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Sample records for high medicare payer

  1. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    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...

  2. Bundled payment reimbursement for anterior and posterior approaches for cervical spondylotic myelopathy: an analysis of private payer and Medicare databases.

    Virk, Sohrab S; Phillips, Frank M; Khan, Safdar N

    2018-03-01

    OBJECTIVE Cervical spondylotic myelopathy (CSM) is a progressive spinal condition that often requires surgery. Studies have shown the clinical equivalency of anterior versus posterior approaches for CSM surgery. The purpose of this study was to determine the amount and type of resources used for anterior and posterior surgical treatment of CSM by using large national databases of clinical and financial information from patients. METHODS This study consists of 2 large cohorts of patients who underwent either an anterior or posterior approach for treatment of CSM. These patients were selected from the Medicare 5% National Sample Administrative Database (SAF5) and the Humana orthopedic database (HORTHO), which is a database of patients with private payer health insurance. The outcome measures were the cost of a 90-day episode of care, as well as a breakdown of the cost components for each surgical procedure between 2005 and 2014. RESULTS A total of 16,444 patients were included in this analysis. In HORTHO, there were 10,332 and 1556 patients treated with an anterior or posterior approach for CSM, respectively. In SAF5, there were 3851 and 705 patients who were treated by an anterior or posterior approach for CSM, respectively. The mean ± SD reimbursements for anterior and posterior approaches in the HORTHO database were $20,863 ± $2014 and $23,813 ± $4258, respectively (p = 0.048). The mean ± SD reimbursements for anterior and posterior approaches in the SAF5 database were $18,219 ± $1053 and $25,598 ± $1686, respectively (p reimbursements for a rehabilitation/skilled nursing facility and hospital/inpatient care for patients who underwent a posterior approach in both the private payer and Medicare databases. In all cohorts in this study, the hospital-related reimbursement was more than double the surgeon-related reimbursement. CONCLUSIONS This study provides resource utilization information for a 90-day episode of care for both anterior and posterior approaches

  3. Hospital revenue cycle management and payer mix: do Medicare and Medicaid undermine hospitals' ability to generate and collect patient care revenue?

    Rauscher, Simone; Wheeler, John R C

    2010-01-01

    The continuing efforts of government payers to contain hospital costs have raised concerns among hospital managers that serving publicly insured patients may undermine their ability to manage the revenue cycle successfully. This study uses financial information from two sources-Medicare cost reports for all US hospitals for 2002 to 2007 and audited financial statements for all bond-issuing, not-for-profit hospitals for 2000 to 2006 to examine the relationship between hospitals' shares of Medicare and Medicaid patients and the amount of patient care revenue they generate as well as the speed with which they collect their revenue. Hospital-level fixed effects regression analysis finds that hospitals with higher Medicare and Medicaid payer mix collect somewhat higher average patient care revenues than hospitals with more privately insured and self-pay patients. Hospitals with more Medicare patients also collect on this revenue faster; serving more Medicaid patients is not associated with the speed of patient revenue collection. For hospital managers, these findings may represent good news. They suggest that, despite increases in the number of publicly insured patients served, managers have frequently been able to generate adequate amounts of patient revenue and collect it in a timely fashion.

  4. Medicare

    ... 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 ...

  5. Medicare

    ... 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 ...

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

    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.

  7. Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries.

    Goldstein, Jennifer N; Zhang, Zugui; Schwartz, J Sanford; Hicks, LeRoi S

    2018-01-01

    Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries. We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated. After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24). Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability. Copyright © 2018 Elsevier Inc. All rights reserved.

  8. The Budget Impact of Including Necitumumab on the Formulary for First-Line Treatment of Metastatic Squamous Non-Small Cell Lung Cancer: U.S. Commercial Payer and Medicare Perspectives.

    Bly, Christopher A; Molife, Cliff; Brown, Jacqueline; Tawney, Mahesh K; Carter, Gebra Cuyun; Cinfio, Frank N; Klein, Robert W

    2018-06-01

    Necitumumab (Neci) was the first biologic approved by the FDA for use in combination with gemcitabine and cisplatin (Neci + GCis) in first-line treatment of metastatic squamous non-small cell lung cancer (msqNSCLC). The potential financial impact on a health plan of adding Neci + GCis to drug formularies may be important to value-based decision makers in the United States, given ever-tightening budget constraints. To estimate the budget impact of introducing Neci + GCis for first-line treatment of msqNSCLC from U.S. commercial and Medicare payer perspectives. The budget impact model estimates the costs of msqNSCLC before and after adoption of Neci + GCis in hypothetical U.S. commercial and Medicare health plans over a 3-year time horizon. The eligible patient population was estimated from U.S. epidemiology statistics. Clinical data were obtained from randomized clinical trials, U.S. prescribing information, and clinical guidelines. Market share projections were based on market research data. Cost data were obtained from online sources and published literature. The incremental aggregate annual health plan, per-patient-per-year (PPPY), and per-member-per-month (PMPM) costs were estimated in 2015 U.S. dollars. One-way sensitivity analyses were conducted to assess the effect of model parameters on results. In a hypothetical 1,000,000-member commercial health plan with an estimated population of 30 msqNSCLC patients receiving first-line chemotherapy, the introduction of Neci + GCis at an initial market share of approximately 5% had an overall year 1 incremental budget impact of $88,394 ($3,177 PPPY, $0.007 PMPM), representing a 2.9% cost increase and reaching $304,079 ($10,397 PPPY, $0.025 PMPM) or a 7.4% cost increase at a market share of 14.7% in year 3. This increase in total costs was largely attributable to Neci drug costs and, in part, due to longer survival and treatment duration for patients treated with Neci+GCis. Overall, treatment costs increased by $81

  9. Stated and Revealed Preferences for Funding New High-Cost Cancer Drugs: A Critical Review of the Evidence from Patients, the Public and Payers.

    MacLeod, Tatjana E; Harris, Anthony H; Mahal, Ajay

    2016-06-01

    The growing focus on patient-centred care has encouraged the inclusion of patient and public input into payer drug reimbursement decisions. Yet, little is known about patient/public priorities for funding high-cost medicines, and how they compare to payer priorities applied in public funding decisions for new cancer drugs. The aim was to identify and compare the funding preferences of cancer patients and the general public against the criteria used by payers making cancer drug funding decisions. A thorough review of the empirical, peer-reviewed English literature was conducted. Information sources were PubMed, EMBASE, MEDLINE, Web of Science, Business Source Complete, and EconLit. Eligible studies (1) assessed the cancer drug funding preferences of patients, the general public or payers, (2) had pre-defined measures of funding preference, and (3) had outcomes with attributes or measures of 'value'. The quality of included studies was evaluated using a health technology assessment-based assessment tool, followed by extraction of general study characteristics and funding preferences, which were categorized using an established WHO-based framework. Twenty-five preference studies were retrieved (11 quantitative, seven qualitative, seven mixed-methods). Most studies were published from 2005 onward, with the oldest dating back to 1997. Two studies evaluated both patient and public perspectives, giving 27 total funding perspectives (41 % payer, 33 % public, 26 % patients). Of 41 identified funding criteria, payers consider the most (35), the general public considers fewer (23), and patients consider the fewest (12). We identify four unique patient criteria: financial protection, access to medical information, autonomy in treatment decision making, and the 'value of hope'. Sixteen countries/jurisdictions were represented. Our results suggest that (1) payers prioritize efficiency (health gains per dollar), while citizens (patients and the general public) prioritize

  10. Negotiating with payers.

    Kaufman, Joel M

    2010-05-01

    Negotiating with payers for better reimbursement, contract language, support for practice enhancement, or changes in policies and procedures is a critical function that may greatly enhance a practice's success over time. This article discusses keys to successful negotiating and several specific areas beyond reimbursement that deserve the reader's attention. Copyright 2010 Elsevier Inc. All rights reserved.

  11. State Policies Influence Medicare Telemedicine Utilization.

    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

  12. Differences in Hospital Readmission Risk across All Payer Groups in South Carolina.

    Chakraborty, Hrishikesh; Axon, Robert Neal; Brittingham, Jordan; Lyons, Genevieve Ray; Cole, Laura; Turley, Christine B

    2017-06-01

    To evaluate differences in hospital readmission risk across all payers in South Carolina (SC). South Carolina Revenue and Fiscal Affairs Office (SCRFA) statewide all payer claims database including 2,476,431 hospitalizations in SC acute care hospitals between 2008 and 2014. We compared the odds of unplanned all-cause 30-day readmission for private insurance, Medicare, Medicaid, uninsured, and other payers and examined interaction effects between payer and index admission characteristics using generalized estimating equations. SCRFA receives claims and administrative health care data from all SC health care facilities in accordance with SC state law. Odds of readmission were lower for females compared to males in private, Medicare, and Medicaid payers. African Americans had higher odds of readmission compared to whites across private insurance, Medicare, and Medicaid, but they had lower odds among the uninsured. Longer length of stay had the strongest association with readmission for private and other payers, whereas an increased number of comorbidities related to the highest readmission odds within Medicaid. Associations between index admission characteristics and readmission likelihood varied significantly with payer. Findings should guide the development of payer-specific quality improvement programs. © Health Research and Educational Trust.

  13. UnitedHealthcare experience illustrates how payers can enable patient engagement.

    Sandy, Lewis G; Tuckson, Reed V; Stevens, Simon L

    2013-08-01

    Patient engagement is crucial to better outcomes and a high-performing health system, but efforts to support it often focus narrowly on the role of physicians and other care providers. Such efforts miss payers' unique capabilities to help patients achieve better health. Using the experience of UnitedHealthcare, a large national payer, this article demonstrates how health plans can analyze and present information to both patients and providers to help close gaps in care; share detailed quality and cost information to inform patients' choice of providers; and offer treatment decision support and value-based benefit designs to help guide choices of diagnostic tests and therapies. As an employer, UnitedHealth Group has used these strategies along with an "earn-back" program that provides positive financial incentives through reduced premiums to employees who adopt healthful habits. UnitedHealth's experience provides lessons for other payers and for Medicare and Medicaid, which have had minimal involvement with demand-side strategies and could benefit from efforts to promote activated beneficiaries.

  14. Offering lung cancer screening to high-risk medicare beneficiaries saves lives and is cost-effective: an actuarial analysis.

    Pyenson, Bruce S; Henschke, Claudia I; Yankelevitz, David F; Yip, Rowena; Dec, Ellynne

    2014-08-01

    By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening. To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer. Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures. Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life-year saved. If all eligible Medicare

  15. Estimated burden of cardiovascular disease and value-based price range for evolocumab in a high-risk, secondary-prevention population in the US payer context.

