender Population in the Medicare Program

    Science.gov (United States)

    Proctor, Kimberly; Haffer, Samuel C.; Ewald, Erin; Hodge, Carla; James, Cara V.

    2016-01-01

    Abstract Purpose: To identify and describe the transgender population in the Medicare program using administrative data. Methods: Using a combination of International Classification of Diseases ninth edition (ICD-9) codes relating to transsexualism and gender identity disorder, we analyzed 100% of the 2013 Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service (FFS) “final action” claims from both institutional and noninstitutional providers (∼1 billion claims) to identify individuals who may be transgender Medicare beneficiaries. To confirm, we developed and applied a multistage validation process. Results: Four thousand ninety-eight transgender beneficiaries were identified, of which ∼90% had confirmatory diagnoses, billing codes, or evidence of a hormone prescription. In general, the racial, ethnic, and geographic distribution of the Medicare transgender population tends to reflect the broader Medicare population. However, age, original entitlement status, and disease burden of the transgender population appear substantially different. Conclusions: Using a variety of claims information, ranging from claims history to additional diagnoses, billing modifiers, and hormone prescriptions, we demonstrate that administrative data provide a valuable resource for identifying a lower bound of the Medicare transgender population. In addition, we provide a baseline description of the diversity and disease burden of the population and a framework for future research. PMID:28861539

  7. The Costs of Decedents in the Medicare Program: Implications for Payments to Medicare+Choice Plans

    Science.gov (United States)

    Buntin, Melinda Beeuwkes; Garber, Alan M; McClellan, Mark; Newhouse, Joseph P

    2004-01-01

    Objective To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life—a group that accounts for more than one-quarter of Medicare's annual expenditures. Data Source Medicare administrative claims for 1994 and 1995. Study Design We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. Data Extraction Methods The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. Principal Findings Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. Conclusions More disaggregated prospective

  8. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Final rule.

    Science.gov (United States)

    2017-11-15

    This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies such as changes to the Medicare Shared Savings Program, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.

  9. 75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

    Science.gov (United States)

    2010-11-03

    ...] Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting AGENCY: Centers for Medicare... guidance and ask questions about the upcoming Community-based Care Transitions Program. The meeting is open... conference will also provide an overview of the Community-based Care Transitions Program (CCTP) and provide...

  10. 78 FR 46339 - Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Temporary Moratoria...

    Science.gov (United States)

    2013-07-31

    ...] Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Temporary Moratoria on... combat fraud, waste, and abuse in Medicare, Medicaid, and the Children's Health Insurance Program (CHIP... Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment...

  11. Medicare program; requirements for the Medicare incentive reward program and provider enrollment. Final rule.

    Science.gov (United States)

    2014-12-05

    This final rule implements various provider enrollment requirements. These include: Expanding the instances in which a felony conviction can serve as a basis for denial or revocation of a provider or supplier's enrollment; if certain criteria are met, enabling us to deny enrollment if the enrolling provider, supplier, or owner thereof had an ownership relationship with a previously enrolled provider or supplier that had a Medicare debt; enabling us to revoke Medicare billing privileges if we determine that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements; and limiting the ability of ambulance suppliers to "backbill" for services performed prior to enrollment.

  12. 78 FR 308 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    Science.gov (United States)

    2013-01-03

    ... (PQRS), the Children's Health Insurance Program (CHIP), and the Pioneer Accountable Care Organization... No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical...

  13. 76 FR 63017 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Science.gov (United States)

    2011-10-11

    ... (Sec. 423.2300) b. Definitions (Sec. 423.2305) (1) Applicable Beneficiary (2) Applicable Drug (3... marketing, including agent/broker training; payments to MA organizations based on quality ratings; standards... program; payment rules for non-contract health care providers; extending current network adequacy...

  14. 76 FR 26805 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    Science.gov (United States)

    2011-05-09

    ..., and hospices in low-wage index areas are unfairly advantaged. The commenter felt that our not wage... Medicare & Medicaid Services 42 CFR Part 418 Medicare Program; Hospice Wage Index for Fiscal Year 2012... [CMS-1355-P] RIN 0938-AQ31 Medicare Program; Hospice Wage Index for Fiscal Year 2012 AGENCY: Centers...

  15. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Reinstatement in other Medicare and Medicaid programs. 460.168 Section 460.168 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Reinstatement in other Medicare and Medicaid programs. To facilitate a participant's reinstatement in other...

  16. 78 FR 45231 - Medicare and Medicaid Programs; Initial Approval of Center for Improvement in Healthcare Quality...

    Science.gov (United States)

    2013-07-26

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3280-FN] Medicare and Medicaid Programs; Initial Approval of Center for Improvement in Healthcare Quality's (CIHQ's) Hospital Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS. ACTION: Final...

  17. CMS Medicare and Medicaid EHR Incentive Program, Electronic Health Record Products Used for Attestation

    Data.gov (United States)

    U.S. Department of Health & Human Services — Data set merges information about the Centers for Medicare and Medicaid Services, Medicare and Medicaid EHR Incentive Programs attestations with the Office of the...

  18. 75 FR 73088 - Medicare Program; Application by the American Association for Accreditation of Ambulatory Surgery...

    Science.gov (United States)

    2010-11-29

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare and Medicaid Services [CMS-2332-PN] Medicare Program; Application by the American Association for Accreditation of Ambulatory Surgery... Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) for recognition as a national...

  19. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Science.gov (United States)

    2010-07-28

    ... Payment Calculation for Eligible Hospitals c. Medicare Share d. Charity Care e. Transition Factor f...), eligible hospitals and critical access hospitals (CAHs) participating in Medicare and Medicaid programs...) technology. This final rule specifies--the initial criteria EPs, eligible hospitals, and CAHs must meet in...

  20. 75 FR 1843 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    Science.gov (United States)

    2010-01-13

    ... Payment Calculation for Eligible Hospitals c. Medicare Share d. Charity Care e. Transition Factor f...) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use... an EP and eligible hospital must meet in order to qualify for the incentive payment; calculation of...

  1. 76 FR 78926 - Medicare and Medicaid Programs; Announcement of Application From Hospital Requesting Waiver for...

    Science.gov (United States)

    2011-12-20

    ... comment period. SUMMARY: This notice with comment period announces a waiver request from Pioneer Community... which the hospital is located: Pioneer Community Hospital (Medicare provider number 25-1302), of... No. 93.773, Medicare--Hospital Insurance; Program No. 93.774, Medicare-- Supplementary Medical...

  2. 75 FR 5599 - Medicare and Medicaid Programs; Announcement of Applications From Hospitals Requesting Waiver for...

    Science.gov (United States)

    2010-02-03

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1341-NC] Medicare and Medicaid Programs; Announcement of Applications From Hospitals Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with...

  3. 78 FR 98 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    Science.gov (United States)

    2013-01-02

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1456-NC] Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with...

  4. 77 FR 51539 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    Science.gov (United States)

    2012-08-24

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1452-NC] Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with...

  5. 78 FR 19269 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    Science.gov (United States)

    2013-03-29

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1457-NC] Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for Organ Procurement Service Area AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice with...

  6. 77 FR 9931 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2011

    Science.gov (United States)

    2012-02-21

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-9069-N] Medicare and Medicaid Programs; Quarterly Listing of Program Issuances--October Through December 2011 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This quarterly...

  7. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Science.gov (United States)

    2010-06-08

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Administration on Aging Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program Funding for Title VI Native American Programs Purpose of Notice: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care Act Medicare...

  8. Measuring Coding Intensity in the Medicare Advantage Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2004, Medicare implemented a risk-adjustment system that pays Medicare Advantage (MA) plans based on diagnoses reported for their enrollees, giving the plans an...

  9. 76 FR 39006 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program; Correction

    Science.gov (United States)

    2011-07-05

    ... and 480 [CMS-3239-CN] RIN 0938-AQ55 Medicare Program; Hospital Inpatient Value-Based Purchasing... Value-Based Purchasing Program.'' DATES: Effective Date: These corrections are effective on July 1, 2011... for the hospital value-based purchasing program. Therefore, in section III. 6. and 7. of this notice...

  10. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Science.gov (United States)

    2011-09-01

    ...), prescription drug benefit program (Part D) and section 1876 cost plans including conforming changes to the MA... accounts (MSA) plans, cost-sharing for dual-eligible enrollees in the MA program and prescription drug pricing, coverage, and payment processes in the Part D program, and requirements governing the marketing...

  11. 78 FR 25013 - Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment

    Science.gov (United States)

    2013-04-29

    .... ACTION: Proposed rule. SUMMARY: This proposed rule would revise the Incentive Reward Program provisions... significant of these revisions include: changing the Incentive Reward Program potential reward amount for... related to the Incentive Reward Program. Frank Whelan, (410) 786-1302, for issues related to provider...

  12. 75 FR 81138 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Science.gov (United States)

    2010-12-27

    ... [CMS-1510-CN2] RIN 0938-AP88 Medicare Program; Home Health Prospective Payment System Rate Update for... ``Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in... Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home...

  13. 75 FR 76293 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Science.gov (United States)

    2010-12-08

    ... [CMS-1510-CN] RIN 0938-AP88 Medicare Program; Home Health Prospective Payment System Rate Update for... Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification... effective as if they had been included in the Medicare Program; Home Health Prospective Payment System Rate...

  14. 77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-10-17

    ... [CMS-1588-F2] RIN 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates..., 2012 Federal Register entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for...

  15. 76 FR 59265 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2011-09-26

    ... [CMS-1351-CN] RIN 0938-AQ29 Medicare Program; Prospective Payment System and Consolidated Billing for... rule entitled ``Medicare Program; Prospective Payment System and Consolidated Billing for Skilled... Payment System (PPS) final rule (76 FR 48486, 48540) inadvertently included several technical errors in...

  16. Results of the Medicare Health Support disease-management pilot program.

    Science.gov (United States)

    McCall, Nancy; Cromwell, Jerry

    2011-11-03

    In the Medicare Modernization Act of 2003, Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program. The Medicare Health Support Pilot Program was a large, randomized study of eight commercial programs for disease management that used nurse-based call centers. We randomly assigned patients with heart failure, diabetes, or both to the intervention or to usual care (control) and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care, acute care utilization, and Medicare expenditures for Medicare fee-for-service beneficiaries. The study included 242,417 patients (163,107 in the intervention group and 79,310 in the control group). The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care. We observed only 14 significant improvements in process-of-care measures out of 40 comparisons. These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ($400 million), with no demonstrable savings in Medicare expenditures. In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.

  17. Medicare and Medicaid programs; advance directives--HCFA. Final rule.

    Science.gov (United States)

    1995-06-27

    This final rule responds to public comments on the March 6, 1992 interim final rule with comment period that amended the Medicare and Medicaid regulations governing provider agreements and contracts to establish requirements for States, hospitals, nursing facilities, skilled nursing facilities, providers of home health care or personal care services, hospice programs and managed care plans concerning advance directives. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when an individual's condition makes him or her unable to express his or her wishes. The intent of the advance directives provisions is to enhance an adult individual's control over medical treatment decisions. This rule confirms the interim final rule with several minor changes based on our review and consideration of public comments.

  18. 77 FR 11130 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

    Science.gov (United States)

    2012-02-24

    ...] Medicare Program; Application by the American Association of Diabetes Educators (AADE) for Continued... American Association of Diabetes Educators' (AADE) request for the Secretary's approval of its... Association of Diabetes Educators for continued recognition as a national accreditation program for...

  19. 78 FR 53149 - Medicare and Medicaid Programs: Continued Approval of American Osteopathic Association/Healthcare...

    Science.gov (United States)

    2013-08-28

    ... the requirements at Sec. 482.41(c)(4), AOA/HFAP revised its standards to include the National Fire... Insurance Program; and No. 93.774, Medicare--Supplementary Medical Insurance Program) Dated: July 19, 2013...

  20. 76 FR 59138 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Science.gov (United States)

    2011-09-23

    ... Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on... $1,350 for judicial review. DATES: Effective Date: This notice is effective on January 1, 2012. FOR...

  1. 75 FR 58407 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Science.gov (United States)

    2010-09-24

    ... Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on... judicial review. DATES: Effective Date: This notice is effective on January 1, 2011. FOR FURTHER...

  2. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Science.gov (United States)

    2013-09-27

    ... Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on... ALJ hearings and $1,430 for judicial review. DATES: This notice is effective on January 1, 2014. FOR...

  3. 77 FR 59618 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Science.gov (United States)

    2012-09-28

    ... Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective for requests for ALJ hearings and judicial review filed on... $1,400 for judicial review. Effective Date: This notice is effective on January 1, 2013. FOR FURTHER...

  4. 76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

    Science.gov (United States)

    2011-05-16

    ... partner with States, providers, beneficiaries and their caregivers, and other stakeholders to improve... conflicting Medicaid and Medicare requirements. This document represents the first step. We have compiled what.... We will then determine which issues to address and in what order and timeframe. All areas are...

  5. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    Science.gov (United States)

    2012-06-26

    ... forth in 42 CFR 414.402 will be used to determine what items will be included in the competitions. These..., regardless of the method of delivery. Non-Mail Order Item--Any item that a beneficiary or caregiver picks up... what Medicare pays for mail order supplies versus non-mail order supplies may encourage fraud and abuse...

  6. 75 FR 52629 - Medicare Program; Establishing Additional Medicare Durable Medical Equipment, Prosthetics...

    Science.gov (United States)

    2010-08-27

    ... outpatient rehabilitation facility (CORF), a home health agency (HHA), or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that... devices used for reduction of fractures and dislocation'' as one of the ``medical and other health...

  7. 77 FR 69850 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2012-11-21

    ... of the Actuary in the Centers for Medicare & Medicaid Services. The estimates underlying these determinations are prepared by actuaries meeting the qualification standards and following the actuarial... alternative analysis and financial projection purposes, and the Office of the Actuary has adopted this...

  8. 75 FR 52760 - Medicare Program; Listening Session Regarding the Implementation of Section 10332 of the Patient...

    Science.gov (United States)

    2010-08-27

    ...] Medicare Program; Listening Session Regarding the Implementation of Section 10332 of the Patient Protection... of the Patient Protection and Affordable Care Act (the Affordable Care Act), which amended section 1874 of the Social Security Act: Availability of Medicare Data for Performance Measurement. The purpose...

  9. 78 FR 8535 - Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement

    Science.gov (United States)

    2013-02-06

    ... develop and test innovative health care payment and service delivery models that show promise of reducing... test innovative payment and service delivery models that reduce spending under Medicare, Medicaid or...] Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement AGENCY: Centers for...

  10. 76 FR 32085 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    Science.gov (United States)

    2011-06-03

    ..., ``Inpatient Psychiatric Facilities Prospective Payment System--Update for Rate Year Beginning July 1, 2011 (RY... [CMS-1346-CN] RIN 0938-AQ23 Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System--Update for Rate Year Beginning July 1, 2011 (RY 2012); Correction AGENCY: Centers for Medicare...

  11. 76 FR 9502 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    Science.gov (United States)

    2011-02-18

    ... [CMS-1510-F2] RIN 0938-AP88 Medicare Program; Home Health Prospective Payment System Rate Update for... set forth an update to the Home Health Prospective Payment System (HH PPS) rates, including: The... the Medicare prospective payment system for HHAs. This correcting amendment corrects a technical error...

  12. 77 FR 29001 - Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency...

    Science.gov (United States)

    2012-05-16

    ... Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Final Rule #0;#0;Federal..., Transparency, and Burden Reduction AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final... on providers of care. CMS has also identified non-regulatory changes to increase transparency and to...

  13. 76 FR 627 - Medicare Program; End-Stage Renal Disease Quality Incentive Program

    Science.gov (United States)

    2011-01-05

    ... important components of the Medicare ESRD payment system. In the proposed rule, we described the evolution...) of the Social Security Act (the Act), as the next step in the evolution of the ESRD quality program...-mix (for example, nursing home patients, patients with complex conditions) that may make meeting the...

  14. Medicare program; appeals of CMS or CMS contractor determinations when a provider or supplier fails to meet the requirements for Medicare billing privileges. Final rule.

    Science.gov (United States)

    2008-06-27

    This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. In addition, this final rule allows Medicare FFS contractors to revoke Medicare billing privileges when a provider or supplier submits a claim or claims for services that could not have been furnished to a beneficiary. This final rule also specifies that a Medicare contractor may establish a Medicare enrollment bar for any provider or supplier whose billing privileges have been revoked. Lastly, the final rule requires that all providers and suppliers receive Medicare payments by electronic funds transfer (EFT) if the provider or supplier, is submitting an initial enrollment application to Medicare, changing their enrollment information, revalidating or re-enrolling in the Medicare program.

  15. 78 FR 57857 - Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of...

    Science.gov (United States)

    2013-09-20

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3287-PN] Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of its Rural Health Clinic Accreditation Program AGENCY: Centers for Medicare and Medicaid Services, HHS. ACTION...

  16. 78 FR 41013 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

    Science.gov (United States)

    2013-07-09

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 431 [CMS-1450-CN] RIN 0938-AR52 Medicare and Medicaid Programs; Home Health Prospective Payment System Rate... period titled ``Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY...

  17. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Science.gov (United States)

    2010-10-01

    ... services for which Medicare payment may be made either directly or indirectly. (b) Auditing, settling and... and benefit quality assurance issues. (e) Developing, and periodically updating, a list of items of...

  18. 76 FR 50224 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Science.gov (United States)

    2011-08-12

    ...] Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center for... (CMS). This two-day training session is the second Accelerated Development Learning Session (ADLS.... Through Accelerated Development Learning Sessions (ADLS), the Innovation Center will test whether...

  19. 76 FR 66931 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    Science.gov (United States)

    2011-10-28

    ...] Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center for... Services (CMS). This two-day training session is the third and final Accelerated Development Learning... the quality of care for beneficiaries. Through Accelerated Development Learning Sessions (ADLS), the...

  20. 75 FR 24437 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Science.gov (United States)

    2010-05-05

    ... including Directors and Board Members of corporations and non-profit organizations and charities. The..., ``Medicare Program; Revisions to Payment Policies, Five-Year Review of Work Relative Value Units, Changes to...

  1. Public financing of the Medicare program will make its uniform structure increasingly costly to sustain.

    Science.gov (United States)

    Baicker, Katherine; Shepard, Mark; Skinner, Jonathan

    2013-05-01

    The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the "one-size-fits-all" Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity.

  2. 77 FR 38066 - Medicare Program; Announcement of a New Opportunity for Participation in the Advance Payment...

    Science.gov (United States)

    2012-06-26

    ...This notice announces a new opportunity for participation in the Advance Payment Model for certain accountable care organizations participating in the Medicare Shared Savings Program scheduled to begin in January 2013.

  3. 76 FR 74067 - Medicare Program; Announcement of a New Application Deadline for the Advance Payment Model

    Science.gov (United States)

    2011-11-30

    ...This notice announces a new application deadline for participation in the Advance Payment Model for certain accountable care organizations participating in the Medicare Shared Savings Program scheduled to begin in 2012.

  4. 75 FR 70013 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Science.gov (United States)

    2010-11-16

    ... 0938-AP89 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal... the July 22, 2010 Federal Register entitled, ``Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2011.'' DATES: Effective Date. This correction is effective for IRF...

  5. Individualizing Medicare.

    Science.gov (United States)

    Chollet, D J

    1999-05-01

    Despite the enactment of significant changes to the Medicare program in 1997, Medicare's Hospital Insurance trust fund is projected to be exhausted just as the baby boom enters retirement. To address Medicare's financial difficulties, a number of reform proposals have been offered, including several to individualize Medicare financing and benefits. These proposals would attempt to increase Medicare revenues and reduce Medicare expenditures by having individuals bear risk--investment market risk before retirement and insurance market risk after retirement. Many fundamental aspects of these proposals have yet to be worked out, including how to guarantee a baseline level of saving for health insurance after retirement, how retirees might finance unanticipated health insurance price increases after retirement, the potential implications for Medicaid of inadequate individual saving, and whether the administrative cost of making the system fair and adequate ultimately would eliminate any rate-of-return advantages from allowing workers to invest their Medicare contributions in corporate stocks and bonds.

  6. Changes in Postacute Care in the Medicare Shared Savings Program.

    Science.gov (United States)

    McWilliams, J Michael; Gilstrap, Lauren G; Stevenson, David G; Chernew, Michael E; Huskamp, Haiden A; Grabowski, David C

    2017-04-01

    Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care. To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Patient attribution to an ACO in the MSSP. Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics. For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or

  7. Measuring coding intensity in the Medicare Advantage program.

    Science.gov (United States)

    Kronick, Richard; Welch, W Pete

    2014-01-01

    In 2004, Medicare implemented a system of paying Medicare Advantage (MA) plans that gave them greater incentive than fee-for-service (FFS) providers to report diagnoses. Risk scores for all Medicare beneficiaries 2004-2013 and Medicare Current Beneficiary Survey (MCBS) data, 2006-2011. Change in average risk score for all enrollees and for stayers (beneficiaries who were in either FFS or MA for two consecutive years). Prevalence rates by Hierarchical Condition Category (HCC). Each year the average MA risk score increased faster than the average FFS score. Using the risk adjustment model in place in 2004, the average MA score as a ratio of the average FFS score would have increased from 90% in 2004 to 109% in 2013. Using the model partially implemented in 2014, the ratio would have increased from 88% to 102%. The increase in relative MA scores appears to largely reflect changes in diagnostic coding, not real increases in the morbidity of MA enrollees. In survey-based data for 2006-2011, the MA-FFS ratio of risk scores remained roughly constant at 96%. Intensity of coding varies widely by contract, with some contracts coding very similarly to FFS and others coding much more intensely than the MA average. Underpinning this relative growth in scores is particularly rapid relative growth in a subset of HCCs. Medicare has taken significant steps to mitigate the effects of coding intensity in MA, including implementing a 3.4% coding intensity adjustment in 2010 and revising the risk adjustment model in 2013 and 2014. Given the continuous relative increase in the average MA risk score, further policy changes will likely be necessary.

  8. 76 FR 41260 - Supplemental Funding for the Senior Medicare Patrol (SMP) Program

    Science.gov (United States)

    2011-07-13

    ... additional funding to double the size of the SMP program. The SMP program expansion has resulted in... DEPARTMENT OF HEALTH AND HUMAN SERVICES Administration on Aging Supplemental Funding for the Senior Medicare Patrol (SMP) Program ACTION: Notice of intent to provide supplemental funding to the...

  9. 76 FR 78741 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Science.gov (United States)

    2011-12-19

    ... Parts 402 and 403 [CMS-5060-P] RIN 0938-AR33 Medicare, Medicaid, Children's Health Insurance Programs...'s Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers... State plan under title XIX (Medicaid) or XXI of the Act (the Children's Health Insurance Program, or...

  10. 76 FR 11782 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of...

    Science.gov (United States)

    2011-03-03

    ...] Medicare, Medicaid, and Children's Health Insurance Programs; Renewal, Expansion, and Renaming of the...'s Health Insurance Program (CHIP) about options for selecting health care coverage under these and... needs are for experts in health disparities, State Health Insurance Assistance Programs (SHIPs), health...

  11. Lessons for the new CMS innovation center from the Medicare health support program.

    Science.gov (United States)

    Barr, Michael S; Foote, Sandra M; Krakauer, Randall; Mattingly, Patrick H

    2010-07-01

    The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

  12. 75 FR 73090 - Medicare Program; Listening Session on Development of Additional Imaging Efficiency Measures for...

    Science.gov (United States)

    2010-11-29

    ...] Medicare Program; Listening Session on Development of Additional Imaging Efficiency Measures for Use in the...), HHS. ACTION: Notice of meeting. SUMMARY: This notice announces a listening session to receive comments... Quality Data Reporting Program (HOP QDRP), which is authorized under section 1833(t)(17) of the Social...

  13. 78 FR 21610 - Expansion Funds for the Support of the Senior Medicare Patrol (SMP) Program

    Science.gov (United States)

    2013-04-11

    ... Grants. Announcement Type: Health Care Fraud Prevention Program Expansion Capacity. Funding Opportunity... DEPARTMENT OF HEALTH AND HUMAN SERVICES Administration for Community Living Expansion Funds for the Support of the Senior Medicare Patrol (SMP) Program ACTION: Notice of intent to provide expansion...

  14. 76 FR 34712 - Medicare Program; Pioneer Accountable Care Organization Model; Extension of the Submission...

    Science.gov (United States)

    2011-06-14

    ... stakeholders to develop initiatives to test innovative payment and service delivery models to reduce program...] Medicare Program; Pioneer Accountable Care Organization Model; Extension of the Submission Deadlines for... of the Pioneer Accountable Care Organization Model letters of intent to June 30, 2011 and the...

  15. 78 FR 9457 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Science.gov (United States)

    2013-02-08

    ... Parts 402 and 403 [CMS-5060-F] RIN 0938-AR33 Medicare, Medicaid, Children's Health Insurance Programs...'s Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers... Vol. 78 Friday, No. 27 February 8, 2013 Part II Department of Health and Human Services Centers...

  16. Effects of a Community-Based Fall Management Program on Medicare Cost Savings.

    Science.gov (United States)

    Ghimire, Ekta; Colligan, Erin M; Howell, Benjamin; Perlroth, Daniella; Marrufo, Grecia; Rusev, Emil; Packard, Michael

    2015-12-01

    Fall-related injuries and health risks associated with reduced mobility or physical inactivity account for significant costs to the U.S. healthcare system. The widely disseminated lay-led A Matter of Balance (MOB) program aims to help older adults reduce their risk of falling and associated activity limitations. This study examined effects of MOB participation on health service utilization and costs for Medicare beneficiaries, as a part of a larger effort to understand the value of community-based prevention and wellness programs for Medicare. A controlled retrospective cohort study was conducted in 2012-2013, using 2007-2011 MOB program data and 2006-2013 Medicare data. It investigated program effects on falls and fall-related fractures, and health service utilization and costs (standardized to 2012 dollars), of 6,136 Medicare beneficiaries enrolled in MOB from 2007 through 2011. A difference-in-differences analysis was employed to compare outcomes of MOB participants with matched controls. MOB participation was associated with total medical cost savings of $938 per person (95% CI=$379, $1,498) at 1 year. Savings per person amounted to $517 (95% CI=$265, $769) for unplanned hospitalizations; $81 for home health care (95% CI=$20, $141); and $234 (95% CI=$55, $413) for skilled nursing facility care. Changes in the incidence of falls or fall-related fractures were not detected, suggesting that cost savings accrue through other mechanisms. This study suggests that MOB and similar prevention programs have the potential to reduce Medicare costs. Further research accounting for program delivery costs would help inform the development of Medicare-covered preventive benefits. Copyright © 2015 American Journal of Preventive Medicine. All rights reserved.

  17. 77 FR 55479 - Medicare, Medicaid, and CHIP Programs: Research and Analysis on Impact of CMS Programs on the...

    Science.gov (United States)

    2012-09-10

    ..., Medicaid, and CHIP Programs: Research and Analysis on Impact of CMS Programs on the Indian Health Care System AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of Single Source Award. SUMMARY: This notice supports expansion of research on the impact of CMS programs on the Indian health...

  18. 75 FR 30041 - Medicare Program; Public Meeting in Calendar Year 2010 for New Clinical Laboratory Tests Payment...

    Science.gov (United States)

    2010-05-28

    ... specified list of new Clinical Procedural Terminology (CPT) codes for clinical laboratory tests in calendar... are codified at 42 CFR part 414, subpart G. A newly created Current Procedural Terminology (CPT) code..., Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program...

  19. 75 FR 30043 - Medicare Program; Meeting of the Advisory Panel on Medicare Education

    Science.gov (United States)

    2010-05-28

    ... imposed * * * by law.'' Such duties are imposed by section 1804 of the Social Security Act (the Act...; Stephen P. Fera, M.B.A., Vice President, Social Mission Programs, Independence Blue Cross; Nan-Kirsten... Education Strategies. Public Comment. Listening Session with CMS Leadership. Next Steps. Individuals or...

  20. 78 FR 79081 - Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid...

    Science.gov (United States)

    2013-12-27

    ... Conditions for Coverage CHAP Community Health Accreditation Program CMHC Community Mental Health Center COI... Pathology Services (Sec. 485.727) N. Emergency Preparedness Regulations for Community Mental Health Centers... Preparedness for Community Mental Health Centers (CMHCs)--Training and Testing (Sec. 485.920(d)) R. Conditions...

  1. Medicare program; offset of Medicare payments to individuals to collect past-due obligations arising from breach of scholarship and loan contracts--HCFA. Final rule.

    Science.gov (United States)

    1992-05-04

    This final rule sets forth the procedures to be followed for collection of past-due amounts owed by individuals who breached contracts under certain scholarship and loan programs. The programs that would be affected are the National Health Service Corps Scholarship, the Physician Shortage Area Scholarship, and the Health Education Assistance Loan. These procedures would apply to those individuals who breached contracts under the scholarship and loan programs and who-- Accept Medicare assignment for services; Are employed by or affiliated with a provider, Health Maintenance Organization, or Competitive Medical Plan that receives Medicare payment for services; or Are members of a group practice that receives Medicare payment for services. This regulation implements section 1892 of the Social Security Act, as added by section 4052 of the Omnibus Budget Reconciliation Act of 1987.

  2. The Medicare Health Outcomes Survey program: Overview, context, and near-term prospects

    Directory of Open Access Journals (Sweden)

    Miller Nancy A

    2004-07-01

    Full Text Available Abstract In 1996, the Centers for Medicare & Medicaid Services (CMS initiated the development of the Medicare Health Outcomes Survey (HOS. It is the first national survey to measure the quality of life and functional health status of Medicare beneficiaries enrolled in managed care. The program seeks to gather valid and reliable health status data in Medicare managed care for use in quality improvement activities, public reporting, plan accountability and improving health outcomes based on competition. The context that led to the development of the HOS was formed by the convergence of the following factors: 1 a recognized need to monitor the performance of managed care plans, 2 technical expertise and advancement in the areas of quality measurement and health outcomes assessment, 3 the existence of a tested functional health status assessment tool (SF-36®1, which was valid for an elderly population, 4 CMS leadership, and 5 political interest in quality improvement. Since 1998, there have been six baseline surveys and four follow up surveys. CMS, working with its partners, performs the following tasks as part of the HOS program: 1 Supports the technical/scientific development of the HOS measure, 2 Certifies survey vendors, 3 Collects Health Plan Employer Data and Information Set(HEDIS®2 HOS data, 4 Cleans, scores, and disseminates annual rounds of HOS data, public use files and reports to CMS, Quality Improvement Organizations (QIOs, Medicare+Choice Organizations (M+COs, and other stakeholders, 5 Trains M+COs and QIOs in the use of functional status measures and best practices for improving care, 6 Provides technical assistance to CMS, QIOs, M+COs and other data users, and 7 Conducts analyses using HOS data to support CMS and HHS priorities. CMS has recently sponsored an evaluation of the HOS program, which will provide the information necessary to enhance the future administration of the program. Information collected to date reveals that the

  3. 75 FR 80762 - Medicare Program; Emergency Medical Treatment and Labor Act: Applicability to Hospital and...

    Science.gov (United States)

    2010-12-23

    ... [CMS-1350-ANPRM] RIN 0938-AQ51 Medicare Program; Emergency Medical Treatment and Labor Act... Emergency Medical Treatment and Labor Act (EMTALA). Specifically, this document serves as a request for... available to persons without Federal government identification, commenters are encouraged to leave their...

  4. 77 FR 5213 - Medicare Program; Emergency Medical Treatment and Labor Act (EMTALA): Applicability to Hospital...

    Science.gov (United States)

    2012-02-02

    ... [CMS-1350-NC] RIN 0938-AQ51 Medicare Program; Emergency Medical Treatment and Labor Act (EMTALA... the applicability of the Emergency Medical Treatment and Labor Act (EMTALA) to hospital inpatients... available to persons without Federal government identification, commenters are encouraged to leave their...

  5. 77 FR 44255 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

    Science.gov (United States)

    2012-07-27

    ...] Medicare Program; Application by the American Association of Diabetes Educators (AADE) for Continued... Register (77 FR 11130) entitled, ``Application by the American Association of Diabetes Educators (AADE) for... Notice. SUMMARY: This final notice announces the approval of an application from the American Association...

  6. 77 FR 17070 - Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for...

    Science.gov (United States)

    2012-03-23

    ... for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the... accrediting body's approved program would be deemed to have met the Medicare conditions. A national... the national accrediting body making the request, describing the nature of the request, and providing...

  7. 76 FR 34633 - Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for...

    Science.gov (United States)

    2011-06-14

    ..., 413, and 476 [CMS-1518-CN] RIN 0938-AQ24 Medicare Program; Proposed Changes to the Hospital Inpatient...-9644 of May 5, 2011 (76 FR 25788), there were a number of technical and typographical errors that are...) endorsement number for the CMS quality measure, Percent of Residents With Pressure Ulcers That Are New or...

  8. 75 FR 72830 - Medicare Program; Quality Improvement Organization (QIO) Contracts: Solicitation of Proposals...

    Science.gov (United States)

    2010-11-26

    ...] Medicare Program; Quality Improvement Organization (QIO) Contracts: Solicitation of Proposals From In-State... the Social Security Act (the Act) to provide at least 6 months' advance notice of the expiration dates of contracts with out- of-State Quality Improvement Organizations (QIOs) before renewing any of those...

  9. 78 FR 59701 - Medicare Program; Approval of Accrediting Organization for Suppliers of Advanced Diagnostic...

    Science.gov (United States)

    2013-09-27

    ...] Medicare Program; Approval of Accrediting Organization for Suppliers of Advanced Diagnostic Imaging... accredit suppliers seeking to furnish the technical component (TC) of advanced diagnostic imaging services... advanced diagnostic imaging (ADI) service and establish procedures to ensure that the criteria used by an...

  10. 75 FR 46948 - Medicare Program; Listening Session Regarding Confidential Feedback Reports and the...

    Science.gov (United States)

    2010-08-04

    ...] Medicare Program; Listening Session Regarding Confidential Feedback Reports and the Implementation of a... Services (CMS), HHS. ACTION: Notice of meeting. SUMMARY: This notice announces a listening session being... modifier to the fee- for-service physician fee schedule. The purpose of the listening session is to solicit...

  11. 76 FR 29249 - Medicare Program; Pioneer Accountable Care Organization Model: Request for Applications

    Science.gov (United States)

    2011-05-20

    ... Affordable Care Act, to test innovative payment and service delivery models that reduce spending under.... This Model will test the effectiveness of a combination of the following: Payment arrangements that...] Medicare Program; Pioneer Accountable Care Organization Model: Request for Applications AGENCY: Centers for...

  12. 75 FR 45699 - Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2010...

    Science.gov (United States)

    2010-08-03

    ... Prospective Payment System and CY 2010 Payment Rates; Changes to the Ambulatory Surgical Center Payment System...-1414-CN2] RIN 0938-AP41 Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2010 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2010...

  13. 75 FR 60640 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2010-10-01

    ...; RIN 0938-AP33 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY 2011 Rates; Provider... Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective...

  14. 77 FR 4908 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-02-01

    ... Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal... the final rule entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates...

  15. 76 FR 59256 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Science.gov (United States)

    2011-09-26

    ...; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size... [CMS-1349-CN] RIN 0938-AQ28 Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units...

  16. 76 FR 13292 - Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2011...

    Science.gov (United States)

    2011-03-11

    ... Prospective Payment System and CY 2011 Payment Rates; Changes to the Ambulatory Surgical Center Payment System..., 2010, entitled ``Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates; Ambulatory Surgical Center Payment System and CY 2011 Payment Rates; Payments to Hospitals for...

  17. 77 FR 65495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-10-29

    ... Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and... Federal Register entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates...

  18. 76 FR 68525 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012

    Science.gov (United States)

    2011-11-04

    ... Prospective Payment System Rate Update for Calendar Year 2012; Final Rule #0;#0;Federal Register / Vol. 76, No... 0938-AQ30 Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012... sets forth updates to the home health prospective payment system (HH PPS) rates, including: the...

  19. 75 FR 34614 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

    Science.gov (United States)

    2010-06-17

    ... Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2010 Rates and to the Long- Term Care Hospital Prospective Payment System and Rate Year 2010 Rates... Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2010 Rates and to the Long-Term Care...

  20. 78 FR 15882 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2013-03-13

    ... Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and... Register entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals...

  1. 76 FR 15105 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Science.gov (United States)

    2011-03-18

    ... Services 42 CFR Part 488 [CMS-2435-F] Medicare and Medicaid Programs; Civil Money Penalties for Nursing... incentives for quality improvement, and to remove uncertainty for nursing homes, we proposed to set the... Vol. 76 Friday, No. 53 March 18, 2011 Part III Department of Health and Human Services Centers for...

  2. 76 FR 65885 - Medicare Program; Changes to the Ambulatory Surgical Centers Patient Rights Conditions for Coverage

    Science.gov (United States)

    2011-10-24

    ... consequence of increasing health care costs to the Medicare program and limiting the choices of those patients... with information concerning the illness, injury or condition that brought the patient to the ASC, as.../grievances relating, but not limited to, mistreatment, neglect, verbal, mental, sexual, or physical abuse...

  3. 78 FR 32663 - Medicare Program; Notification of Closure of Teaching Hospitals and Opportunity To Apply for...

    Science.gov (United States)

    2013-05-31

    ...] Medicare Program; Notification of Closure of Teaching Hospitals and Opportunity To Apply for Available... announces the closure of two teaching hospitals and the initiation of an application process where hospitals... modifying language at section 1886(d)(5)(B)(v) of the Act, to instruct the Secretary to establish a process...

  4. 76 FR 66929 - Medicare and Medicaid Programs; The American Association for Accreditation of Ambulatory Surgery...

    Science.gov (United States)

    2011-10-28

    ...] Medicare and Medicaid Programs; The American Association for Accreditation of Ambulatory Surgery Facilities... receipt of a deeming application from the American Association for Accreditation of Ambulatory Surgery... of Ambulatory Surgery Facilities (AAAASF's) request for deeming authority for RHCs. This notice also...

  5. Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries.

    Science.gov (United States)

    Zeng, Wu; Stason, William B; Fournier, Stephen; Razavi, Moaven; Ritter, Grant; Strickler, Gail K; Bhalotra, Sarita M; Shepard, Donald S

    2013-05-01

    This study reports outcomes of a Medicare-sponsored demonstration of two intensive lifestyle modification programs (LMPs) in patients with symptomatic coronary heart disease: the Cardiac Wellness Program of the Benson-Henry Mind Body Institute (MBMI) and the Dr Dean Ornish Program for Reversing Heart Disease® (Ornish). This multisite demonstration, conducted between 2000 and 2008, enrolled Medicare beneficiaries who had had an acute myocardial infarction or a cardiac procedure within the preceding 12 months or had stable angina pectoris. Health and economic outcomes are compared with matched controls who had received either traditional or no cardiac rehabilitation following similar cardiac events. Each program included a 1-year active intervention of exercise, diet, small-group support, and stress reduction. Medicare claims were used to examine 3-year outcomes. The analysis includes 461 elderly, fee-for-service, Medicare participants and 1,795 controls. Cardiac and non-cardiac hospitalization rates were lower in participants than controls in each program and were statistically significant in MBMI (P costs of $3,801 and $4,441 per participant for the MBMI and Ornish Programs, respectively, were offset by reduced health care costs yielding non-significant three-year net savings per participant of about $3,500 in MBMI and $1,000 in Ornish. A trend towards lower mortality compared with controls was observed in MBMI participants (P = .07). Intensive, year-long LMPs reduced hospitalization rates and suggest reduced Medicare costs in elderly beneficiaries with symptomatic coronary heart disease. Copyright © 2013 Mosby, Inc. All rights reserved.

  6. Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008

    Directory of Open Access Journals (Sweden)

    Menz Hylton B

    2009-10-01

    Full Text Available Abstract Background In 2004, as an extension of the Enhanced Primary Care (EPC program, the Australian Government introduced a policy of providing Medicare rebates for allied health services provided to patients with chronic or complex health conditions. The objective of this study was to evaluate the utilisation of podiatry services provided under this scheme between 2004 and 2008. Methods Data pertaining to the Medicare item 10962 for the calendar years 2004-2008 were extracted from the Australian Medicare Benefits Schedule (MBS database and cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number of consultations provided and to assess for temporal trends over the five-year assessment period. The total cost to Medicare over this period was also determined. Results During the 2004-2008 period, a total of 1,338,044 EPC consultations were provided by podiatrists in Australia. Females exhibited higher utilisation than males (63 versus 37%, and those aged over 65 years accounted for 75% of consultations. There was a marked increase in the number of consultations provided from 2004 to 2008, and the total cost of providing EPC podiatry services during this period was $62.9 M. Conclusion Podiatry services have been extensively utilised under the EPC program by primary care patients, particularly older women, and the number of services provided has increased dramatically between 2004 and 2008. Further research is required to determine whether the EPC program enhances clinical outcomes compared to standard practice.

  7. Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008.

    Science.gov (United States)

    Menz, Hylton B

    2009-10-30

    In 2004, as an extension of the Enhanced Primary Care (EPC) program, the Australian Government introduced a policy of providing Medicare rebates for allied health services provided to patients with chronic or complex health conditions. The objective of this study was to evaluate the utilisation of podiatry services provided under this scheme between 2004 and 2008. Data pertaining to the Medicare item 10962 for the calendar years 2004-2008 were extracted from the Australian Medicare Benefits Schedule (MBS) database and cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number of consultations provided and to assess for temporal trends over the five-year assessment period. The total cost to Medicare over this period was also determined. During the 2004-2008 period, a total of 1,338,044 EPC consultations were provided by podiatrists in Australia. Females exhibited higher utilisation than males (63 versus 37%), and those aged over 65 years accounted for 75% of consultations. There was a marked increase in the number of consultations provided from 2004 to 2008, and the total cost of providing EPC podiatry services during this period was $62.9 M. Podiatry services have been extensively utilised under the EPC program by primary care patients, particularly older women, and the number of services provided has increased dramatically between 2004 and 2008. Further research is required to determine whether the EPC program enhances clinical outcomes compared to standard practice.

  8. Sugar daddy. Most Americans know Medicare as the health insurance program for the elderly, but to providers, it's a jobs program, a capital financier and a safety net.

    Science.gov (United States)

    Hallam, K; Gardner, J

    1999-11-08

    Most Americans know Medicare as the health insurance program that covers the elderly. But to providers it's much more that. The program pays for medical education, finances capital projects and subsidizes care for the indigent. Should Medicare continue making those add-on payments? Is that the program's mission? The debate is intensifying.

  9. 75 FR 78246 - Medicare Program; Re-Chartering of the Advisory Panel on Ambulatory Payment Classification (APC...

    Science.gov (United States)

    2010-12-15

    ...] Medicare Program; Re-Chartering of the Advisory Panel on Ambulatory Payment Classification (APC) Groups... announces the re-chartering of the Advisory Panel on Ambulatory Payment Classification (APC) Groups (the... (APC) groups and their associated weights established under the Medicare hospital Outpatient...

  10. Plenary III–04: Responses to Drug Costs: Year Three of the Medicare Part D Program

    OpenAIRE

    Fung, Vicki; Reed, Mary; Hsu, John

    2010-01-01

    Background/Aims: Many Medicare Part D beneficiaries face substantial prescription drug cost-sharing. In the first year of the program, many beneficiaries reported substantial drug use changes in response to the coverage gap. In response, an increasing number of plans offer generic drug coverage during the gap. We compared responses to Part D costs among beneficiaries with generic-only gap coverage and full gap coverage in 2008, the third year of the Part D program.

  11. The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations.

    Science.gov (United States)

    Gu, Qian; Koenig, Lane; Faerberg, Jennifer; Steinberg, Caroline Rossi; Vaz, Christopher; Wheatley, Mary P

    2014-06-01

    To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations. Medicare inpatient claims to calculate condition-specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics. Regression analyses and projections were used to estimate risk-adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP. Both patient dual-eligible status and a hospital's dual-eligible share of Medicare discharges have a positive impact on risk-adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high-dual hospitals are more likely to have excess readmissions than low-dual hospitals. As a result, HRRP penalties will disproportionately fall on high-dual hospitals, which are more likely to have negative all-payer margins, raising concerns of unintended consequences of the program for vulnerable populations. Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations. © Health Research and Educational Trust.

  12. Medicare 1144 Outreach

    Data.gov (United States)

    Social Security Administration — The purpose of this exchange is to identify any Medicare beneficiary who may be eligible for Medicare cost sharing under the Medicaid program, notify these potential...

  13. 78 FR 14689 - Medicare Program; Extension of the Payment Adjustment for Low-volume Hospitals and the Medicare...

    Science.gov (United States)

    2013-03-07

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 412... philosophy and principles identified in Executive Order 12866 and 13563, the RFA, and section 1102(b) of the.... Approved: March 1, 2013. Kathleen Sebelius, Secretary, Department of Health and Human Services. [FR Doc...

  14. Medicare Home Health Services: A Difficult Program to Control

    Science.gov (United States)

    1981-09-25

    represent about one-third of all visits provided under the program. Family and friends altio provide similar services to the elderly and consequently...example, that the individual is to be confined to his or her home but that this does not necessarily mean that the patient is bedridden . At the same...34feebleness" and "insecurity" cannot be considered home- bound. We believe that in many cases (particularly for the elderly ) it would be extremely

  15. 76 FR 65909 - Medicare and Medicaid Program; Regulatory Provisions To Promote Program Efficiency, Transparency...

    Science.gov (United States)

    2011-10-24

    ... Efficiency, Transparency, and Burden Reduction AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS...-regulatory changes to increase transparency and to become a better business partner. As explained in the plan...

  16. Medicare's Hospital Readmissions Reduction Program in Surgery May Disproportionately Affect Minority-serving Hospitals.

    Science.gov (United States)

    Shih, Terry; Ryan, Andrew M; Gonzalez, Andrew A; Dimick, Justin B

    2015-06-01

    To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals. The Hospital Readmissions Reduction Program will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown. We examined national Medicare beneficiaries undergoing coronary artery bypass grafting in 2008 to 2010 (N = 255,250 patients, 1186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the Hospital Readmissions Reduction Program formula using only coronary artery bypass grafting readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile whereas non-minority-serving hospitals were those in the bottom quintile. Projected readmission penalties were compared across quintiles. Forty-seven percent of hospitals (559 of 1186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1186) would be penalized less than 1% of total Medicare revenue whereas 5% of hospitals (55 of 1186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs 32%) and were projected almost triple the reductions in reimbursement ($112 million vs $41 million). Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals' narrow profit margins, readmission penalties may have a profound impact on these hospitals' ability to care for disadvantaged patients.

  17. 77 FR 69859 - Medicare Program; Part A Premiums for CY 2013 for the Uninsured Aged and for Certain Disabled...

    Science.gov (United States)

    2012-11-21

    ...)(A) of the Act specifies that the premium that these individuals will pay for CY 2013 will be equal... program or the Railroad Retirement Act and certain others do not have to pay premiums for Medicare Part A.... SUPPLEMENTARY INFORMATION: I. Background Section 1818 of the Social Security Act (the Act) provides for...

  18. 76 FR 67570 - Medicare Program; Part A Premiums for CY 2012 for the Uninsured Aged and for Certain Disabled...

    Science.gov (United States)

    2011-11-01

    ... program or the Railroad Retirement Act and certain others do not have to pay premiums for Medicare Part A... will pay for CY 2012 will be equal to the premium for uninsured aged enrollees reduced by 45 percent.... SUPPLEMENTARY INFORMATION: I. Background Section 1818 of the Social Security Act (the Act) provides for...

  19. 78 FR 64951 - Medicare Program; Part A Premiums for CY 2014 for the Uninsured Aged and for Certain Disabled...

    Science.gov (United States)

    2013-10-30

    ...)(A) of the Act specifies that the premium that these individuals will pay for CY 2014 will be equal... OASDI program or the Railroad Retirement Act and certain others do not have to pay premiums for Medicare...-6390. SUPPLEMENTARY INFORMATION: I. Background Section 1818 of the Social Security Act (the Act...

  20. MACRA, MIPS, and the New Medicare Quality Payment Program: An Update for Radiologists.

    Science.gov (United States)

    Rosenkrantz, Andrew B; Nicola, Gregory N; Allen, Bibb; Hughes, Danny R; Hirsch, Joshua A

    2017-03-01

    The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 advances the goal of tying Medicare payments to quality and value. In April 2016, CMS published an initial proposed rule for MACRA, renaming it the Quality Payment Program (QPP). Under QPP, clinicians receive payments through either advanced alternative payment models or the Merit-Based Incentive Payment System (MIPS), a consolidation of existing federal performance programs that applies positive or negative adjustments to fee-for-service payments. Most physicians will participate in MIPS. This review highlights implications of the QPP and MIPS for radiologists. Although MIPS incorporates radiology-specific quality measures, radiologists will also be required to participate in other practice improvement activities, including patient engagement. Recognizing physicians' unique practice patterns, MIPS will provide special considerations in performance evaluation for physicians with limited face-to-face patient interaction. Although such considerations will affect radiologists' likelihood of success under QPP, many practitioners will be ineligible for the considerations under currently proposed criteria. Reporting using qualified clinical data registries will benefit radiologists' performance by allowing expanded arrays of MIPS and non-MIPS specialty-specific measures. A group practice reporting option will substantially reduce administrative burden but introduce new challenges by requiring uniform determination of patient-facing status and performance measurement for all of the group's physicians (diagnostic radiologists, interventional radiologists, and nonradiologists) under the same taxpayer identification number. Given that the initial MIPS performance period begins in 2017, radiologists must begin preparing for QPP and taking actions to ensure their future success under this new quality-based payment system. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights

  1. Medicare program; contracts with health maintenance organizations (HMOs) and competitive medical plans (CMPs)--HCFA. Final rule with comment period.

    Science.gov (United States)

    1995-09-01

    This rule clarifies and updates portions of the HCFA regulations that pertain to the following: The conditions that an HMO or CMP must meet to qualify for a Medicare contract (Subpart J). The contract requirements (Subpart L). The rules for enrollment, entitlement, and disenrollment of Medicare beneficiaries in a contracting HMO or CMP (Subpart K). How a Medicare contract is affected when there is change of ownership or leasing of facilities of a contracting HMO or CMP (Subpart M). These are technical and editorial changes that do not affect the substance of the regulations. They are intended to make it easier to find particular provisions, to provide overviews of the different program aspects, and to better ensure uniform understanding of the rules.

  2. Impact of the Medicare Chronic Disease Management program on the conduct of Australian dietitians' private practices.

    Science.gov (United States)

    Jansen, Sarah; Ball, Lauren; Lowe, Catherine

    2015-04-01

    This study explored private practice dietitians' perceptions of the impact of the Australian Chronic Disease Management (CDM) program on the conduct of their private practice, and the care provided to patients. Twenty-five accredited practising dietitians working in primary care participated in an individual semistructured telephone interview. Interview questions focussed on dietitians' perceptions of the proportion of patients receiving care through the CDM program, fee structures, adhering to reporting requirements and auditing. Transcript data were thematically analysed using a process of open coding. Half of the dietitians (12/25) reported that most of their patients (>75%) received care through the CDM program. Many dietitians (19/25) reported providing identical care to patients using the CDM program and private patients, but most (17/25) described spending substantially longer on administrative tasks for CDM patients. Dietitians experienced pressure from doctors and patients to keep their fees low or to bulk-bill patients using the CDM program. One-third of interviewed dietitians (8/25) expressed concern about the potential to be audited by Medicare. Recommendations to improve the CDM program included increasing the consultation length and subsequent rebate available for dietetic consultations, and increasing the number of consultations to align with dietetic best-practice guidelines. The CDM program creates challenges for dietitians working in primary care, including how to sustain the quality of patient-centred care and yet maintain equitable business practices. To ensure the CDM program appropriately assists patients to receive optimal care, further review of the CDM program within the scope of dietetics is required.

  3. Recovery of renal function among ESRD patients in the US medicare program.

    Directory of Open Access Journals (Sweden)

    Sumit Mohan

    Full Text Available BACKGROUND: Patients started on long term hemodialysis have typically had low rates of reported renal recovery with recent estimates ranging from 0.9-2.4% while higher rates of recovery have been reported in cohorts with higher percentages of patients with acute renal failure requiring dialysis. STUDY DESIGN: Our analysis followed approximately 194,000 patients who were initiated on hemodialysis during a 2-year period (2008 & 2009 with CMS-2728 forms submitted to CMS by dialysis facilities, cross-referenced with patient record updates through the end of 2010, and tracked through December 2010 in the CMS SIMS registry. RESULTS: We report a sustained renal recovery (i.e no return to ESRD during the available follow up period rate among Medicare ESRD patients of > 5% - much higher than previously reported. Recovery occurred primarily in the first 2 months post incident dialysis, and was more likely in cases with renal failure secondary to etiologies associated with acute kidney injury. Patients experiencing sustained recovery were markedly less likely than true long-term ESRD patients to have permanent vascular accesses in place at incident hemodialysis, while non-White patients, and patients with any prior nephrology care appeared to have significantly lower rates of renal recovery. We also found widespread geographic variation in the rates of renal recovery across the United States. CONCLUSIONS: Renal recovery rates in the US Medicare ESRD program are higher than previously reported and appear to have significant geographic variation. Patients with diagnoses associated with acute kidney injury who are initiated on long-term hemodialysis have significantly higher rates of renal recovery than the general ESRD population and lower rates of permanent access placement.

  4. 76 FR 24213 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Science.gov (United States)

    2011-04-29

    ... 2012 IRF PPS Federal Prospective Payment Rates A. Proposed Market Basket Increase Factor, Productivity.... Proposed Productivity Adjustment 3. Proposed Calculation of the IRF PPS Market Basket Increase Factor for... Medicare Provider Analysis and Review MFP Multifactor Productivity MMSEA Medicare, Medicaid, and SCHIP...

  5. 78 FR 61191 - Medicare Program; FY 2014 Inpatient Prospective Payment Systems: Changes to Certain Cost...

    Science.gov (United States)

    2013-10-03

    ... calculated by the our Office of the Actuary, to determine both the aggregate amount of empirically justified... Office of the Actuary used the March 2013 update of the Medicare Hospital Cost Report Information System..., as these hospitals do not receive a Medicare DSH payment. The CMS Office of the Actuary's final...

  6. Catching flies with vinegar: a critique of the Centers for Medicare and Medicaid self-disclosure program.

    Science.gov (United States)

    Veilleux, Jean Wright

    2012-01-01

    This Article argues that the current approach of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) to enforcement of the Ethics in Patient Referrals Act (the "Stark Law") is unnecessarily punitive and discourages health-care providers from self-disclosing even very minor violations of the Stark Law. This Article suggests a number of specific changes to encourage provider self-disclosure and proposes that CMS create a demonstration project under the authority of the Patient Protection and Affordable Care Act to test the reforms. A demonstration project provides the perfect vehicle to prove that increased self-disclosure protocols for the Stark Law can decrease the government's costs of enforcement, improve program integrity, and encourage providers to deal responsibly with the inevitable minor lapses in compliance that arise in such an enormous government program as Medicare.

  7. 77 FR 25283 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Science.gov (United States)

    2012-04-27

    ... osteopathy, dentistry, and podiatry, as required in order to become certified by the appropriate specialty...'' (January 23, 2004, 69 FR 3434). A final rule titled ``Medicare, Medicaid, and Children's Health Insurance...

  8. 78 FR 47935 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    Science.gov (United States)

    2013-08-06

    .... Accounting Statement 7. Conclusion B. Regulatory Flexibility Act Analysis C. Unfunded Mandates Reform Act...-eligible beneficiaries would receive their drugs through the Medicare Part D benefit, which would work... rate than higher-skilled occupations, using the [[Page 47943

  9. 75 FR 59272 - Medicare and Medicaid Programs; Announcement of an Application from a Hospital Requesting Waiver...

    Science.gov (United States)

    2010-09-27

    ... in which the hospital is located: War Memorial Hospital (Medicare provider number 51-1309), of..., Virginia Beach, VA 23453. The Hospital's Designated OPO is: Center for Organ Recovery and Education, RIDC...

  10. 76 FR 2453 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    Science.gov (United States)

    2011-01-13

    ... program based on conditions for coverage. This new program will necessarily be a fluid model, subject to... rewarding better value, outcomes, and innovations instead of merely volume. Use of Measures: Public....hospitalcompare.hhs.gov , after a 30-day preview period. An interactive Web tool, this Web site assists...

  11. Evaluation of an integrated adherence program aimed to increase Medicare Part D star rating measures.

    Science.gov (United States)

    Leslie, R Scott; Tirado, Breanne; Patel, Bimal V; Rein, Philip J

    2014-12-01

    The Centers for Medicare Medicaid Services (CMS) Plan Quality and Performance Program, or Star Ratings Program, allows Medicare beneficiaries to compare quality of care among available Medicare Advantage prescription drug (MA-PD) plans and stand-alone prescription drug plans (PDPs). Health plans have increased intervention efforts and applied existing care management infrastructure as an approach to improving member medication adherence and subsequent Part D star rating performance. Independent Care Health Plan (iCare), an MA-PD plan; MedImpact Healthcare Systems, Inc. (MedImpact), a pharmacy benefits manager; and US MED, a mail order pharmacy, partnered to engage and enroll iCare's dual-eligible special needs population in an intervention designed to improve patient medication adherence and health plan performance for 3 Part D patient safety outcome measures: Medication Adherence for Oral Diabetes Medications (ODM), Medication Adherence for Hypertension (HTN), and Medication Adherence for Cholesterol (CHOL). To (a) assess the effectiveness of a coordinated member-directed medication adherence intervention and (b) determine the overall impact of the intervention on adherence rates and CMS Part D star rating adherence measures.  Administrative pharmacy claims and health plan eligibility data from MedImpact's databases were used to identify members using 3 target medication classes. Adherence was estimated by the proportion of days covered (PDC) for all members. Those members considered at high risk for nonadherence were prioritized for care management services. Risk factors were based on members' use of more than 1 target medication class, newly started therapy, and suboptimal adherence (PDC  less than  80%) in the most recent 6-month period. Data files listing member adherence rates and contact information were formatted and loaded monthly into iCare's care management system, which triggered an alert for care coordinators to counsel members on the importance

  12. 75 FR 21175 - Medicare and Medicaid Programs; Waiver of Disapproval of Nurse Aide Training Program in Certain...

    Science.gov (United States)

    2010-04-23

    ... within a reasonable distance of the facility; Assures that an adequate environment exists for operating... final rule on these operational issues, we will work with all interested stakeholders to develop the..., Health Records, Medicaid, Medicare, Nursing [[Page 21179

  13. 76 FR 68467 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2011

    Science.gov (United States)

    2011-11-04

    ... Stuart Caplan, (410) 786-8564 Emission Tomography Registry RN, MAS. Sites. XII Medicare-Approved JoAnna... Stuart Caplan, (410) 786-8564 Emission Tomography for RN, MAS. Dementia Trials. All Other Information...

  14. 75 FR 21329 - Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying...

    Science.gov (United States)

    2010-04-23

    ... includes payment for premiums for Medicare Part B. Section 4732 of the Balanced Budget Act of 1997 (BBA... formula for determining State allotments. However, since certain States projected a deficit in their... minimize the impact on States with FY QI allotments that might be greater than their QI expenditures for...

  15. 75 FR 65282 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    Science.gov (United States)

    2010-10-22

    .... Palliative care in an LTC facility involves addressing physical, intellectual, emotional, social, and... Disability, Aging and Long-Term Care Policy and the Urban Institute; ``Synthesis and Analysis of Medicare..., mental, social, or emotional status; clinical complications that suggested a need to alter the care plan...

  16. 78 FR 32661 - Medicare, Medicaid, and Children's Health Insurance Programs; Renewal of the Advisory Panel on...

    Science.gov (United States)

    2013-05-31

    ... health coverage options available. The Advisory Panel on Outreach and Education allows us to consider a... Education (APOE) and Request for Nominations AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS... Education (APOE) has been renewed. It also requests nominations for individuals to serve on the APOE. DATES...

  17. 75 FR 8374 - Medicare Program; Meeting of the Practicing Physicians Advisory Council, March 8, 2010; Correction

    Science.gov (United States)

    2010-02-24

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1566-CN... 22, 2010 (75 FR 3743), there were a number of technical errors that are identified and corrected in... telephone at the number listed in the FOR FURTHER INFORMATION CONTACT section of this notice by the date...

  18. 76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Science.gov (United States)

    2011-07-18

    ...) 786-4533, and Jana Lindquist, (410) 786-4533, Partial hospitalization and community mental health... Laboratory Fee Schedule CMHC Community Mental Health Center CMS Centers for Medicare & Medicaid Services CPT... community mental health centers (CMHCs)) and hospital outpatient services that are furnished to inpatients...

  19. 76 FR 35683 - Medicare Program; Conditions of Participation (CoPs) for Community Mental Health Centers

    Science.gov (United States)

    2011-06-17

    ... Community Mental Health Centers; Proposed Rule #0;#0;Federal Register / Vol. 76 , No. 117 / Friday June 17... (CoPs) for Community Mental Health Centers AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS... participation (CoPs) that community mental health centers (CMHCs) would have to meet in order to participate in...

  20. 75 FR 46169 - Medicare Program; Proposed Changes to the Hospital Outpatient Prospective Payment System and CY...

    Science.gov (United States)

    2010-08-03

    ... hospitalization and community mental health center issues. James Poyer, (410) 786-2261, Reporting of quality data... Community mental health center CMS Centers for Medicare & Medicaid Services CoP Conditions of Participation... (which includes partial hospitalization services furnished by community mental health centers (CMHCs...

  1. 77 FR 41547 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013...

    Science.gov (United States)

    2012-07-13

    ... national standardized 60- day episode rates, the national per-visit rates, the low-utilization payment... Care Hospital LUPA Low Utilization Payment Amount MEPS Medical Expenditures Panel Survey MMA Medicare... units of services, adjustments for geographic differences in wage levels, outlier payments, the...

  2. 75 FR 38026 - Medicare Program; Identification of Backward Compatible Version of Adopted Standard for E...

    Science.gov (United States)

    2010-07-01

    ... testimony, industry also stated that the changes that were present in NCPDP SCRIPT 10.6 created an environment where long-term care (LTC) facilities could carry out e-prescribing under Medicare Part D. They.... Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or...

  3. 75 FR 81278 - Medicare Program: Solicitation of Comments Regarding Development of a Recovery Audit Contractor...

    Science.gov (United States)

    2010-12-27

    ... Director.) Specific conflict of interest rules that should apply to RACs for the Medicare Parts C and D... Remuneration (DIR). The DIR information reported by plans includes rebates paid by pharmaceutical manufacturers, as well as other remuneration received by the plan that has the effect of reducing their drug costs...

  4. 75 FR 39641 - Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes

    Science.gov (United States)

    2010-07-12

    ... law judge (ALJ) reverses the civil money penalty determination in whole or in part, the escrowed..., widespread harm, or resulting in a resident's death is not eligible for the civil money penalty reduction... Penalties for Nursing Homes AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed...

  5. 78 FR 43281 - Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical...

    Science.gov (United States)

    2013-07-19

    ... Index MFP Multi-Factor Productivity MIEA-TRHCA The Medicare Improvements and Extension Act, Division B... calculating direct PE RVUs from the top- down to the bottom-up methodology beginning in CY 2007. We adopted a... $20 million. 2. Calculation of Payments Based on RVUs To calculate the payment for each physicians...

  6. 78 FR 74229 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical...

    Science.gov (United States)

    2013-12-10

    ... MFP Multi-Factor Productivity MGMA Medical Group Management Association MIEA-TRHCA The Medicare... 69624), we revised the methodology for calculating direct PE RVUs from the top- down to the bottom-up... Based on RVUs To calculate the payment for each physicians' service, the components of the fee schedule...

  7. 77 FR 34326 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-06-11

    ... identify outlier cases for both inpatient operating and inpatient capital related payments, which is... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 412... Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality...

  8. 76 FR 5861 - Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements...

    Science.gov (United States)

    2011-02-02

    ... Improvement Protection Act of 2000 (Pub. L. 106-544) CAH Critical access hospital CAP Competitive acquisition... corporations and non-profit organizations and charities. The ``Report to Congress on Steps Taken to Assure... primarily payable under Part A of Medicare, such as hospitals, home health agencies (including home health...

  9. 76 FR 19365 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

    Science.gov (United States)

    2011-04-07

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1357-N] RIN... document, demonstrates that this notice is consistent with the regulatory philosophy and principles.... Kathleen Sebelius, Secretary, Department of Health and Human Services. Addendum This addendum includes...