    Toth, Peter P; Danese, Mark; Villa, Guillermo; Qian, Yi; Beaubrun, Anne; Lira, Armando; Jansen, Jeroen P

    2017-06-01

    To estimate real-world cardiovascular disease (CVD) burden and value-based price range of evolocumab for a US-context, high-risk, secondary-prevention population. Burden of CVD was assessed using the UK-based Clinical Practice Research Datalink (CPRD) in order to capture complete CV burden including CV mortality. Patients on standard of care (SOC; high-intensity statins) in CPRD were selected based on eligibility criteria of FOURIER, a phase 3 CV outcomes trial of evolocumab, and categorized into four cohorts: high-risk prevalent atherosclerotic CVD (ASCVD) cohort (n = 1448), acute coronary syndrome (ACS) (n = 602), ischemic stroke (IS) (n = 151), and heart failure (HF) (n = 291) incident cohorts. The value-based price range for evolocumab was assessed using a previously published economic model. The model incorporated CPRD CV event rates and considered CV event reduction rate ratios per 1 mmol/L reduction in low-density lipoprotein-cholesterol (LDL-C) from a meta-analysis of statin trials by the Cholesterol Treatment Trialists Collaboration (CTTC), i.e. CTTC relationship. Multiple-event rates of composite CV events (ACS, IS, or coronary revascularization) per 100 patient-years were 12.3 for the high-risk prevalent ASCVD cohort, and 25.7, 13.3, and 23.3, respectively, for incident ACS, IS, and HF cohorts. Approximately one-half (42%) of the high-risk ASCVD patients with a new CV event during follow-up had a subsequent CV event. Combining these real-world event rates and the CTTC relationship in the economic model, the value-based price range (credible interval) under a willingness-to-pay threshold of $150,000/quality-adjusted life-year gained for evolocumab was $11,990 ($9,341-$14,833) to $16,856 ($12,903-$20,678) in ASCVD patients with baseline LDL-C levels ≥70 mg/dL and ≥100 mg/dL, respectively. Real-world CVD burden is substantial. Using the observed CVD burden in CPRD and the CTTC relationship, the cost-effectiveness analysis showed

  16. Prospects of Single Tax Payers

    Tofan Ivan M.

    2014-03-01

    Full Text Available The article speaks about problem aspects of taxation, which were set by the state for the single tax administering due to permanent and system changes in the tax legislation. It shows the necessity of search for alternative methods of administering in the process of taxation of single tax payers by fiscal services. The goal of the article is the study of prospects of further taxation of entrepreneurs – single tax payers on the basis of analysis of conditions and principles created by the state for the business. The article used methods of system analysis, comparison, forecasting and modelling. It analyses the process of evolution of the simplified taxation system, accounting and reporting from the moment of its adoption until today. The article presents the structure of the quantitative composition of single tax payers depending on the selected groups. It marks out and characterises administrative and fiscal factors that do not facilitate further development of entrepreneurship in Ukraine. In the result of the conducted studies the article outlines problem aspects of organisation of taxation of the small business and offers specific and real ways of their overcoming or partial solution.

  17. Individualizing Medicare.

    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.

  18. Cost of transfusion-dependent myelodysplastic syndrome (MDS) from a German payer?s perspective

    2010-01-01

    Abstract No curative treatment exists for patients with myelodysplastic syndrome (MDS) besides allogeneic stem cell transplantation. Hence, palliative treatment is provided for a life time accruing high health care cost. As no study in cost of MDS exists in Germany, the objective of this study was to assess and analyze costs of transfusion-dependent low/intermediate-1-risk MDS in Germany from a payers? perspective. From seven centers, 116 low/intermediate-1-risk transfusion-depende...

  19. Innovative care models for high-cost Medicare beneficiaries: delivery system and payment reform to accelerate adoption.

    Davis, Karen; Buttorff, Christine; Leff, Bruce; Samus, Quincy M; Szanton, Sarah; Wolff, Jennifer L; Bandeali, Farhan

    2015-05-01

    About a third of Medicare beneficiaries are covered by Medicare Advantage (MA) plans or accountable care organizations (ACOs). As a result of assuming financial risk for Medicare services and/or being eligible for shared savings, these organizations have an incentive to adopt models of delivering care that contribute to better care, improved health outcomes, and lower cost. This paper identifies innovative care models across the care continuum for high-cost Medicare beneficiaries that MA plans and ACOs could adopt to improve care while potentially achieving savings. It suggests policy changes that would accelerate testing and spread of promising care delivery model innovations. Targeted review of the literature to identify care delivery models focused on high-cost or high-risk Medicare beneficiaries. This paper presents select delivery models for high-risk Medicare beneficiaries across the care continuum that show promise of yielding better care at lower cost that could be considered for adoption by MA plans and ACOs. Common to these models are elements of the Wagner Chronic Care Model, including practice redesign to incorporate a team approach to care, the inclusion of nonmedical personnel, efforts to promote patient engagement, supporting provider education on innovations,and information systems allowing feedback of information to providers. The goal of these models is to slow the progression to long-term care, reduce health risks, and minimize adverse health impacts, all while achieving savings.These models attempt to maintain the ability of high-risk individuals to live in the home or a community-based setting, thereby avoiding costly institutional care. Identifying and implementing promising care delivery models will become increasingly important in launching successful population health initiatives. MA plans and ACOs stand to benefit financially from adopting care delivery models for high-risk Medicare beneficiaries that reduce hospitalization. Spreading

  20. Payer leverage and hospital compliance with a benchmark: a population-based observational study

    DeMonner Sonya

    2007-07-01

    Full Text Available Abstract Background Since 1976, Medicare has linked reimbursement for hospitals performing organ transplants to the attainment of certain benchmarks, including transplant volume. While Medicare is a stakeholder in all transplant services, its role in renal transplantation is likely greater, given its coverage of end-stage renal disease. Thus, Medicare's transplant experience allows us to examine the role of payer leverage in motivating hospital benchmark compliance. Methods Nationally representative discharge data for kidney (n = 29,272, liver (n = 7,988, heart (n = 3,530, and lung (n = 1,880 transplants from the Nationwide Inpatient Sample (1993 – 2003 were employed. Logistic regression techniques with robust variance estimators were used to examine the relationship between hospital volume compliance and Medicare market share; generalized estimating equations were used to explore the association between patient-level operative mortality and hospital volume compliance. Results Medicare's transplant market share varied by organ [57%, 28%, 27%, and 18% for kidney, lung, heart, and liver transplants, respectively (P P Conclusion These data highlight the influence of payer leverage–an important contextual factor in value-based purchasing initiatives. For uncommon diagnoses, these data suggest that at least 30% of a provider's patients might need to be "at risk" for an incentive to motivate compliance.

  1. 78 FR 78802 - Medicare Program; Right of Appeal for Medicare Secondary Payer Determination Relating to...

    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...

  2. Does good medication adherence really save payers money?

    Stuart, Bruce C; Dai, Mingliang; Xu, Jing; Loh, Feng-Hua E; S Dougherty, Julia

    2015-06-01

    Despite a growing consensus that better adherence with evidence-based medications can save payers money, assertions of cost offsets may be incomplete if they fail to consider additional drug costs and/or are biased by healthy adherer behaviors unobserved in typical medical claims-based analyses. The objective of this study was to determine whether controlling for healthy adherer bias (HAB) materially affected estimated medical cost offsets and additional drug spending associated with higher adherence. A total of 1273 Medicare beneficiaries with diabetes enrolled in Part D plans between 2006 and 2009. Using survey and claims data from the Medicare Current Beneficiary Survey, we measured medical and drug costs associated with good and poor adherence (proportion of days covered ≥ 80% and <80%, respectively) to oral antidiabetic drugs, ACE inhibitors/ARBs, and statins over 2 years. To test for HAB, we estimated pairs of regression models, one set containing variables typically controlled for in conventional claims analysis and a second set with survey-based variables selected to capture HAB effects. We found consistent evidence that controlling for HAB reduces estimated savings in medical costs from better adherence, and likewise, reduces estimates of additional adherence-related drug spending. For ACE inhibitors/ARBs we estimate that controlling for HAB reduced adherence-related medical cost offsets from $6389 to $4920 per person (P<0.05). Estimates of additional adherence-related drug costs were 26% and 14% lower in HAB-controlled models (P < 0.05). These results buttress the economic case for action by health care payers to improve medication adherence among insured persons with chronic disease. However, given the limitations of our research design, further research on larger samples with other disease states is clearly warranted.

  3. Better Patient Care At High-Quality Hospitals May Save Medicare Money And Bolster Episode-Based Payment Models.

    Tsai, Thomas C; Greaves, Felix; Zheng, Jie; Orav, E John; Zinner, Michael J; Jha, Ashish K

    2016-09-01

    US policy makers are making efforts to simultaneously improve the quality of and reduce spending on health care through alternative payment models such as bundled payment. Bundled payment models are predicated on the theory that aligning financial incentives for all providers across an episode of care will lower health care spending while improving quality. Whether this is true remains unknown. Using national Medicare fee-for-service claims for the period 2011-12 and data on hospital quality, we evaluated how thirty- and ninety-day episode-based spending were related to two validated measures of surgical quality-patient satisfaction and surgical mortality. We found that patients who had major surgery at high-quality hospitals cost Medicare less than those who had surgery at low-quality institutions, for both thirty- and ninety-day periods. The difference in Medicare spending between low- and high-quality hospitals was driven primarily by postacute care, which accounted for 59.5 percent of the difference in thirty-day episode spending, and readmissions, which accounted for 19.9 percent. These findings suggest that efforts to achieve value through bundled payment should focus on improving care at low-quality hospitals and reducing unnecessary use of postacute care. Project HOPE—The People-to-People Health Foundation, Inc.

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

    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.

  5. Adaptive Pathways: Possible Next Steps for Payers in Preparation for Their Potential Implementation

    Vella Bonanno, Patricia; Ermisch, Michael; Godman, Brian; Martin, Antony P.; Van Den Bergh, Jesper; Bezmelnitsyna, Liudmila; Bucsics, Anna; Arickx, Francis; Bybau, Alexander; Bochenek, Tomasz; van de Casteele, Marc; Diogene, Eduardo; Eriksson, Irene; Fürst, Jurij; Gad, Mohamed; Greičiūtė-Kuprijanov, Ieva; van der Graaff, Martin; Gulbinovic, Jolanta; Jones, Jan; Joppi, Roberta; Kalaba, Marija; Laius, Ott; Langner, Irene; Mardare, Ileana; Markovic-Pekovic, Vanda; Magnusson, Einar; Melien, Oyvind; Meshkov, Dmitry O.; Petrova, Guenka I.; Selke, Gisbert; Sermet, Catherine; Simoens, Steven; Schuurman, Ad; Ramos, Ricardo; Rodrigues, Jorge; Zara, Corinne; Zebedin-Brandl, Eva; Haycox, Alan

    2017-01-01

    Medicines receiving a conditional marketing authorization through Medicines Adaptive Pathways to Patients (MAPPs) will be a challenge for payers. The “introduction” of MAPPs is already seen by the European Medicines Agency (EMA) as a fait accompli, with payers not consulted or involved. However, once medicines are approved through MAPPs, they will be evaluated for funding by payers through different activities. These include Health Technology Assessment (HTA) with often immature clinical data and high uncertainty, financial considerations, and negotiations through different types of agreements, which can require monitoring post launch. Payers have experience with new medicines approved through conditional approval, and the fact that MAPPs present additional challenges is a concern from their perspective. There may be some activities where payers can collaborate. The final decisions on whether to reimburse a new medicine via MAPPs will have more variation than for medicines licensed via conventional processes. This is due not only to increasing uncertainty associated with medicines authorized through MAPPs but also differences in legal frameworks between member states. Moreover, if the financial and side-effect burden from the period of conditional approval until granting full marketing authorization is shifted to the post-authorization phase, payers may have to bear such burdens. Collection of robust data during routine clinical use is challenging along with high prices for new medicines during data collection. This paper presents the concept of MAPPs and possible challenges. Concerns and potential ways forward are discussed and a number of recommendations are presented from the perspective of payers. PMID:28878667