  10. 77 FR 23722 - Medicare Program; Extension of Certain Wage Index Reclassifications and Special Exceptions for...

    Science.gov (United States)

    2012-04-20

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-1442-N... regulatory philosophy and principles identified in Executive Order 12866 and 13563, the RFA, and section 1102.... Kathleen Sebelius, Secretary, Department of Health and Human Services. [FR Doc. 2012-9598 Filed 4-19-12; 8...

  11. 78 FR 54842 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical...

    Science.gov (United States)

    2013-09-06

    ... millions) (2) change (3) Total $3,625 1% Eye and ocular adnexa 1,496 -3 Digestive system 743 8 Nervous... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405...: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality...

  12. Low-Cost Generic Program Use by Medicare Beneficiaries: Implications for Medication Exposure Misclassification in Administrative Claims Data.

    Science.gov (United States)

    Pauly, Nathan J; Talbert, Jeffery C; Brown, Joshua

    2016-06-01

    Administrative claims data are used for a wide variety of research and quality assurance purposes; however, they are prone to medication exposure misclassification if medications are purchased without using an insurance benefit. Low-cost generic drug programs (LCGPs) offered at major chain pharmacies are a relatively new and sparsely investigated source of exposure misclassification. LCGP medications are often purchased out of pocket; thus, a pharmacy claim may never be submitted, and the exposure may go unobserved in claims data. As heavy users of medications, Medicare beneficiaries have much to gain from the affordable medications offered through LCGPs. This use may put them at increased risk of exposure misclassification in claims data. Many high-risk medications (HRMs) and medications tracked for adherence and utilization quality metrics are available through LCGPs, and exposure misclassification of these medications may impact the quality assurance efforts reliant on administrative claims data. Presently, there is little information regarding the use of these programs among a geriatric population. To (a) quantify the prevalence of LCGP users in a nationally representative population of Medicare beneficiaries; (b) compare clinical and demographic characteristics of LCGP users and nonusers; (c) assess determinants of LCGP use and medications acquired through these programs; and (d) analyze patterns of LCGP use during the years 2007-2012. This study relied on data from the Medical Expenditure Panel Survey (MEPS) from 2007 to 2012. The first 3 objectives were completed with a cohort of individuals in the most recent MEPS panel, while the fourth objective was completed with a separate cohort composed of individuals who participated in MEPS from 2007 to 2012. Inclusion in either study cohort required that individuals were Medicare beneficiaries aged 65 years or greater, used at least 1 prescription drug during their 2-year panel period, and participated in all 5

  13. Value-Based Payment Reform and the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015: A Primer for Plastic Surgeons.

    Science.gov (United States)

    Squitieri, Lee; Chung, Kevin C

    2017-07-01

    In 2015, the U.S. Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act, which effectively repealed the Centers for Medicare and Medicaid Services sustainable growth rate formula and established the Centers for Medicare and Medicaid Services Quality Payment Program. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The Quality Payment Program includes two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. The Merit-Based Incentive Payment System pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced alternative payment model pathway is available to providers who participate in qualifying Advanced Alternative Payment Models and is associated with an initial 5 percent payment incentive. The first performance period for the Merit-Based Incentive Payment System opens January 1, 2017, and closes on December 31, 2017, and is associated with payment adjustments in January of 2019. The Centers for Medicare and Medicaid Services estimates that the majority of providers will begin participation in 2017 through the Merit-Based Incentive Payment System pathway, but aims to have 50 percent of payments tied to quality or value through Advanced Alternative Payment Models by 2018. In this article, the authors describe key components of the Medicare Access and Children's Health Insurance Program Reauthorization Act to providers navigating through the Quality Payment Program and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

  14. Medicare Non-Utilization Project (MNUP)

    Data.gov (United States)

    Social Security Administration — A program integrity initiative using a data exchange between SSA and the Centers for Medicare and Medicaid Services (CMS).CMS will identify Medicare Part B enrollees...

  15. Statistical Uncertainty in the Medicare Shared Savings...

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to analysis reported in Statistical Uncertainty in the Medicare Shared Savings Program published in Volume 2, Issue 4 of the Medicare and Medicaid Research...

  16. Medicare FFS Jurisdiction Error Rate Contribution Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services CMS is dedicated to continually strengthening and improving the Medicare program, which provides vital services to...

  17. An effectiveness and cost-benefit analysis of a hospital-based discharge transition program for elderly Medicare recipients.

    Science.gov (United States)

    Saleh, Shadi S; Freire, Chris; Morris-Dickinson, Gwendolyn; Shannon, Trip

    2012-06-01

    To investigate the business case of postdischarge care transition (PDCT) among Medicare beneficiaries by conducting a cost-benefit analysis. Randomized controlled trial. A general hospital in upstate New York State. Elderly Medicare beneficiaries being treated from October 2008 through December 2009 were randomly selected to receive services as part of a comprehensive PDCT program (intervention--173 patients) or regular discharge process (control--160 patients) and followed for 12 months. The intervention comprised five activities: development of a patient-centered health record, a structured discharge preparation checklist of critical activities, delivery of patient self-activation and management sessions, follow-up appointments, and coordination of data flow. Cost-benefit ratio of the PDCT program; self-management skills and abilities. The 1-year readmission analysis revealed that control participants were more likely to be readmitted than intervention participants (58.2% vs 48.2%; P = .08); with most of that difference observed in the 91 to 365 days after discharge. Findings from the cost-benefit analysis revealed a cost-benefit ratio of 1.09, which indicates that, for every $1 spent on the program, a saving of $1.09 was realized. In addition, participating in a care transition program significantly enhanced self-management skills and abilities. Postdischarge care transition programs have a dual benefit of enhancing elderly adults' self-management skills and abilities and producing cost savings. This study builds a case for the inclusion of PDCT programs as a reimbursable service in benefit packages. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

  18. 75 FR 58789 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-April Through June 2010

    Science.gov (United States)

    2010-09-24

    ... Office of Management and Budget for collections of information in CMS regulations and a list of Medicare- approved carotid stent facilities. Included in this notice is a list of the American College of Cardiology... special one-time notices regarding national coverage provisions. Also included in this notice is a list of...

  19. 75 FR 14905 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-October Through December 2009

    Science.gov (United States)

    2010-03-26

    ... under Medicare. This notice also includes listings of all approval numbers from the Office of Management... stent facilities. Included in this notice is a list of the American College of Cardiology's National Cardiovascular Data registry sites, active CMS coverage-related guidance documents, and special one-time notices...

  20. Choice Inconsistencies among the Elderly: Evidence from Plan Choice in the Medicare Part D Program: Comment.

    Science.gov (United States)

    Ketcham, Jonathan D; Kuminoff, Nicolai V; Powers, Christopher A

    2016-12-01

    Consumers' enrollment decisions in Medicare Part D can be explained by Abaluck and Gruber’s (2011) model of utility maximization with psychological biases or by a neoclassical version of their model that precludes such biases. We evaluate these competing hypotheses by applying nonparametric tests of utility maximization and model validation tests to administrative data. We find that 79 percent of enrollment decisions from 2006 to 2010 satisfied basic axioms of consumer theory under the assumption of full information. The validation tests provide evidence against widespread psychological biases. In particular, we find that precluding psychological biases improves the structural model's out-of-sample predictions for consumer behavior.

  1. Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program.

    Science.gov (United States)

    Mellor, Jennifer; Daly, Michael; Smith, Molly

    2017-08-01

    To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference-in-differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  2. Description and outcomes of a Medicare case management program by nurses.

    Science.gov (United States)

    Allen, S A

    1999-01-01

    During the current environment of cost-cutting and restructuring, case management is viewed as a means of providing comprehensive, coordinated care while reducing costs. Studies of community-based case management have been disappointing. This study evaluates a Medicare service, Management and Evaluation of the Care Plan (MAE), as a model of nurses providing case management in the home. Three groups were compared: MAE (N = 176), non-MAE (N = 187) and newly discharged (N = 93). Utilization data was collected over one year. Overall, subjects were unmarried older women with three functional limitations, four medical diagnoses and averaged 43 home care visits and one hospitalization. MAE patients were older, had more functional and environmental limitations, less ADL independence, and a worse prognosis, yet used significantly less health care than non-MAE recipients did. Regression analysis was performed using group membership and hospital and home care utilization as dependent variables. Although the project was conducted at one site, overall the sample was similar to the national Medicare population.

  3. The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program.

    Directory of Open Access Journals (Sweden)

    Rene Soria-Saucedo

    Full Text Available The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan's quality in the public sector--the Medicare Advantage (MA star ratings--we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings' compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans.

  4. The Role of Geography in the Assessment of Quality: Evidence from the Medicare Advantage Program.

    Science.gov (United States)

    Soria-Saucedo, Rene; Xu, Peng; Newsom, Jack; Cabral, Howard; Kazis, Lewis E

    2016-01-01

    The Affordable Care Act set in motion a renewed emphasis on quality of care evaluation. However, the evaluation strategies of quality by the Centers for Medicare and Medicaid Services do not consider geography when comparisons are made among plans. Using an overall measure of a plan's quality in the public sector--the Medicare Advantage (MA) star ratings--we explored the impact of geography in these ratings. We identified 2,872 U.S counties in 2010. The geographic factor predicted a larger fraction of the MA ratings' compared to socio-demographic factors which explained less. Also, after the risk adjustments, almost half of the U.S. states changed their ranked position in the star ratings. Further, lower MA star ratings were identified in the Southeastern region. These findings suggest that the geographic component effect on the ratings is not trivial and should be considered in future adjustments of the metric, which may enhance the transparency, accountability, and importantly level the playing field more effectively when comparing quality across health plans.

  5. 75 FR 71799 - Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates...

    Science.gov (United States)

    2010-11-24

    ...The final rule with comment period in this document revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (Affordable Care Act). In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2011. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Affordable Care Act. In this final rule with comment period, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These changes are applicable to services furnished on or after January 1, 2011. In this document, we also are including two final rules that implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest. In the interim final rule with comment period that is included in this document, we are changing the effective date for otherwise eligible hospitals and critical access hospitals that have been reclassified from urban to rural under section 1886(d)(8)(E) of the Social Security

  6. Society for Health Psychology (APA Division 38) and Society of Behavioral Medicine joint position statement on the Medicare Diabetes Prevention Program.

    Science.gov (United States)

    Fitzpatrick, Stephanie L; Wilson, Dawn K; Pagoto, Sherry L

    2017-06-01

    Beginning in January 2018, the Centers for Medicare and Medicaid Services (CMS) plans to cover the Diabetes Prevention Program (DPP), also referred to as Medicare DPP. The American Psychological Association Society for Health Psychology (SfHP) and the Society for Behavioral Medicine (SBM) reviewed the proposed plan. SfHP and SBM are in support of the CMS decision to cover DPP for Medicare beneficiaries but have a significant concern that aspects of the proposal will limit the public health impact. Concerns include the emphasis on weight outcomes to determine continued coverage and the lack of details regarding requirements for coaches. SfHP and SBM are in strong support of modifications to the proposal that would remove the minimum weight loss stipulation to determine coverage and to specify type and qualifications of "coaches."

  7. Medicare program; revision to accrual basis of accounting policy--HCFA. Proposed rule.

    Science.gov (United States)

    1998-05-18

    Current policy provides that payroll taxes a provider becomes obligated to remit to governmental agencies are included in allowable costs under Medicare only in the cost reporting period in which payment (upon which the payroll taxes are based) is actually made to an employee. Therefore, for payroll accrued in one year but not paid until the next year, the associated payroll taxes on the payroll are not an allowable cost until the next year. This proposed rule would make one exception, in the situation where payment would be made to the employee in the current year but for the fact the regularly scheduled payment date is after the end of the year. In that case, the rule would require allowance in the current year of accrued taxes on payroll that is accrued through the end of the year but not paid until the beginning of the next year, thus allowing accrued taxes on end-of-the year payroll in the same year that the accrual of the payroll itself is allowed. The effect of this proposal is not on the allowability of cost but rather only on the timing of payment; that is, the cost of payroll taxes on and-of-the-year payroll would be allowable in the current period rather than in the following period.

  8. 76 FR 72707 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Science.gov (United States)

    2011-11-25

    ... recommendations to the Medicare Trustees on how the Trustees might more accurately estimate health spending in the long run. The Panel's discussion is expected to be very technical in nature and will focus on the... making recommendations to the Medicare Trustees on how the Trustees might more accurately project health...

  9. 76 FR 13515 - Medicare Program; Revisions to the Reductions and Increases to Hospitals' FTE Resident Caps for...

    Science.gov (United States)

    2011-03-14

    ...' FTE Resident Caps for Graduate Medical Education Payment Purposes AGENCY: Centers for Medicare... education affiliated groups for the purpose of determining possible full-time equivalent resident cap... caps for direct GME under Medicare for certain hospitals, and to authorize the ``redistribution'' of...

  10. How Successful Is Medicare Advantage?

    Science.gov (United States)

    Newhouse, Joseph P; McGuire, Thomas G

    2014-01-01

    Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan

  11. 77 FR 217 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Science.gov (United States)

    2012-01-04

    ... lines was not applied correctly. We have corrected our programming logic in the OPPS data process to... made to the programming logic described in the CY 2012 OPPS/ASC final (see 76 FR 74141). The correct...

  12. 42 CFR 413.87 - Payments for Medicare+Choice nursing and allied health education programs.

    Science.gov (United States)

    2010-10-01

    ... reimbursement for approved nursing and allied health education programs and the methodology for determining the... receives payment for a nursing or allied health education program under § 413.85 may receive an additional... establishes a nursing or allied health education program after FY 1998 and receives reasonable cost payment...

  13. 77 FR 24409 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

    Science.gov (United States)

    2012-04-24

    ..., to correct our programming logic in the OPPS data process to apply the line item trim correctly. We... center crosswalk in our programming logic and the packaging status of two drug codes. III. Summary of... dataset used to model the OPPS. In reviewing the program logic used to establish the APC median costs for...

  14. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative Appeals and Judicial Review. Final rule with comment period; final rule.

    Science.gov (United States)

    2015-11-13

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2016 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, this document includes certain finalized policies relating to the hospital inpatient prospective payment system: Changes to the 2-midnight rule under the short inpatient hospital stay policy; and a payment transition for hospitals that lost their status as a Medicare-dependent, small rural hospital (MDH) because they are no longer in a rural area due to the implementation of the new Office of Management and Budget delineations in FY 2015 and have not reclassified from urban to rural before January 1, 2016. In addition, this document contains a final rule that finalizes certain 2015 proposals, and addresses public comments received, relating to the changes in the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports.

  15. 78 FR 4151 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    Science.gov (United States)

    2013-01-18

    ...) Program using the Quality Reporting Document Architecture (QRDA) Category I. The comment period for the.... (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons... Reporting (IQR) Program using the Quality Reporting Document Architecture (QRDA) Category I beginning with...

  16. 77 FR 53257 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-08-31

    ... Estimated Net Savings for Current HACs g. Previously Considered Candidate HACs--RTI Analysis of Frequency of... Program 1. Background 2. Budget Neutrality Offset Amount for FY 2013 L. Hospital Routine Services... Program a. Administrative Requirements (1) Requirements Regarding QualityNet Account and Administrator for...

  17. Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.

    Science.gov (United States)

    Lehmann, C U; Longhurst, C A; Hersh, W; Mohan, V; Levy, B P; Embi, P J; Finnell, J T; Turner, A M; Martin, R; Williamson, J; Munger, B

    2015-01-01

    In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.

  18. 76 FR 71571 - Medicare Program; Town Hall Meeting on FY 2013 Applications for New Medical Services and...

    Science.gov (United States)

    2011-11-18

    ... a diagnosis affects the management of the patient. Use of the device significantly improves clinical... Payments Under the Hospital Inpatient Prospective Payment System AGENCY: Centers for Medicare & Medicaid... and technologies under the hospital inpatient prospective payment system (IPPS). Interested parties...

  19. Medicare program; revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to Part B for CY 2014. Final rule with comment period.

    Science.gov (United States)

    2013-12-10

    This major final rule with comment period addresses changes to the physician fee schedule, clinical laboratory fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule with comment period also includes a discussion in the Supplementary Information regarding various programs. (See the Table of Contents for a listing of the specific issues addressed in the final rule with comment period.)

  20. The Hospital-Acquired Conditions (HAC) reduction program: using cranberry treatment to reduce catheter-associated urinary tract infections and avoid Medicare payment reduction penalties.

    Science.gov (United States)

    Saitone, T L; Sexton, R J; Sexton Ward, A

    2018-01-01

    The Affordable Care Act (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program. The Centers for Medicare and Medicaid Services (CMS) established a total HAC scoring methodology to rank hospitals based upon their HAC performance. Hospitals that rank in the lowest quartile based on their HAC score are subject to a 1% reduction in their total Medicare reimbursements. In FY 2017, 769 hospitals incurred payment reductions totaling $430 million. This study analyzes how improvements in the rate of catheter-associated urinary tract infections (CAUTI), based on the implementation of a cranberry-treatment regimen, impact hospitals' HAC scores and likelihood of avoiding the Medicare-reimbursement penalty. A simulation model is developed and implemented using public data from the CMS' Hospital Compare website to determine how hospitals' unilateral and simultaneous adoption of cranberry to improve CAUTI outcomes can affect HAC scores and the likelihood of a hospital incurring the Medicare payment reduction, given results on cranberry effectiveness in preventing CAUTI based on scientific trials. The simulation framework can be adapted to consider other initiatives to improve hospitals' HAC scores. Nearly all simulated hospitals improved their overall HAC score by adopting cranberry as a CAUTI preventative, assuming mean effectiveness from scientific trials. Many hospitals with HAC scores in the lowest quartile of the HAC-score distribution and subject to Medicare reimbursement reductions can improve their scores sufficiently through adopting a cranberry-treatment regimen to avoid payment reduction. The study was unable to replicate exactly the data used by CMS to establish HAC scores for FY 2018. The study assumes that hospitals subject to the Medicare payment reduction were not using cranberry as a prophylactic treatment for their catheterized patients, but is unable to confirm that this is true in all cases. The study also assumes that hospitalized catheter

  1. Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; electronic reporting pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; revision to Quality Improvement Organization regulations. Final rule with comment period.

    Science.gov (United States)

    2012-11-15

    This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2013 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program. We are continuing the electronic reporting pilot for the Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality Improvement Organizations (QIOs), including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes, and technical changes. The technical changes to the QIO regulations reflect CMS' commitment to the general principles of the President's Executive Order on Regulatory Reform, Executive Order 13563 (January 18, 2011).

  2. Canadian Medicare: prognosis guarded.

    OpenAIRE

    Naylor, C D; Fooks, C; Williams, J I

    1995-01-01

    Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making ...

  3. Medicare Appeals Council Decisions

    Data.gov (United States)

    U.S. Department of Health & Human Services — Decisions of the Departmental Appeals Board's Medicare Appeals Council involving claims for entitlement to Medicare and individual claims for Medicare coverage and...

  4. Medicare Hospice Benefits

    Science.gov (United States)

    CENTERS for MEDICARE & MEDICAID SERVICES Medicare Hospice Benefits This official government booklet includes information about Medicare hospice benefits: Who’s eligible for hospice care What services are included in hospice care How ...

  5. 77 FR 27869 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2012-05-11

    ... Considered HAC Candidate: Iatrogenic Pneumothorax With Venous Catheterization 3. Present on Admission (POA.... History of Measures Adopted for the Hospital IQR Program b. Maintenance of Technical Specifications for...-Associated Infection (HAI) Measures (A) Proposed Central Line Associated Blood Stream Infections ((CLABSI...

  6. 78 FR 26879 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    Science.gov (United States)

    2013-05-08

    ... Prospective Payment System for Federal Fiscal Year 2014; Proposed Rule #0;#0;Federal Register / Vol. 78, No... Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2014 AGENCY... IRF prospective payment system's (PPS) case-mix groups and a description of the methodology and data...

  7. 76 FR 51475 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Science.gov (United States)

    2011-08-18

    ...-Associated Secondary Diagnoses for Current HACs h. RTI Analysis of Estimated Net Savings for Current HACs i.... Changes to the Demonstration Program Made by the Affordable Care Act 3. FY 2012 Budget Neutrality Adjustment a. Component of the FY 2012 Budget Neutrality Adjustment that Accounts for Estimated Demonstration...

  8. How State-Funded Home Care Programs Respond to Changes in Medicare Home Health Care: Resource Allocation Decisions on the Front Line

    Science.gov (United States)

    Corazzini, Kirsten

    2003-01-01

    Objective To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment. Data Sources/Study Setting Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders. Study Design Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N=2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices. Data Collection/Extraction Methods Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients. Principal Findings Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels. Conclusions Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics. PMID:14596390

  9. The Impact of Hospital-Acquired Conditions on Medicare..

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to findings reported in The Impact of Hospital-Acquired Conditions on Medicare Program Payments, published in Volume 4, Issue 4 of the Medicare and...

  10. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018. Final rule.

    Science.gov (United States)

    2017-08-03

    This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2018 as required by the statute. As required by section 1886(j)(5) of the Social Security Act (the Act), this rule includes the classification and weighting factors for the IRF prospective payment system's (IRF PPS) case-mix groups and a description of the methodologies and data used in computing the prospective payment rates for FY 2018. This final rule also revises the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes that are used to determine presumptive compliance under the "60 percent rule," removes the 25 percent payment penalty for inpatient rehabilitation facility patient assessment instrument (IRF-PAI) late transmissions, removes the voluntary swallowing status item (Item 27) from the IRF-PAI, summarizes comments regarding the criteria used to classify facilities for payment under the IRF PPS, provides for a subregulatory process for certain annual updates to the presumptive methodology diagnosis code lists, adopts the use of height/weight items on the IRF-PAI to determine patient body mass index (BMI) greater than 50 for cases of single-joint replacement under the presumptive methodology, and revises and updates measures and reporting requirements under the IRF quality reporting program (QRP).

  11. Cognition, Health Literacy, and Actual and Perceived Medicare Knowledge Among Inner-City Medicare Beneficiaries.

    Science.gov (United States)

    Sivakumar, Haran; Hanoch, Yaniv; Barnes, Andrew J; Federman, Alex D

    2016-01-01

    Poor Medicare knowledge is associated with worse health outcomes, especially in low-income patients. We examined the association of health literacy and cognition with actual and perceived Medicare knowledge in a sample of inner-city older adults. We conducted a cross-sectional analysis of data on 336 adults ages 65 years and older with Medicare coverage recruited from senior centers and low-income housing facilities in Manhattan, New York. Actual Medicare knowledge was determined by a summary score of 9 true/false questions about the Medicare program and perceived Medicare knowledge with a single item. Validated measures were used to assess health literacy and general cognition. Among respondents, 63.1% had high actual Medicare knowledge, and 36.0% believed that they knew what they needed to know about Medicare. Actual and perceived Medicare knowledge were poorly correlated (r = -.01, p > .05). In multivariable models, low health literacy was significantly associated with actual Medicare knowledge (β = -8.30, SE = 2.71, p information about the Medicare program and diminish their ability to make fully informed choices.

  12. 77 FR 70163 - Medicare Program; Town Hall Meeting on FY 2014 Applications for New Medical Services and...

    Science.gov (United States)

    2012-11-23

    ... evidence that use of the device to make a diagnosis affects the management of the patient. Use of the... the device. ++ Decreased pain, bleeding or other quantifiable symptoms. ++ Reduced recovery time. In... technology that substantially improves the diagnosis or treatment of Medicare beneficiaries before...

  13. 78 FR 71555 - Medicare Program; Town Hall Meeting on FY 2015 Applications for New Medical Services and...

    Science.gov (United States)

    2013-11-29

    ... evidence that use of the device to make a diagnosis affects the management of the patient. Use of the... the device. ++ Decreased pain, bleeding or other quantifiable symptoms. ++ Reduced recovery time. In... technology that substantially improves the diagnosis or treatment of Medicare beneficiaries before...

  14. 75 FR 68798 - Medicare Program; Part A Premiums for CY 2011 for the Uninsured Aged and for Certain Disabled...

    Science.gov (United States)

    2010-11-09

    ... Retirement Act and certain others do not have to pay premiums for Medicare Part A.) Section 1818A of the Act... specifies that the premium that these individuals will pay for CY 2011 will be equal to the premium for... consequential effect on State, local, or tribal governments or on the private sector. However, States are...

  15. 76 FR 32409 - Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule

    Science.gov (United States)

    2011-06-06

    .../Kyphoplasty 7. Closed Treatment of Distal Radial Fracture 8. Orthopaedic Surgery--Thigh/Knee 9. Treatment of Ankle Fracture 10. Orthopaedic Surgery/Podiatry 11. Application of Cast and Strapping 12. Cardiothoracic... Immunology MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173) MMSV...

  16. 75 FR 76468 - Office of the Assistant Secretary for Planning and Evaluation; Medicare Program; Meeting of the...

    Science.gov (United States)

    2010-12-08

    ... recommendations to the Medicare Trustees on how the Trustees might more accurately estimate health spending in the long run. The Panel's discussion is expected to be very technical in nature and will focus on the... Trustees on how the Trustees might more accurately estimate the long term rate of health spending in the...

  17. 77 FR 31359 - Medicare and Medicaid Programs; Announcement of the Re-Approval of the Joint Commission as an...

    Science.gov (United States)

    2012-05-25

    ... Organization Under the Clinical Laboratory Improvement Amendments of 1988 AGENCY: Centers for Medicare... Commission for re-approval as an accreditation organization for clinical laboratories under the Clinical... On October 31, 1988, the Congress enacted the Clinical Laboratory Improvement Amendments of 1988...

  18. 76 FR 18930 - Medicare Programs: Changes to the End-Stage Renal Disease Prospective Payment System Transition...

    Science.gov (United States)

    2011-04-06

    ... Payment System Transition Budget-Neutrality Adjustment AGENCY: Centers for Medicare & Medicaid Services... in the CY 2011 ESRD Prospective Payment System (PPS) final rule for renal dialysis services provided...-Stage Renal Disease Prospective Payment System'', hereinafter, referred to as the CY 2011 ESRD PPS final...

  19. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals. Final rule; interim final rule with comment period.

    Science.gov (United States)

    2015-08-17

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform(SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016.As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare dependent,small rural hospital (MDH)Program and changes to the payment adjustment for low-volume hospitals under the IPPS.We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014.In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals,PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR)Incentive Program. We also are updating policies relating to the

  20. Pre-Medicare Eligible Individuals' Decision-Making In Medicare Part D: An Interview Study

    Directory of Open Access Journals (Sweden)

    Tao Jin

    2010-01-01

    Full Text Available Objectives: The objective of this study was to elicit salient beliefs among pre-Medicare eligible individuals regarding (1 the outcomes associated with enrolling in the Medicare Part D program; (2 those referents who might influence participants' decisions about enrolling in the Part D program; and (3 the perceived barriers and facilitators facing those considering enrolling in the Part D program. Methods: Focused interviews were used for collecting data. A sample of 10 persons between 62 and 64 years of age not otherwise enrolled in the Medicare program was recruited. Interviews were audio taped and field notes were taken concurrently. Audio recordings were reviewed to amend field notes until obtaining a thorough reflection of interviews. Field notes were analyzed to elicit a group of beliefs, which were coded into perceived outcomes, the relevant others who might influence Medicare Part D enrollment decisions and perceived facilitators and impediments. By extracting those most frequently mentioned beliefs, modal salient sets of behavioral beliefs, relevant referents, and control beliefs were identified. Results: Analyses showed that (1 most pre-Medicare eligible believed that Medicare Part D could "provide drug coverage", "save money on medications", and "provide financial and health security in later life". However, "monthly premiums", "the formulary with limited drug coverage" and "the complexity of Medicare Part D" were perceived as major disadvantages; (2 immediate family members are most likely to influence pre-Medicare eligible's decisions about Medicare Part D enrollment; and (3 internet and mailing educational brochures are considered to be most useful resources for Medicare Part D enrollment. Major barriers to enrollment included the complexity and inadequacy of insurance plan information. Conclusion: There are multiple factors related to decision-making surrounding the Medicare Part D enrollment. These factors include the advantages

  1. Use of Medicare's Diabetes Self-Management Training Benefit

    Science.gov (United States)

    Strawbridge, Larisa M.; Lloyd, Jennifer T.; Meadow, Ann; Riley, Gerald F.; Howell, Benjamin L.

    2015-01-01

    Medicare began reimbursing for outpatient diabetes self-management training (DSMT) in 2000; however, little is known about program utilization. Individuals diagnosed with diabetes in 2010 were identified from a 20% random selection of the Medicare fee-for-service population (N = 110,064). Medicare administrative and claims files were used to…

  2. Medicare Update: Annual Wellness Visit

    Science.gov (United States)

    ... counseling services or programs, designed to reduce risk factors, such as for weight loss, smoking cessation, fall prevention, and nutrition. • Review of the responses to the Health Risk Assessment Prepared by Leslie Fried, Alzheimer’s Association Medicare Advocacy Project. Rev. Feb 1, 2012 ...

  3. Medicare and Rural Health

    Science.gov (United States)

    ... community has a significant impact on the local economy. In rural areas, Medicare reimbursement is a critical source of that healthcare spending, particularly since the higher percentage of elderly population in rural areas mean that Medicare accounts for ...

  4. Medicare Cost Reports

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare certified institutional providers are required to submit an annual cost report to a Medicare Administrative Contractor. The cost report contains provider...

  5. Medicare Current Beneficiary Survey

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Characteristics and Perceptions of the Medicare Population Data from the 2010 Medicare Current Beneficiary Survey is a series of source books based on the...

  6. State Policies Influence Medicare Telemedicine Utilization.

    Science.gov (United States)

    Neufeld, Jonathan D; Doarn, Charles R; Aly, Reem

    2016-01-01

    Medicare policy regarding telemedicine reimbursement has changed little since 2000. Many individual states, however, have added telemedicine reimbursement for either Medicaid and/or commercial payers over the same period. Because telemedicine programs must serve patients from all or most payers, it is likely that these state-level policy changes have significant impacts on telemedicine program viability and utilization of services from all payers, not just those services and payers affected directly by state policy. This report explores the impact of two significant state-level policy changes-one expanding Medicaid telemedicine coverage and the other introducing telemedicine parity for commercial payers-on Medicare utilization in the affected states. Medicare claims data from 2011-2013 were examined for states in the Great Lakes region. All valid claims for live interactive telemedicine professional fees were extracted and linked to their states of origin. Allowed encounters and expenditures were calculated in total and on a per 1,000 members per year basis to standardize against changes in the Medicare population by state and year. Medicare telemedicine encounters and professional fee expenditures grew sharply following changes in state Medicaid and commercial payer policy in the examined states. Medicare utilization in Illinois grew by 173% in 2012 (over 2011) following Medicaid coverage expansion, and Medicare utilization in Michigan grew by 118% in 2013 (over 2012) following adoption of telemedicine parity for commercial payers. By contrast, annual Medicare telemedicine utilization growth in surrounding states (in which there were no significant policy changes during these years) varied somewhat but showed no discernible pattern. Although Medicare telemedicine policy has changed little since its inception, changes in state policies with regard to telemedicine reimbursement appear to have significant impacts on the practical viability of telemedicine programs

  7. Your Medicare Benefits

    Science.gov (United States)

    ... schedule a lung cancer screening counseling and shared decision making visit with your doctor to discuss the benefits ... when they’re available in your MyMedicare.gov account. 58 Section 3: For more information Visit Medicare. gov for general information about Medicare ...

  8. Medicare Prescription Drug Coverage - General Information

    Data.gov (United States)

    U.S. Department of Health & Human Services — The MMA legislation provides seniors and people with disabilities with the first comprehensive prescription drug benefit ever offered under the Medicare program, the...

  9. Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2015-11-05

    This final rule will update Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2016. As required by the Affordable Care Act, this rule implements the 3rd year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking and provides a clarification regarding the use of the "initial encounter'' seventh character applicable to certain ICD-10-CM code categories. This final rule will also finalize reductions to the national, standardized 60-day episode payment rate in CY 2016, CY 2017, and CY 2018 of 0.97 percent in each year to account for estimated case-mix growth unrelated to increases in patient acuity (nominal case-mix growth) between CY 2012 and CY 2014. In addition, this rule implements a HH value-based purchasing (HHVBP) model, beginning January 1, 2016, in which all Medicare-certified HHAs in selected states will be required to participate. Finally, this rule finalizes minor changes to the home health quality reporting program and minor technical regulations text changes.

  10. Canadian Medicare: prognosis guarded.

    Science.gov (United States)

    Naylor, C D; Fooks, C; Williams, J I

    1995-08-01

    Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making across-the-board cuts. (3) Replace blame with praise:give health care professionals and institutions credit for their contributions. (4) Learn from the successful programs and policies already in place across the country. (5) Foster horizontal and vertical integration of services. (6) Promote physician leadership by rewarding efforts to promote the efficient use of resources. (7) Monitor the effects of cutbacks: physician groups should cooperate with government in maintaining a national "report card" on services, costs and the health status of Canadians.

  11. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR)

    Science.gov (United States)

    2017-08-14

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2018. Some of these changes implement certain statutory provisions contained in the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, the 21st Century Cures Act, and other legislation. We also are making changes relating to the provider-based status of Indian Health Service (IHS) and Tribal facilities and organizations and to the low-volume hospital payment adjustment for hospitals operated by the IHS or a Tribe. In addition, we are providing the market basket update that will apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2018. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2018. In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities). We also are establishing new requirements or revising existing requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. We also are making changes relating to transparency of accrediting organization survey

  12. Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program.

    Science.gov (United States)

    Chen, Lena M; Epstein, Arnold M; Orav, E John; Filice, Clara E; Samson, Lok Wong; Joynt Maddox, Karen E

    2017-08-01

    Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients. To compare performance in the PVBM Program by practice characteristics. Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013. High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries). Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs. Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next best cost score (z score, -0.18 [95% CI, -0.25 to -0.10]), then

  13. Medicare program; revision to accrual basis of accounting policy. Health Care Financing Administration (HCFA), HHS. Final rule.

    Science.gov (United States)

    1999-09-27

    Medicare policy provides that payroll taxes that a provider becomes obligated to remit to governmental agencies are included in allowable costs only in the cost reporting period in which payment (upon which the payroll taxes are based) is actually made to an employee. Therefore, for payroll accrued in 1 year but not paid until the next year, the associated payroll taxes are not an allowable cost until the next year. This final rule provides for an exception when payment would be made to the employee in the current year but for the fact the regularly scheduled payment date is after the end of the year. In that case, the rule requires allowance in the current year of accrued taxes on payroll that is accrued through the end of the year but not paid until the beginning of the next year, thus allowing accrued taxes on end-of-the year payroll in the same year that the accrual of the payroll itself is allowed. The effect of this rule is not on the allowability of cost but rather only on the timing of payment; that is, the cost of payroll taxes on end-of-the-year payroll is allowable in the current period rather than in the following period.

  14. Medicare program; replacement of reasonable charge methodology by fee schedules for parenteral and enteral nutrients, equipment, and supplies. Final rule.

    Science.gov (United States)

    2001-08-28

    This final rule implements fee schedules for payment of parenteral and enteral nutrition (PEN) items and services furnished under the prosthetic device benefit, defined in section 1861(s)(8) of the Social Security Act. The authority for establishing these fee schedules is provided by the Balanced Budget Act of 1997, which amended the Social Security Act at section 1842(s). Section 1842(s) of the Social Security Act specifies that statewide or other area wide fee schedules may be implemented for the following items and services still subject to the reasonable charge payment methodology: medical supplies; home dialysis supplies and equipment; therapeutic shoes; parenteral and enteral nutrients, equipment, and supplies; electromyogram devices; salivation devices; blood products; and transfusion medicine. This final rule describes changes made to the proposed fee schedule payment methodology for these items and services and provides that the fee schedules for PEN items and services are effective for all covered items and services furnished on or after January 1, 2002. Fee schedules will not be implemented for electromyogram devices and salivation devices at this time since these items are not covered by Medicare. In addition, fee schedules will not be implemented for medical supplies, home dialysis supplies and equipment, therapeutic shoes, blood products, and transfusion medicine at this time since the data required to establish these fee schedules are inadequate.

  15. Medicare Modernization Act (MMA) IRS Medicare Part D

    Data.gov (United States)

    Social Security Administration — SSA uses the Internal Revenue Service (IRS) information in determing the eligibility of Medicare recipients to receive subsidy payments for Medicare premiums. SSA...

  16. Financial Performance of Rural Medicare ACOs.

    Science.gov (United States)

    Nattinger, Matthew C; Mueller, Keith; Ullrich, Fred; Zhu, Xi

    2018-12-01

    The Centers for Medicare & Medicaid Services (CMS) has facilitated the development of Medicare accountable care organizations (ACOs), mostly through the Medicare Shared Savings Program (MSSP). To inform the operation of the Center for Medicare & Medicaid Innovation's (CMMI) ACO programs, we assess the financial performance of rural ACOs based on different levels of rural presence. We used the 2014 performance data for Medicare ACOs to examine the financial performance of rural ACOs with different levels of rural presence: exclusively rural, mostly rural, and mixed rural/metropolitan. Of the ACOs reporting performance data, we identified 97 ACOs with a measurable rural presence. We found that successful rural ACO financial performance is associated with the ACO's organizational type (eg, physician-based) and that 8 of the 11 rural ACOs participating in the Advanced Payment Program (APP) garnered savings for Medicare. Unlike previous work, we did not find an association between ACO size or experience and rural ACO financial performance. Our findings suggest that rural ACO financial success is likely associated with factors unique to rural environments. Given the emphasis CMS has placed on rural ACO development, further research to identify these factors is warranted. © 2016 National Rural Health Association.

  17. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

    Science.gov (United States)

    Barbieri, John S; Miller, Jeffrey J; Nguyen, Harrison P; Forman, Howard P; Bolognia, Jean L; VanBeek, Marta J

    2017-06-01

    As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

  18. Pre-Medicare Eligible Individuals’ Decision-Making In Medicare Part D: An Interview Study

    Directory of Open Access Journals (Sweden)

    Tao Jin, B.S. Pharm, Ph.D. Candidate

    2010-01-01

    Full Text Available ObjectivesThe objective of this study was to elicit salient beliefs among pre-Medicare eligible individuals regarding (1 the outcomes associated with enrolling in the Medicare Part D program; (2 those referents who might influence participants’ decisions about enrolling in the Part D program; and (3 the perceived barriers and facilitators facing those considering enrolling in the Part D program.MethodsFocused interviews were used for collecting data. A sample of 10 persons between 62 and 64 years of age not otherwise enrolled in the Medicare program was recruited. Interviews were audio taped and field notes were taken concurrently. Audio recordings were reviewed to amend field notes until obtaining a thorough reflection of interviews. Field notes were analyzed to elicit a group of beliefs, which were coded into perceived outcomes, the relevant others who might influence Medicare Part D enrollment decisions and perceived facilitators and impediments. By extracting those most frequently mentioned beliefs, modal salient sets of behavioral beliefs, relevant referents, and control beliefs were identified.ResultsAnalyses showed that (1 most pre-Medicare eligible believed that Medicare Part D could “provide drug coverage”, “save money on medications”, and “provide financial and health security in later life”. However, “monthly premiums”, “the formulary with limited drug coverage” and “the complexity of Medicare Part D” were perceived as major disadvantages; (2 immediate family members are most likely to influence pre-Medicare eligible’s decisions about Medicare Part D enrollment; and (3 internet and mailing educational brochures are considered to be most useful resources for Medicare Part D enrollment. Major barriers to enrollment included the complexity and inadequacy of insurance plan information.ConclusionThere are multiple factors related to decision-making surrounding the Medicare Part D enrollment. These factors

  19. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

    Science.gov (United States)

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  20. Public/private partnerships for prescription drug coverage: policy formulation and outcomes in Quebec's universal drug insurance program, with comparisons to the Medicare prescription drug program in the United States.

    Science.gov (United States)

    Pomey, Marie-Pascale; Forest, Pierre-Gerlier; Palley, Howard A; Martin, Elisabeth

    2007-09-01

    In January 1997, the government of Quebec, Canada, implemented a public/private prescription drug program that covered the entire population of the province. Under this program, the public sector collaborates with private insurers to protect all Quebecers from the high cost of drugs. This article outlines the principal features and history of the Quebec plan and draws parallels between the factors that led to its emergence and those that led to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) in the United States. It also discusses the challenges and similarities of both programs and analyzes Quebec's ten years of experience to identify adjustments that may help U.S. policymakers optimize the MMA.

  1. Medicare and state health care programs: fraud and abuse, civil money penalties and intermediate sanctions for certain violations by health maintenance organizations and competitive medical plans--HHS. Final rule.

    Science.gov (United States)

    1994-07-15

    This final rule implements sections 9312(c)(2), 9312(f), and 9434(b) of Public Law 99-509, section 7 of Public Law 100-93, section 4014 of Public Law 100-203, sections 224 and 411(k)(12) of Public Law 100-360, and section 6411(d)(3) of Public Law 101-239. These provisions broaden the Secretary's authority to impose intermediate sanctions and civil money penalties on health maintenance organizations (HMOs), competitive medical plans, and other prepaid health plans contracting under Medicare or Medicaid that (1) substantially fail to provide an enrolled individual with required medically necessary items and services; (2) engage in certain marketing, enrollment, reporting, or claims payment abuses; or (3) in the case of Medicare risk-contracting plans, employ or contract with, either directly or indirectly, an individual or entity excluded from participation in Medicare. The provisions also condition Federal financial participation in certain State payments on the State's exclusion of certain prohibited entities from participation in HMO contracts and waiver programs. This final rule is intended to significantly enhance the protections for Medicare beneficiaries and Medicaid recipients enrolled in a HMO, competitive medical plan, or other contracting organization under titles XVIII and XIX of the Social Security Act.

  2. Clinical and Economic Impact of a Digital, Remotely-Delivered Intensive Behavioral Counseling Program on Medicare Beneficiaries at Risk for Diabetes and Cardiovascular Disease.

    Directory of Open Access Journals (Sweden)

    Fang Chen

    Full Text Available Type 2 diabetes and cardiovascular disease impose substantial clinical and economic burdens for seniors (age 65 and above and the Medicare program. Intensive Behavioral Counseling (IBC interventions like the National Diabetes Prevention Program (NDPP, have demonstrated effectiveness in reducing excess body weight and lowering or delaying morbidity onset. This paper estimated the potential health implications and medical savings of a digital version of IBC modeled after the NDPP.Participants in this digital IBC intervention, the Omada program, include 1,121 overweight or obese seniors with additional risk factors for diabetes or heart disease. Weight changes were objectively measured via participant use of a networked weight scale. Participants averaged 6.8% reduction in body weight within 26 weeks, and 89% of participants completed 9 or more of the 16 core phase lessons. We used a Markov-based microsimulation model to simulate the impact of weight loss on future health states and medical expenditures over 10 years. Cumulative per capita medical expenditure savings over 3, 5 and 10 years ranged from $1,720 to 1,770 (3 years, $3,840 to $4,240 (5 years and $11,550 to $14,200 (10 years. The range reflects assumptions of weight re-gain similar to that seen in the DPP clinical trial (lower bound or minimal weight re-gain aligned with age-adjusted national averages (upper bound. The estimated net economic benefit after IBC costs is $10,250 to $12,840 cumulative over 10 years. Simulation outcomes suggest reduced incidence of diabetes by 27-41% for participants with prediabetes, and stroke by approximately 15% over 5 years.A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings. These findings affirm recommendations for IBC coverage by the U.S. Preventive Services Task Force.

  3. Effect of medicare payment on rural health care systems.

    Science.gov (United States)

    McBride, Timothy D; Mueller, Keith J

    2002-01-01

    Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

  4. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period.

    Science.gov (United States)

    2016-11-04

    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

  5. 78 FR 9057 - Medicare Program; Request for Information on the Use of Clinical Quality Measures (CQMs) Reported...

    Science.gov (United States)

    2013-02-07

    ... Physician Quality Reporting System (PQRS), the Electronic Health Record (EHR) Incentive Program, and Other... Physician Quality Reporting System (PQRS), as well as the Electronic Health Record (EHR) Incentive Program.... Maintenance of Certification Twenty-four member boards of the American Board of Medical Specialties (ABMS...

  6. Medicare and Medicaid programs; modifications to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and other changes to EHR Incentive Program; and health information technology: revision to the certified EHR technology definition and EHR certification changes related to standards. Final rule.

    Science.gov (United States)

    2014-09-04

    This final rule changes the meaningful use stage timeline and the definition of certified electronic health record technology (CEHRT) to allow options in the use of CEHRT for the EHR reporting period in 2014. It also sets the requirements for reporting on meaningful use objectives and measures as well as clinical quality measure (CQM) reporting in 2014 for providers who use one of the CEHRT options finalized in this rule for their EHR reporting period in 2014. In addition, it finalizes revisions to the Medicare and Medicaid EHR Incentive Programs to adopt an alternate measure for the Stage 2 meaningful use objective for hospitals to provide structured electronic laboratory results to ambulatory providers; to correct the regulation text for the measures associated with the objective for hospitals to provide patients the ability to view online, download, and transmit information about a hospital admission; and to set a case number threshold exemption for CQM reporting applicable for eligible hospitals and critical access hospitals (CAHs) beginning with FY 2013. Finally, this rule finalizes the provisionally adopted replacement of the Data Element Catalog (DEC) and the Quality Reporting Document Architecture (QRDA) Category III standards with updated versions of these standards.

  7. Medicare and Medicaid fraud and abuse regulations.

    Science.gov (United States)

    Liang, F Z; Black, B L

    1991-11-01

    Specific business arrangements that are protected under legislation and regulations governing parties doing business with Medicare or Medicaid are discussed. Regulations implementing the Medicare and Medicaid Patient Protection Act of 1987 specify practices and activities that are not subject to criminal penalties under the antikickback provisions of the Social Security Act or to exclusion from Medicare or state health-care programs. As of July 29, 1991, all organized health-care settings that receive payments from either Medicare or state health-care programs must comply with these regulations. The final rule sets forth "safe harbors"--exceptions to prohibitions against (1) kickbacks, bribes, rebates, and other illegal activities involving remunerations for patient referrals and (2) inducements to purchase or lease goods paid for by Medicare or state health-care programs. The safe harbors comprise 11 broad categories--investment interests, space rental, equipment rental, personal services and management contracts, purchase of a medical practice, referral services, warranties, discounts, employees, group purchasing organizations, and waiver of deductibles and coinsurance. Implications for pharmacy are discussed. These regulations will affect the purchase of pharmaceuticals by institutional pharmacies. Each institution should review its current practices to determine whether they are within the safe harbors.

  8. Medicare Data to Calculate Your Primary Service Areas

    Data.gov (United States)

    U.S. Department of Health & Human Services — The following data is being made available to applicants to the Medicare Shared Savings Program (Shared Savings Program), in order to allow them to calculate their...

  9. Medicare Enrollment Dashboard

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Enterprise Data and Analytics has developed a new interactive Medicare Enrollment Dashboard, which provides current information on the number of...

  10. Medicare Coverage Database

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Coverage Database (MCD) contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local articles, and proposed NCD...

  11. Medicare Hospice Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — More Medicare beneficiaries are taking advantage of the quality and compassionate care provided through the hospice benefit. As greater numbers of beneficiaries have...

  12. Mapping Medicare Disparities Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Minority Health has designed an interactive map, the Mapping Medicare Disparities Tool, to identify areas of disparities between subgroups of...

  13. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Issues Stop Overregulating My OR EHR Incentive Program Global Codes and Data Collection New Medicare Card Project Medicare Enrollment and Participation Medicare Payment Rules Physician Quality Reporting System (PQRS) Value-Based Payment Modifier Third Party ...

  14. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

    Science.gov (United States)

    Barbieri, John S; Miller, Jeffrey J; Nguyen, Harrison P; Forman, Howard P; Bolognia, Jean L; VanBeek, Marta J

    2017-06-01

    With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

  15. 77 FR 33547 - Privacy Act of 1974, as Amended; Computer Matching Program (SSA/Centers for Medicare and Medicaid...

    Science.gov (United States)

    2012-06-06

    ...: Social Security Administration (SSA). ACTION: Notice of a new computer matching program that will expire... protections for such persons. The Privacy Act, as amended, regulates the use of computer matching by Federal... SOCIAL SECURITY ADMINISTRATION [Docket No. SSA 2012-0015] Privacy Act of 1974, as Amended...

  16. 76 FR 42771 - Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B...

    Science.gov (United States)

    2011-07-19

    ... Payment Window. Pam West, (410) 786-2302, for issues related to the technical corrections. Rebecca Cole or... artery bypass graft CAD--Coronary artery disease CAH--Critical Access Hospital CAHEA--Committee on Allied... Program CBSA--Core-Based Statistical Area CDC--Centers for Disease Control and Prevention CEM--Cardiac...

  17. 42 CFR 403.206 - General standards for Medicare supplemental policies.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false General standards for Medicare supplemental policies. 403.206 Section 403.206 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies...

  18. Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). Final rule.

    Science.gov (United States)

    2017-01-03

    This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

  19. Medicare Hospital Spending Per Patient - State

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  20. Medicare Hospital Spending Per Patient - Hospital

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  1. Medicare Hospital Spending Per Patient - National

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  2. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    Science.gov (United States)

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.

  3. 30-day hospital readmission after robotic partial nephrectomy--are we prepared for Medicare readmission reduction program?

    Science.gov (United States)

    Brandao, Luis Felipe; Zargar, Homayoun; Laydner, Humberto; Akca, Oktay; Autorino, Riccardo; Ko, Oliver; Samarasekera, Dinesh; Li, Jianbo; Rabets, John; Krishnan, Jayram; Haber, Georges-Pascal; Kaouk, Jihad; Stein, Robert J

    2014-09-01

    After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  4. Disease prevention policy under Medicare: a historical and political analysis.

    Science.gov (United States)

    Schauffler, H H

    1993-01-01

    I review the history and politics of Medicare disease prevention policy and identify factors associated with the success or failure of legislative initiatives to add preventive services benefits to Medicare. Between 1965 and 1990, 453 bills for Medicare preventive services were introduced in the U.S. Congress, but not until 1980, after 350 bills had failed, was the first preventive service added to the Medicare program. Medicare currently pays for only four of the 44 preventive services recommended for the elderly by the U.S. Preventive Services Task Force (pneumococcal and hepatitis B vaccinations, Pap smears, and mammography). In addition, Congress has funded demonstration programs for the influenza vaccine and comprehensive preventive services. The preventive services added to Medicare reflect the bias of the biomedical model toward screening and immunizations. Counseling services have received the least legislative attention. Factors associated with successful enactment include single-benefit bills, incorporation into budget-deficit reduction legislation, documented evidence of cost-effectiveness, public hearings, sponsorship by chairs of key congressional committees, and persistent congressional leadership. Factors associated with failure include lack of support from Medicare beneficiaries, lack of professional support, impact on total Medicare expenditures, disagreement over or failure to address payment and financing mechanisms, and competing congressional priorities.

  5. Medicare Utilization for Part B

    Data.gov (United States)

    U.S. Department of Health & Human Services — This link takes you to the Medicare utilization statistics for Part B (Supplementary Medical Insurance SMI) which includes the Medicare Part B Physician and Supplier...

  6. Medicare and Medicaid Linked Files

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) has been developed to allow for the examination of all Medicare and Medicaid enrollment and...

  7. Medicare Utilization for Part A

    Data.gov (United States)

    U.S. Department of Health & Human Services — This link takes you to the Medicare utilization statistics for Part A (Hospital Insurance HI) which include the Medicare Ranking for all Short-Stay Hospitals by...

  8. Medicare Administrative Contractor Performance Evaluation

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) has compiled a summary of overall Medicare Administrative Contractor (MAC) performance information as measured...

  9. Medicare and Medicaid Research Review

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS), Office of Information Products and Data Analysis (OIPDA), is pleased to present our journal, Medicare and...

  10. Medicare, physicians, and patients.

    Science.gov (United States)

    Hacker, Joseph F

    2004-05-01

    There are many other provisions to the MMA. It is important to remind our patients that these changes are voluntary. If patients are satisfied with their current Medicare benefits and plan, they need not change to these new plans. However, as physicians we should familiarize ourselves with these new Medicare options so as to better advise our patients. For more information, visit www.ama-assn.org. The Medical Society of Delaware will strive to keep you informed as these new changes are implemented.

  11. Market characteristics and awareness of managed care options among elderly beneficiaries enrolled in traditional Medicare.

    Science.gov (United States)

    Mittler, Jessica N; Landon, Bruce E; Zaslavsky, Alan M; Cleary, Paul D

    2011-10-14

    Medicare beneficiaries' awareness of Medicare managed care plans is critical for realizing the potential benefits of coverage choices. To assess the relationships of the number of Medicare risk plans, managed care penetration, and stability of plans in an area with traditional Medicare beneficiaries' awareness of the program. Cross-sectional analysis of Medicare Current Beneficiary Survey data about beneficiaries' awareness and knowledge of Medicare managed care plan availability. Logistic regression models used to assess the relationships between awareness and market characteristics. Traditional Medicare beneficiaries (n = 3,597) who had never been enrolled in Medicare managed care, but had at least one plan available in their area in 2002, and excluding beneficiaries under 65, receiving Medicaid, or with end stage renal disease. Traditional Medicare beneficiaries' knowledge of Medicare managed care plans in general and in their area. Having more Medicare risk plans available was significantly associated with greater awareness, and having an intermediate number of plans (2-4) was significantly associated with more accurate knowledge of Medicare risk plan availability than was having fewer or more plans. Medicare may have more success engaging consumers in choice and capturing the benefits of plan competition by more actively selecting and managing the plan choice set. Public Domain.

  12. Changes in initial expenditures for benign prostatic hyperplasia evaluation in the Medicare population: a comparison to overall Medicare inflation.

    Science.gov (United States)

    Bellinger, Adam S; Elliott, Sean P; Yang, Liu; Wei, John T; Saigal, Christopher S; Smith, Alexandria; Wilt, Timothy J; Strope, Seth A

    2012-05-01

    Benign prostatic hyperplasia creates significant expenses for the Medicare program. We determined expenditure trends for benign prostatic hyperplasia evaluative testing after urologist consultation and placed these trends in the context of overall Medicare expenditures. Using a 5% national sample of Medicare beneficiaries from 2000 to 2007 we developed a cohort of 40,253 with claims for new visits to urologists for diagnoses consistent with symptomatic benign prostatic hyperplasia. We assessed trends in initial inflation and geography adjusted expenditures within 12 months of diagnosis by evaluative test categories derived from the 2003 American Urological Association guideline on the management of benign prostatic hyperplasia. Using governmental reports on Medicare expenditure trends for benign prostatic hyperplasia we compared expenditures to overall and imaging specific Medicare expenditures. Comparisons were assessed by the Z-test and regression analysis for linear trends, as appropriate. Between 2000 and 2007 inflation adjusted total Medicare expenditures per patient for the initial evaluation of patients with benign prostatic hyperplasia seen by urologists increased from $255.44 to $343.98 (p inflation adjusted expenditures increased for benign prostatic hyperplasia related evaluations. This growth was slower than the overall growth in Medicare expenditures. The increase in BPH related imaging expenditures was restrained compared to that of the Medicare program as a whole. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  13. Applying the 2003 Beers Update to Elderly Medicare Enr...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Applying the 2003 Beers Update to Elderly Medicare Enrollees in the Part D Program Inappropriate prescribing of certain medications known as Beers drugs may be...

  14. Vertical integration strategies: revenue effects in hospital and Medicare markets.

    Science.gov (United States)

    Cody, M

    1996-01-01

    The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

  15. MEDICARE: Improvements Needed in Provider Communications and Contracting Procedures

    National Research Council Canada - National Science Library

    Aronovitz, Leslie

    2001-01-01

    .... Under Medicare's fee-for-service system-which accounts for over 80 percent of program beneficiaries physicians, hospitals, and other providers submit claims to receive reimbursement for services...

  16. Medicare Advantage Plans

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  17. Your Medicare Rights

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  18. What Is Medicare?

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  19. What Medicare Covers

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  20. Claims and Appeals (Medicare)

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  1. Medicare hospital spending per patient (Medicare Spending per Beneficiary) – Additional Decimal Places

    Data.gov (United States)

    U.S. Department of Health & Human Services — The "Medicare hospital spending per patient (Medicare Spending per Beneficiary)" measure shows whether Medicare spends more, less or about the same per Medicare...

  2. Medicare program; payment policies under the physician fee schedule, five-year review of work relative value units, clinical laboratory fee schedule: signature on requisition, and other revisions to part B for CY 2012. Final rule with comment period.

    Science.gov (United States)

    2011-11-28

    This final rule with comment period addresses changes to the physician fee schedule and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also addresses, implements or discusses certain statutory provisions including provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. In addition, this final rule with comment period discusses payments for Part B drugs; Clinical Laboratory Fee Schedule: Signature on Requisition; Physician Quality Reporting System; the Electronic Prescribing (eRx) Incentive Program; the Physician Resource-Use Feedback Program and the value modifier; productivity adjustment for ambulatory surgical center payment system and the ambulance, clinical laboratory, and durable medical equipment prosthetics orthotics and supplies (DMEPOS) fee schedules; and other Part B related issues.

  3. Predictors of regional Medicare expenditures for otolaryngology physician services.

    Science.gov (United States)

    Smith, Alden; Handorf, Elizabeth; Arjmand, Ellis; Lango, Miriam N

    2017-06-01

    To describe geographic variation in spending and evaluate regional Medicare expenditures for otolaryngologist services with population- and beneficiary-related factors, physician supply, and hospital system factors. Cross-sectional study. The average regional expenditures for otolaryngology physician services were defined as the total work relative value units (wRVUs) collected by otolaryngologists in a hospital referral region (HRR) per thousand Medicare beneficiaries in the HRR. A multivariable linear regression model tested associations with regional sociodemographics (age, sex, race, income, education), the physician and hospital bed supply, and the presence of an otolaryngology residency program. In 2012, the mean Medicare expenditure for otolaryngology provider services across HRRs was 224 wRVUs per thousand Medicare beneficiaries (standard deviation [SD] 104), ranging from 31 to 604 wRVUs per thousand Medicare beneficiaries. In 2013, the average Medicare expenditures for each HRR was highly correlated with expenditures collected in 2012 (Pearson correlation coefficient .997, P = .0001). Regional Medicare expenditures were independently and positively associated with otolaryngology, medical specialist, and hospital bed supply in the region, and were negatively associated with the supply of primary care physicians and presence of an otolaryngology residency program after adjusting for other factors. The magnitude of associations with physician supply and hospital factors was stronger than any population or Medicare beneficiary factor. Wide variations in regional Medicare expenditures for otolaryngology physician services, highly stable over 2 years, were strongly associated with regional health system factors. Changes in health policy for otolaryngology care may require coordination with other physician specialties and integrated hospital systems. NA. Laryngoscope, 127:1312-1317, 2017. © 2016 The American Laryngological, Rhinological and Otological Society

  4. Collision course? Donald Trump, Paul Ryan, and the fate of Medicare.

    Science.gov (United States)

    Oberlander, Jonathan

    2018-04-10

    The election of Donald Trump as president of the United States raises questions about the future of Medicare. How will Medicare fare under Republican-led government? There are several compelling reasons that the Trump administration and Congressional Republicans might avoid Medicare reform, including the political risks of taking on a popular program, the difficulties the party has encountered in trying to dismantle the Patient Protection and Affordable Care Act (ACA), the importance of older Americans to the GOP coalition, and President Trump's views about Medicare. However, because of fiscal pressures and the commitment of Speaker of the House Paul Ryan and other Republicans to entitlement reform, the GOP nonetheless could end up attempting to make major changes in Medicare. Alternatively, Republican efforts to repeal and undermine the ACA could unintentionally enhance the political fortunes of proposals to expand Medicare. Consequently, the fate of Medicare during the Trump administration remains highly uncertain.

  5. Disease management for chronically ill beneficiaries in traditional Medicare.

    Science.gov (United States)

    Bott, David M; Kapp, Mary C; Johnson, Lorraine B; Magno, Linda M

    2009-01-01

    We summarize the Centers for Medicare and Medicaid Services' (CMS's) experience with disease management (DM) in fee-for-service Medicare. Since 1999, the CMS has conducted seven DM demonstrations involving some 300,000 beneficiaries in thirty-five programs. Programs include provider-based, third-party, and hybrid models. Reducing costs sufficient to cover program fees has proved particularly challenging. Final evaluations on twenty programs found three with evidence of quality improvement at or near budget-neutrality, net of fees. Interim monitoring covering at least twenty-one months on the remaining fifteen programs suggests that four are close to covering their fees. Characteristics of the traditional Medicare program present a challenge to these DM models.

  6. Examining Measures of Income and Poverty in Medicare Administrative Data.

    Science.gov (United States)

    Samson, Lok Wong; Finegold, Kenneth; Ahmed, Azeem; Jensen, Matthew; Filice, Clara E; Joynt, Karen E

    2017-12-01

    Disparities by economic status are observed in the health status and health outcomes of Medicare beneficiaries. For health services and health policy researchers, one barrier to addressing these disparities is the ability to use Medicare data to ascertain information about an individual's income level or poverty, because Medicare administrative data contains limited information about individual economic status. Information gleaned from other sources-such as the Medicaid and Supplemental Security Income programs-can be used in some cases to approximate the income of Medicare beneficiaries. However, such information is limited in its availability and applicability to all beneficiaries. Neighborhood-level measures of income can be used to infer individual-level income, but level of neighborhood aggregation impacts accuracy and usability of the data. Community-level composite measures of economic status have been shown to be associated with health and health outcomes of Medicare beneficiaries and may capture neighborhood effects that are separate from individual effects, but are not readily available in Medicare data and do not serve to replace information about individual economic status. There is no single best method of obtaining income data from Medicare files, but understanding strengths and limitations of different approaches to identifying economic status will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using measures of income.

  7. Medicare Managed Care plan Performance, A Comparison...

    Data.gov (United States)

    U.S. Department of Health & Human Services — The study evaluates the performance of Medicare managed care, Medicare Advantage, Plans in comparison to Medicare fee-for-service Plans in three states with...

  8. Medicare and Medicaid programs; CY 2015 Home Health Prospective Payment System rate update; Home Health Quality Reporting Requirements; and survey and enforcement requirements for home health agencies. Final rule.

    Science.gov (United States)

    2014-11-06

    This final rule updates Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2015. As required by the Affordable Care Act, this rule implements the second year of the four-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule provides information on our efforts to monitor the potential impacts of the rebasing adjustments and the Affordable Care Act mandated face-to-face encounter requirement. This rule also implements: Changes to simplify the face-to-face encounter regulatory requirements; changes to the HH PPS case-mix weights; changes to the home health quality reporting program requirements; changes to simplify the therapy reassessment timeframes; a revision to the Speech-Language Pathology (SLP) personnel qualifications; minor technical regulations text changes; and limitations on the reviewability of the civil monetary penalty provisions. Finally, this rule also discusses Medicare coverage of insulin injections under the HH PPS, the delay in the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), and a HH value-based purchasing (HH VBP) model.

  9. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... My OR EHR Incentive Program Global Codes and Data Collection Patient Opioid Use New Medicare Card Project Medicare ... self-care checklist Evaluation (Complete the Ostomy Patient Survey . We need your opinion!) Program outcomes The ACS ...

  10. Medicare depreciation; useful life guidelines--HCFA. Proposed rule.

    Science.gov (United States)

    1982-09-30

    We are proposing to amend Medicare regulations to clarify which useful life guidelines providers of health care services may use to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize HHS useful life guidelines or, if none have been published by HHS, the American Hospital Association (AHA) useful life guidelines of 1973 or IRS guidelines. We are proposing to eliminate the reference to IRS guidelines because those previously acceptable for Medicare purposes are outdated and have been made obsolete by the IRS or by statutory change. We would also delete the specific reference to the 1973 AHA guidelines. In addition, we intend this amendment to clarify that certain tax legislation on accelerated depreciation, recently passed by Congress, does not apply to the Medicare program.

  11. Improving the design of competitive bidding in Medicare Advantage.

    Science.gov (United States)

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders.