  6. Adaptive Pathways: Possible Next Steps for Payers in Preparation for Their Potential Implementation.

    Vella Bonanno, Patricia; Ermisch, Michael; Godman, Brian; Martin, Antony P; Van Den Bergh, Jesper; Bezmelnitsyna, Liudmila; Bucsics, Anna; Arickx, Francis; Bybau, Alexander; Bochenek, Tomasz; van de Casteele, Marc; Diogene, Eduardo; Eriksson, Irene; Fürst, Jurij; Gad, Mohamed; Greičiūtė-Kuprijanov, Ieva; van der Graaff, Martin; Gulbinovic, Jolanta; Jones, Jan; Joppi, Roberta; Kalaba, Marija; Laius, Ott; Langner, Irene; Mardare, Ileana; Markovic-Pekovic, Vanda; Magnusson, Einar; Melien, Oyvind; Meshkov, Dmitry O; Petrova, Guenka I; Selke, Gisbert; Sermet, Catherine; Simoens, Steven; Schuurman, Ad; Ramos, Ricardo; Rodrigues, Jorge; Zara, Corinne; Zebedin-Brandl, Eva; Haycox, Alan

    2017-01-01

    Medicines receiving a conditional marketing authorization through Medicines Adaptive Pathways to Patients (MAPPs) will be a challenge for payers. The "introduction" of MAPPs is already seen by the European Medicines Agency (EMA) as a fait accompli, with payers not consulted or involved. However, once medicines are approved through MAPPs, they will be evaluated for funding by payers through different activities. These include Health Technology Assessment (HTA) with often immature clinical data and high uncertainty, financial considerations, and negotiations through different types of agreements, which can require monitoring post launch. Payers have experience with new medicines approved through conditional approval, and the fact that MAPPs present additional challenges is a concern from their perspective. There may be some activities where payers can collaborate. The final decisions on whether to reimburse a new medicine via MAPPs will have more variation than for medicines licensed via conventional processes. This is due not only to increasing uncertainty associated with medicines authorized through MAPPs but also differences in legal frameworks between member states. Moreover, if the financial and side-effect burden from the period of conditional approval until granting full marketing authorization is shifted to the post-authorization phase, payers may have to bear such burdens. Collection of robust data during routine clinical use is challenging along with high prices for new medicines during data collection. This paper presents the concept of MAPPs and possible challenges. Concerns and potential ways forward are discussed and a number of recommendations are presented from the perspective of payers.

  7. WHY DO AMERICANS STILL NEED SINGLE-PAYER HEALTH CARE AFTER MAJOR HEALTH REFORM?

    Chaufan, Claudia

    2015-01-01

    Many observers have considered the Affordable Care Act (ACA) the most significant health care overhaul since Medicare, in the tradition of Great Society programs. And yet, in opinion polls, Americans across the political spectrum repeatedly express their strong support for Medicare, alongside their disapproval of the ACA. This feature of American public opinion is often seen as a contradiction and often explained as "incoherence," a mere feature of Americans' "muddled mind." In this article I argue that what explains this seeming contradiction is not any peculiarity of Americans' psychology but rather the grip of the corporate class on the political process and on key social institutions (e.g., mass media, judiciary), no less extraordinary today than in the past. I also argue that ordinary Americans, like millions of their counterparts in the world, would eagerly support a single-payer national health program that speaks to their interests rather than to those of the 1 percent. I will describe the ACA, compare it to Medicare, explain the concept of single payer, and conclude that the task is not to persuade presumably recalcitrant Americans to support the ACA but rather to organize a mass movement to struggle for what is right and join the rest of the world in the road toward health justice.

  8. Health Spending By State 1991-2014: Measuring Per Capita Spending By Payers And Programs.

    Lassman, David; Sisko, Andrea M; Catlin, Aaron; Barron, Mary Carol; Benson, Joseph; Cuckler, Gigi A; Hartman, Micah; Martin, Anne B; Whittle, Lekha

    2017-07-01

    As the US health sector evolves and changes, it is informative to estimate and analyze health spending trends at the state level. These estimates, which provide information about consumption of health care by residents of a state, serve as a baseline for state and national-level policy discussions. This study examines per capita health spending by state of residence and per enrollee spending for the three largest payers (Medicare, Medicaid, and private health insurance) through 2014. Moreover, it discusses in detail the impacts of the Affordable Care Act implementation and the most recent economic recession and recovery on health spending at the state level. According to this analysis, these factors affected overall annual growth in state health spending and the payers and programs that paid for that care. They did not, however, substantially change state rankings based on per capita spending levels over the period. Project HOPE—The People-to-People Health Foundation, Inc.

  9. How Successful Is Medicare Advantage?

    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

  10. Payer source influence on effectiveness of lifestyle medicine programs.

    Vogelgesang, Joseph; Drozek, David; Nakazawa, Masato; Shubrook, Jay H

    2015-09-01

    Many chronic diseases are responsive to interventions focused on diet and physical activity. The Complete Health Improvement Program (CHIP) is an intensive, community-based lifestyle intervention that effectively treats many chronic diseases and their risk factors. This is a pilot study examining the effect of payer source for CHIP tuition on participants' outcomes. Seventy-nine self-selected participants (73.4% female) attended 1 of 3 CHIP classes (classes 7-9) offered January through May 2013 in Athens, Ohio. Participants were categorized into 3 groups based on the source(s) of their tuition payment: self-pay, employer-pay, or scholarship. Chronic disease risk factors for each individual were assessed at the beginning and conclusion of the program. Outcome variables included percent reduction between pre- and post CHIP measures in body mass index, systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and fasting blood glucose. Results were compared between type of payer source (out of pocket vs employer and/or scholarship) and between each individual CHIP class attended. There was no statistical difference in outcomes based on payer source. Those who received funding through their employer or a scholarship experienced similar effects from a lifestyle intervention program as those who paid out of pocket. This study demonstrates that the benefit of CHIP for reducing chronic disease risk factors exists independent of payment source, and thus suggests its benefit may cross socioeconomic lines.

  11. Did recent changes in Medicare reimbursement hit teaching hospitals harder?

    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.

  12. Medicare Appeals Council Decisions

    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...

  13. Medicare Hospice Benefits

    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 ...

  14. How well does a single question about health predict the financial health of Medicare managed care plans?

    Bierman, A S; Bubolz, T A; Fisher, E S; Wasson, J H

    1999-01-01

    Responses to simple questions that predict subsequent health care utilization are of interest to both capitated health plans and the payer. To determine how responses to a single question about general health status predict subsequent health care expenditures. Participants in the 1992 Medicare Current Beneficiary Survey were asked the following question: "In general, compared to other people your age, would you say your health is: excellent, very good, good, fair or poor?" To obtain each participant's total Medicare expenditures and number of hospitalizations in the ensuing year, we linked the responses to this question with data from the 1993 Medicare Continuous History Survey. Nationally representative sample of 8775 noninstitutionalized Medicare beneficiaries 65 years of age and older. Annual age- and sex-adjusted Medicare expenditures and hospitalization rates. Eighteen percent of the beneficiaries rated their health as excellent, 56% rated it as very good or good, 17% rated it as fair, and 7% rated it as poor. Medicare expenditures had a marked inverse relation to self-assessed health ratings. In the year after assessment, age- and sex-adjusted annual expenditures varied fivefold, from $8743 for beneficiaries rating their health as poor to $1656 for beneficiaries rating their health as excellent. Hospitalization rates followed the same pattern: Respondents who rated their health as poor had 675 hospitalizations per 1000 beneficiaries per year compared with 136 per 1000 for those rating their health as excellent. The response to a single question about general health status strongly predicts subsequent health care utilization. Self-reports of fair or poor health identify a group of high-risk patients who may benefit from targeted interventions. Because the current Medicare capitation formula does not account for health status, health plans can maximize profits by disproportionately enrolling beneficiaries who judge their health to be good. However, they are at

  15. 42 CFR 411.22 - Reimbursement obligations of primary payers and entities that received payment from primary payers.

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Reimbursement obligations of primary payers and... Provisions § 411.22 Reimbursement obligations of primary payers and entities that received payment from... reimburse CMS for any payment if it is demonstrated that the primary payer has or had a responsibility to...

  16. Differences in the rates of patient safety events by payer: implications for providers and policymakers.

    Spencer, Christine S; Roberts, Eric T; Gaskin, Darrell J

    2015-06-01

    The reduction of adverse patient safety events and the equitable treatment of patients in hospitals are clinical and policy priorities. Health services researchers have identified disparities in the quality of care provided to patients, both by demographic characteristics and insurance status. However, less is known about the extent to which disparities reflect differences in the places where patients obtain care, versus disparities in the quality of care provided to different groups of patients in the same hospital. In this study, we examine whether the rate of adverse patient safety events differs by the insurance status of patients within the same hospital. Using discharge data from hospitals in 11 states, we compared risk-adjusted rates for 13 AHRQ Patient Safety Indicators by Medicare, Medicaid, and Private payer insurance status, within the same hospitals. We used multivariate regression to assess the relationship between insurance status and rates of adverse patient safety events within hospitals. Medicare and Medicaid patients experienced significantly more adverse safety events than private pay patients for 12 and 7 Patient Safety Indicators, respectively (at P patients had significantly lower event rates than private payers on 2 Patient Safety Indicators. Risk-adjusted Patient Safety Indicator rates varied with patients' insurance within the same hospital. More research is needed to determine the cause of differences in care quality received by patients at the same hospital, especially if quality measures are to be used for payment.

  17. A payer-provider partnership for integrated care of patients receiving dialysis.

    Kindy, Justin; Roer, David; Wanovich, Robert; McMurray, Stephen

    2018-04-01

    Patients with end-stage renal disease (ESRD) are clinically complex, requiring intensive and costly care. Coordinated care may improve outcomes and reduce costs. The objective of this study was to determine the impact of a payer-provider care partnership on key clinical and economic outcomes in enrolled patients with ESRD.  Retrospective observational study. Data on patient demographics and clinical outcomes were abstracted from the electronic health records of the dialysis provider. Data on healthcare costs were collected from payer claims. Data were collected for a baseline period prior to initiation of the partnership (July 2011-June 2012) and for two 12-month periods following initiation (April 2013-March 2014 and April 2014-March 2015). Among both Medicare Advantage and commercial insurance program members, the rate of central venous catheter use for vascular access was lower following initiation of the partnership compared with the baseline period. Likewise, hospital admission rates, emergency department visit rates, and readmission rates were lower following partnership initiation. Rates of influenza and pneumococcal vaccination were higher than 95% throughout all 3 time periods. Total medical costs were lower for both cohorts of members in the second 12-month period following partnership initiation compared with the baseline period. Promising trends were observed among members participating in this payer-provider care partnership with respect to both clinical and economic outcomes. This suggests that collaborations with shared incentives may be a valuable approach for patients with ESRD.

  18. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance.

    Woolhandler, Steffie; Himmelstein, David U; Angell, Marcia; Young, Quentin D

    2003-08-13

    The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care--the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least 200 billion dollars annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program

  19. Adaptive Pathways: Possible Next Steps for Payers in Preparation for Their Potential Implementation

    Patricia Vella Bonanno

    2017-08-01

    Full Text Available Medicines receiving a conditional marketing authorization through Medicines Adaptive Pathways to Patients (MAPPs will be a challenge for payers. The “introduction” of MAPPs is already seen by the European Medicines Agency (EMA as a fait accompli, with payers not consulted or involved. However, once medicines are approved through MAPPs, they will be evaluated for funding by payers through different activities. These include Health Technology Assessment (HTA with often immature clinical data and high uncertainty, financial considerations, and negotiations through different types of agreements, which can require monitoring post launch. Payers have experience with new medicines approved through conditional approval, and the fact that MAPPs present additional challenges is a concern from their perspective. There may be some activities where payers can collaborate. The final decisions on whether to reimburse a new medicine via MAPPs will have more variation than for medicines licensed via conventional processes. This is due not only to increasing uncertainty associated with medicines authorized through MAPPs but also differences in legal frameworks between member states. Moreover, if the financial and side-effect burden from the period of conditional approval until granting full marketing authorization is shifted to the post-authorization phase, payers may have to bear such burdens. Collection of robust data during routine clinical use is challenging along with high prices for new medicines during data collection. This paper presents the concept of MAPPs and possible challenges. Concerns and potential ways forward are discussed and a number of recommendations are presented from the perspective of payers.