  12. Looking at CER from Medicare's perspective.

    Science.gov (United States)

    Mohr, Penny

    2012-05-01

    Comparative effectiveness research (CER) is rapidly adding to the amount of data available to health care coverage and payment decision makers. Medicare's decisions have a large effect on coverage and reimbursement policies throughout the health insurance industry and will likely influence the entire U.S. health care system; thus, examining its role in integrating CER into policy is crucial. To describe the potential benefits of CER to support payment and coverage decisions in the Medicare program, limitations on its use,the role of the Centers for Medicare & Medicaid Services (CMS) in improving the infrastructure for CER, and to discuss challenges that must be addressed to integrate CER into CMS's decision-making process. A defining feature of CER is that it provides the type of evidence that will help decision makers, such as patients, clinicians, and payers,make more informed treatment and policy decisions. Because CMS is responsible for more than 47 million elderly and disabled beneficiaries, the way that Medicare uses CER has the potential to have a large impact on public and individual health. Currently many critical payment and coverage decisions within the Medicare program are made on the basis of poor quality evidence, and CER has the potential to greatly improve the quality of decision making. Despite common misconceptions, CMS is not prohibited by law from using CER apart from some reasonable limitations. CMS is,however, required to support the development of the CER infrastructure by making their data more readily available to researchers. While CER has substantial potential to improve the quality of the agency's policy decisions,challenges remain to integrate CER into Medicare's processes. These challenges include statutory ambiguities, lack of sufficient staff and internal resources to take advantage of CER, and the lack of an active voice in setting priorities for CER and study design. Although challenges exist, CER has the potential to greatly

  13. Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships: partial delay of effective date. Interim final rule with comment period; partial delay in effective date.

    Science.gov (United States)

    2001-12-03

    This interim final rule with comment period delays for 1 year the effective date of the last sentence of 42 CFR 411.354(d)(1). Section 411.354(d)(1) was promulgated in the final rule entitled "Medicare and Medicaid Programs; Physicians' Referrals to Health Care Entities With Which They Have Financial Relationships," published in the Federal Register on January 4, 2001 (66 FR 856). A 1-year delay in the effective date of the last sentence in Section 411.354(d)(1) will give Department officials the opportunity to reconsider the definition of compensation that is "set in advance" as it relates to percentage compensation methodologies in order to avoid unnecessarily disrupting existing contractual arrangements for physician services. Accordingly, the last sentence of Section 411.354(d)(1), which would have become effective January 4, 2002, will not become effective until January 6,2003.

  14. Reductions in mortality among Medicare beneficiaries following the implementation of Medicare Part D.

    Science.gov (United States)

    Semilla, April P; Chen, Fang; Dall, Timothy M

    2015-07-01

    Medicare Part D is a prescription drug program that provides seniors and disabled individuals enrolled in Medicare with outpatient drug coverage benefits. Part D has been shown to increase access to medicines and improve medication adherence; however, the effect of Part D on health outcomes has not yet been extensively studied. In this study, we used a published and validated Markov-based microsimulation model to quantify the relationships among medication use, disease incidence and severity, and mortality. Based on the simulation results, we estimate that since the implementation of Part D in 2006, nearly 200,000 Medicare beneficiaries have lived at least 1 year longer. Reductions in mortality have occurred because of fewer deaths associated with medication-sensitive conditions such as diabetes, congestive heart failure, stroke, and myocardial infarction. Improved access to medication through Medicare Part D helps patients improve blood pressure, cholesterol, and blood glucose levels, which in turn can prevent or delay the onset of disease and the incidence of adverse health events, thus reducing mortality.

  15. Center for Medicare & Medicaid Services (CMS) , Medicare Claims data

    Data.gov (United States)

    U.S. Department of Health & Human Services — 2003 forward. CMS compiles claims data for Medicare and Medicaid patients across a variety of categories and years. This includes Inpatient and Outpatient claims,...

  16. Reforming Medicare through 'version 2.0' of accountable care.

    Science.gov (United States)

    Lieberman, Steven M

    2013-07-01

    Medicare needs fundamental reform to achieve fiscal sustainability, improve value and quality, and preserve beneficiaries' access to physicians. Physician fees will fall by one-quarter in 2014 under current law, and the dire federal budget outlook virtually precludes increasing Medicare spending. There is a growing consensus among policy makers that reforming fee-for-service payment, which has long served as the backbone of Medicare, is unavoidable. Accountable care organizations (ACOs) provide a new payment alternative but currently have limited tools to control cost growth or engage and reward beneficiaries and providers. To fundamentally reform Medicare, this article proposes an enhanced version of ACOs that would eliminate the scheduled physician fee cuts, allow fees to increase with inflation, and enhance ACOs' ability to manage care. In exchange, the proposal would require modest reductions in overall Medicare spending and require ACOs to accept increased accountability and financial risk. It would cause per beneficiary Medicare spending by 2023 to fall 4.2 percent below current Congressional Budget Office projections and help the program achieve fiscal sustainability.

  17. Reforming funding for chronic illness: Medicare-CDM.

    Science.gov (United States)

    Swerissen, Hal; Taylor, Michael J

    2008-02-01

    Chronic diseases are a major challenge for the Australian health care system in terms of both the provision of quality care and expenditure, and these challenges will only increase in the future. Various programs have been instituted under the Medicare system to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model. This paper proposes a realignment and extension of current Medicare chronic disease management programs into a framework that provides general practitioners and other health professionals with the necessary "tools" for high quality care planning and ongoing management, and incorporating international models of outcome-linked funding. The integration of social support services with the Medicare system is also a necessary step in providing high quality care for patients with complex needs requiring additional support.

  18. Competitive pricing and the challenge of cost control in medicare.

    Science.gov (United States)

    Coulam, Robert F; Feldman, Roger D; Dowd, Bryan E

    2011-08-01

    The Medicare program faces a serious challenge: it must find ways to control costs but must do so through a system of congressional oversight that necessarily limits its choices. We look at one approach to prudent purchasing - competitive pricing - that Medicare has attempted many times and in various ways since the beginning of the program, and in all but one case unsuccessfully due to the politics of provider opposition working through Congress and the courts. We look at some related efforts to change Medicare pricing to explore when the program has been successful in making dramatic changes in how it pays for health care. A set of recommendations emerges for ways to respond to the impediments of law and politics that have obstructed change to more efficient payment methods. Except in unusual cases, competitive pricing threatens too many stakeholders in too many ways for key political actors to support it. But an unusual case may arise in the coming Medicare fiscal crisis, a crisis related in part to the prices Medicare pays. At that point, competitive pricing may look less like a problem and more like a solution coming at a time when the system badly needs one.

  19. Chronic Conditions among Medicare Beneficiaries

    Data.gov (United States)

    U.S. Department of Health & Human Services — The data used in the chronic condition reports are based upon CMS administrative enrollment and claims data for Medicare beneficiaries enrolled in the...

  20. Medicare Referring Provider DMEPOS PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset, which is part of CMSs Medicare Provider Utilization and Payment Data, details information on Durable Medical Equipment, Prosthetics, Orthotics and...

  1. Medicare Provider Data - Hospice Providers

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Hospice Utilization and Payment Public Use File provides information on services provided to Medicare beneficiaries by hospice providers. The Hospice PUF...

  2. Medicare and Medicaid Statistical Supplement

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Enterprise Data and Analytics (OEDA) produced an annual Medicare and Medicaid Statistical Supplement report providing detailed statistical...

  3. Medicare program; revision to accrual basis of accounting policy. Department of Health and Human Services (HHS), Health Care Financing Administration (HCFA). Final rule.

    Science.gov (United States)

    1999-09-27

    Medicare policy provides that payroll taxes that a provider becomes obligated to remit to governmental agencies are included in allowable costs only in the cost reporting period in which payment (upon which the payroll taxes are based) is actually made to an employee. Therefore, for payroll accrued in 1 year but not paid until the next year, the associated payroll taxes are not an allowable cost until the next year. This final rule provides for an exception when payment would be made to the employee in the current year but for the fact that regularly scheduled payment date is after the end of the year. In that case, the rule requires allowance in the current year of accrued taxes on payroll that is accrued through the end of the year but not paid until the beginning of the next year, thus allowing accrued taxes on end-of-the year payroll in the same year that the accrual of the payroll itself is allowed. The effect of this rule is not on the allowability of cost but rather only on the timing of payment; that is, the cost of payroll taxes on end-of-the-year payroll is allowable in the current period rather than in the following period.

  4. Patient-centered care: an opportunity to accomplish the "Three Aims" of the National Quality Strategy in the Medicare ESRD program.

    Science.gov (United States)

    O'Hare, Ann M; Armistead, Nancy; Schrag, Wendy L Funk; Diamond, Louis; Moss, Alvin H

    2014-12-05

    In light of mounting federal government debt and levels of Medicare spending that are widely viewed as unsustainable, commentators have called for a transformation of the United States health care system to deliver better care at lower costs. This article presents the priorities of the Coalition for Supportive Care of Kidney Patients for how clinicians might achieve this transformation for patients with advanced CKD and their families. The authors suspect that much of the high-intensity, high-cost care currently delivered to patients with advanced kidney disease may be unwanted and that the "Three Aims" put forth by the National Quality Strategy of better care for the individual, better health for populations, and reduced health care costs may be within reach for patients with CKD and ESRD. This work describes the coalition's vision for a more patient-centered approach to the care of patients with kidney disease and argues for more concerted efforts to align their treatments with their goals, values, and preferences. Key priorities to achieve this vision include using improved prognostic models and decision science to help patients, their families, and their providers better understand what to expect in the future; engaging patients and their families in shared decision-making before the initiation of dialysis and during the course of dialysis treatment; and tailoring treatment strategies throughout the continuum of their care to address what matters most to individual patients. Copyright © 2014 by the American Society of Nephrology.

  5. Physician Reimbursement in Medicare Advantage Compared With Traditional Medicare and Commercial Health Insurance.

    Science.gov (United States)

    Trish, Erin; Ginsburg, Paul; Gascue, Laura; Joyce, Geoffrey

    2017-09-01

    (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%). Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.

  6. 42 CFR 403.322 - Termination of agreements for Medicare recognition of State systems.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Termination of agreements for Medicare recognition of State systems. 403.322 Section 403.322 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Recognition of State...

  7. Funding a Health Disparities Research Agenda: The Case of Medicare Home Health Care

    Science.gov (United States)

    Davitt, Joan K.

    2014-01-01

    Medicare home health care provides critical skilled nursing and therapy services to patients in their homes, generally after a period in an inpatient facility or nursing home. Disparities in access to, or outcomes of, home health care can result in patient deterioration and increased cost to the Medicare program if patient care needs intensify.…

  8. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... QPP Resource Center 2018 Information 2017 Information Program Rules Surgeon Specific Registry Metabolic and Bariatric Surgery Accreditation ... Card Project Medicare Enrollment and Participation Medicare Payment Rules Physician Quality Reporting System (PQRS) Value-Based Payment ...

  9. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... OR EHR Incentive Program Global Codes and Data Collection Patient Opioid Use New Medicare Card Project Medicare ... History History of the American College of Surgeons Collections Highlights Research 25- and 50-Year Fellows Recognition ...

  10. Paying Medicare Advantage plans: To level or tilt the playing field.

    Science.gov (United States)

    Glazer, Jacob; McGuire, Thomas G

    2017-12-01

    Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and subsidizes MA plans based on a "benchmark" for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Many analysts recommend equalizing Medicare's subsidy across the options - referred to in policy circles as a "level playing field." This paper studies the normative question of how to set the level of the benchmark, applying the versatile model developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic. Copyright © 2016. Published by Elsevier B.V.

  11. Controlling prescription drug costs: regulation and the role of interest groups in Medicare and the Veterans Health Administration.

    Science.gov (United States)

    Frakt, Austin B; Pizer, Steven D; Hendricks, Ann M

    2008-12-01

    Medicare and the Veterans Health Administration (VA) both finance large outpatient prescription drug programs, though in very different ways. In the ongoing debate on how to control Medicare spending, some suggest that Medicare should negotiate directly with drug manufacturers, as the VA does. In this article we relate the role of interest groups to policy differences between Medicare and the VA and, in doing so, explain why such a large change to the Medicare drug program is unlikely. We argue that key policy differences are attributable to stable differences in interest group involvement. While this stability makes major changes in Medicare unlikely, it suggests the possibility of leveraging VA drug purchasing to achieve savings in Medicare. This could be done through a VA-administered drug-only benefit for Medicare-enrolled veterans. Such a partnership could incorporate key elements of both programs: capacity to accept large numbers of enrollees (like Medicare) and leverage to negotiate prescription drug prices (like the VA). Moreover, it could be implemented at no cost to the VA while achieving savings for Medicare and beneficiaries.

  12. Cataract surgery among Medicare beneficiaries.

    Science.gov (United States)

    Schein, Oliver D; Cassard, Sandra D; Tielsch, James M; Gower, Emily W

    2012-10-01

    To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States. Cataract surgery performed on Medicare beneficiaries in 2003 and 2004. Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003-2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, sex, race and state; surgical volume by facility type and surgeon characteristics; time interval between first- and second-eye cataract surgery. The national cataract surgery rate for 2003-2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those aged 75-84 years. After adjustment for age and sex, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient. The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, sex, age, and by certain provider characteristics.

  13. Recent Health Care Use and Medicaid Entry of Medicare Beneficiaries.

    Science.gov (United States)

    Keohane, Laura M; Trivedi, Amal N; Mor, Vincent

    2017-10-01

    To examine the relationship between Medicaid entry and recent health care use among Medicare beneficiaries. We identified Medicare beneficiaries without full Medicaid or use of hospital or nursing home services in 2008 (N = 2,163,387). A discrete survival analysis estimated beneficiaries' monthly likelihood of entry into the full Medicaid program between January 2009 and June 2010. During the 18-month study period, Medicaid entry occurred for 1.1% and 3.7% of beneficiaries who aged into Medicare or originally qualified for Medicare due to disability, respectively. Among beneficiaries who aged into Medicare, 49% of new Medicaid participants had no use of inpatient, skilled nursing facility, or nursing home services during the study period. Individuals who recently used inpatient, skilled nursing facility or nursing home services had monthly rates of 1.9, 14.0, and 38.1 new Medicaid participants per 1,000 beneficiaries, respectively, compared with 0.4 new Medicaid participants per 1,000 beneficiaries with no recent use of these services. Although recent health care use predicted greater likelihood of Medicaid entry, half of new Medicaid participants used no hospital or nursing home care during the study period. These patterns should be considered when designing and evaluating interventions to reform health care delivery for dual-eligible beneficiaries. © The Author 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  14. Reforming Access: Trends in Medicaid Enrollment for New Medicare Beneficiaries, 2008-2011.

    Science.gov (United States)

    Keohane, Laura M; Rahman, Momotazur; Mor, Vincent

    2016-04-01

    To evaluate whether aligning the Part D low-income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries. Medicare enrollment records for years 2007-2011. We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008-2011). We identified new Medicare beneficiaries in the years 2008-2011 and their participation in Medicaid based on Medicare enrollment records. The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions. Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries' access to benefits. © Health Research and Educational Trust.

  15. Medicares Physician Quality Reporting System (PQRS)...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicares Physician Quality Reporting System (PQRS) allows providers to report measures of process quality and health outcomes. The authors of Medicares Physician...

  16. Measuring Coding Intensity in Medicare Advantage - SUPP.

    Data.gov (United States)

    U.S. Department of Health & Human Services — In 2004, Medicare implemented a risk-adjustment system that pays Medicare Advantage (MA) plans based on diagnoses reported for their enrollees, giving the plans an...

  17. Identifiable Data Files - Medicare Provider Analysis and ...

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Provider Analysis and Review (MEDPAR) File contains data from claims for services provided to beneficiaries admitted to Medicare certified inpatient...

  18. Medicare Physician and Other Supplier Interactive Dataset

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) has prepared a public data set, the Medicare Provider Utilization and Payment Data - Physician and Other...

  19. Medicare Current Beneficiary Survey - Limited Data Set

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a representative national sample of the Medicare population. There are two...

  20. Beneficiary Activation in the Medicare Population

    Data.gov (United States)

    U.S. Department of Health & Human Services — According to findings reported in Beneficiary Activation in the Medicare Population, published in Volume 4, Issue 4 of the Medicare and Medicaid Research Review,...

  1. Medicares Hospice Benefit - Analysis of Utilization and..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Descriptive analyses reported in Medicares Hospice Benefit - Analysis of Utilization and Resource Use, published in Volume 4, Issue 3 of the Medicare and Medicaid...

  2. Assessing Measurement Error in Medicare Coverage

    Data.gov (United States)

    U.S. Department of Health & Human Services — Assessing Measurement Error in Medicare Coverage From the National Health Interview Survey Using linked administrative data, to validate Medicare coverage estimates...

  3. Plan selection in Medicare Part D: Evidence from administrative data

    Science.gov (United States)

    Heiss, Florian; Leive, Adam; McFadden, Daniel; Winter, Joachim

    2014-01-01

    We study the Medicare Part D prescription drug insurance program as a bellwether for designs of private, non-mandatory health insurance markets, focusing on the ability of consumers to evaluate and optimize their choices of plans. Our analysis of administrative data on medical claims in Medicare Part D suggests that fewer than 25 percent of individuals enroll in plans that are ex ante as good as the least cost plan specified by the Plan Finder tool made available to seniors by the Medicare administration, and that consumers on average have expected excess spending of about $300 per year, or about 15 percent of expected total out-of-pocket cost for drugs and Part D insurance. These numbers are hard to reconcile with decision costs alone; it appears that unless a sizeable fraction of consumers place large values on plan features other than cost, they are not optimizing effectively. PMID:24308882

  4. Relationships between Medicare Advantage contract characteristics and quality-of-care ratings: an observational analysis of Medicare Advantage star ratings.

    Science.gov (United States)

    Xu, Peng; Burgess, James F; Cabral, Howard; Soria-Saucedo, Rene; Kazis, Lewis E

    2015-03-03

    The Centers for Medicare & Medicaid Services (CMS) publishes star ratings on Medicare Advantage (MA) contracts to measure plan quality of care with implications for reimbursement and bonuses. To investigate whether MA contract characteristics are associated with quality of care through the Medicare plan star ratings. Retrospective study of MA star ratings in 2010. Unadjusted and adjusted multivariable linear regression models assessed the relationship between 5-star rating summary scores and plan characteristics. CMS MA contracts nationally. 409 (71%) of a total of 575 MA contracts, covering 10.56 million Medicare beneficiaries (90% of the MA population) in the United States in 2010. The MA quality ratings summary score (stars range from 1 to 5) is a quality measure based on 36 indicators related to processes of care, health outcomes, access to care, and beneficiary satisfaction. Nonprofit, larger, and older MA contracts were more likely to receive higher star ratings. Star ratings ranged from 2 to 5. Nonprofit contracts received an average 0.55 (95% CI, 0.42 to 0.67) higher star ratings than for-profit contracts (P  star ratings than for-profit contracts. When comparing health plans in the future, the CMS should give increasing attention to for-profit plans with lower quality ratings and consider developing programs to assist newer and smaller plans in improving their care for Medicare beneficiaries. None.

  5. Opioid Prescribing Practices of Neurosurgeons: Analysis of Medicare Part D.

    Science.gov (United States)

    Khalid, Syed I; Adogwa, Owoicho; Lilly, Daniel T; Desai, Shyam A; Vuong, Victoria D; Mehta, Ankit I; Cheng, Joseph

    2018-04-01

    The Centers for Disease Control have declared that the United States is amidst a continuing opioid epidemic, with drug overdose-related death tripling between 1999 and 2014. Among the 47,055 overdose-related deaths that occurred in 2014, 28,647 (60.9%) of them involved an opioid. The Part D Prescriber Public Use File, which is based on beneficiaries enrolled in the Medicare Part D prescription drug program, was used to query information on prescription drug events incurred by Medicare beneficiaries with a Part D prescription drug plan from 31 June 2014 to 30 June 2015. Only those providers with the specialty description of neurosurgeon, as reported on the provider's Part B claims, were included in this study. A total of 271,502 beneficiaries, accounting for 971,581 claims and 22,152,689 day supplies of medication, accounted for the $52,956,428.40 paid by the Centers for Medicare and Medicaid Services for medication that the 4085 neurosurgeons submitted to the Centers for Medicare and Medicaid Services Part D program in the 2014 calendar year. During the same year, 402,767 (41.45%) claims for 158,749 (58.47%) beneficiaries accounted for 6,458,624 (29.16%) of the day supplies of medications and $13,962,630.11 (26.37%) of the total money spent by the Centers for Medicare and Medicaid Services Part D that year. Nationwide, the ratio of opioid claims to total Medicare Part D beneficiaries was 1.48. No statistically significant regional differences were found. The opioid misuse epidemic is a complex and national issue with patterns of prescription not significantly different between regions. All neurosurgeons must be cognizant of their prescribing practices so as to best support the resolution of this public health crisis. Copyright © 2017. Published by Elsevier Inc.

  6. Trends in readmission rates for safety net hospitals and non-safety net hospitals in the era of the US Hospital Readmission Reduction Program: a retrospective time series analysis using Medicare administrative claims data from 2008 to 2015.

    Science.gov (United States)

    Salerno, Amy M; Horwitz, Leora I; Kwon, Ji Young; Herrin, Jeph; Grady, Jacqueline N; Lin, Zhenqiu; Ross, Joseph S; Bernheim, Susannah M

    2017-07-13

    To compare trends in readmission rates among safety net and non-safety net hospitals under the US Hospital Readmission Reduction Program (HRRP). A retrospective time series analysis using Medicare administrative claims data from January 2008 to June 2015. We examined 3254 US hospitals eligible for penalties under the HRRP, categorised as safety net or non-safety net hospitals based on the hospital's proportion of patients with low socioeconomic status. Admissions for Medicare fee-for-service patients, age ≥65 years, discharged alive, who had a valid five-digit zip code and did not have a principal discharge diagnosis of cancer or psychiatric illness were included, for a total of 52 516 213 index admissions. Mean hospital-level, all-condition, 30-day risk-adjusted standardised unplanned readmission rate, measured quarterly, along with quarterly rate of change, and an interrupted time series examining: April-June 2010, after HRRP was passed, and October-December 2012, after HRRP penalties were implemented. 58.0% (SD 15.3) of safety net hospitals and 17.1% (SD 10.4) of non-safety net hospitals' patients were in the lowest quartile of socioeconomic status. The mean safety net hospital standardised readmission rate declined from 17.0% (SD 3.7) to 13.6% (SD 3.6), whereas the mean non-safety net hospital declined from 15.4% (SD 3.0) to 12.7% (SD 2.5). The absolute difference in rates between safety net and non-safety net hospitals declined from 1.6% (95% CI 1.3 to 1.9) to 0.9% (0.7 to 1.2). The quarterly decline in standardised readmission rates was 0.03 percentage points (95% CI 0.03 to 0.02, preadmission rates for safety net hospitals have decreased more rapidly than those for non-safety net hospitals. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  7. Making It Safe to Grow Old: A Financial Simulation Model for Launching MediCaring Communities for Frail Elderly Medicare Beneficiaries.

    Science.gov (United States)

    Bernhardt, Antonia K; Lynn, Joanne; Berger, Gregory; Lee, James A; Reuter, Kevin; Davanzo, Joan; Montgomery, Anne; Dobson, Allen

    2016-09-01

    At age 65, the average man and woman can respectively expect 1.5 years and 2.5 years of requiring daily help with "activities of daily living." Available services fail to match frail elders' needs, thereby routinely generating errors, unreliability, unwanted services, unmet needs, and high costs. The number of elderly Medicare beneficiaries likely to be frail will triple between 2000 and 2050. Low retirement savings, rising medical and long-term care costs, and declining family caregiver availability portend gaps in badly needed services. The financial simulation reported here for 4 diverse MediCaring Communities shows lower per capita costs. Program savings are substantial and can improve coverage and function of local supportive services within current overall Medicare spending levels. The Altarum Institute Center for Elder Care and Advanced Illness has developed a reform model, MediCaring Communities, to improve services for frail elderly Medicare beneficiaries through longitudinal care planning, better-coordinated and more desirable medical and social services, and local monitoring and management of a community's quality and supply of services. This study uses financial simulation to determine whether communities could implement the model within current Medicare and Medicaid spending levels, an important consideration to enable development and broad implementation. The financial simulation for MediCaring Communities uses 4 diverse communities chosen for adequate size, varying health care delivery systems, and ability to implement reforms and generate data rapidly: Akron, Ohio; Milwaukie, Oregon; northeastern Queens, New York; and Williamsburg, Virginia. For each community, leaders contributed baseline population and program effect estimates that reflected projections from reported research to build the model. The simulation projected third-year savings between $269 and $537 per beneficiary per month and cumulative returns on investment between 75% and 165%. The

  8. Medicare program; revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015. Final rule with comment period.

    Science.gov (United States)

    2014-11-13

    This major final rule with comment period addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. See the Table of Contents for a listing of the specific issues addressed in this rule.

  9. Medicare Special Needs Plan (SNP)

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  10. Medicare Preventive and Screening Services

    Science.gov (United States)

    ... Glossary MyMedicare.gov Login Search Main Menu , collapsed Main Menu Sign Up / Change Plans Getting started with ... setup: setupNotifier, notify: notify }; lrNotifier.setup(); $("#menu-btn, li.toolbarmenu .toolbarmenu-a").click(function() { // var isExpanded = ' is ...

  11. COMPETITIVE BIDDING IN MEDICARE ADVANTAGE: EFFECT OF BENCHMARK CHANGES ON PLAN BIDS

    Science.gov (United States)

    Song, Zirui; Landrum, Mary Beth; Chernew, Michael E.

    2013-01-01

    Bidding has been proposed to replace or complement the administered prices in Medicare pays to hospitals and health plans. In 2006, the Medicare Advantage program implemented a competitive bidding system to determine plan payments. In perfectly competitive models, plans bid their costs and thus bids are insensitive to the benchmark. Under many other models of competition, bids respond to changes in the benchmark. We conceptualize the bidding system and use an instrumental variable approach to study the effect of benchmark changes on bids. We use 2006–2010 plan payment data from the Centers for Medicare and Medicaid Services, published county benchmarks, actual realized fee-for-service costs, and Medicare Advantage enrollment. We find that a $1 increase in the benchmark leads to about a $0.53 increase in bids, suggesting that plans in the Medicare Advantage market have meaningful market power. PMID:24308881

  12. Competitive bidding in Medicare Advantage: effect of benchmark changes on plan bids.

    Science.gov (United States)

    Song, Zirui; Landrum, Mary Beth; Chernew, Michael E

    2013-12-01

    Bidding has been proposed to replace or complement the administered prices that Medicare pays to hospitals and health plans. In 2006, the Medicare Advantage program implemented a competitive bidding system to determine plan payments. In perfectly competitive models, plans bid their costs and thus bids are insensitive to the benchmark. Under many other models of competition, bids respond to changes in the benchmark. We conceptualize the bidding system and use an instrumental variable approach to study the effect of benchmark changes on bids. We use 2006-2010 plan payment data from the Centers for Medicare and Medicaid Services, published county benchmarks, actual realized fee-for-service costs, and Medicare Advantage enrollment. We find that a $1 increase in the benchmark leads to about a $0.53 increase in bids, suggesting that plans in the Medicare Advantage market have meaningful market power. Copyright © 2013 Elsevier B.V. All rights reserved.

  13. Medicare's post-acute care payment: a review of the issues and policy proposals.

    Science.gov (United States)

    Linehan, Kathryn

    2012-12-07

    Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.

  14. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting

    Science.gov (United States)

    2017-08-04

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2018. It also revises and rebases the market basket index by updating the base year from 2010 to 2014, and by adding a new cost category for Installation, Maintenance, and Repair Services. The rule also finalizes revisions to the SNF Quality Reporting Program (QRP), including measure and standardized resident assessment data policies and policies related to public display. In addition, it finalizes policies for the Skilled Nursing Facility Value-Based Purchasing Program that will affect Medicare payment to SNFs beginning in FY 2019. The final rule also clarifies the regulatory requirements for team composition for surveys conducted for investigating a complaint and aligns regulatory provisions for investigation of complaints with the statutory requirements. The final rule also finalizes the performance period for the National Healthcare Safety Network (NHSN) Healthcare Personnel (HCP) Influenza Vaccination Reporting Measure included in the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) for Payment Year 2020.

  15. 75 FR 19677 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2010-04-15

    ... recommended using a standard that emphasizes the materiality of the requirements that sponsors must meet... commenters requested that CMS more clearly articulate the methodology it will apply to past performance... performance methodology available through publication in our manuals. We believe that the manuals provide us...

  16. 76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Science.gov (United States)

    2011-04-15

    ... reflect provisions in the ACA which are already in effect. Table 2 lists the key changes. While these ACA...) (ACA) and make other changes to the regulations based on our experience in the administration of the... Professional and the Employment of a Medical Director (Sec. 422.562, Sec. 422.566, Sec. 423.562, and Sec. 423...

  17. 75 FR 71189 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Science.gov (United States)

    2010-11-22

    ... changes to the regulations to reflect provisions in the ACA which either are already in effect, or have an... Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act) (ACA) and make... Necessity Decisions by a Physician or Other Health Care Professional and the Employment of a Medical...

  18. 78 FR 31283 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2013-05-23

    ... organizations and Part D sponsors to reduce administrative costs such as marketing costs, profits, and other... directly apply to Cost HMOs/CMPs (Cost Health Maintenance Organizations/Competitive Medical Plans), HCPPs... the benefits offered by Cost HMOs/CMPs and employers/unions offering HCPPs. We are finalizing our...

  19. 78 FR 12427 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2013-02-22

    .... In essence, a Cost HMO/CMP or an HCPP that did not meet the minimum MLR requirement on the Part D... MLR provisions. Note that there also are terms defined in other sections of the Part 422 Subpart X and Part 423 Subpart X (for example, ``incurred claims'' is defined in Sec. 422.2420(b) and Sec. 423.2420(b...

  20. 77 FR 32407 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Science.gov (United States)

    2012-06-01

    ....100 as being effective January 1, 2013. We also inadvertently omitted references to several sections... with section 553(b) of the Administrative Procedure Act (APA) (5 U.S.C. 553(b)). However, we can waive... the finding and the reasons therefore in the notice. Section 553(b) of the APA ordinarily requires a...

  1. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Science.gov (United States)

    2010-06-10

    ... changes to Sec. 423.551 regarding changes in ownership during a PDP term of contract. In presenting these... Administrative Procedure Act (APA) (5 U.S.C. 553(b)). In addition, section 553(d) of the APA (5 U.S.C. 553(b... effective date if the Secretary finds, for good cause, that the notice and comment process is impracticable...

  2. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2013 rates; hospitals' resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers. final rule.

    Science.gov (United States)

    2012-08-31

    (ASCs) that are participating in Medicare. We are establishing requirements for the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program.

  3. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule.

    Science.gov (United States)

    2014-08-22

    are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers. We are aligning the reporting and submission timelines for clinical quality measures for the Medicare HER Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions. In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.

  4. Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2016-11-03

    This final rule updates the Home Health Prospective Payment System (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor; effective for home health episodes of care ending on or after January 1, 2017. This rule also: Implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates; updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 2nd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; finalizes changes to the methodology used to calculate payments made under the HH PPS for high-cost "outlier" episodes of care; implements changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care; discusses our efforts to monitor the potential impacts of the rebasing adjustments; includes an update on subsequent research and analysis as a result of the findings from the home health study; and finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model, which was implemented on January 1, 2016; and updates to the Home Health Quality Reporting Program (HH QRP).

  5. Medicare Part D and Portfolio Choice.

    Science.gov (United States)

    Ayyagari, Padmaja; He, Daifeng

    2016-05-01

    This study evaluates the impact of medical expenditure risk on portfolio choice among the elderly. The risk of large medical expenditures can be substantial for elderly individuals and is only partially mitigated by access to health insurance. The presence of deductibles, copayments, and other cost-sharing mechanisms implies that medical spending risk can be viewed as an undiversifiable background risk. Economic theory suggests that increases in background risk reduce the optimal financial risk that an individual or household is willing to bear (Pratt and Zeckhauser 1987; Elmendorf and Kimball 2000). In this study, we evaluate this hypothesis by estimating the impact of the introduction of the Medicare Part D program, which significantly reduced prescription drug spending risk for seniors, on portfolio choice.

  6. 76 FR 60050 - Medicaid Program: Money Follows the Person Rebalancing Demonstration Program

    Science.gov (United States)

    2011-09-28

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid Program: Money Follows the Person Rebalancing Demonstration Program AGENCY: Centers for Medicare & Medicaid... Medicaid beneficiaries with disabling and chronic conditions from institutions into the community. The...

  7. MEDICARE PAYMENTS AND SYSTEM-LEVEL HEALTH-CARE USE

    Science.gov (United States)

    ROBBINS, JACOB A.

    2015-01-01

    The rapid growth of Medicare managed care over the past decade has the potential to increase the efficiency of health-care delivery. Improvements in care management for some may improve efficiency system-wide, with implications for optimal payment policy in public insurance programs. These system-level effects may depend on local health-care market structure and vary based on patient characteristics. We use exogenous variation in the Medicare payment schedule to isolate the effects of market-level managed care enrollment on the quantity and quality of care delivered. We find that in areas with greater enrollment of Medicare beneficiaries in managed care, the non–managed care beneficiaries have fewer days in the hospital but more outpatient visits, consistent with a substitution of less expensive outpatient care for more expensive inpatient care, particularly at high levels of managed care. We find no evidence that care is of lower quality. Optimal payment policies for Medicare managed care enrollees that account for system-level spillovers may thus be higher than those that do not. PMID:27042687

  8. Model citizens. Outsourcing helps start-up Medicare HMO.

    Science.gov (United States)

    Slavic, B; Adami, S

    1999-04-01

    Health Plans of Pennsylvania (HPP), the managed care arm of Crozer-Keystone Health System, in Media, Pa. Selecting the information systems and building the infrastructure to support the start-up of a new Medicare HMO product. HPP chose to outsource the information systems needed to integrate all the components of managed care administration into a cost-effective and cohesive program. Because of its aggressive programming and start-up of the MedCarePlus product offering, HPP became the first plan in the country to submit Medicare claims data electronically for encounter reporting to the Health Care Financing Administration (HCFA). "Through an integrated team approach, an organization truly can benefit from the economies of scale gained through outsourcing."

  9. Access to Care for Medicare-Medicaid Dually Eligible Beneficiaries: The Role of State Medicaid Payment Policies.

    Science.gov (United States)

    Zheng, Nan Tracy; Haber, Susan; Hoover, Sonja; Feng, Zhanlian

    2017-12-01

    Medicaid programs are not required to pay the full Medicare coinsurance and deductibles for Medicare-Medicaid dually eligible beneficiaries. We examined the association between the percentage of Medicare cost sharing paid by Medicaid and the likelihood that a dually eligible beneficiary used evaluation and management (E&M) services and safety net provider services. Medicare and Medicaid Analytic eXtract enrollment and claims data for 2009. Multivariate analyses used fee-for-service dually eligible and Medicare-only beneficiaries in 20 states. A comparison group of Medicare-only beneficiaries controlled for state factors that might influence utilization. Paying 100 percent of the Medicare cost sharing compared to 20 percent increased the likelihood (relative to Medicare-only) that a dually eligible beneficiary had any E&M visit by 6.4 percent. This difference in the percentage of cost sharing paid decreased the likelihood of using safety net providers, by 37.7 percent for federally qualified health centers and rural health centers, and by 19.8 percent for hospital outpatient departments. Reimbursing the full Medicare cost-sharing amount would improve access for dually eligible beneficiaries, although the magnitude of the effect will vary by state and type of service. © Health Research and Educational Trust.

  10. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.

    Science.gov (United States)

    2013-08-19

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of the changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2013. We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes that were applied to the LTCH PPS by the Affordable Care Act. Generally, these updates and statutory changes will be applicable to discharges occurring on or after October 1, 2013, unless otherwise specified in this final rule. In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or have revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program. In addition, we are revising the conditions of participation (CoPs) for hospitals relating to the

  11. The Role of Medicare's Inpatient Cost-Sharing in Medicaid Entry.

    Science.gov (United States)

    Keohane, Laura M; Trivedi, Amal N; Mor, Vincent

    2018-04-01

    To isolate the effect of greater inpatient cost-sharing on Medicaid entry among Medicare beneficiaries. Medicare administrative data (years 2007-2010) were linked to nursing home assessments and area-level socioeconomic indicators. Medicare beneficiaries who are readmitted to a hospital must pay an additional deductible ($1,100 in 2010) if their readmission occurs more than 59 days following discharge. In a regression discontinuity analysis, we take advantage of this Medicare benefit feature to test whether beneficiaries with greater cost-sharing have higher rates of Medicaid enrollment. We identified 221,248 Medicare beneficiaries with an initial hospital stay and a readmission 53-59 days later (no deductible) or 60-66 days later (charged a deductible). Among beneficiaries in low-socioeconomic areas with two hospitalizations, those readmitted 60-66 days after discharge were 21 percent more likely to join Medicaid compared with those readmitted 53-59 days following their initial hospitalization (absolute difference in adjusted risk of Medicaid entry: 3.7 percent vs. 3.1 percent, p = .01). Increasing Medicare cost-sharing requirements may promote Medicaid enrollment among low-income beneficiaries. Potential savings from an increased cost-sharing in the Medicare program may be offset by increased Medicaid participation. © Health Research and Educational Trust.

  12. The Medicare Annual Wellness Visit.

    Science.gov (United States)

    Colburn, Jessica L; Nothelle, Stephanie

    2018-02-01

    The Medicare Annual Wellness Visit is an annual preventive health benefit, which was created in 2011 as part of the Patient Protection and Affordable Care Act. The visit provides an opportunity for clinicians to review preventive health recommendations and screen for geriatric syndromes. In this article, the authors review the requirements of the Annual Wellness Visit, discuss ways to use the Annual Wellness Visit to improve the care of geriatric patients, and provide suggestions for how to incorporate this benefit into a busy clinic. Copyright © 2017 Elsevier Inc. All rights reserved.

  13. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Program Federal Legislation Federal Legislation Federal Legislation Health Care Reform Summary Letters on Health Care Reform Medicare Physician Payment Medical Liability Reform Opioids ...

  14. Paying Medicare Advantage Plans: To Level or Tilt the Playing Field

    Science.gov (United States)

    Glazer, Jacob; McGuire, Thomas G.

    2017-01-01

    Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and makes a subsidy payment to an MA plan based on a “benchmark” for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Presently, about 30% of beneficiaries are in MA, and Medicare subsidizes MA plans more on average than TM. Many analysts recommend equalizing Medicare’s subsidy across the options – referred to in policy circles as a “level playing field.” This paper studies the normative question of how to set the level of the benchmark, applying the versatile model of plan choice developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic. PMID:28318667

  15. County-Level Population Economic Status and Medicare Imaging Resource Consumption.

    Science.gov (United States)

    Rosenkrantz, Andrew B; Hughes, Danny R; Prabhakar, Anand M; Duszak, Richard

    2017-06-01

    The aim of this study was to assess relationships between county-level variation in Medicare beneficiary imaging resource consumption and measures of population economic status. The 2013 CMS Geographic Variation Public Use File was used to identify county-level per capita Medicare fee-for-service imaging utilization and nationally standardized costs to the Medicare program. The County Health Rankings public data set was used to identify county-level measures of population economic status. Regional variation was assessed, and multivariate regressions were performed. Imaging events per 1,000 Medicare beneficiaries varied 1.8-fold (range, 2,723-4,843) at the state level and 5.3-fold (range, 1,228-6,455) at the county level. Per capita nationally standardized imaging costs to Medicare varied 4.2-fold (range, $84-$353) at the state level and 14.1-fold (range, $33-$471) at the county level. Within individual states, county-level utilization varied on average 2.0-fold (range, 1.1- to 3.1-fold), and costs varied 2.8-fold (range, 1.1- to 6.4-fold). For both large urban populations and small rural states, Medicare imaging resource consumption was heterogeneously variable at the county level. Adjusting for county-level gender, ethnicity, rural status, and population density, countywide unemployment rates showed strong independent positive associations with Medicare imaging events (β = 26.96) and costs (β = 4.37), whereas uninsured rates showed strong independent positive associations with Medicare imaging costs (β = 2.68). Medicare imaging utilization and costs both vary far more at the county than at the state level. Unfavorable measures of county-level population economic status in the non-Medicare population are independently associated with greater Medicare imaging resource consumption. Future efforts to optimize Medicare imaging use should consider the influence of local indigenous socioeconomic factors outside the scope of traditional beneficiary-focused policy

  16. Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries.

    Science.gov (United States)

    Gross, D J; Alecxih, L; Gibson, M J; Corea, J; Caplan, C; Brangan, N

    1999-04-01

    To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration. We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing. Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and

  17. Is expanding Medicare coverage cost-effective?

    Directory of Open Access Journals (Sweden)

    Muennig Peter

    2005-03-01

    Full Text Available Abstract Background Proposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients. Methods Data from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics. Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios. Results Medicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone. Conclusion Supplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.

  18. PACE and the Medicare+Choice risk-adjusted payment model.

    Science.gov (United States)

    Temkin-Greener, H; Meiners, M R; Gruenberg, L

    2001-01-01

    This paper investigates the impact of the Medicare principal inpatient diagnostic cost group (PIP-DCG) payment model on the Program of All-Inclusive Care for the Elderly (PACE). Currently, more than 6,000 Medicare beneficiaries who are nursing home certifiable receive care from PACE, a program poised for expansion under the Balanced Budget Act of 1997. Overall, our analysis suggests that the application of the PIP-DCG model to the PACE program would reduce Medicare payments to PACE, on average, by 38%. The PIP-DCG payment model bases its risk adjustment on inpatient diagnoses and does not capture adequately the risk of caring for a population with functional impairments.

  19. MediCaring: development and test marketing of a supportive care benefit for older people.

    Science.gov (United States)

    Lynn, J; O'Connor, M A; Dulac, J D; Roach, M J; Ross, C S; Wasson, J H

    1999-09-01

    take it now. Preferences were generally stable at 1 month. In multivariate regression, those preferring MediCaring were wealthier, more often white, more often living in senior housing, and using more homecare services. However, they were not more often in poor health or needing ADL assistance. Older persons aged more than 80 years can understand a health benefit choice; most liked the aims of a new supportive care benefit, and 34% would change immediately from Medicare to a supportive care benefit such as MediCaring,. These findings encourage further development of special programs of care, such as MediCaring, that prioritize comfort and support for the old old.

  20. Medicare Provider Utilization and Payment Data - Outpatient

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Outpatient Utilization and Payment Public Use File (Outpatient PUF) presents information on common outpatient services provided to Medicare fee-for-service...

  1. Basic Stand Alone Medicare Inpatient Claims PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Inpatient Public Use Files (PUF) named CMS 2008 BSA Inpatient Claims PUF with information from 2008 Medicare...

  2. Medicare Provider Payment Data - Home Health Agencies

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Home Health Agency PUF contains information on utilization, payment (Medicare payment and standard payment), and submitted charges organized by CMS Certification...

  3. Medicare Referring Provider (DMEPOS) Data CY2013

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) released a new dataset, the Referring Provider Durable Medical Equipment, Prosthetics, Orthotics and Supplies...

  4. Medicare Provider Payment Data - Skilled Nursing Facilities

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Skilled Nursing Facility Utilization and Payment Public Use File (Skilled Nursing Facility PUF) provides information on services provided to Medicare...

  5. Medicare Provider Analysis and Review (MEDPAR)

    Data.gov (United States)

    U.S. Department of Health & Human Services — MEDPAR files contain information on Medicare beneficiaries using hospital inpatient services. The data is provided by the state and the Diagnosis Related Groups...

  6. Medicare Referring Provider DMEPOS PUF CY2013

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset, which is part of CMSs Medicare Provider Utilization and Payment Data, details information on Durable Medical Equipment, Prosthetics, Orthotics and...

  7. Medicare Provider Utilization and Payment Data - Inpatient

    Data.gov (United States)

    U.S. Department of Health & Human Services — The data provided here include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS)...

  8. Medicare Geographic Variation - Public Use File

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Geographic Variation Public Use File provides the ability to view demographic, utilization and quality indicators at the state level (including...

  9. Medicare Demonstration Projects and Evaluation Reports

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) conducts and sponsors a number of innovative demonstration projects to test and measure the effect of potential...

  10. Enhancing Medicares Hospital Acquired Conditions Policy

    Data.gov (United States)

    U.S. Department of Health & Human Services — The current Medicare policy of non-payment to hospitals for Hospital Acquired Conditions (HAC) seeks to avoid payment for preventable complications identified within...

  11. Appeals - Redetermination by a Medicare Contractor

    Data.gov (United States)

    U.S. Department of Health & Human Services — A redetermination is an examination of a claim by the fiscal intermediary (FI), carrier, or Medicare Administrative Contractor (MAC) personnel who are different from...

  12. Linking Medicare, Medicaid, and Cancer Registry Data...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Linking Medicare, Medicaid, and Cancer Registry Data to Study the Burden of Cancers in West Virginia In the United States, the elderly carry an unequal burden of...

  13. Medicare Preventive Services Quick Reference Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — This educational tool provides the following information on Medicare preventive services Healthcare Common Procedure Coding System (HCPCS)-Current Procedural...

  14. Telehealth and Medicare - Payment Policy, Current Use...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Despite legislative changes from 2001 to 2008 that increased Medicare payment rates for telehealth and decreased regulatory burdens, the study Telehealth and...

  15. Medicare-Medicaid Eligible Beneficiaries and Potentiall...

    Data.gov (United States)

    U.S. Department of Health & Human Services — More than one in four hospitalizations for those with both Medicare and full Medicaid coverage was potentially avoidable, according to findings reported in...

  16. Costs and Clinical Quality Among Medicare Beneficiaries..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Authors of Costs and Clinical Quality Among Medicare Beneficiaries - Associations with Health Center Penetration of Low-Income Residents, published in Volume 4,...

  17. Medicare Provider Data - Physician and Other Supplier

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Physician and Other Supplier Public Use File (Physician and Other Supplier PUF) provides information on services and procedures provided to Medicare...

  18. Geographic Variation in Medicare Spending Dashboard

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Geographic Variation Dashboards present Medicare fee-for-service per-capita spending at the state and county level in an interactive format. We calculated the...

  19. Medicare Part D Opioid Drug Mapping Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Part D opioid prescribing mapping tool is an interactive tool that shows geographic comparisons, at the state, county, and ZIP code levels, of...

  20. Medicare covers the majority of FDA-approved devices and Part B drugs, but restrictions and discrepancies remain.

    Science.gov (United States)

    Chambers, James D; May, Katherine E; Neumann, Peter J

    2013-06-01

    The Food and Drug Administration (FDA) and Medicare use different standards to determine, first, whether a new drug or medical device can be marketed to the public and, second, if the federal health insurance program will pay for use of the drug or device. This discrepancy creates hurdles and uncertainty for drug and device manufacturers. We analyzed discrepancies between FDA approval and Medicare national coverage determinations for sixty-nine devices and Part B drugs approved during 1999-2011. We found that Medicare covered FDA-approved drugs or devices 80 percent of the time. However, Medicare often added conditions beyond FDA approval, particularly for devices and most often restricting coverage to patients with the most severe disease. In some instances, Medicare was less restrictive than the FDA. Our findings highlight the importance for drug and device makers of anticipating Medicare's needs when conducting clinical studies to support their products. Our findings also provide important insights for the FDA's and Medicare's pilot parallel review program.

  1. Pre-Enrollment Reimbursement Patterns of Medicare Beneficiaries Enrolled in “At-Risk” HMOs

    Science.gov (United States)

    Eggers, Paul W.; Prihoda, Ronald

    1982-01-01

    The Health Care Financing Administration (HCFA) has initiated several demonstration projects to encourage HMOs to participate in the Medicare program under a risk mechanism. These demonstrations are designed to test innovative marketing techniques, benefit packages, and reimbursement levels. HCFA's current method for prospective payments to HMOs is based on the Adjusted Average Per Capita Cost (AAPCC). An important issue in prospective reimbursement is the extent to which the AAPCC adequately reflects the risk factors which arise out of the selection process of Medicare beneficiaries into HMOs. This study examines the pre-enrollment reimbursement experience of Medicare beneficiaries who enrolled in the demonstration HMOs to determine whether or not a non-random selection process took place. The three demonstration HMOs included in the study are the Fallon Community Health Plan, the Greater Marshfield Community Health Plan, and the Kaiser-Permanente medical program of Portland, Oregon. The study includes 18,085 aged Medicare beneficiaries who had enrolled in the three plans as of April, 1981. We included comparison groups consisting of a 5 percent random sample of aged Medicare beneficiaries (N = 11,240) living in the same geographic areas as the control groups. The study compares the groups by total Medicare reimbursements for the years 1976 through 1979. Adjustments were made for AAPCC factor differences in the groups (age, sex, institutional status, and welfare status). In two of the HMO areas there was evidence of a selection process among the HMOs enrollees. Enrollees in the Fallon and Kaiser health plans were found to have had 20 percent lower Medicare reimbursements than their respective comparison groups in the four years prior to enrollment. This effect was strongest for inpatient services, but a significant difference also existed for use of physician and outpatient services. In the Marshfield HMO there was no statistically significant difference in pre

  2. Proportion and Patterns of Hospice Discharges in Medicare Advantage Compared to Medicare Fee-for-Service.

    Science.gov (United States)

    Teno, Joan M; Christian, Thomas J; Gozalo, Pedro; Plotzke, Michael

    2018-03-01

    When Medicare Advantage (MA) patients elect hospice, all covered services are reimbursed under the Medicare fee-for-service (FFS) program. This financial arrangement may incentivize MA plans to refer persons to hospice near end of life when costs of care typically rise. To characterize hospice discharge patterns for MA versus FFS patients and examine whether patterns differ by MA concentration across hospital referral regions (HRRs). The rate and pattern of live discharges and length of stay (LOS) between FFS and MA patients were examined. A multivariate mixed-effects model examined whether hospice patients in MA versus FFS had differential patterns of discharges. In addition, we tested whether concentrations of MA hospice patients in a patient's HRR were associated with different patterns of discharges. In fiscal year 2014, there were 1,199,533 hospice discharges with 331,142 MA patients having a slightly higher live discharge rate (15.8%) compared to 868,391 FFS hospice discharges (15.4%). After controlling for patient characteristics, the adjusted odds ratio (AOR) was 1.01 (95% CI 0.99-1.02). MA patients were less likely to have early live discharges (AOR 0.87 95% CI 0.84-0.91) and burdensome transitions (AOR 0.61 95% CI 0.58-0.64) but did not differ in live discharges post 210 days. Among hospice deaths, MA hospice patients were less likely to have a three-day or less LOS (AOR 0.95 95% 0.94-0.96) and a LOS exceeding 180 days (AOR 0.97 95% 0.96-0.99). The concentration of MA patients in a HRR had minimal impact. MA hospice patients' discharge patterns raised less concerns than FFS.

  3. Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program. Final rule.

    Science.gov (United States)

    2017-11-01

    This rule updates and makes revisions to the end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2018. It also updates the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). This rule also sets forth requirements for the ESRD Quality Incentive Program (QIP), including for payment years (PYs) 2019 through 2021.

  4. How Do Pharmacists Assist Medicare Beneficiaries with Limited Income? A Cross-Sectional Study of Community Pharmacies in Alabama.

    Science.gov (United States)

    Westrick, Salisa C; Hastings, Tessa J; McFarland, Stuart J; Hohmann, Lindsey A; Hohmann, Natalie S

    2016-09-01

    Many Medicare beneficiaries have limited income and report problems paying for their medications. Programs are available to assist these low-income individuals. However, these programs are underused because of lack of general awareness and perceived complexity of program applications. To (a) determine the frequency of encounters by pharmacists with Medicare beneficiaries who cannot afford prescription drugs; (b) identify strategies that pharmacists use to assist Medicare beneficiaries who cannot afford prescription drugs; and (c) explore what pharmacists know about programs for Medicare beneficiaries with limited income. This study used a mixed-mode survey of 350 randomly sampled community pharmacies located in 32 counties in Alabama with a high proportion of Medicare beneficiaries who were potentially eligible for low-income subsidy programs. Measures included frequency of encounters by pharmacists with Medicare beneficiaries who could not afford their medications, strategies used to assist Medicare beneficiaries, and pharmacists' knowledge of programs for Medicare beneficiaries with limited income. Of 350 surveys sent, 12 were nondeliverable, and 151 were completed (response rate=44.6%). About 50% of respondents reported encountering Medicare beneficiaries who could not afford their medications at least weekly. Various strategies were reported, including refiling claims that were previously denied every day (40.7%), contacting insurance companies at least once per week (43.2%), and loaning medications at least 2-3 times per month (29.1%). Only 12.6% reported referring beneficiaries to the Aging and Disability Resource Centers (ADRCs) to assess eligibility for limited-income programs. When asked about programs for beneficiaries with limited income, the answers were predominantly "don't know for sure." Several strategies were used by pharmacists in an attempt to help limited-income Medicare beneficiaries obtain their medications. Lack of knowledge about financial

  5. Using research for successful Medicare and Medicaid risk marketing.

    Science.gov (United States)

    Jacobs, S; Nelson, A M; Wood, S D

    1996-01-01

    Medicare/Medicaid risk marketing is a vital business challenge, one that countless managed care organizations are facing right now. Early entry into new markets and aggressive participation in existing markets are essential to meet competitive pressures. Health plans intent on success in government risk programs should conduct research to learn the medical needs, wants, and desires of older persons in the geographic area they serve. Original, market-specific research yields critical marketing and clinical data that can be used to improve care and member satisfaction along with customer loyalty and retention.

  6. 42 CFR 423.800 - Administration of subsidy program.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Administration of subsidy program. 423.800 Section 423.800 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Premiums and Cost...

  7. 42 CFR 423.159 - Electronic prescription drug program.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Electronic prescription drug program. 423.159 Section 423.159 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Cost Control and Quality...

  8. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Science.gov (United States)

    2012-01-12

    ... proposed to include definitions of ``actually paid,'' ``administrative costs,'' ``allowable retiree costs... theories under which we might have such authority. Also in the January 12, 2009 Federal Register, we..., and our final rule with comment period set forth three theories under which we might have such...

  9. Health care utilization among Medicare-Medicaid dual eligibles: a count data analysis

    Directory of Open Access Journals (Sweden)

    Shin Jaeun

    2006-04-01

    Full Text Available Abstract Background Medicare-Medicaid dual eligibles are the beneficiaries of both Medicare and Medicaid. Dual eligibles satisfy the eligibility conditions for Medicare benefit. Dual eligibles also qualify for Medicaid because they are aged, blind, or disabled and meet the income and asset requirements for receiving Supplement Security Income (SSI assistance. The objective of this study is to explore the relationship between dual eligibility and health care utilization among Medicare beneficiaries. Methods The household component of the nationally representative Medical Expenditure Panel Survey (MEPS 1996–2000 is used for the analysis. Total 8,262 Medicare beneficiaries are selected from the MEPS data. The Medicare beneficiary sample includes individuals who are covered by Medicare and do not have private health insurance during a given year. Zero-inflated negative binomial (ZINB regression model is used to analyse the count data regarding health care utilization: office-based physician visits, hospital inpatient nights, agency-sponsored home health provider days, and total dental visits. Results Dual eligibility is positively correlated with the likelihood of using hospital inpatient care and agency-sponsored home health services and the frequency of agency-sponsored home health days. Frequency of dental visits is inversely associated with dual eligibility. With respect to racial differences, dually eligible Afro-Americans use more office-based physician and dental services than white duals. Asian duals use more home health services than white duals at the 5% statistical significance level. The dual eligibility programs seem particularly beneficial to Afro-American duals. Conclusion Dual eligibility has varied impact on health care utilization across service types. More utilization of home healthcare among dual eligibles appears to be the result of delayed realization of their unmet healthcare needs under the traditional Medicare-only program

  10. Footing the bill: the introduction of Medicare Benefits Schedule rebates for podiatry services in Australia

    Directory of Open Access Journals (Sweden)

    Short Anthony J

    2009-12-01

    Full Text Available Abstract The introduction of Medicare Benefits Schedule items for allied health professionals in 2004 was a pivotal event in the public funding of non-medical primary care services. This commentary seeks to provide supplementary discussion of the article by Menz (Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008 Journal of Foot and Ankle Research 2009, 2:30, by placing these findings within the context of the podiatry profession, clinical decision making and the broader health workforce and government policy.

  11. Newspaper Coverage of the Harvard Medicare Project: Regional Distinctions/Discreet Disregard?

    Science.gov (United States)

    Payne, J. Gregory

    A study examined American newspaper coverage of the Harvard Medicare Project proposal of 1986, a major health policy proposal calling for comprehensive reforms in the national health program. Using Burrelle's news clipping service which includes every daily newspaper (over 1500) in the United States, all 75 newspaper articles on the project from…

  12. High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare.

    Science.gov (United States)

    Rahman, Momotazur; Keohane, Laura; Trivedi, Amal N; Mor, Vincent

    2015-10-01

    Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending. Project HOPE—The People-to-People Health Foundation, Inc.

  13. How Medicare Could Provide Dental, Vision, and Hearing Care for Beneficiaries.

    Science.gov (United States)

    Willink, Amber; Shoen, Cathy; Davis, Karen

    2018-01-01

    The Medicare program specifically excludes coverage of dental, vision, and hearing services. As a result, many beneficiaries do not receive necessary care. Those that do are subject to high out-of-pocket costs. Examine gaps in access to dental, vision, and hearing services for Medicare beneficiaries and design a voluntary dental, vision, and hearing benefit plan with cost estimates. Uses the Medicare Current Beneficiary Survey, Cost and Use File, 2012, with population and costs projected to 2016 values. Among Medicare beneficiaries, 75 percent of people who needed a hearing aid did not have one; 70 percent of people who had trouble eating because of their teeth did not go to the dentist in the past year; and 43 percent of people who had trouble seeing did not have an eye exam in the past year. Lack of access was particularly acute for poor beneficiaries. Because few people have supplemental insurance covering these additional services, among people who received care, three-fourths of their costs of dental and hearing services and 60 percent of their costs of vision services were paid out of pocket. We propose a basic benefit package for dental, vision, and hearing services offered as a premium-financed voluntary insurance option under Medicare. Assuming the benefit package could be offered for $25 per month, we estimate the total coverage costs would be $1.924 billion per year, paid for by premiums. Subsidies to reach low-income beneficiaries would follow the same design as the Part D subsidy.

  14. Changes in the Medicare home health care market: the impact of reimbursement policy.

    Science.gov (United States)

    Choi, Sunha; Davitt, Joan K

    2009-03-01

    The Balanced Budget Act of 1997 introduced 2 new reimbursement structures, the Interim Payment System (IPS, 1997-2000) and the Prospective Payment System (PPS, begun October 2000) for Medicare home health agencies (HHAs) under the fee-for-service program. This article describes and compares the impact of these changes on the Medicare home health market from a period before the BBA through the IPS and PPS in relation to agency characteristics. A secondary analysis of 1996, 1999, and 2002 Provider of Services data was conducted on all Medicare-certified HHAs. Frequencies and rates of change were calculated by agency characteristics to describe changes in the number of active agencies through those years. Logistic regression models were used to compare factors associated with market exits under different payment systems. The results indicate dramatic but disproportional changes in response to the IPS and the PPS among Medicare home health care agencies. Agency closures were greater and market entries fewer during the IPS, but more branch offices/subunits were closed during the PPS. Proprietary and freestanding agencies experienced greater volatility throughout, with the greatest number of closures seen in Region VI (Dallas). These results demonstrate the direct impact of policy changes on the home health care market and highlight the need to evaluate policy changes to understand both intended and unintended impacts on health markets. Future research should analyze the effect of these policy changes on other healthcare providers and systems and their impact on health outcomes for Medicare beneficiaries.

  15. Medicare-Medicaid Enrollee Profiles (State and National)

    Data.gov (United States)

    U.S. Department of Health & Human Services — Today there are over 10 million Medicare-Medicaid enrollees in the United States.To provide a greater understanding of the Medicare-Medicaid enrollee population, the...

  16. Medicare Post-Acute Care Episodes and Payment Bundling

    Data.gov (United States)

    U.S. Department of Health & Human Services — Published in Volume 4, Issue 1, of Medicare and Medicaid Research Review, this paper provides an overview of results examining alternative Medicare post-acute care...

  17. Ever Enrolled Medicare Population Estimates from the MCBS..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Findings reported in Ever Enrolled Medicare Population Estimates from the MCBS Access to Care (ATC) Files, published in Volume 4, Issue 2 of the Medicare and...

  18. Medicare Advantage Rates and Statistics - FFS Data (1998-...

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare fee-for-service data for each county broken out by aged, disabled, and ESRD beneficiaries including data on total Medicare fee-for-service reimbursement and...

  19. Medicare and Medicaid Trends in Health Care Sectors

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) provides monthly and fiscal-year-to-date income and expenditure trends for Medicare Hospital Insurance (HI) and...

  20. Medicare Part D Roulette, Potential Implications of Random..

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare Part D Roulette, Potential Implications of Random Assignment and Plan Restrictions Dual-eligible (Medicare and Medicaid) beneficiaries are randomly assigned...

  1. Medicare Advantage Rates and Statistics - FFS Data 2008-2014

    Data.gov (United States)

    U.S. Department of Health & Human Services — Medicare fee-for-service data for each county broken out by aged, disabled, and ESRD beneficiaries including data on total Medicare fee-for-service reimbursement and...

  2. Utilization of substance abuse treatment services under Medicare, 2001-2002.

    Science.gov (United States)

    Vandivort, Rita; Teich, Judith L; Cowell, Alexander J; Chen, Hong

    2009-06-01

    In 2006, the Medicare program covered 37 million elderly persons and 7 million persons younger than 65 years, but little is known about substance abuse (SA) service utilization. Using the 5% Sample of Medicare claims data, the study examines individuals who used SA detoxification ("detox") and/or rehabilitation ("rehab") services under Medicare in 2001 and 2002. SA claimants less than 65 years of age (disabled) were compared to claimants more than 65 years of age (elderly). The disabled were more likely to have a co-occurring mental disorder than elderly claimants (50% vs. 14%) and more likely to have serious mental illness (21% vs. 2.3%). Disabled claimants were more than three times as likely to receive any detox service as elderly claimants (17% vs. 6%). The rate of claimants receiving rehab services within 30 days of detox is about one third for disabled claimants and one quarter for elderly claimants.

  3. Demand for a Medicare prescription drug benefit: exploring consumer preferences under a managed competition framework.

    Science.gov (United States)

    Cline, Richard R; Mott, David A

    2003-01-01

    Several proposals for adding a prescription drug benefit to the Medicare program rely on consumer choice and market forces to promote efficiency. However, little information exists regarding: 1) the extent of price sensitivity for such plans among Medicare beneficiaries, or 2) the extent to which drug-only insurance plans using various cost-control mechanisms might experience adverse selection. Using data from a survey of elderly Wisconsin residents regarding their likely choices from a menu of hypothetical drug plans, we show that respondents are likely to be price sensitive with respect to both premiums and out-of-pocket costs but that selection problems may arise in these markets. Outside intervention may be necessary to ensure the feasibility of a market-based approach to a Medicare drug benefit.

  4. Raising awareness of Medicare member rights among seniors and caregivers in California.

    Science.gov (United States)

    Olson, Rebecca; Grossman, Ruth M; Fu, Patricia L; Sabogal, Fabio

    2010-01-01

    Many Medicare recipients do not understand their health care rights. Lumetra, formerly California's Medicare quality improvement organization, developed a multifaceted outreach program to increase beneficiary awareness of its services and of the right to file quality-of-care complaints and discharge appeals. Layered outreach activities to Medicare members and their caregivers in 2 targeted counties consisted of paid media, direct mailings, community outreach, and online marketing. Calls to Lumetra's helpline and visits to its Web site--measures of beneficiary awareness of case review services--increased by 106% and 1214%, respectively, in the targeted counties during the 4-month outreach period. Only small increases occurred in nontargeted counties. Increases in quality-of-care complaints and discharge appeal rates were detected during a longer follow-up period.

  5. Medicare managed care. How physicians can make it better.

    Science.gov (United States)

    Roggin, G M

    1997-12-01

    The federal government is attempting to control anticipated, increased Medicare health care costs by providing the senior population with incentives to encourage their movement into managed care programs. For-profit corporate HMOs that currently dominate the managed care arena are coming under increased competitive pressure at a time when their perception of profiteering is undergoing increased public scrutiny. If physicians are to take advantage of this window of opportunity and successfully enter the Medicare managed care marketplace, they must identify the major deficiencies existing in the current model, and fashion a new product that divests itself of the profit orientation of current corporate HMOs. A nonprofit version of a highly integrated, multispecialty provider service organization (PSO) provides an appropriate model to effectively compete with the corporate HMO. The ideal physician-controlled managed care model must: develop a responsive policy board structure; create practice guidelines that decrease variation in physician practice; achieve an appropriate balance between primary and specialty medical care; and adopt a quality-assurance program that effectively addresses both process and outcome data.