  20. Biosimilars: How Can Payers Get Long-Term Savings?

    Mestre-Ferrandiz, Jorge; Towse, Adrian; Berdud, Mikel

    2016-06-01

    The term 'biosimilar' refers to an alternative similar version of an off-patent innovative originator biotechnology product (the 'reference product'). Several biosimilars have been approved in Europe, and a number of top-selling biological medicines have lost, or will lose, patent protection over the next 5 years. We look at the experience in Europe so far. The USA has finally implemented a regulatory route for biosimilar approval. We recommend that European and US governments and payers take a strategic approach to get value for money from the use of biosimilars by (1) supporting and incentivising generation of high-quality comprehensive outcomes data on the effectiveness and safety of biosimilars and originator products; and (2) ensuring that incentives are in place for budget holders to benefit from price competition. This may create greater willingness on the part of budget holders and clinicians to use biosimilar and originator products with comparable outcomes interchangeably, and may drive down prices. Other options, such as direct price cuts for originator products or substitution rules without outcomes data, are likely to discourage biosimilar entry. With such approaches, governments may achieve a one-off cut in originator prices but may put at risk the creation of a more competitive market that would, in time, produce much greater savings. It was the creation of competitive markets for chemical generic drugs-notably, in the USA, the UK and Germany-rather than price control, that enabled payers to achieve the high discounts now taken for granted.

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

    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.

  2. Medicare and Rural Health

    ... 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 ...

  3. Medicare 1144 Outreach

    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...

  4. Medicare Cost Reports

    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

    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. Your Medicare Benefits

    ... 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 ...

  7. The effects of Medicare Health Management Organizations on hospital operating profit in Florida.

    Large, John T; Sear, Alan M

    2005-02-01

    Between 1992 and 1997, the number of members enrolled in Medicare Health Management Organizations (HMOs) nationwide in the USA more than doubled. During this period, managed care organizations wielded considerable influence over the health care of a large segment of the Medicare population in Florida. This study examined the impact on operational profit of 148 short-term, acute-care Florida hospitals in this period from Medicare HMO patients, as part of a hospital's payer mix. Three measures of hospital profitability were used: operating profit per actual bed, total operating profit with no adjustment for bed size, and operating margins. The multivariate statistical model employed in this study was a linear mixed model with an autoregressive order one (AR[1]) parametric structure on the covariance matrix. The results of the study indicate that Florida hospitals experienced greater profit pressures from Medicare HMO inpatients than from traditional Medicare inpatients. Further, these hospitals could have experienced positive profit effects with greater traditional Medicare participation and negative financial effects with greater Medicare HMO participation. Additionally, Medicare HMO patients appear to have been admitted to hospitals in worse health condition than those in traditional Medicare. Medicare HMO patients were more likely to have used emergency rooms as the source of admission than traditional Medicare patients. Also, Medicare HMO patients were more likely to have been admitted as emergent cases than traditional Medicare patients. Other research has shown that Medicare HMO patients, at the time of enrolment, are probably healthier than traditional Medicare enrollees, but here they appear to have been admitted to hospitals with higher levels of severity of illness. Explanations are offered for these findings.

  8. Cataract surgery among Medicare beneficiaries.

    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.

  9. Budget Impact Analysis to Estimate the Cost Dynamics of Treating Refractory Gastroesophageal Reflux Disease With Radiofrequency Energy: a Payer Perspective.

    Gregory, David; Scotti, Dennis J; Buck, Daniel; Triadafilopoulos, George

    2016-05-01

    A minimally invasive endoscopic treatment that utilizes radio-frequency energy (RFE) has received increased attention as an appropriate middle-ground approach in the treatment of refractory gastroesophageal reflux disease (GERD) and as an alternative to complicated and invasive surgical procedures. The objective of this study was to develop a longitudinal budget impact analysis from the payer perspective to estimate the direct medical costs of treatment for the refractory GERD patient population and to estimate the budgetary impact of further extending the RFE treatment option to other target populations. A retrospective analysis of claims designed to assess the longitudinal costs and budget impact on payer expenditures associated with managing and treating GERD surgically (Nissen fundoplication [NF]), endoscopically (RFE), or medically was performed. Both Medicare and commercially insured claims databases were interrogated for such population-level analyses. At current adoption rates (less than 1% of procedures), RFE demonstrated overall cost savings ranging from 7.3% to 50.5% in the 12-month time period following the index procedure (inclusive of procedure costs) when compared to medical management and fundoplication across the commercial and Medicare patient populations. Increasing the total number of RFE procedures to 2% of total cases performed generated per-member, per-month (PMPM) savings of $0.28 in the Medicare population and $0.37 in the commercially insured population. Further increases yielded higher PMPM savings. Adding to the clinical importance of RFE in filling the gap between medical and surgical management, this economic analysis demonstrates to payers that the adoption of RFE can create notable savings to their plans when compared to surgery or medical management.

  10. Impact of the Medicare Catastrophic Coverage Act on nursing homes.

    Laliberte, L; Mor, V; Berg, K; Intrator, O; Calore, K; Hiris, J

    1997-01-01

    The Medicare Catastrophic Coverage Act (MCCA) of 1988 altered eligibility and coverage for skilled nursing facility (SNF) care and changed Medicaid eligibility rules for nursing-home residents. Detailed data on the residents of a for-profit nursing-home chain and Medicare claims for a 1 percent sample of beneficiaries were used to examine the impact of the MCCA on nursing homes. The case mix of nursing-home admissions was scrutinized, specifically for length of stay, discharge disposition, rate of hospitalization, and changes in payer source. Findings revealed that, although the proportion of Medicare-financed nursing-home care increased, as did the case-mix severity of residents during the MCCA period, there was no corollary reduction in hospital use by nursing-home residents.

  11. Provider-Payer Partnerships as an Engine for Continuous Quality Improvement.

    Balfour, Margaret E; Zinn, Tylar E; Cason, Karena; Fox, Jerimya; Morales, Myra; Berdeja, Cesar; Gray, Jay

    2018-03-01

    The authors describe a quality improvement approach in which a crisis center and a payer collaborate to improve care. Each crisis visit is considered as a potentially missed opportunity for community stabilization. Daily data on crisis visits are sent to the payer for a more up-to-date analysis of trends than is possible with financial claims data, which may lag behind services provided by up to 90 days. Using these trend data, the two organizations collaborate to identify patterns that lead to opportunities for improvement and develop multiple rapid-cycle projects for better management of services, resulting in significant decreases in readmissions and in the number of high utilizers.

  12. Medicare payment changes and physicians' incomes.

    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.

  13. The Price Elasticity of Specialty Drug Use: Evidence from Cancer Patients in Medicare Part D.

    Jung, Jeah Kyoungrae; Feldman, Roger; McBean, A Marshall

    2017-12-01

    Specialty drugs can bring substantial benefits to patients with debilitating conditions, such as cancer, but their costs are very high. Insurers/payers have increased patient cost-sharing for specialty drugs to manage specialty drug spending. We utilized Medicare Part D plan formulary data to create the initial price (cost-sharing in the initial coverage phase in Part D), and estimated the total demand (both on- and off-label uses) for specialty cancer drugs among elderly Medicare Part D enrollees with no low-income subsidies (non-LIS) as a function of the initial price. We corrected for potential endogeneity associated with plan choice by instrumenting the initial price of specialty cancer drugs with the initial prices of specialty drugs in unrelated classes. We report three findings. First, we found that elderly non-LIS beneficiaries with cancer were less likely to use a Part D specialty cancer drug when the initial price was high: the overall price elasticity of specialty cancer drug spending ranged between -0.72 and -0.75. Second, the price effect in Part D specialty cancer drug use was not significant among newly diagnosed patients. Finally, we found that use of Part B-covered cancer drugs was not responsive to the Part D specialty cancer drug price. As the demand for costly specialty drugs grows, it will be important to identify clinical circumstances where specialty drugs can be valuable and ensure access to high-value treatments.

  14. Estimated Budget Impact of Adopting the Affordable Care Act's Required Smoking Cessation Coverage on United States Healthcare Payers.

    Baker, Christine L; Ferrufino, Cheryl P; Bruno, Marianna; Kowal, Stacey

    2017-01-01

    Despite abundant information on the negative impacts of smoking, more than 40 million adult Americans continue to smoke. The Affordable Care Act (ACA) requires tobacco cessation as a preventive service with no patient cost share for all FDA-approved cessation medications. Health plans have a vital role in supporting smoking cessation by managing medication access, but uncertainty remains on the gaps between smoking cessation requirements and what is actually occurring in practice. This study presents current cessation patterns, real-world drug costs and plan benefit design data, and estimates the 1- to 5-year pharmacy budget impact of providing ACA-required coverage for smoking cessation products to understand the fiscal impact to a US healthcare plan. A closed cohort budget impact model was developed in Microsoft Excel ® to estimate current and projected costs for US payers (commercial, Medicare, Medicaid) covering smoking cessation medicines, with assumptions for coverage and smoking cessation product utilization based on current, real-world national and state-level trends for hypothetical commercial, Medicare, and Medicaid plans with 1 million covered lives. A Markov methodology with five health states captures quit attempt and relapse patterns. Results include the number of smokers attempting to quit, number of successful quitters, annual costs, and cost per-member per-month (PMPM). The projected PMPM cost of providing coverage for smoking cessation medications is $0.10 for commercial, $0.06 for Medicare, and $0.07 for Medicaid plans, reflecting a low incremental PMPM impact of covering two attempts ranging from $0.01 for Medicaid to $0.02 for commercial and Medicare payers. The projected PMPM impact of covering two quit attempts with access to all seven cessation medications at no patient cost share remains low. Results of this study reinforce that the impact of adopting the ACA requirements for smoking cessation coverage will have a limited near-term impact

  15. "Managed competition" for Ireland? The single versus multiple payer debate.

    Mikkers, Misja

    2014-09-01

    A persistent feature of international health policy debate is whether a single-payer or multiple-payer system can offer superior performance. In Ireland, a major reform proposal is the introduction of \\'managed competition\\' based on the recent reforms in the Netherlands, which would replace many functions of Ireland\\'s public payer with a system of competing health insurers from 2016. This article debates whether Ireland meets the preconditions for effective managed competition, and whether the government should implement the reform according to its stated timeline. We support our arguments by discussing the functioning of the Dutch and Irish systems.

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

    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...