  6. 75 FR 46833 - 45th Anniversary of Medicare and Medicaid

    Science.gov (United States)

    2010-08-03

    ... Part III The President Proclamation 8544--45th Anniversary of Medicare and Medicaid #0; #0; #0..., 2010 45th Anniversary of Medicare and Medicaid By the President of the United States of America A Proclamation When President Lyndon B. Johnson signed Medicare and Medicaid into law on July 30, 1965, millions...

  7. Specialty Drug Spending Trends Among Medicare And Medicare Advantage Enrollees, 2007–11

    OpenAIRE

    Trish, Erin; Joyce, Geoffrey; Goldman, Dana P.

    2014-01-01

    Specialty pharmaceuticals include most injectable and biologic agents used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis, and cancer. We analyzed trends in specialty drug spending among Medicare beneficiaries ages sixty-five and older using 2007–11 pharmacy claims data from a 20 percent sample of Medicare beneficiaries. Annual specialty drug spending per beneficiary who used specialty drugs increased considerably during the study period, from $2,641 to $8,976. H...

  8. Organizational Attributes Associated With Medicare ACO Quality Performance.

    Science.gov (United States)

    Zhu, Xi; Mueller, Keith; Huang, Huang; Ullrich, Fred; Vaughn, Thomas; MacKinney, A Clinton

    2018-05-08

    To evaluate associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance. We conducted cross-sectional and longitudinal analyses of ACO quality performance using data from the Centers for Medicare and Medicaid Services and additional sources. The sample included 322 and 385 MSSP ACOs that had successfully reported quality measures in 2014 and 2015, respectively. Results show that after adjusting for other organizational factors, rural ACOs' average quality score was comparable to that of ACOs serving other geographic categories. ACOs with hospital-system sponsorship, larger beneficiary panels, and higher posthospitalization follow-up rates achieved better quality performance. There is no significant difference in average quality performance between rural ACOs and other ACOs after adjusting for structural and service-provision factors. MSSP ACO quality performance is positively associated with hospital-system sponsorship, beneficiary panel size, and posthospitalization follow-up rate. © 2018 National Rural Health Association.

  9. The quality of Medicaid and Medicare data obtained from CMS and its contractors: implications for pharmacoepidemiology.

    Science.gov (United States)

    Leonard, Charles E; Brensinger, Colleen M; Nam, Young Hee; Bilker, Warren B; Barosso, Geralyn M; Mangaali, Margaret J; Hennessy, Sean

    2017-04-26

    Administrative claims of United States Centers for Medicare and Medicaid Services (CMS) beneficiaries have long been used in non-experimental research. While CMS performs in-house checks of these claims, little is known of their quality for conducting pharmacoepidemiologic research. We performed exploratory analyses of the quality of Medicaid and Medicare data obtained from CMS and its contractors. Our study population consisted of Medicaid beneficiaries (with and without dual coverage by Medicare) from California, Florida, New York, Ohio, and Pennsylvania. We obtained and compiled 1999-2011 data from these state Medicaid programs (constituting about 38% of nationwide Medicaid enrollment), together with corresponding national Medicare data for dually-enrolled beneficiaries. This descriptive study examined longitudinal patterns in: dispensed prescriptions by state, by quarter; and inpatient hospitalizations by federal benefit, state, and age group. We further examined discrepancies between demographic characteristics and disease states, in particular frequencies of pregnancy complications among men and women beyond childbearing age, and prostate cancers among women. Dispensed prescriptions generally increased steadily and consistently over time, suggesting that these claims may be complete. A commercially-available National Drug Code lookup database was able to identify the dispensed drug for 95.2-99.4% of these claims. Because of co-coverage by Medicare, Medicaid data appeared to miss a substantial number of hospitalizations among beneficiaries ≥ 45 years of age. Pregnancy complication diagnoses were rare in males and in females ≥ 60 years of age, and prostate cancer diagnoses were rare in females. CMS claims from five large states obtained directly from CMS and its contractors appeared to be of high quality. Researchers using Medicaid data to study hospital outcomes should obtain supplemental Medicare data on dual enrollees, even for non-elders. Not

  10. Competitive bidding in Medicare: who benefits from competition?

    Science.gov (United States)

    Song, Zirui; Landrum, Mary Beth; Chernew, Michael E

    2012-09-01

    To conduct the first empirical study of competitive bidding in Medicare. We analyzed 2006-2010 Medicare Advantage data from the Centers for Medicare and Medicaid Services using longitudinal models adjusted for market and plan characteristics. A $1 increase in Medicare's payment to health maintenance organization (HMO) plans led to a $0.49 (P service plans included, higher Medicare payments increased bids less ($0.33 per dollar), suggesting more competition among these latter plans. As a market-based alternative to cost control through administrative pricing, competitive bidding relies on private insurance plans proposing prices they are willing to accept for insuring a beneficiary. However, competition is imperfect in the Medicare bidding market. As much as half of every dollar in increased plan payment went to higher bids rather than to beneficiaries. While having more insurers in a market lowered bids, the design of any bidding system for Medicare should recognize this shortcoming of competition.

  11. What can the past of pay-for-performance tell us about the future of Value-Based Purchasing in Medicare?

    Science.gov (United States)

    Ryan, Andrew M; Damberg, Cheryl L

    2013-06-01

    The Medicare program has implemented pay-for-performance (P4P), or Value-Based Purchasing, for inpatient care and for Medicare Advantage plans, and plans to implement a program for physicians in 2015. In this paper, we review evidence on the effectiveness of P4P and identify design criteria deemed to be best practice in P4P. We then assess the extent to which Medicare's existing and planned Value-Based Purchasing programs align with these best practices. Of the seven identified best practices in P4P program design, the Hospital Value-Based Purchasing program is strongly aligned with two of the best practices, moderately aligned with three, weakly aligned with one, and has unclear alignment with one best practice. The Physician Value-Based Purchasing Modifier is strongly aligned with two of the best practices, moderately aligned with one, weakly aligned with three, and has unclear alignment with one of the best practices. The Medicare Advantage Quality Bonus Program is strongly aligned with four of the best practices, moderately aligned with two, and weakly aligned with one of the best practices. We identify enduring gaps in P4P literature as it relates to Medicare's plans for Value-Based Purchasing and discuss important issues in the future of these implementations in Medicare. Copyright © 2013 Elsevier Inc. All rights reserved.

  12. Varied Differences in the Health Status Between Medicare Advantage and Fee-for-Service Enrollees

    Directory of Open Access Journals (Sweden)

    Yunjie Song PhD

    2014-12-01

    Full Text Available This article examines the differences in mortality measured health status between the Medicare Advantage (MA program and Fee-for-Service (FFS program from 1999 to 2007. At the national level, differences in mortality rates were associated with MA market share. In some counties, enrollees in the MA program were 40% less likely to die than their peers in the FFS program, but in other counties, they were 20% more likely to die. Cost shifting between the two programs could bias county classifications of average FFS spending, and enlarged disparities in health status could make it difficult to evaluate risk adjusters.

  13. 77 FR 17143 - Medicaid Program; Eligiblity Changes Under the Affordable Care Act of 2010

    Science.gov (United States)

    2012-03-23

    ... Medicare and Medicaid Services 42 CFR Parts 431, 435 and 457 Medicaid Program; Eligibility Changes Under... for Medicare & Medicaid Services 42 CFR Parts 431, 435, and 457 [CMS-2349-F] RIN 0938-AQ62 Medicaid Program; Eligiblity Changes Under the Affordable Care Act of 2010 AGENCY: Centers for Medicare & Medicaid...

  14. The Economics of Medicare Accountable Care Organizations

    Science.gov (United States)

    Blackstone, Erwin A.; Fuhr, Joseph P.

    2016-01-01

    Background Accountable care organizations (ACOs) have been created to improve patient care, enhance population health, and reduce costs. Medicare in particular has focused on ACOs as a primary device to improve quality and reduce costs. Objective To examine whether the current Medicare ACOs are likely to be successful. Discussion Patients receiving care in ACOs have little incentive to use low-cost quality providers. Furthermore, the start-up costs of ACOs for providers are high, contributing to the minimal financial success of ACOs. We review issues such as reducing readmissions, palliative care, and the difficulty in coordinating care, which are major cost drivers. There are mixed incentives facing hospital-controlled ACOs, whereas physician-controlled ACOs could play hospitals against each other to obtain high quality and cost reductions. This discussion also considers whether the current structure of ACOs is likely to be successful. Conclusion The question remains whether Medicare ACOs can achieve the Triple Aim of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” Care coordination in ACOs and information technology are proving more complicated and expensive to implement than anticipated. Even if ACOs can decrease healthcare costs and increase quality, it is unclear if the current incentives system can achieve these objectives. A better public policy may be to implement a system that encompasses the best practices of successful private integrated systems rather than promoting ACOs. PMID:27066191

  15. Medicare payment changes and physicians' incomes.

    Science.gov (United States)

    Weeks, William B; Wallace, Amy E

    2002-01-01

    An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.

  16. Medicare Cancer Screening in the Context of Clinical Guidelines: 2000 to 2012.

    Science.gov (United States)

    Maroongroge, Sean; Yu, James B

    2018-04-01

    Cancer screening is a ubiquitous and controversial public health issue, particularly in the elderly population. Despite extensive evidence-based guidelines for screening, it is unclear how cancer screening has changed in the Medicare population over time. We characterize trends in cancer screening for the most common cancer types in the Medicare fee-for-service (FFS) program in the context of conflicting guidelines from 2000 to 2012. We performed a descriptive analysis of retrospective claims data from the Medicare FFS program based on billing codes. Our data include all claims for Medicare part B beneficiaries who received breast, colorectal (CRC), or prostate cancer screening from 2000 to 2012 based on billing codes. We utilize a Monte Carlo permutation method to detect changes in screening trends. In total, 231,416,732 screening tests were analyzed from 2000 to 2012, representing an average of 436.8 tests per 1000 beneficiaries per year. Mammography rates declined 7.4%, with digital mammography extensively replacing film. CRC cancer screening rates declined overall. As a percentage of all CRC screening tests, colonoscopy grew from 32% to 71%. Prostate screening rates increased 16% from 2000 to 2007, and then declined to 7% less than its 2000 rate by 2012. Both the aggressiveness of screening guidelines and screening rates for the Medicare FFS population peaked and then declined from 2000 to 2012. However, guideline publications did not consistently precede utilization trend shifts. Technology adoption, practical and financial concerns, and patient preferences may have also contributed to the observed trends. Further research should be performed on the impact of multiple, conflicting guidelines in cancer screening.

  17. The liberal party and the achievement of national Medicare.

    Science.gov (United States)

    Bryden, P E

    2009-01-01

    The process that led to the implementation of a full national health insurance system in Canada was as complicated and contested as the battles that were fought over Medicare in Saskatchewan. The federal Liberal party had to first adopt health insurance as a serious component of its electoral platform, devise a strategy for dealing with provinces which had constitutional jurisdiction over health, and finally wrestle with those within the party--and within the cabinet--who continued to question whether Canada was financially prepared to administer such a costly program. The strategies were devised and the battles were fought privately, but had an important effect on the timing and shape of a national health insurance system.

  18. The Center For Medicare And Medicaid Innovation's blueprint for rapid-cycle evaluation of new care and payment models.

    Science.gov (United States)

    Shrank, William

    2013-04-01

    The Affordable Care Act established the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models. The goal is to reduce program expenditures while preserving or improving the quality of care provided to beneficiaries of Medicare, Medicaid, and the Children's Health Insurance Program. Central to the success of the Innovation Center is a new, rapid-cycle approach to evaluation. This article describes that approach--setting forth how the Rapid Cycle Evaluation Group aims to deliver frequent feedback to providers in support of continuous quality improvement, while rigorously evaluating the outcomes of each model tested. This article also describes the relationship between the group's work and that of the Office of the Actuary at the Centers for Medicare and Medicaid Services, which plays a central role in the assessment of new models.

  19. Do Medicare Advantage Plans Minimize Costs? Investigating the Relationship Between Benchmarks, Costs, and Rebates.

    Science.gov (United States)

    Zuckerman, Stephen; Skopec, Laura; Guterman, Stuart

    2017-12-01

    Medicare Advantage (MA), the program that allows people to receive their Medicare benefits through private health plans, uses a benchmark-and-bidding system to induce plans to provide benefits at lower costs. However, prior research suggests medical costs, profits, and other plan costs are not as low under this system as they might otherwise be. To examine how well the current system encourages MA plans to bid their lowest cost by examining the relationship between costs and bonuses (rebates) and the benchmarks Medicare uses in determining plan payments. Regression analysis using 2015 data for HMO and local PPO plans. Costs and rebates are higher for MA plans in areas with higher benchmarks, and plan costs vary less than benchmarks do. A one-dollar increase in benchmarks is associated with 32-cent-higher plan costs and a 52-cent-higher rebate, even when controlling for market and plan factors that can affect costs. This suggests the current benchmark-and-bidding system allows plans to bid higher than local input prices and other market conditions would seem to warrant. To incentivize MA plans to maximize efficiency and minimize costs, Medicare could change the way benchmarks are set or used.

  20. Physician trainees' decision making and information processing: choice size and Medicare Part D.

    Science.gov (United States)

    Barnes, Andrew J; Hanoch, Yaniv; Martynenko, Melissa; Wood, Stacey; Rice, Thomas; Federman, Alex D

    2013-01-01

    Many patients expect their doctor to help them choose a Medicare prescription drug plan. Whether the size of the choice set affects clinicians' decision processes and strategy selection, and the quality of their choice, as it does their older patients, is an important question with serious financial consequences. Seventy medical students and internal medicine residents completed a within-subject design using Mouselab, a computer program that allows the information-acquisition process to be examined. We examined highly numerate physician trainees' decision processes, strategy, and their ability to pick the cheapest drug plan-as price was deemed the most important factor in Medicare beneficiaries' plan choice-from either 3 or 9 drug plans. Before adjustment, participants were significantly more likely to identify the lowest cost plan when facing three versus nine choices (67.3% vs. 32.8%, pinformation on each attribute (pdecision strategies focusing on comparing alternate plans across a single attribute (search pattern, pdecision process and strategy, numeracy, and amount of medical training, the odds were 10.75 times higher that trainees would choose the lowest cost Medicare Part D drug plan when facing 3 versus 9 drug plans (pdecision environment are needed and suggest physicians' role in their patients' Part D choices may be most productive when assisting seniors with forecasting their expected medication needs and then referring them to the Medicare website or helpline.

  1. State Program Integrity Assessment (SPIA)

    Data.gov (United States)

    U.S. Department of Health & Human Services — The State Program Integrity Assessment (SPIA) is the Centers for Medicare and Medicaid Services (CMS) first national data collection on state Medicaid program...

  2. Recovery Audit Program

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Recovery Audit Programs mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on...

  3. CMS Program Statistics

    Data.gov (United States)

    U.S. Department of Health & Human Services — The CMS Office of Enterprise Data and Analytics has developed CMS Program Statistics, which includes detailed summary statistics on national health care, Medicare...

  4. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Medicare Payment Rules Physician Quality Reporting System (PQRS) Value-Based Payment Modifier Third Party Payors State Legislation ... Records (EHR) Incentive Program Physician Quality Reporting System Value-Based Payment Modifier Quality and Resource Use Reports ...

  5. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Communications to the Profession Advocacy Advocacy Overview Quality Payment Program QPP Resource Center QPP Resource Center 2018 ... Summary Letters on Health Care Reform Medicare Physician Payment Medical Liability Reform Opioids and Surgical Care GME ...

  6. Ostomy Home Skills Program

    Medline Plus

    Full Text Available ... Policy Updates Selected Research Findings Quality Program Initiatives Communications to the Profession Advocacy Advocacy Overview Quality Payment ... Participation Medicare Inpatient & Outpatient Rules Physician Quality Reporting System (PQRS) Value-Based Payment Modifier Accountable Care Organizations ...

  7. Volume of Requests for Internet Medicare Replacement Cards

    Data.gov (United States)

    Social Security Administration — This dataset provides monthly volumes at the national level from federal fiscal year 2008 onwards for Internet Medicare Replacement Card. The dataset includes only...

  8. Did recent changes in Medicare reimbursement hit teaching hospitals harder?

    Science.gov (United States)

    Konetzka, R Tamara; Zhu, Jingsan; Volpp, Kevin G

    2005-11-01

    To inform the policy debate on Medicare reimbursement by examining the financial effects of the Balanced Budget Act of 1997 (BBA) and subsequent adjustments on major academic medical centers, minor teaching hospitals, and nonteaching hospitals. The authors simulated the impacts of BBA and subsequent BBA adjustments to predict the independent effects of changes in Medicare reimbursement on hospital revenues using 1997-2001 Medicare Cost Reports for all short-term acute-care hospitals in the United States. The authors also calculated actual (nonsimulated) operating and total margins among major teaching, minor teaching, and nonteaching hospitals to account for hospital response to the changes. The BBA and subsequent refinements reduced Medicare revenues to a greater degree in major teaching hospitals, but the fact that such hospitals had a smaller proportion of Medicare patients meant that the BBA reduced overall revenues by similar percentages across major, minor, and nonteaching hospitals. Consistently lower margins may have made teaching hospitals more vulnerable to cuts in Medicare support. Recent Medicare changes affected revenues at teaching and nonteaching hospitals more similarly than is commonly believed. However, the Medicare cuts under the BBA probably exacerbated preexisting financial strain on major teaching hospitals, and increased Medicare funding may not suffice to eliminate the strain. This report's findings are consistent with recent calls to support needed services of teaching hospitals through all-payer or general funds.

  9. Pharmacy Utilization: A Study to Predict BAMC Outpatient Pharmacy Usage by Dual-Eligible Military Retiree/Medicare-Eligible Beneficiaries Resulting From Implementation of the TRICARE Senior Pharmacy Program (TSRx)

    National Research Council Canada - National Science Library

    Lankowicz, Andrew

    2001-01-01

    .... The problem that confronted Brooke Army Medical Center (BAMC) was the lack of knowledge about the effect that the TSRx program might have on utilization of the hospital s outpatient pharmacies. A survey (Appendix C...

  10. New options to integrate care and financing for persons dually eligible for Medicare and Medicaid.

    Science.gov (United States)

    Hayes, Katherine Jett; Thorpe, Jane Hyatt

    2012-01-01

    This paper reviews barriers to clinical and financial integration in services for dual eligibles prior to passage of the ACA, identifies models used by states to integrate care through contract and waiver authorities available to CMS prior to passage of the ACA, describes two new demonstrations proposed by CMS through the Medicare-Medicaid Coordination Office and Innovation Center, and discusses several new models available for consideration by federal and state policymakers. These options draw on experience from existing programs and waivers to provide suggested changes to existing programs, as well as a permanent state plan option for a fully integrated, capitated care model. This model could be made available to states prior to the completion of the demonstration process begun by the Medicare-Medicaid Coordination Office and Innovation Center.

  11. Medicare Payment Penalties and Safety Net Hospital Profitability: Minimal Impact on These Vulnerable Hospitals.

    Science.gov (United States)

    Bazzoli, Gloria J; Thompson, Michael P; Waters, Teresa M

    2018-02-08

    To examine relationships between penalties assessed by Medicare's Hospital Readmission Reduction Program and Value-Based Purchasing Program and hospital financial condition. Centers for Medicare and Medicaid Services, American Hospital Association, and Area Health Resource File data for 4,824 hospital-year observations. Bivariate and multivariate analysis of pooled cross-sectional data. Safety net hospitals have significantly higher HRRP/VBP penalties, but, unlike nonsafety net hospitals, increases in their penalty rate did not significantly affect their total margins. Safety net hospitals appear to rely on nonpatient care revenues to offset higher penalties for the years studied. While reassuring, these funding streams are volatile and may not be able to compensate for cumulative losses over time. © Health Research and Educational Trust.

  12. Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources.

    Science.gov (United States)

    Menger, Richard P; Wolf, Michael E; Kukreja, Sunil; Sin, Anthony; Nanda, Anil

    2015-01-01

    Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery. Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012. In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure. Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving

  13. The Relationship Between Magnet Designation, Electronic Health Record Adoption, and Medicare Meaningful Use Payments.

    Science.gov (United States)

    Lippincott, Christine; Foronda, Cynthia; Zdanowicz, Martin; McCabe, Brian E; Ambrosia, Todd

    2017-08-01

    The objective of this study was to examine the relationship between nursing excellence and electronic health record adoption. Of 6582 US hospitals, 4939 were eligible for the Medicare Electronic Health Record Incentive Program, and 6419 were eligible for evaluation on the HIMSS Analytics Electronic Medical Record Adoption Model. Of 399 Magnet hospitals, 330 were eligible for the Medicare Electronic Health Record Incentive Program, and 393 were eligible for evaluation in the HIMSS Analytics Electronic Medical Record Adoption Model. Meaningful use attestation was defined as receipt of a Medicare Electronic Health Record Incentive Program payment. The adoption electronic health record was defined as Level 6 and/or 7 on the HIMSS Analytics Electronic Medical Record Adoption Model. Logistic regression showed that Magnet-designated hospitals were more likely attest to Meaningful Use than non-Magnet hospitals (odds ratio = 3.58, P electronic health records than non-Magnet hospitals (Level 6 only: odds ratio = 3.68, P electronic health record use, which involves earning financial incentives for successful adoption. Continued investigation is needed to examine the relationships between the quality of nursing care, electronic health record usage, financial implications, and patient outcomes.

  14. Associations Between Medicare Part D and Out-of-Pocket Spending, HIV Viral Load, Adherence, and ADAP Use in Dual Eligibles With HIV.

    Science.gov (United States)

    Belenky, Nadya; Pence, Brian W; Cole, Stephen R; Dusetzina, Stacie B; Edmonds, Andrew; Oberlander, Jonathan; Plankey, Michael W; Adedimeji, Adebola; Wilson, Tracey E; Cohen, Jennifer; Cohen, Mardge H; Milam, Joel E; Golub, Elizabeth T; Adimora, Adaora A

    2018-01-01

    The implementation of Medicare part D on January 1, 2006 required all adults who were dually enrolled in Medicaid and Medicare (dual eligibles) to transition prescription drug coverage from Medicaid to Medicare part D. Changes in payment systems and utilization management along with the loss of Medicaid protections had the potential to disrupt medication access, with uncertain consequences for dual eligibles with human immunodeficiency virus (HIV) who rely on consistent prescription coverage to suppress their HIV viral load (VL). To estimate the effect of Medicare part D on self-reported out-of-pocket prescription drug spending, AIDS Drug Assistance Program (ADAP) use, antiretroviral adherence, and HIV VL suppression among dual eligibles with HIV. Using 2003-2008 data from the Women's Interagency HIV Study, we created a propensity score-matched cohort and used a difference-in-differences approach to compare dual eligibles' outcomes pre-Medicare and post-Medicare part D to those enrolled in Medicaid alone. Transition to Medicare part D was associated with a sharp increase in the proportion of dual eligibles with self-reported out-of-pocket prescription drug costs, followed by an increase in ADAP use. Despite the increase in out-of-pocket costs, both adherence and HIV VL suppression remained stable. Medicare part D was associated with increased out-of-pocket spending, although the increased spending did not seem to compromise antiretroviral therapy adherence or HIV VL suppression. It is possible that increased ADAP use mitigated the increase in out-of-pocket spending, suggesting successful coordination between Medicare part D and ADAP as well as the vital role of ADAP during insurance transitions.

  15. 42 CFR 412.79 - Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent...

    Science.gov (United States)

    2010-10-01

    ... OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Determination of Transition Period Payment Rates for the Prospective Payment System for Inpatient... § 412.73(c)(14) through (c)(16). (e) DRG adjustment. The applicable hospital-specific cost per discharge...

  16. Medicare Part D: Are Insurers Gaming the Low Income Subsidy Design?

    Science.gov (United States)

    Decarolis, Francesco

    2015-04-01

    This paper shows how in Medicare Part D insurers' gaming of the subsidy paid to low-income enrollees distorts premiums and raises the program cost. Using plan-level data from the first five years of the program, I find multiple instances of pricing strategy distortions for the largest insurers. Instrumental variable estimates indicate that the changes in a concentration index measuring the manipulability of the subsidy can explain a large share of the premium growth observed between 2006 and 2011. Removing this distortion could reduce the cost of the program without worsening consumer welfare.

  17. Medicare Spending for Breast, Prostate, Lung, and Colorectal Cancer Patients in the Year of Diagnosis and Year of Death.

    Science.gov (United States)

    Chen, Christopher T; Li, Ling; Brooks, Gabriel; Hassett, Michael; Schrag, Deborah

    2017-07-26

    To characterize spending patterns for Medicare patients with incident breast, prostate, lung, and colorectal cancer. 2007-2012 data from the Surveillance, Epidemiology, and End Results Program linked with Medicare fee-for-service claims. We calculate per-patient monthly and yearly mean and median expenditures, by cancer type, stage at diagnosis, and spending category, over the years of diagnosis and death. Over the year of diagnosis, mean spending was $35,849, $26,295, $55,597, and $63,063 for breast, prostate, lung, and colorectal cancer, respectively. Over the year of death, spending was similar across different cancer types and stage at diagnosis. Characterization of Medicare spending according to clinically meaningful categories may assist development of oncology alternative payment models and cost-effectiveness models. © Health Research and Educational Trust.

  18. 76 FR 33565 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Science.gov (United States)

    2011-06-08

    ... surgery, air embolism, catheter-associated urinary tract infection, blood incompatibility, pressure ulcer... specified geographic areas and must pay a fee equal to the cost of making the data available. Congress also... preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by standard...

  19. 76 FR 67572 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2011-11-01

    ... section 1839 of the Act, requires that, starting on January 1,2007, the Part B premium a beneficiary pays... private sector costs of this notice fall below this threshold as well. Executive Order 13132 establishes... B premium rate for 2012 is $99.90, which is equal to 50 percent of the monthly actuarial rate for...

  20. 75 FR 68790 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2010-11-09

    ... the Act, requires that, starting on January 1, 2007, the Part B premium a beneficiary pays each month... private sector costs of this notice fall below this threshold as well. Executive Order 13132 establishes... B premium rate for 2011 is $115.40, which is equal to 50 percent of the monthly actuarial rate for...

  1. 78 FR 64943 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    Science.gov (United States)

    2013-10-30

    ... section 1839 of the Act, requires that, starting on January 1, 2007, the Part B premium a beneficiary pays... governments or on the private sector. Executive Order 13132 establishes certain requirements that an agency... B premium rate for all enrollees for 2014 is $104.90, which is equal to 50 percent of the monthly...

  2. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Science.gov (United States)

    2011-12-07

    ... organizations engaged in performance measurement or data aggregation that may potentially be approved to receive... three areas: Organizational and governance capabilities, addition of claims data from other sources, and... where multiple organizations will possess sufficient claims data from other sources. Additionally, we...

  3. 78 FR 78802 - Medicare Program; Right of Appeal for Medicare Secondary Payer Determination Relating to...

    Science.gov (United States)

    2013-12-27

    ... ``More Search Options'' tab. 2. By regular mail. You may mail written comments to the following address... million or more in any 1 year). We have determined that the effect of this proposed rule on the economy...

  4. 76 FR 52955 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Science.gov (United States)

    2011-08-24

    ... Panel's discussion is expected to be very technical in nature and will focus on the actuarial and... discussion is expected to focus on highly technical aspects of estimation involving economics and actuarial science. Panelists are not restricted, however, in the topics that they choose to discuss. Procedure and...

  5. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Science.gov (United States)

    2011-09-21

    ... to be very technical in nature and will focus on the actuarial and economic assumptions and methods... discussion is expected to focus on highly technical aspects of estimation involving economics and actuarial science. Panelists are not restricted, however, in the topics that they choose to discuss. Procedure and...

  6. 78 FR 63986 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2013-10-25

    ..., clinical trial design, health care data management and analysis, patient advocacy, health care economics... economics Medical ethics Other relevant professions We are looking particularly for experts in a number of... provide detailed information concerning such matters as financial holdings, consultancies, and research...

  7. 77 FR 50110 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2012-08-20

    ... economics, medical ethics or other relevant professions. The MEDCAC works from an agenda provided by the... analysis Patient advocacy Health care economics Medical ethics Other relevant professions We are looking... asked to provide detailed information concerning such matters as financial holdings, consultancies, and...

  8. 76 FR 71573 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2011-11-18

    ... economics, medical ethics, or other relevant professions. The MEDCAC works from an agenda provided by the... trial design Health care data management and analysis Patient advocacy Health care economics Medical... concerning such matters as financial holdings, consultancies, and research grants or contracts in order to...

  9. 75 FR 58414 - Medicare Program; Meeting of the Medicare Evidence Development and Coverage Advisory Committee...

    Science.gov (United States)

    2010-09-24

    ...: Individuals may register online at http://www.cms.gov/mcd/index_list.asp?list_type=mcac via e-mail at MEDCAC... meeting: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=mcac . We require that you declare at the... at http://www.cms.gov/mcd/index_list.asp?list_type=mcac , via e-mail at [email protected

  10. 75 FR 8982 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2010-02-26

    ... and men, members of all racial and ethnic groups, and physically challenged individuals are adequately..., members of all racial and ethnic groups, and physically challenged individuals are adequately represented... appears to have no conflict of interest that would preclude membership. We are requesting that all...

  11. 75 FR 78705 - Medicare Program; Request for Nominations for Members for the Medicare Evidence Development...

    Science.gov (United States)

    2010-12-16

    ... interests of both women and men, members of all racial and ethnic groups, and physically challenged... that the nominee is willing to serve as a member of the MEDCAC and appears to have no conflict of..., consultancies, and research grants or contracts in order to permit evaluation of possible sources of conflict of...

  12. 78 FR 6272 - Rules Relating to Additional Medicare Tax; Correction

    Science.gov (United States)

    2013-01-30

    ... Rules Relating to Additional Medicare Tax; Correction AGENCY: Internal Revenue Service (IRS), Treasury... regulations are relating to Additional Hospital Insurance Tax on income above threshold amounts (``Additional Medicare Tax''), as added by the Affordable Care Act. Specifically, these proposed regulations provide...

  13. Geographic variation in Medicare and the military healthcare system.

    Science.gov (United States)

    Adesoye, Taiwo; Kimsey, Linda G; Lipsitz, Stuart R; Nguyen, Louis L; Goodney, Philip; Olaiya, Samuel; Weissman, Joel S

    2017-08-01

    To compare geographic variation in healthcare spending and utilization between the Military Health System (MHS) and Medicare across hospital referral regions (HRRs). Retrospective analysis. Data on age-, sex-, and race-adjusted Medicare per capita expenditure and utilization measures by HRR were obtained from the Dartmouth Atlas for 2007 to 2010. Similarly, adjusted data from 2007 and 2010 were obtained from the MHS Data Repository and patients assigned to HRRs. We compared high- and low-spending regions, and computed coefficient of variation (CoV) and correlation coefficients for healthcare spending, hospital inpatient days, hip surgery, and back surgery between MHS and Medicare patients. We found significant variation in spending and utilization across HRRs in both the MHS and Medicare. CoV for spending was higher in the MHS compared with Medicare, (0.24 vs 0.15, respectively) and CoV for inpatient days was 0.36 in the MHS versus 0.19 in Medicare. The CoV for back surgery was also greater in the MHS compared with Medicare (0.47 vs 0.29, respectively). Per capita Medicare spending per HRR was significantly correlated to adjusted MHS spending (r = 0.3; P spending markets in both systems were not comparable; lower spending markets were located mostly in the Midwest. In comparing 2 systems with similar pricing schemes, differences in spending likely reflect variation in utilization and the influence of local provider culture.

  14. Understanding Trends in Medicare Spending, 2007-2014.

    Science.gov (United States)

    Keohane, Laura M; Gambrel, Robert J; Freed, Salama S; Stevenson, David; Buntin, Melinda B

    2018-03-06

    To analyze the sources of per-beneficiary Medicare spending growth between 2007 and 2014, including the role of demographic characteristics, attributes of Medicare coverage, and chronic conditions. Individual-level Medicare spending and enrollment data. Using an Oaxaca-Blinder decomposition model, we analyzed whether changes in price-standardized, per-beneficiary Medicare Part A and B spending reflected changes in the composition of the Medicare population or changes in relative spending levels per person. We identified a 5 percent sample of fee-for-service Medicare beneficiaries age 65 and above from years 2007 to 2014. Mean payment-adjusted Medicare per-beneficiary spending decreased by $180 between the 2007-2010 and 2011-2014 time periods. This decline was almost entirely attributable to lower spending levels for beneficiaries. Notably, declines in marginal spending levels for beneficiaries with chronic conditions were associated with a $175 reduction in per-beneficiary spending. The decline was partially offset by the increasing prevalence of certain chronic diseases. Still, we are unable to attribute a large share of the decline in spending levels to observable beneficiary characteristics or chronic conditions. Declines in spending levels for Medicare beneficiaries with chronic conditions suggest that changing patterns of care use may be moderating spending growth. © Health Research and Educational Trust.

  15. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Science.gov (United States)

    2010-10-01

    ... change in practice location, a change of any managing employee, and a change in billing services. A... 42 Public Health 3 2010-10-01 2010-10-01 false Deactivation of Medicare billing privileges. 424.540 Section 424.540 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND...

  16. Variation in Payment Rates under Medicare's Inpatient Prospective Payment System.

    Science.gov (United States)

    Krinsky, Sam; Ryan, Andrew M; Mijanovich, Tod; Blustein, Jan

    2017-04-01

    To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates. © Health Research and Educational Trust.

  17. 20 CFR 404.1018b - Medicare qualified government employment.

    Science.gov (United States)

    2010-04-01

    ... AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1018b Medicare qualified government employment. (a) General. The work of a... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Medicare qualified government employment. 404...

  18. The bribery statute: a new weapon against Medicare fraud.

    Science.gov (United States)

    Cozort, L A

    2001-03-01

    A May 2000 U.S. Supreme Court decision determining when a Federal bribery statute can be used to fight Medicare fraud has ramifications for healthcare providers. In Fischer v. United States, the Court concluded that healthcare providers that participate in Medicare are considered to receive benefits as set forth in the bribery statute and thus can be prosecuted for fraudulent activities against the government under the statute. The statute mandates a fine, imprisonment for up to 10 years, or both for anyone convicted under it. Provider organizations that receive Medicare payments and business associates of such organizations should be aware that the government may step up its use of the bribery law in prosecuting fraudulent activity. In addition, although the case pertained specifically to healthcare providers that participate in Medicare, providers that do not participate in Medicare may wish to evaluate the advisability of accepting other Federal funding because of the possible reach of the bribery statute.

  19. MIPPA: First Broad Changes to Medicare Part D Plan Operations.

    Science.gov (United States)

    LeMasurier, Jean D; Edgar, Babette

    2009-04-01

    In July 2008, as part of broad Medicare reform, Congress passed the first major legislative changes to Medicare Part D since its enactment in 2003-the Medicare Improvements for Patients and Providers Act. This new legislation has significant implications for how Part D plans can market and enroll Medicare beneficiaries. The new legislation also strengthened beneficiary protections, expanded the low-income subsidy provisions originally included in Part D, and expanded Part D coverage. These changes have significant implications for the operation of Part D plans and can affect those involved in benefit design, including specialty pharmacy coverage. This article discusses the major changes that took effect on January 1, 2009, and have immediate implications for Part D plan sponsors, including Medicare Advantage plans and stand-alone prescription drug plans.

  20. Section 525(a) of the bankruptcy code plainly does not apply to Medicare provider agreements.

    Science.gov (United States)

    Sperow, E H

    2001-01-01

    Section 525(a) of the Bankruptcy Code prevents government entities from discriminating against debtors based on the debtor's bankruptcy filing. This Article analyzes how this provision is applied to healthcare providers who file for bankruptcy. Some commentators have expressed concerns that because of Section 525, the federal government is unable to deny a bankrupt provider a new Medicare provider agreement due to the debtor's failure to pay debts discharged during bankruptcy. This Article, however, argues that Section 525 does not apply to a provider agreements because it is not a "license, permit, charter, franchise, or other similar grant" as defined by the statute. Therefore, the author concludes that debtor healthcare providers should not be allowed back into the Medicare program without first paying their statutorily required debts.

  1. Financial Incentives and Physician Practice Participation in Medicare's Value-Based Reforms.

    Science.gov (United States)

    Markovitz, Adam A; Ramsay, Patricia P; Shortell, Stephen M; Ryan, Andrew M

    2017-07-26

    To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms. Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013). We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures. We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey. There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment

  2. Improving Refill Adherence in Medicare Patients With Tailored and Interactive Mobile Text Messaging: Pilot Study

    Science.gov (United States)

    Jeong, Erwin W; Feger, Erin; Noble, Harmony K; Kmiec, Magdalen; Prayaga, Ram S

    2018-01-01

    Background Nonadherence is a major concern in the management of chronic conditions such as hypertension, cardiovascular disease, and diabetes where patients may discontinue or interrupt their medication for a variety of reasons. Text message reminders have been used to improve adherence. However, few programs or studies have explored the benefits of text messaging with older populations and at scale. In this paper, we present a program design using tailored and interactive text messaging to improve refill rates of partially adherent or nonadherent Medicare members of a large integrated health plan. Objective The aim of this 3-month program was to gain an understanding of whether tailored interactive text message dialogues could be used to improve medication refills in Medicare patients with one or more chronic diseases. Methods We used the mPulse Mobile interactive text messaging solution with partially adherent and nonadherent Medicare patients (ie, over age 65 years or younger with disabilities) of Kaiser Permanente Southern California (KP), a large integrated health plan, and compared refill rates of the text messaging group (n=12,272) to a group of partially adherent or nonadherent Medicare patients at KP who did not receive text messages (nontext messaging group, n=76,068). Both groups were exposed to other forms of refill and adherence outreach including phone calls, secure emails, and robo-calls from December 2016 to February 2017. Results The text messaging group and nontext messaging group were compared using an independent samples t test to test difference in group average of refill rates. There was a significant difference in medication refill rates between the 2 groups, with a 14.07 percentage points higher refill rate in the text messaging group (Pimprove medication refill rates among Medicare patients. These findings also support using interactive text messaging as a cost-effective, convenient, and user-friendly solution for patient engagement

  3. Executive function, episodic memory, and Medicare expenditures.

    Science.gov (United States)

    Bender, Alex C; Austin, Andrea M; Grodstein, Francine; Bynum, Julie P W

    2017-07-01

    We examined the relationship between health care expenditures and cognition, focusing on differences across cognitive systems defined by global cognition, executive function, or episodic memory. We used linear regression models to compare annual health expenditures by cognitive status in 8125 Nurses' Health Study participants who completed a cognitive battery and were enrolled in Medicare parts A and B. Adjusting for demographics and comorbidity, executive impairment was associated with higher total annual expenditures of $1488 per person (P episodic memory impairment was found. Expenditures exhibited a linear relationship with executive function, but not episodic memory ($584 higher for every 1 standard deviation decrement in executive function; P < .01). Impairment in executive function is specifically and linearly associated with higher health care expenditures. Focusing on management strategies that address early losses in executive function may be effective in reducing costly services. Copyright © 2017 the Alzheimer's Association. Published by Elsevier Inc. All rights reserved.

  4. Medication adherence and Medicare expenditure among beneficiaries with heart failure.

    Science.gov (United States)

    Lopert, Ruth; Shoemaker, J Samantha; Davidoff, Amy; Shaffer, Thomas; Abdulhalim, Abdulla M; Lloyd, Jennifer; Stuart, Bruce

    2012-09-01

    To (1) measure utilization of and adherence to heart failure medications and (2) assess whether better adherence is associated with lower Medicare spending. Pooled cross-sectional design using six 3-year cohorts of Medicare beneficiaries with congestive heart failure (CHF) from 1997 through 2005 (N = 2204). Adherence to treatment was measured using average daily pill counts. Bivariate and multivariate methods were used to examine the relationship between medication adherence and Medicare spending. Multivariate analyses included extensive variables to control for confounding, including healthy adherer bias. Approximately 58% of the cohort were taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), 72% a diuretic, 37% a beta-blocker, and 34% a cardiac glycoside. Unadjusted results showed that a 10% increase in average daily pill count for ACE inhibitors or ARBs, beta-blockers, diuretics, or cardiac glycosides was associated with reductions in Medicare spending of $508 (not significant [NS]), $608 (NS), $250 (NS), and $1244 (P <.05), respectively. Estimated adjusted marginal effects of a 10% increase in daily pill counts for beta-blockers and cardiac glycosides were reductions in cumulative 3-year Medicare spending of $510 to $561 and $750 to $923, respectively (P <.05). Higher levels of medication adherence among Medicare beneficiaries with CHF were associated with lower cumulative Medicare spending over 3 years, with savings generally exceeding the costs of the drugs in question.

  5. Medicare and Medicaid Programs; CY 2018 Home Health Prospective Payment System Rate Update and CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

    Science.gov (United States)

    2017-11-07

    This final rule updates the home health prospective payment system (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor, effective for home health episodes of care ending on or after January 1, 2018. This rule also: Updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the third year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between calendar year (CY) 2012 and CY 2014; and discusses our efforts to monitor the potential impacts of the rebasing adjustments that were implemented in CY 2014 through CY 2017. In addition, this rule finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model and to the Home Health Quality Reporting Program (HH QRP). We are not finalizing the implementation of the Home Health Groupings Model (HHGM) in this final rule.

  6. Medicare Under Age 65 and Medicaid Patients Have Poorer Bowel Preparations: Implications for Recommendations for an Early Repeat Colonoscopy.

    Directory of Open Access Journals (Sweden)

    Bryan B Brimhall

    Full Text Available Colonoscopy is performed on patients across a broad spectrum of demographic characteristics. These characteristics may aggregate by patient insurance provider and influence bowel preparation quality and the prevalence of adenomas. The purpose of this study was to evaluate the association of insurance status and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, adenoma detection rate (ADR, and advanced ADR (AADR.This is a cohort study of outpatient colonoscopies (n = 3113 at a single academic medical center. Patient insurance status was categorized into five groups: 1 Medicare < 65y; 2 Medicare ≥ 65y; 3 Tricare/VA; 4 Medicaid/Colorado Indigent Care Program (CICP; and 5 commercial insurance. We used multivariable logistic or linear regression modeling to estimate the risks for the association between patient insurance and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, ADR, and AADR. Models were adjusted for appropriate covariates.Medicare patients < 65y (OR 4.91; 95% CI: 3.25-7.43 and Medicaid/CICP patients (OR 4.23; 95% CI: 2.65-7.65 were more likely to have a suboptimal preparation compared to commercial insurance patients. Medicare patients < 65y (OR 5.58; 95% CI: 2.85-10.92 and Medicaid/CICP patients (OR 3.64; CI: 1.60-8.28 were more likely to receive a recommendation for an early repeat colonoscopy compared to commercial insurance patients. Medicare patients < 65y had a significantly higher adjusted ADR (OR 1.50; 95% CI: 1.03-2.18 and adjusted AADR (OR 1.99; 95% CI: 1.15-3.44 compared to commercial insurance patients.Understanding the reasons for the higher rate of a suboptimal bowel preparation in Medicare < 65y and Medicaid/CICP patients and reducing this rate is critical to improving colonoscopy outcomes and reducing healthcare costs in these populations.

  7. 42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false PACE benefits under Medicare and Medicaid. 460.90 Section 460.90 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... FOR THE ELDERLY (PACE) PACE Services § 460.90 PACE benefits under Medicare and Medicaid. If a Medicare...

  8. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    Science.gov (United States)

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payment in no-fault... Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.53 Basis for conditional Medicare payment in no-fault cases. (a) A conditional Medicare payment may be made in no-fault...

  9. Early Results of Medicare's Bundled Payment Initiative for a 90-Day Total Joint Arthroplasty Episode of Care.

    Science.gov (United States)

    Iorio, Richard; Clair, Andrew J; Inneh, Ifeoma A; Slover, James D; Bosco, Joseph A; Zuckerman, Joseph D

    2016-02-01

    In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare." A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. IV economic and decision analyses-developing an economic or decision model. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.

    Science.gov (United States)

    Gong, Dan; Jun, Lin; Tsai, James C

    2017-08-01

    To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries. The 2005-2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule. Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we calculated the Medicare payment-service volume elasticities for noncomplex (CPT 66984) and complex (CPT 66982) cataract surgeries. Service volume data were extracted from the CMS Part B National Summary and Carrier Summary Data Files. Payment data were extracted from the Medicare Physician Fee Schedule. From 2005 to 2009, the proportion of total cataract services billed as complex increased from 3.2 to 6.7 percent. Every 1 percent decrease in Medicare payment was associated with a nonsignificant change in noncomplex cataract service volume (elasticity = 0.15, 95 percent CI [-0.09, 0.38]) but a statistically significant increase in complex cataract service volume (elasticity = -1.12, 95 percent CI [-1.60, -0.63]). Reduced Medicare payment was associated with a significant increase in complex cataract service volume but not in noncomplex cataract service volume, resulting in a shift toward performing a greater proportion of complex cataract surgeries from 2005 to 2009. © Health Research and Educational Trust.

  11. Medicare Part D is associated with reducing the financial burden of health care services in Medicare beneficiaries with diagnosed diabetes.

    Science.gov (United States)

    Li, Rui; Gregg, Edward W; Barker, Lawrence E; Zhang, Ping; Zhang, Fang; Zhuo, Xiaohui; Williams, Desmond E; Soumerai, Steven B

    2013-10-01

    Medicare Part D, implemented in 2006, provided coverage for prescription drugs to all Medicare beneficiaries. To examine the effect of Part D on the financial burden of persons with diagnosed diabetes. We conducted an interrupted time-series analysis using data from the 1996 to 2008 Medical Expenditure Panel Survey (11,178 persons with diabetes who were covered by Medicare, and 8953 persons aged 45-64 y with diabetes who were not eligible for Medicare coverage). We then compared changes in 4 outcomes: (1) annual individual out-of-pocket expenditure (OOPE) for prescription drugs; (2) annual individual total OOPE for all health care services; (3) annual total family OOPE for all health care services; and (4) percentage of persons with high family financial burden (OOPE ≥10% of income). For Medicare beneficiaries with diabetes, Part D was associated with a 28% ($530) decrease in individual annual OOPE for prescription drugs, a 23% ($560) reduction in individual OOPE for all health care, a 23% ($863) reduction in family OOPE for all health care, and a 24% reduction in the percentage of families with high financial burden in 2006. There were similar reductions in 2007 and 2008. By 2008, the percentage of Medicare beneficiaries with diabetes living in high financial burden families was 37% lower than it would have been had Part D not been in place. Introduction of Part D coverage was associated with a substantial reduction in the financial burden of Medicare beneficiaries with diabetes and their families.

  12. Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics With Performance.

    Science.gov (United States)

    Albright, Benjamin B; Lewis, Valerie A; Ross, Joseph S; Colla, Carrie H

    2016-03-01

    Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for 8 measures of preventive care quality. To create composite measures of preventive care quality and examine associations of ACO characteristics with performance. This is a cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics. Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified 2 underlying factors among 8 measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries. ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration.

  13. Medicare-Medicaid Ever-enrolled Trends Report

    Data.gov (United States)

    U.S. Department of Health & Human Services — This detailed Excel document accompanies the PDF report on national trends in Medicare-Medicaid dual enrollment from 2006 through the year prior to the current year....

  14. Beneficiary price sensitivity in the Medicare prescription drug plan market.

    Science.gov (United States)

    Frakt, Austin B; Pizer, Steven D

    2010-01-01

    The Medicare stand-alone prescription drug plan (PDP) came into existence in 2006 as part of the Medicare prescription drug benefit. It is the most popular plan type among Medicare drug plans and large numbers of plans are available to all beneficiaries. In this article we present the first analysis of beneficiary price sensitivity in the PDP market. Our estimate of elasticity of enrollment with respect to premium, -1.45, is larger in magnitude than has been found in the Medicare HMO market. This high degree of beneficiary price sensitivity for PDPs is consistent with relatively low product differentiation, low fixed costs of entry in the PDP market, and the fact that, in contrast to changing HMOs, beneficiaries can select a PDP without disrupting doctor-patient relationships.

  15. State-County Profiles of Medicare-Medicaid dual Benes

    Data.gov (United States)

    U.S. Department of Health & Human Services — This 6-page document provides key statistics on Medicare-Medicaid dual enrollees enrollment, service utilization, expenditures, and chronic conditions for 2012. 2012...

  16. Use of Hospitalists by Medicare Benes, A National Picture

    Data.gov (United States)

    U.S. Department of Health & Human Services — The number of physicians working as hospitalists is thought to have increased dramatically since the term emerged in 1990. In Use of Hospitalists by Medicare...

  17. Basic Stand Alone Medicare Claims Public Use Files

    Data.gov (United States)

    U.S. Department of Health & Human Services — CMS is committed to increasing access to its Medicare claims data through the release of de-identified data files available for public use. They contain...

  18. State and National Profiles of Medicare-Medicaid dual Benes

    Data.gov (United States)

    U.S. Department of Health & Human Services — These documents provide key statistics on Medicare-Medicaid dual enrollees enrollment, service utilization, expenditures, and chronic conditions for 2007 through 2011.

  19. Basic Stand Alone Medicare DME Line Items PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This release contains the Basic Stand Alone (BSA) Durable Medical Equipment (DME) Line Items Public Use Files (PUF) with information from Medicare DME claims. The...

  20. Basic Stand Alone Medicare Prescription Drug Events PUF

    Data.gov (United States)

    U.S. Department of Health & Human Services — This is a Public Use File for Prescription Drug Events drawn from the 2008 Beneficiary Summary File of Medicare beneficiaries enrolled during the calendar year 2008,...

  1. Medicare Part D Prescriber Look-up Tool

    Data.gov (United States)

    U.S. Department of Health & Human Services — This look-up tool is a searchable database that allows you to look up a Medicare Part D prescriber by National Provider Identifier (NPI), or by name and location....

  2. Characteristics of otolaryngology claims to Medicare in 2012.

    Science.gov (United States)

    Bhattacharyya, Neil; Lin, Harrison W

    2014-11-01

    The Medicare provider utilization and payment public use datafile for 2012 was analyzed with respect to otolaryngology specialty providers to characterize otolaryngology services billed to and reimbursed by Medicare, both overall and according to provider characteristics. Among 8450 otolaryngology specialty providers submitting claims, the top 5 billed services were (count in millions): 99213 (2.23), 95165 (1.81), 99203 (0.92), 99214 (0.83), and 69210 (0.71), and the top 5 total reimbursed services were (aggregate total reimbursements in millions): 99213 ($114), 99203 ($68), 99214 ($63), 31231 ($60), and 31575 ($47). There was a mean of 1567 services billed per provider with an average (yearly) total reimbursement from Medicare of $76,068 per provider. These data characterize the current level of provision of otolaryngology services to the Medicare population. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2014.

  3. 75 FR 37971 - Providing Stability and Security for Medicare Reimbursements

    Science.gov (United States)

    2010-06-30

    ... Part IV The President Memorandum of June 25, 2010--Providing Stability and Security for Medicare Reimbursements #0; #0; #0; Presidential Documents #0; #0; #0;#0;Federal Register / Vol. 75, No. 125 / Wednesday...

  4. The National Market for Medicare Clinical Laboratory Testing

    Data.gov (United States)

    U.S. Department of Health & Human Services — Current Medicare payment policy for outpatient laboratory services is outdated. Future reforms, such as competitive bidding, should consider the characteristics of...

  5. Launching a medicare advantage plan: smart planning saves headaches.

    Science.gov (United States)

    Abrams, Robert J; Mullaney, Teri L

    2007-11-01

    If you're considering setting up a Medicare Advantage plan, the following are important considerations: Financial analysis. Payment rates. Medical costs. Marketing and operational costs. Technology infrastructure. Staffing.

  6. National Profile of Medicare-Medicaid dual Beneficiaries

    Data.gov (United States)

    U.S. Department of Health & Human Services — This provides key statistics on Medicare-Medicaid dual enrollees enrollment, service utilization, expenditures, and chronic conditions for 2012. 2012 is the most...

  7. Medicare Advantage-Part D Contract and Enrollment Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Medicare Advantage (MA) - Part D Contract and Enrollment Data section serves as a centralized repository for publicly available data on contracts and plans,...

  8. The price sensitivity of Medicare beneficiaries: a regression discontinuity approach.

    Science.gov (United States)

    Buchmueller, Thomas C; Grazier, Kyle; Hirth, Richard A; Okeke, Edward N

    2013-01-01

    We use 4 years of data from the retiree health benefits program of the University of Michigan to estimate the effect of price on the health plan choices of Medicare beneficiaries. During the period of our analysis, changes in the University's premium contribution rules led to substantial price changes. A key feature of this 'natural experiment' is that individuals who had retired before a certain date were exempted from having to pay any premium contributions. This 'grandfathering' creates quasi-experimental variation that is ideal for estimating the effect of price. Using regression discontinuity methods, we compare the plan choices of individuals who retired just after the grandfathering cutoff date and were therefore exposed to significant price changes to the choices of a 'control group' of individuals who retired just before that date and therefore did not experience the price changes. The results indicate a statistically significant effect of price, with a $10 increase in monthly premium contributions leading to a 2 to 3 percentage point decrease in a plan's market share. Copyright © 2012 John Wiley & Sons, Ltd.

  9. Methodology of quality improvement projects for the Texas Medicare population.

    Science.gov (United States)

    Pendergrass, P W; Abel, R L; Bing, M; Vaughn, R; McCauley, C

    1998-07-01

    The Texas Medical Foundation, the quality improvement organization for the state of Texas, develops local quality improvement projects for the Medicare population. These projects are developed as part of the Health Care Quality Improvement Program undertaken by the Health Care Financing Administration. The goal of a local quality improvement project is to collaborate with providers to identify and reduce the incidence of unintentional variations in the delivery of care that negatively impact outcomes. Two factors are critical to the success of a quality improvement project. First, as opposed to peer review that is based on implicit criteria, quality improvement must be based on explicit criteria. These criteria represent key steps in the delivery of care that have been shown to improve outcomes for a specific disease. Second, quality improvement must be performed in partnership with the health care community. As such, the health care community must play an integral role in the design and evaluation of a quality improvement project and in the design and implementation of the resulting quality improvement plan. Specifically, this article provides a historical perspective for the transition from peer review to quality improvement. It discusses key steps used in developing and implementing local quality improvement projects including topic selection, quality indicator development, collaborator recruitment, and measurement of performance/improvement. Two Texas Medical Foundation projects are described to highlight the current methodology and to illustrate the impact of quality improvement projects.

  10. Chronic Disease Prevalence and Medicare Advantage Market Penetration

    OpenAIRE

    Steven W. Howard; Stephanie Lazarus Bernell; Faizan M. Casim; Jennifer Wilmott; Lindsey Pearson; Caitlin M. Byler; Zidong Zhang

    2015-01-01

    By March 2015, 30% of all Medicare beneficiaries were enrolled in Medicare Advantage (MA) plans. Research to date has not explored the impacts of MA market penetration on individual or population health outcomes. The primary objective of this study is to examine the relationships between MA market penetration and the beneficiary?s portfolio of cardiometabolic diagnoses. This study uses 2004 to 2008 Medical Expenditure Panel Survey (MEPS) Household Component data to construct an aggregate inde...

  11. Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model. Final rule.

    Science.gov (United States)

    2016-11-04

    This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year 2017. It also finalizes policies for coverage and payment for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury. This rule also sets forth requirements for the ESRD Quality Incentive Program, including the inclusion of new quality measures beginning with payment year (PY) 2020 and provides updates to programmatic policies for the PY 2018 and PY 2019 ESRD QIP. This rule also implements statutory requirements for bid surety bonds and state licensure for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). This rule also expands suppliers' appeal rights in the event of a breach of contract action taken by CMS, by revising the appeals regulation to extend the appeals process to all types of actions taken by CMS for a supplier's breach of contract, rather than limit an appeal for the termination of a competitive bidding contract. The rule also finalizes changes to the methodologies for adjusting fee schedule amounts for DMEPOS using information from CBPs and for submitting bids and establishing single payment amounts under the CBPs for certain groupings of similar items with different features to address price inversions. Final changes also are made to the method for establishing bid limits for items under the DMEPOS CBPs. In addition, this rule summarizes comments on the impacts of coordinating Medicare and Medicaid Durable Medical Equipment for dually eligible beneficiaries. Finally, this rule also summarizes comments received in response to a request for information related to the Comprehensive ESRD Care Model and future payment models affecting renal care.

  12. 77 FR 26827 - Medicaid Program; Community First Choice Option

    Science.gov (United States)

    2012-05-07

    ... Medicare & Medicaid Services 42 CFR Part 441 Medicaid Program; Community First Choice Option; Final Rule #0... [CMS-2337-F] RIN 0938-AQ35 Medicaid Program; Community First Choice Option AGENCY: Centers for Medicare... Affordable Care Act, which establishes a new State option to provide home and community-based attendant...

  13. Routine medicare and radiation exposure. Introductory remarks

    International Nuclear Information System (INIS)

    Hirata, Hideki; Saito, Tsutomu

    2013-01-01

    As an introduction of the title series, outlines of radiation in physics, chemistry, biochemistry, biological effect and protection are explained from the clinical doctors' aspect of routine medicare, and of radiation exposure in which people's interest is raised after the Fukushima Nuclear Power Plant Accident in 2011. For physics, ionizing effects of radiation are described in relation to its quantum energy transfer and its medical utilization like imaging and radiotherapy. Then mentioned in brief is the radiation from elements consisting of human body, cosmic ray and background radiation from the earth, with reference to natural and standardized limits of exposure doses. Radiations from 226 Rn and 40 K are explained as an instance of environmental natural sources together with the concepts of radioactive decay series/scheme, of internal exposure, of hazard like double strand break (DSB) and of medical use such as boron neutron capture therapy (BNCT). For an artifact radiation source, shown are fission products of 235 U by neutron, first yielded in 1945. Evidence of evolution in biochemical repair mechanisms of DSB is explained with a comparison of irradiated drosophila mutation where linear non-threshold (LNT) hypothesis is proposed, and human non-homologous end joining and homologous recombination. Historical process of occupational, medical, public exposures and their protection is finally described from the discovery of X-ray in 1895 to the first ICRP publication in 1958 via the A-bomb explosion in 1945. (T.T.)

  14. 77 FR 9179 - Medicare Program; Reporting and Returning of Overpayments

    Science.gov (United States)

    2012-02-16

    ...'s name, number and tax identification number; and the date of service. The voluntary refund process... reporting form include: (1) Accountants and auditors (external and in-house); and (2) miscellaneous in-house... accountant). Consequently, in order to determine the burden cost, we utilize the average hourly wage of these...

  15. Medicare Advantage and Fee-for-Service Performance on Clinical Quality and Patient Experience Measures: Comparisons from Three Large States.

    Science.gov (United States)

    Timbie, Justin W; Bogart, Andy; Damberg, Cheryl L; Elliott, Marc N; Haas, Ann; Gaillot, Sarah J; Goldstein, Elizabeth H; Paddock, Susan M

    2017-12-01

    To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs. Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida. We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences. Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims. Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons. Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts. © Health Research and Educational Trust.

  16. Can a More User-Friendly Medicare Plan Finder Improve Consumers' Selection of Medicare Plans?

    Science.gov (United States)

    Martino, Steven C; Kanouse, David E; Miranda, David J; Elliott, Marc N

    2017-10-01

    To evaluate the efficacy for consumers of two potential enhancements to the Medicare Plan Finder (MPF)-a simplified data display and a "quick links" home page designed to match the specific tasks that users seek to accomplish on the MPF. Participants (N = 641) were seniors and adult caregivers of seniors who were recruited from a national online panel. Participants browsed a simulated version of the MPF, made a hypothetical plan choice, and reported on their experience. Participants were randomly assigned to one of eight conditions in a fully factorial design: 2 home pages (quick links, current MPF home page) × 2 data displays (simplified, current MPF display) × 2 plan types (stand-alone prescription drug plan [PDP], Medicare Advantage plan with prescription drug coverage [MA-PD]). The quick links page resulted in more favorable perceptions of the MPF, improved users' understanding of the information, and increased the probability of choosing the objectively best plan. The simplified data display resulted in a more favorable evaluation of the website, better comprehension of the displayed information, and, among those choosing a PDP only, an increased probability of choosing the best plan. Design enhancements could markedly improve average website users' understanding, ability to use, and experience of using the MPF. © Health Research and Educational Trust.

  17. Medicare incentive payments for meaningful use of electronic health records: accounting and reporting developments.

    Science.gov (United States)

    2012-02-01

    The Healthcare Financial Management Association through its Principles and Practices (P&P) Board publishes issue analyses to provide short-term practical assistance on emerging issues in healthcare financial management. In a new issue analysis excerpted in this article, HFMA's P&P Board provides some clarity to the healthcare industry on certain accounting and reporting issues resulting from incentive payments under the Medicare program for the meaningful use of electronic health record (EHR) technology. Consultation on these matters with independent auditors is highly recommended.

  18. Medicare capitation model, functional status, and multiple comorbidities: model accuracy

    Science.gov (United States)

    Noyes, Katia; Liu, Hangsheng; Temkin-Greener, Helena

    2012-01-01

    Objective This study examined financial implications of CMS-Hierarchical Condition Categories (HCC) risk-adjustment model on Medicare payments for individuals with comorbid chronic conditions. Study Design The study used 1992-2000 data from the Medicare Current Beneficiary Survey and corresponding Medicare claims. The pairs of comorbidities were formed based on the prior evidence about possible synergy between these conditions and activities of daily living (ADL) deficiencies and included heart disease and cancer, lung disease and cancer, stroke and hypertension, stroke and arthritis, congestive heart failure (CHF) and osteoporosis, diabetes and coronary artery disease, CHF and dementia. Methods For each beneficiary, we calculated the actual Medicare cost ratio as the ratio of the individual’s annualized costs to the mean annual Medicare cost of all people in the study. The actual Medicare cost ratios, by ADLs, were compared to the HCC ratios under the CMS-HCC payment model. Using multivariate regression models, we tested whether having the identified pairs of comorbidities affects the accuracy of CMS-HCC model predictions. Results The CMS-HCC model underpredicted Medicare capitation payments for patients with hypertension, lung disease, congestive heart failure and dementia. The difference between the actual costs and predicted payments was partially explained by beneficiary functional status and less than optimal adjustment for these chronic conditions. Conclusions Information about beneficiary functional status should be incorporated in reimbursement models since underpaying providers for caring for population with multiple comorbidities may provide severe disincentives for managed care plans to enroll such individuals and to appropriately manage their complex and costly conditions. PMID:18837646

  19. 76 FR 19655 - Medicare Program; Waiver Designs in Connection With the Medicare Shared Savings Program and the...

    Science.gov (United States)

    2011-04-07

    ...) of the Social Security Act (of the Act), as added by the Affordable Care Act (ACA) authorizes the Secretary to waive certain fraud and abuse laws as necessary to carry out the provisions of section 1899 of... Secretary to waive the same fraud and abuse laws, among others, as necessary solely for the purposes of...

  20. Medicare program; update of ratesetting methodology, payment rates, payment policies, and the list of covered procedures for ambulatory surgical centers effective October 1, 1998; reopening of comment period and delay in adoption of the proposed rule as final--HCFA. Notice of reopening of comment period for proposed rule and delay in adoption of provisions of the proposed rule as final.

    Science.gov (United States)

    1998-10-01

    This notice reopens the comment period for a proposed rule affecting Medicare payments to ambulatory surgical centers (ASCs) that was originally published in the Federal Register on June 12, 1998 (63 FR 32290). This document gives notice of a delay in the adoption of the provisions of the June 12, 1998 ASC proposed rule as a final rule to be concurrent with the adoption as final of the hospital outpatient prospective payment system (PPS) that is the subject of a proposed rule published in the Federal Register on September 8, 1998 (63 FR 47551). In addition this document confirms that the current ASC payment rates that are effective for services furnished on or after October 1, 1998, will remain in effect until rebased ASC rates and the provisions of the June 12, 1998 ASC proposed rule are adopted as final to be concurrent with the adoption as final of the Medicare hospital PPS.