  17. Reimbursement issues facing patients, providers, and payers.

    Antman, K

    1993-11-01

    Escalating costs of health care delivery and the current constraints imposed by the federal budget deficit seriously threaten to compromise patient care and innovative biomedical research. Recent third-party refusal to cover some patients treated in protocols has had considerable impact on trial research. In addition, reimbursement for conventional care sometimes has been refused if delivered as part of a study (e.g., MOPP therapy versus ABVD therapy) or for an indication that is not specifically cited on the Food and Drug Administration label. Who should cover the patient care costs of patients participating in clinical trials? One approach would have patients cover these costs themselves. A second approach is the reinstitution of patient care costs into research grants. A third possibility is that the pharmaceutical industry support patient care costs of clinical research. Historically, hospital expenses of patients participating in studies have been paid by health insurance policies. In the absence of a clinical trial, many patients would be treated with Food and Drug Administration-approved therapies despite a lack of substantial benefit. Such marginal treatments are compensated by third-party payers routinely. The current system is arbitrary and expensive, compromises research and development, and equates new treatment with no treatment. By refusing to reimburse the patient care costs of investigational therapy, third-party carriers are, in fact, making medical decisions. There is a growing and legitimate concern that the pace of clinical research will be impeded significantly at a time when many exciting developments will be ready for clinical trials. The molecular steps in carcinogenesis are being documented rapidly for common malignancies, such as colon cancer. Immunologic, biologic, and hormonal approaches, and emerging technologies, such as marrow transplant or antibody toxin conjugates, already are being studied in the clinic. Health policy legislation

  18. The impact of the 2006 Massachusetts health care reform law on spine surgery patient payer-mix status and age.

    Villelli, Nicolas W; Yan, Hong; Zou, Jian; Barbaro, Nicholas M

    2017-12-01

    OBJECTIVE Several similarities exist between the Massachusetts health care reform law of 2006 and the Affordable Care Act (ACA). The authors' prior neurosurgical research showed a decrease in uninsured surgeries without a significant change in surgical volume after the Massachusetts reform. An analysis of the payer-mix status and the age of spine surgery patients, before and after the policy, should provide insight into the future impact of the ACA on spine surgery in the US. METHODS Using the Massachusetts State Inpatient Database and spine ICD-9-CM procedure codes, the authors obtained demographic information on patients undergoing spine surgery between 2001 and 2012. Payer-mix status was assigned as Medicare, Medicaid, private insurance, uninsured, or other, which included government-funded programs and workers' compensation. A comparison of the payer-mix status and patient age, both before and after the policy, was performed. The New York State data were used as a control. RESULTS The authors analyzed 81,821 spine surgeries performed in Massachusetts and 248,757 in New York. After 2008, there was a decrease in uninsured and private insurance spine surgeries, with a subsequent increase in the Medicare and "other" categories for Massachusetts. Medicaid case numbers did not change. This correlated to an increase in surgeries performed in the age group of patients 65-84 years old, with a decrease in surgeries for those 18-44 years old. New York showed an increase in all insurance categories and all adult age groups. CONCLUSIONS After the Massachusetts reform, spine surgery decreased in private insurance and uninsured categories, with the majority of these surgeries transitioning to Medicare. Moreover, individuals who were younger than 65 years did not show an increase in spine surgeries, despite having greater access to health insurance. In a health care system that requires insurance, the decrease in private insurance is primarily due to an increasing elderly

  19. Medicare home health care patient case-mix before and after the Balanced Budget Act of 1997: effect on dual eligible beneficiaries.

    Shih, Huai-Che; Temkin-Greener, Helena; Votava, Kathryn; Friedman, Bruce

    2014-01-01

    The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. We used Medical Expenditure Panel Survey data to assess the impact of the BBA on Medicare HHC patient case-mix measured by the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. There was a significant increase in Medicare HHC patient case-mix between the pre-BBA and Prospective Payment System (PPS) periods. The increase in the standardized-predicted risk score from the Interim Payment System period to PPS was nearly 4 times greater for the dual eligibles (Medicare-Medicaid) than for the Medicare-only population. This significantly greater rise in the HHC resources required by dual eligibles as compared to nonduals could be due to a shift in HHC payers from Medicare only to Medicaid rather than be an actual increase in case-mix per se.

  20. Looking at CER from Medicare's perspective.

    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

  1. Medicare Enrollment Dashboard

    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...

  2. Medicare Coverage Database

    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...

  3. Medicare Hospice Data

    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...

  4. Mapping Medicare Disparities Tool

    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...

  5. Variation in Private Payer Coverage of Rheumatoid Arthritis Drugs.

    Chambers, James D; Wilkinson, Colby L; Anderson, Jordan E; Chenoweth, Matthew D

    2016-10-01

    Payers in the United States issue coverage determinations to guide how their enrolled beneficiaries use prescription drugs. Because payers create their own coverage policies, how they cover drugs can vary, which in turn can affect access to care by beneficiaries. To examine how the largest private payers based on membership cover drugs indicated for rheumatoid arthritis and to determine what evidence the payers reported reviewing when formulating their coverage policies. Coverage policies issued by the 10 largest private payers that make their policies publicly available were identified for rheumatoid arthritis drugs. Each coverage determination was compared with the drug's corresponding FDA label and categorized according to the following: (a) consistent with the label, (b) more restrictive than the label, (c) less restrictive than the label, or (d) mixed (i.e., more restrictive than the label in one way but less restrictive in another). Each coverage determination was also compared with the American College of Rheumatology (ACR) 2012 treatment recommendations and categorized using the same relative restrictiveness criteria. The policies were then reviewed to identify the evidence that the payers reported reviewing. The identified evidence was divided into the following 6 categories: randomized controlled trials; other clinical studies (e.g., observational studies); health technology assessments; clinical reviews; cost-effectiveness analyses; and clinical guidelines. Sixty-nine percent of coverage determinations were more restrictive than the corresponding FDA label; 15% were consistent; 3% were less restrictive; and 13% were mixed. Thirty-four percent of coverage determinations were consistent with the ACR recommendations, 33% were more restrictive; 17% were less restrictive; and 17% were mixed. Payers most often reported reviewing randomized controlled trials for their coverage policies (an average of 2.3 per policy). The payers reported reviewing an average of

  6. Payer Perspectives on Patient-Reported Outcomes in Health Care Decision Making: Oncology Examples.

    Brogan, Andrew P; DeMuro, Carla; Barrett, Amy M; D'Alessio, Denise; Bal, Vasudha; Hogue, Susan L

    2017-02-01

    by cancer type in the importance of PRO data but felt that it was most important to collect PRO data in phase 3 and postmarketing studies. Payers surveyed also anticipated an increasing significance for PRO data over the next 5-10 years. Characteristics of PRO data that maximize influence on payer decision making were reported to be (a) quality, well-controlled, and transparent PRO evidence; (b) psychometric validation of the PRO measure in targeted populations; and (c) publication in peer-reviewed journals. In markets with decentralized health care decision making, PRO data currently have more influence at the local level. Inclusion of PRO data in cancer treatment guidelines is key for centralized markets. Payers surveyed generally considered collecting PRO data postprogression to be useful. Of the 16 interviewees, 11 indicated that it is worthwhile to collect PRO data postprogression and that positive PRO data may support continued therapy at the physician's discretion upon regulatory approval, even in progressive disease. PRO data may help to differentiate treatments, particularly after clinical progression in oncology. Payers worldwide recognize high-quality PRO data as a key component of their decision-making process and anticipate the growing importance of PRO data in the future. This study and preparation of this article were funded by Novartis Pharmaceuticals. This research was performed under a research contract between RTI Health Solutions and Novartis Pharmaceuticals. Brogan, Hogue, Demuro, and Barrett are employees of RTI Health Solutions. D'Alessio and Bal are employees of Novartis Pharmaceuticals. Study concept and design were contributed by DeMuro, Barrett, Bal, and Hogue. Brogan and Hogue took the lead in data collection, assisted by DeMuro and Bal. Data interpretation was performed by Brogan and Hogue, assisted by the other authors. The manuscript was written by D'Alessio and Brogan, along with the other authors, and revised primarily by Brogan

  7. Access to Posthospitalization Acute Care Facilities is Associated with Payer Status for Open Abdominal Aortic Repair and Open Lower Extremity Revascularization in the Vascular Quality Initiative.

    Ulloa, Jesus G; Woo, Karen; Tseng, Chi-Hong; Maggard-Gibbons, Melinda; Rigberg, David

    2017-07-01

    Uninsured patients may not have access to postacute care facilities that play an important role in clinical recovery, and functional outcomes after vascular surgery. We sought to determine whether discharge disposition is associated with insurance status. We retrospectively reviewed data from the Vascular Quality Initiative ® for patients who underwent open abdominal aortic repair, infrainguinal bypass, or suprainguinal bypass (SB) between January 2012 and July 2015. Mixed-effects logistic regression analysis with clustering at the surgeon and facility level was used to calculate 95% confidence intervals for discharge disposition to home, skilled nursing facility (SNF) or rehabilitation (Rehab) facility by payer status (Medicare, Medicaid, Commercial, Military/Veterans Affairs, Non-US Insurance, or Self-pay), with adjustment for patient, operative, and postoperative characteristics. The study cohort comprised 18,478 procedures (open abdominal aortic repair = 2,817; infrainguinal bypass = 11,572; suprainguinal bypass = 4,089) after we excluded procedures with missing data and in-hospital deaths. Twenty-four percent of the cohort was discharged to an SNF or Rehab site. On univariate analysis, the odds ratio (OR) of discharge home was 4.38 (95% CI: 3.33-5.77) for self-pay as compared to Medicare. On mixed-effects analysis, the adjusted odds of discharge home for self-pay as compared to Medicare remained high (OR = 3.09; 95% CI: 2.23-4.26), after adjustment for age, gender, race/ethnicity, preoperative ambulatory status, number of comorbidities, case urgency, total operative time, presence of a postoperative complication, procedure type, and length of stay. Adjusted odds for discharge to SNF (OR = 0.26; 95% CI: 0.15-0.46) and Rehab (OR = 0.50; 95% CI: 0.35-0.72) were lowest for self-pay status. Access to postacute care facilities is associated with insurance status. Self-pay (uninsured) patients are less likely to have access to discharge services that may

  8. Billing third party payers for pharmaceutical care services.

    Poirier, S; Buffington, D E; Memoli, G A

    1999-01-01

    To describe the steps pharmacists must complete when seeking compensation from third party payers for pharmaceutical care services. Government publications; professional publications, including manuals and newsletters; authors' personal experience. Pharmacists in increasing numbers are meeting with success in getting reimbursed by third party payers for patient care activities. However, many pharmacists remain reluctant to seek compensation because they do not understand the steps involved. Preparatory steps include obtaining a provider/supplier number, procuring appropriate claim forms, developing data collection and documentation systems, establishing professional fees, creating a marketing plan, and developing an accounting system. To bill for specific patient care services, pharmacists need to collect the patient's insurance information, obtain a statement of medical necessity from the patient's physician, complete the appropriate claim form accurately, and submit the claim with supporting documentation to the insurer. Although many claims from pharmacists are rejected initially, pharmacists who work with third party payers to understand the reasons for denial of payment often receive compensation when claims are resubmitted. Pharmacists who follow these guidelines for billing third party payers for pharmaceutical care services should notice an increase in the number of paid claims.

  9. Procedural volume, cost, and reimbursement of outpatient incisional hernia repair: implications for payers and providers.

    Song, Chao; Liu, Emelline; Tackett, Scott; Shi, Lizheng; Marcus, Daniel

    2017-06-01

    This analysis aimed to evaluate trends in volumes and costs of primary elective incisional ventral hernia repairs (IVHRs) and investigated potential cost implications of moving procedures from inpatient to outpatient settings. A time series study was conducted using the Premier Hospital Perspective ® Database (Premier database) for elective IVHR identified by International Classification of Diseases, Ninth revision, Clinical Modification codes. IVHR procedure volumes and costs were determined for inpatient, outpatient, minimally invasive surgery (MIS), and open procedures from January 2008-June 2015. Initial visit costs were inflation-adjusted to 2015 US dollars. Median costs were used to analyze variation by site of care and payer. Quantile regression on median costs was conducted in covariate-adjusted models. Cost impact of potential outpatient migration was estimated from a Medicare perspective. During the study period, the trend for outpatient procedures in obese and non-obese populations increased. Inpatient and outpatient MIS procedures experienced a steady growth in adoption over their open counterparts. Overall median costs increased over time, and inpatient costs were often double outpatient costs. An economic model demonstrated that a 5% shift of inpatient procedures to outpatient MIS procedures can have a cost surplus of ∼ US $1.8 million for provider or a cost-saving impact of US $1.7 million from the Centers for Medicare & Medicaid Services perspective. The study was limited by information in the Premier database. No data were available for IVHR cases performed in free-standing ambulatory surgery centers or federal healthcare facilities. Volumes and costs of outpatient IVHRs and MIS procedures increased from January 2008-June 2015. Median costs were significantly higher for inpatients than outpatients, and the difference was particularly evident for obese patients. A substantial cost difference between inpatient and outpatient MIS cases

  10. Medicare Hospital Spending Per Patient - State

    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...

  11. Medicare Hospital Spending Per Patient - Hospital

    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...

  12. Medicare Hospital Spending Per Patient - National

    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...

  13. Benchmarking Insulin Treatment Persistence Among Patients with Type 2 Diabetes Across Different U.S. Payer Segments.

    Wei, Wenhui; Jiang, Jenny; Lou, Youbei; Ganguli, Sohini; Matusik, Mark S

    2017-03-01

    Treatment persistence with basal insulins is crucial to achieving sustained glycemic control, which is associated with a reduced risk of microvascular disease and other complications of type 2 diabetes (T2D). However, studies suggest that persistence with basal insulin treatment is often poor. To measure and benchmark real-world basal insulin treatment persistence among patients with T2D across different payer segments in the United States. This was a retrospective observational study of data from a national pharmacy database (Walgreen Co., Deerfield, IL). The analysis included patients with T2D aged ≥ 18 years who filled ≥ 1 prescription for basal insulins between January 2013 and June 2013 (the index prescription) and who had also filled prescriptions for ≥ 1 oral antidiabetes drug in the database. Patients with claims for premixed insulin were excluded. Treatment persistence was defined as remaining on the study medication(s) during the 1-year follow-up period. Patients were stratified according to treatment history (existing basal insulin users vs. new insulin users), payer segments (commercially insured, Medicare, Medicaid, or cash-pay), type of basal insulin (insulin glargine, insulin detemir, or neutral protamine Hagedorn insulin [NPH]), and device for insulin administration (pen or vial/syringe). A total of 274,102 patients were included in this analysis, 82% of whom were existing insulin users. In terms of payer segments, 45.3% of patients were commercially insured, 47.8% had Medicare, 5.9% had Medicaid, and 1.1% were cash-pay. At the 1-year follow-up, basal insulin treatment persistence rate was 66.8% overall, 61.7% for new users, and 67.9% for existing users. In general, for both existing and new basal insulin users, higher persistence rate and duration were associated with Medicare versus cash-pay patients, use of insulin pens versus vial/syringe, and use of insulin glargine versus NPH. This large-scale study provides a benchmark of basal insulin

  14. Medicare Utilization for Part B

    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...

  15. Medicare and Medicaid Linked Files

    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...

  16. Medicare Utilization for Part A

    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...

  17. Medicare Administrative Contractor Performance Evaluation

    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...

  18. Medicare and Medicaid Research Review

    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...

  19. Medicare, physicians, and patients.

    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.

  20. Medicare Advantage Plans

    ... 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. Your Medicare Rights

    ... 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 ...

  2. What Is Medicare?

    ... 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 ...

  3. What Medicare Covers

    ... 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 ...

  4. Claims and Appeals (Medicare)

    ... 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 ...

  5. Diabetes benefit management: evolving strategies for payers.

    Tzeel, Albert L

    2011-11-01

    Over the next quarter century, the burden of type 2 diabetes mellitus (T2DM) is expected to at least double. Currently, 1 in every 10 healthcare dollars is spent on diabetes management; by 2050, it has been projected that the annual costs of managing T2DM will rise to $336 billion. Without substantial, systemic changes, T2DM management costs will lead to a potentially untenable strain on the healthcare system. However, the appropriate management of diabetes can reduce associated mortality and delay comorbidities. In addition, adequate glycemic control can improve patient outcomes and significantly reduce diabetes-related complications. This article provides an overview of key concepts associated with a value-based insurance design (VBID) approach to T2DM coverage. By promoting the use of services or treatments that provide high benefits relative to cost, and by alternatively discouraging patients from utilizing services whose benefits do not justify their cost, VBID improves the quality of healthcare while simultaneously reining in spending. VBID initiatives tend to focus on chronic disease management and generally target prescription drug use. However, some programs have expanded their scope by incorporating services traditionally offered by wellness and disease management programs. The concept of VBID is growing, and it is increasingly being implemented by a diverse and growing number of public and private entities, including pharmacy benefit managers, health plans, and employers. This article provides key background on VBID strategies, with a focus on T2DM management. It also provides a road map for health plans seeking to implement VBID as part of their programs.

  6. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    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...

  7. Contract law: relationship between dermatologists and third-party payers.

    Askanas, A V

    1993-04-01

    The relationship between third-party payers and dermatologists is generally governed by a written contract. That relationship can be more beneficial to the dermatologist, and chances of liability may be decreased, both for breach of contract and for malpractice, if the dermatologist pays close attention to the language in the contract. All contracts are generally negotiable; detrimental language in the contract often may be removed or changed. This article presents information to help prepare dermatologists to review and negotiate contracts.

  8. Feasibility of Economic Analysis of Radiation Therapy Oncology Group (RTOG) 91-11 Using Medicare Data

    Konski, Andre; Bhargavan, Mythreyi; Owen, Jean; Paulus, Rebecca; Cooper, Jay; Forastiere, Arlene; Ang, K. Kian; Watkins-Bruner, Deborah

    2011-01-01

    Purpose: The specific aim of this analysis was to evaluate the feasibility of performing a cost-effectiveness analysis using Medicare data from patients treated on a randomized Phase III clinical trial. Methods and Materials: Cost data included Medicare Part A and Part B costs from all providers-inpatient, outpatient, skilled nursing facility, home health, hospice, and physicians-and were obtained from the Centers for Medicare and Medicaid Services for patients eligible for Medicare, treated on Radiation Therapy Oncology Group (RTOG) 9111 between 1992 and 1996. The 47-month expected discounted (annual discount rate of 3%) cost for each arm of the trial was calculated in 1996 dollars, with Kaplan-Meier sampling average estimates of survival probabilities for each month and mean monthly costs. Overall and disease-free survival was also discounted 3%/year. The analysis was performed from a payer's perspective. Incremental cost-effectiveness ratios were calculated comparing the chemotherapy arms to the radiation alone arm. Results: Of the 547 patients entered, Medicare cost data and clinical outcomes were available for 66 patients. Reasons for exclusion included no RTOG follow-up, Medicare HMO enrollment, no Medicare claims since trial entry, and trial entry after 1996. Differences existed between groups in tumor characteristics, toxicity, and survival, all which could affect resource utilization. Conclusions: Although we were able to test the methodology of economic analysis alongside a clinical trial using Medicare data, the results may be difficult to translate to the entire trial population because of non-random missing data. Methods to improve Medicare data capture and matching to clinical trial samples are required.

  9. The Little State That Couldn't Could? The Politics of "Single-Payer" Health Coverage in Vermont.

    Fox, Ashley M; Blanchet, Nathan J

    2015-06-01

    In May 2011, a year after the passage of the Affordable Care Act (ACA), Vermont became the first state to lay the groundwork for a single-payer health care system, known as Green Mountain Care. What can other states learn from the Vermont experience? This article summarizes the findings from interviews with nearly 120 stakeholders as part of a study to inform the design of the health reform legislation. Comparing Vermont's failed effort to adopt single-payer legislation in 1994 to present efforts, we find that Vermont faced similar challenges but greater opportunities in 2010 that enabled reform. A closely contested gubernatorial election and a progressive social movement opened a window of opportunity to advance legislation to design three comprehensive health reform options for legislative consideration. With a unified Democratic government under the leadership of a single-payer proponent, a high-profile policy proposal, and relatively weak opposition, a framework for a single-payer system was adopted by the legislature - though with many details and political battles to be fought in the future. Other states looking to reform their health systems more comprehensively than national reform can learn from Vermont's design and political strategy. Copyright © 2015 by Duke University Press.

  10. Canadian Medicare: prognosis guarded.

    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 ...

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

    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...

  12. Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries

    Burke, Laura G; Wild, Robert C; Orav, E John; Hsia, Renee Y

    2018-01-01

    Objective There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED). Design, setting and participants Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012. Outcomes measures Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling. Results High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (−0.68% per year; 95% CI −0.71% to −0.65%; Pbilled as high intensity

  13. Geographic variation in Medicare and the military healthcare system.

    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. Payers' Views of the Changes Arising through the Possible Adoption of Adaptive Pathways.

    Ermisch, Michael; Bucsics, Anna; Vella Bonanno, Patricia; Arickx, Francis; Bybau, Alexander; Bochenek, Tomasz; van de Casteele, Marc; Diogene, Eduardo; Fürst, Jurij; Garuolienė, Kristina; van der Graaff, Martin; Gulbinovič, Jolanta; Haycox, Alan; Jones, Jan; Joppi, Roberta; Laius, Ott; Langner, Irene; Martin, Antony P; Markovic-Pekovic, Vanda; McCullagh, Laura; Magnusson, Einar; Nilsen, Ellen; Selke, Gisbert; Sermet, Catherine; Simoens, Steven; Sauermann, Robert; Schuurman, Ad; Ramos, Ricardo; Vlahovic-Palcevski, Vera; Zara, Corinne; Godman, Brian

    2016-01-01

    Payers are a major stakeholder in any considerations and initiatives concerning adaptive licensing of new medicinal products, also referred to as Medicines Adaptive Pathways to patients (MAPPs). Firstly, the scope and necessity of MAPPs need further scrutiny, especially with regard to the definition of unmet need. Conditional approval pathways already exist for new medicines for seriously debilitating or life-threatening diseases and only a limited number of new medicines are innovative. Secondly, MAPPs will result in new medicines on the market with limited evidence about their effectiveness and safety. Additional data are to be collected after approval. Consequently, adaptive pathways may increase the risk of exposing patients to ineffective or unsafe medicines. We have already seen medicines approved conventionally that subsequently proved ineffective or unsafe amongst a wider, more co-morbid population as well as medicines that could have been considered for approval under MAPPs but subsequently proved ineffective or unsafe in Phase III trials and were never licensed. Thirdly, MAPPs also put high demands on payers. Routine collection of patient level data is difficult with high transaction costs. It is not clear who will fund these. Other challenges for payers include shifts in the risk governance framework, implications for evaluation and HTA, increased complexity of setting prices, difficulty with ensuring equity in the allocation of resources, definition of responsibility and liability and implementation of stratified use. Exit strategies also need to be agreed in advance, including price reductions, rebates, or reimbursement withdrawals when price premiums are not justified. These issues and concerns will be discussed in detail including potential ways forward.

  15. Is There Evidence for Systematic Upcoding of ASA Physical Status Coincident with Payer Incentives? A Regression Discontinuity Analysis of the National Anesthesia Clinical Outcomes Registry.

    Schonberger, Robert B; Dutton, Richard P; Dai, Feng

    2016-01-01

    Modifications in physician billing patterns have been shown to occur in response to payer incentives, but the phenomenon remains largely unexplored in billing for anesthesia services. Within the field of anesthesiology, Medicare's policy not to provide additional reimbursement for higher ASA physical status scores contrasts with the practices of most private payers, and this pattern of reimbursement introduces a change in billing incentives once patients attain Medicare eligibility. We hypothesized that, coincident with the onset of widespread Medicare eligibility at age 65 years, a discontinuity in reported ASA physical status scores would be observed after controlling for the underlying trend of increasing ASA physical status scores with age. This phenomenon would manifest as a pattern of upcoding of ASA physical status scores for patients younger than 65 years that would become less common in patients age 65 years and older. Using data on age, sex, ASA physical status scores, and type of surgery from the National Anesthesia Clinical Outcomes Registry, we used a quasi-experimental regression discontinuity design to analyze whether there was evidence for a discontinuity in reported ASA physical status scores occurring at age 65 years for the nondeferrable anesthesia services accompanying hip, femur, or lower leg fracture repair. A total of 49,850 records were analyzed. In models designed to detect regression discontinuity at 65 years of age, neither the binary variable "age ≥ 65" nor the interaction term of age × age ≥ 65 was a statistically significant predictor of the outcome of ASA physical status score. The statistical inference was unchanged when ASA physical status scores were reclassified as a binary outcome (I-II vs III-V) and when different bandwidths around age 65 years were used. To test the validity of our study design for detecting regression discontinuity, simulations of the occurrence of deliberate upcoding of ASA physical status scores

  16. Characteristics of Patient-Centered Medical Home Initiatives that Generated Savings for Medicare: a Qualitative Multi-Case Analysis.

    Burton, Rachel A; Lallemand, Nicole M; Peters, Rebecca A; Zuckerman, Stephen

    2018-02-05

    Through the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare, Medicaid, and private payers offered supplemental payments to 849 primary care practices that became patient-centered medical homes (PCMHs) in eight states; practices also received technical assistance and data reports. Average Medicare payments were capped at $10 per beneficiary per month in each state. Since there was variation in the eight participating states' demonstration designs, experiences, and outcomes, we conducted a qualitative multi-case analysis to identify the key factors that differentiated states that were estimated to have generated net savings for Medicare from states that did not. States' MAPCP Demonstration initiatives were comprehensively profiled in case studies based on secondary document review, three rounds of annual interviews with state staff, payers, practices, and other stakeholders, and other data sources. Case study findings were summarized in a case-ordered predictor-outcome matrix, which identified the presence or absence of key demonstration design features and experiences and arrayed states based on the amount of net savings or losses they generated for Medicare. We then used this matrix to identify initiative features that were present in at least three of the four states that generated net savings and absent from at least three of the four states that did not generate savings. A majority of the states that generated net savings: required practices to be recognized PCMHs to enter the demonstration, did not allow late entrants into the demonstration, used a consistent demonstration payment model across participating payers, and offered practices opportunities to earn performance bonuses. Practices in states that generated net savings also tended to report receiving the demonstration payments and bonuses they expected to receive, without any issues. Designers of future PCMH initiatives may increase their likelihood of generating net savings by

  17. Variation in provider vaccine purchase prices and payer reimbursement.

    Freed, Gary L; Cowan, Anne E; Gregory, Sashi; Clark, Sarah J

    2009-12-01

    The purpose of this work was to collect data regarding vaccine prices and reimbursements in private practices. Amid reports of physicians losing money on vaccines, there are limited supporting data to show how much private practices are paying for vaccines and how much they are being reimbursed by third-party payers. We conducted a cross-sectional survey of a convenience sample of private practices in 5 states (California, Georgia, Michigan, New York, and Texas) that purchase vaccines for administration to privately insured children/adolescents. Main outcome measures included prices paid to purchase vaccines recommended for children and adolescents and reimbursement from the 3 most common, non-Medicaid payers for vaccine purchase and administration. Detailed price and reimbursement data were provided by 76 practices. There was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30 for specific vaccines. There was also significant variation in insurance reimbursement for vaccine purchase, with maximum and minimum reimbursements for a single vaccine differing from $8 to more than $80. Mean net yield per dose (reimbursement for vaccine purchase minus price paid per dose) varied across vaccines from a low of approximately $3 to more than $24. Reimbursement for the first dose of vaccine administered ranged from $0 to more than $26, with a mean of $16.62. There is a wide range of prices paid by practices for the same vaccine product and in the reimbursement for vaccines and administration fees by payers. This variation highlights the need for individual practices to understand their own costs and reimbursements and to seek opportunities to reduce costs and increase reimbursements.

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

    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...

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

    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

  20. Medicare Part D is associated with reducing the financial burden of health care services in Medicare beneficiaries with diagnosed diabetes.

    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.

  1. On the complaint of unconstitutionality of the Stuttgart Court decisions against non-payers and part payers of electricity bills

    Fischerhof, H.

    1980-01-01

    In a decision dated December 20, 1979, the Federal Constitutional Court refused to accept the complaint of unconstitutionality brought by the Technische Werke (Municipal Utilities) of the city of Stuttgart (TWS) against two decisions by the Stuttgart Municipal Court in favor of non-payers and part payers of electricity bills. The reasons given for the refusal to accept the complaint state that there was every indication of the Stuttgart judgements being faulty. On the basis of this finding, TWS can continue to demand payment in full of their electricity bills. The Federal Constitutional Court maintains that civil rights could not be applied to TWS as a corporation under private law, whose activities exclusively consisted in providing the public with means of existence and whose shares were held in full by an agency with rights of jurisdiction. In a footnote, the author argues that the refusal to grant protection of civil rights to TWS was in conflict with the equal rights principle. (HSCH) [de

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

    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

  3. 78 FR 43820 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    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...

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

    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. Canadian Medicare: prognosis guarded.

    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.

  6. Nursing home 5-star rating system exacerbates disparities in quality, by payer source.

    Konetzka, R Tamara; Grabowski, David C; Perraillon, Marcelo Coca; Werner, Rachel M

    2015-05-01

    Market-based reforms in health care, such as public reporting of quality, may inadvertently exacerbate disparities. We examined how the Centers for Medicare and Medicare Services' five-star rating system for nursing homes has affected residents who are dually enrolled in Medicare and Medicaid ("dual eligibles"), a particularly vulnerable and disadvantaged population. Specifically, we assessed the extent to which dual eligibles and non-dual eligibles avoided the lowest-rated nursing homes and chose the highest-rated homes once the five-star rating system began, in late 2008. We found that both populations resided in better-quality homes over time but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non-dual eligibles. Thus, the gap in quality, as measured by a nursing home's star rating, grew over time. Furthermore, we found that the benefit of the five-star system to dual eligibles was largely due to providers' improving their ratings, not to consumers' choosing different providers. We present evidence suggesting that supply constraints play a role in limiting dual eligibles' responses to quality ratings, since high-quality providers tend to be located close to relatively affluent areas. Increases in Medicaid payment rates for nursing home services may be the only long-term solution. Project HOPE—The People-to-People Health Foundation, Inc.

  7. 76 FR 67801 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    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...

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

    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,...

  9. Beneficiary price sensitivity in the Medicare prescription drug plan market.

    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.

  10. Chronic Conditions among Medicare Beneficiaries

    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...

  11. Medicare Referring Provider DMEPOS PUF

    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...

  12. Medicare Provider Data - Hospice Providers

    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...

  13. Medicare and Medicaid Statistical Supplement

    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...

  14. Guidelines and Value-Based Decision Making: An Evolving Role for Payers.

    McCauley, Janet L

    2015-01-01

    Payers use evidence-based guidelines to promote effective health diagnoses and treatments for their members and to ensure that members are not subject to harmful or wasteful care. Payer guidelines inform coverage, but the content of these guidelines relies on the same evidentiary base as clinical treatment guidelines. Recent strategies to foster value through benefit design and alternative reimbursement methodologies illustrate emerging applications for evidence-based guidelines. The current focus on cost effectiveness within health technology assessment, comparative effectiveness research in collaboration with payers, and transparency around payer evidence assessment could better align payers' interests in evidence-based care with those of other stakeholders. The move to value in health care will depend upon credible clinical evidence to enable informed decision making. ©2015 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

  15. The Economics of Medicare Accountable Care Organizations

    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

  16. 77 FR 22071 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    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...

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

    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. Substantial Physician Turnover And Beneficiary 'Churn' In A Large Medicare Pioneer ACO.

    Hsu, John; Vogeli, Christine; Price, Mary; Brand, Richard; Chernew, Michael E; Mohta, Namita; Chaguturu, Sreekanth K; Weil, Eric; Ferris, Timothy G

    2017-04-01

    Alternative payment models, such as accountable care organizations (ACOs), attempt to stimulate improvements in care delivery by better alignment of payer and provider incentives. However, limited attention has been paid to the physicians who actually deliver the care. In a large Medicare Pioneer ACO, we found that the number of beneficiaries per physician was low (median of seventy beneficiaries per physician, or less than 5 percent of a typical panel). We also found substantial physician turnover: More than half of physicians either joined (41 percent) or left (18 percent) the ACO during the 2012-14 contract period studied. When physicians left the ACO, most of their attributed beneficiaries also left the ACO. Conversely, about half of the growth in the beneficiary population was because of new physicians affiliating with the ACO; the remainder joined after switching physicians. These findings may help explain the muted financial impact ACOs have had overall, and they raise the possibility of future gaming on the part of ACOs to artificially control spending. Policy refinements include coordinated and standardized risk-sharing parameters across payers to prevent any dilution of the payment incentives or confusion from a cacophony of incentives across payers. Project HOPE—The People-to-People Health Foundation, Inc.

  19. Anticoagulant use for the prevention of stroke in patients with atrial fibrillation: findings from a multi-payer analysis.

    Lang, Kathleen; Bozkaya, Duygu; Patel, Aarti A; Macomson, Brian; Nelson, Winnie; Owens, Gary; Mody, Samir; Schein, Jeff; Menzin, Joseph

    2014-07-28

    Oral anticoagulation is recommended for stroke prevention in intermediate/high stroke risk atrial fibrillation (AF) patients. The objective of this study was to demonstrate the usefulness of analytic software tools for descriptive analyses of disease management in atrial AF; a secondary objective is to demonstrate patterns of potential anticoagulant undertreatment in AF. Retrospective data analyses were performed using the Anticoagulant Quality Improvement Analyzer (AQuIA), a software tool designed to analyze health plan data. Two-year data from five databases were analyzed: IMS LifeLink (IMS), MarketScan Commercial (MarketScanCommercial), MarketScan Medicare Supplemental (MarketScanMedicare), Clinformatics™ DataMart, a product of OptumInsight Life Sciences (Optum), and a Medicaid Database (Medicaid). Included patients were ≥ 18 years old with a new or existing diagnosis of AF. The first observed AF diagnosis constituted the index date, with patient outcomes assessed over a one year period. Key study measures included stroke risk level, anticoagulant use, and frequency of International Normalized Ratio (INR) monitoring. High stroke risk (CHADS2 ≥ 2 points) was estimated in 54% (IMS), 22% (MarketScanCommercial), 64% (MarketscanMedicare), 42% (Optum) and 62% (Medicaid) of the total eligible population. Overall, 35%, 29%, 38%, 39% and 16% of all AF patients received an anticoagulant medication in IMS, MarketScanCommercial, MarketScanMedicare, Optum and Medicaid, respectively. Among patients at high risk for stroke, 19% to 51% received any anticoagulant. The AQuIA provided a consistent platform for analysis across multiple AF populations with varying baseline characteristics. Analyzer results show that many high-risk AF patients in selected commercial, Medicare-eligible, and Medicaid populations do not receive appropriate thromboprophylaxis, as recommended by treatment guidelines.

  20. Medicare Non-Utilization Project (MNUP)

    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...

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

    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...

  2. Measuring Coding Intensity in Medicare Advantage - SUPP.

    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...

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

    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...

  4. Medicare Physician and Other Supplier Interactive Dataset

    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...

  5. Medicare Current Beneficiary Survey - Limited Data Set

    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...

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

    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...

  7. Beneficiary Activation in the Medicare Population

    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,...

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

    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...

  9. Medicare FFS Jurisdiction Error Rate Contribution Data

    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...

  10. Assessing Measurement Error in Medicare Coverage

    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...

  11. 76 FR 21372 - Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions...

    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...

  12. Innovative payer engagement strategies: will the convergence lead to better value creation in personalized medicine?

    Akhmetov, Ildar; Bubnov, Rostyslav V

    2017-12-01

    As reimbursement authorities are gaining greater power to influence the prescription behavior of physicians, it remains critical for life science companies focusing on personalized medicine to develop "tailor-made" payer engagement strategies to secure reimbursement and assure timely patient access to their innovative products. Depending on the types of such engagement, pharmaceutical and diagnostic companies may benefit by obtaining access to medical and pharmacy claims data, getting invaluable upfront inputs on evidence requirements and clinical trial design, and strengthening trust by payers, therefore avoiding uncertainties with regards to pricing, reimbursement, and research and development reinvestment. This article aims to study the evolving trend of partnering among two interdependent, yet confronting, stakeholder groups-payers and producers-as well as to identify the most promising payer engagement strategies based on cocreation of value introduced by life science companies in the past few years. We analyzed the recent case studies from both therapeutic and diagnostic realms considered as the "best practices" in payer engagement. The last 5 years were a breakout period for deals between life science companies and reimbursement authorities in the area of personalized medicine with a number of felicitous collaborative practices established already, and many more yet to emerge. We suggest that there are many ways for producers and payers to collaborate throughout the product life cycle-from data exchange and scientific counseling to research collaboration aimed at reducing healthcare costs, addressing adherence issues, and diminishing risks associated with future launches. The presented case studies provide clear insights on how successful personalized medicine companies customize their state-of-the-art payer engagement strategies to ensure closer proximity with payers and establish longer-term trust-based relationships.

  13. Changes in Payer Mix and Physician Reimbursement After the Affordable Care Act and Medicaid Expansion

    Christine D. Jones MD, MS

    2015-08-01

    Full Text Available Although uncompensated care for hospital-based care has fallen dramatically since the implementation of the Affordable Care Act and Medicaid expansion, the changes in hospital physician reimbursement are not known. We evaluated if payer mix and physician reimbursement by encounter changed between 2013 and 2014 in an academic hospitalist practice in a Medicaid expansion state. This was a retrospective cohort study of all general medicine inpatient admissions to an academic hospitalist group in 2013 and 2014. The proportion of encounters by payer and reimbursement/inpatient encounter were compared in 2013 versus 2014. A sensitivity analysis determined the relative contribution of different factors to the change in reimbursement/encounter. Among 37 540 and 40 397 general medicine inpatient encounters in 2013 and 2014, respectively, Medicaid encounters increased (17.3% to 30.0%, P < .001, uninsured encounters decreased (18.4% to 6.3%, P < 0.001, and private payer encounters also decreased (14.1% to 13.3%, P = .001. The median reimbursement/encounter increased 4.2% from $79.98/encounter in 2013 to $83.36/encounter in 2014 (P < .001. In a sensitivity analysis, changes in length of stay, proportions in encounter type by payer, payer mix, and reimbursement for encounter type by payer accounted for −0.7%, 0.8%, 2.0%, and 2.3% of the reimbursement change, respectively. From 2013 to 2014, Medicaid encounters increased, and uninsured and private payer encounters decreased within our hospitalist practice. Reimbursement/encounter also increased, much of which could be attributed to a change in payer mix. Further analyses of physician reimbursement in Medicaid expansion and non-expansion states would further delineate reimbursement changes that are directly attributable to Medicaid expansion.

  14. Comparative analysis on the probability of being a good payer

    Mihova, V.; Pavlov, V.

    2017-10-01

    Credit risk assessment is crucial for the bank industry. The current practice uses various approaches for the calculation of credit risk. The core of these approaches is the use of multiple regression models, applied in order to assess the risk associated with the approval of people applying for certain products (loans, credit cards, etc.). Based on data from the past, these models try to predict what will happen in the future. Different data requires different type of models. This work studies the causal link between the conduct of an applicant upon payment of the loan and the data that he completed at the time of application. A database of 100 borrowers from a commercial bank is used for the purposes of the study. The available data includes information from the time of application and credit history while paying off the loan. Customers are divided into two groups, based on the credit history: Good and Bad payers. Linear and logistic regression are applied in parallel to the data in order to estimate the probability of being good for new borrowers. A variable, which contains value of 1 for Good borrowers and value of 0 for Bad candidates, is modeled as a dependent variable. To decide which of the variables listed in the database should be used in the modelling process (as independent variables), a correlation analysis is made. Due to the results of it, several combinations of independent variables are tested as initial models - both with linear and logistic regression. The best linear and logistic models are obtained after initial transformation of the data and following a set of standard and robust statistical criteria. A comparative analysis between the two final models is made and scorecards are obtained from both models to assess new customers at the time of application. A cut-off level of points, bellow which to reject the applications and above it - to accept them, has been suggested for both the models, applying the strategy to keep the same Accept Rate as

  15. Negotiating with third party payers: one community pharmacy's experience.

    Fridy, Kimberly; DeHart, Renee M; Monk-Tutor, Mary R

    2002-01-01

    attempts at contract negotiation between one pharmacy and nine third party payers. The difficulty of achieving successful results and the necessity of carefully considering the time and cost of contract negotiations underscore how important it is for independent pharmacists to concentrate their efforts on contracts and terms they have an opportunity to change.

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

    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.

  17. Medicare Update: Annual Wellness Visit

    ... 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 ...

  18. Medicare Special Needs Plan (SNP)

    ... 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. Medicare Preventive and Screening Services

    ... 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. Variations in Medicare Reimbursement in Radiation Oncology: An Analysis of the Medicare Provider Utilization and Payment Data Set

    Vu, Charles C.; Lanni, Thomas B.; Robertson, John M.

    2016-01-01

    Purpose: The purposes of this study were to summarize recently published data on Medicare reimbursement to individual radiation oncologists and to identify the causes of variation in Medicare reimbursement in radiation oncology. Methods and Materials: The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF), which details nearly all services provided by radiation oncologists in 2012, was used for this study. The data were filtered and analyzed by physician and by billing code. Statistical analysis was performed to identify differences in reimbursements based on sex, rurality, billing of technical services, or location in a certificate of need (CON) state. Results: There were 4135 radiation oncologists who received a total of $1,499,625,803 in payments from Medicare in 2012. Seventy-five percent of radiation oncologists were male. The median reimbursement was $146,453. The code with the highest total reimbursement was 77418 (radiation treatment delivery intensity modulated radiation therapy [IMRT]). The most commonly billed evaluation and management (E/M) code for new visits was 99205 (49%). The most commonly billed E/M code for established visits was 99213 (54%). Forty percent of providers billed none of their new office visits using 99205 (the highest E/M billing code), whereas 34% of providers billed all of their new office visits using 99205. For the 1510 radiation oncologists (37%) who billed technical services, median Medicare reimbursement was $606,008, compared with $93,921 for all other radiation oncologists (P<.001). On multivariate analysis, technical services billing (P<.001), male sex (P<.001), and rural location (P=.007) were predictive of higher Medicare reimbursement. Conclusions: The billing of technical services, with their high capital and labor overhead requirements, limits any comparison in reimbursement between individual radiation oncologists or between radiation oncologists and other

  1. Variations in Medicare Reimbursement in Radiation Oncology: An Analysis of the Medicare Provider Utilization and Payment Data Set

    Vu, Charles C.; Lanni, Thomas B.; Robertson, John M., E-mail: JRobertson@beaumont.edu

    2016-04-01

    Purpose: The purposes of this study were to summarize recently published data on Medicare reimbursement to individual radiation oncologists and to identify the causes of variation in Medicare reimbursement in radiation oncology. Methods and Materials: The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF), which details nearly all services provided by radiation oncologists in 2012, was used for this study. The data were filtered and analyzed by physician and by billing code. Statistical analysis was performed to identify differences in reimbursements based on sex, rurality, billing of technical services, or location in a certificate of need (CON) state. Results: There were 4135 radiation oncologists who received a total of $1,499,625,803 in payments from Medicare in 2012. Seventy-five percent of radiation oncologists were male. The median reimbursement was $146,453. The code with the highest total reimbursement was 77418 (radiation treatment delivery intensity modulated radiation therapy [IMRT]). The most commonly billed evaluation and management (E/M) code for new visits was 99205 (49%). The most commonly billed E/M code for established visits was 99213 (54%). Forty percent of providers billed none of their new office visits using 99205 (the highest E/M billing code), whereas 34% of providers billed all of their new office visits using 99205. For the 1510 radiation oncologists (37%) who billed technical services, median Medicare reimbursement was $606,008, compared with $93,921 for all other radiation oncologists (P<.001). On multivariate analysis, technical services billing (P<.001), male sex (P<.001), and rural location (P=.007) were predictive of higher Medicare reimbursement. Conclusions: The billing of technical services, with their high capital and labor overhead requirements, limits any comparison in reimbursement between individual radiation oncologists or between radiation oncologists and other

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

    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.

  3. Three-year post-transplant medicare payments in kidney transplant recipients: Associations with pre-transplant comorbidities

    Gerardo Machnicki

    2011-01-01

    Full Text Available Little is known about the influence of pre-transplant comorbidities on post-transplant expenditures. We estimated the associations between pre-transplant comorbidities and post-transplant Medicare costs, using several comorbidity classification systems. We included recipients of first-kidney deceased donor transplants from 1995 through 2002 for whom Medicare was the primary payer for at least one year pre-transplant (N = 25,175. We examined pre-transplant comorbidities as classified by International Classification of Diseases (ICD-9-CM codes from Medicare claims with the Clinical Cla-ssifications Software (CCS and Charlson and Elixhauser algorithms. Post-transplant costs were calcu-lated from payments on Medicare claims. We developed models considering Organ Procurement and Transplantation Network (OPTN variables plus: 1 CCS categories, 2 Charlson, 3 Elixhauser, 4 num-ber of Charlson and 5 number of Elixhauser comorbidities, independently. We applied a novel regression methodology to account for censoring. Costs were estimated at individual and population levels. The comorbidities with the largest impact on mean Medicare payments included cardiovascular disease, ma-lignancies, cerebrovascular disease, mental conditions and functional limitations. Skin ulcers and infec-tions, rheumatic and other connective tissue disease and liver disease also contributed to payments and have not been considered or described previously. A positive graded relationship was found between costs and the number of pre-transplant comorbidities. In conclusion, we showed that expansion beyond the usually considered pre-transplant comorbidities with inclusion of CCS and Charlson or Elixhauser comorbidities increased the knowledge about comorbidities related to augmented Medicare payments. Our expanded methodology can be used by others to assess more accurately the financial implications of renal transplantation to Medicare and individual transplant centers.

  4. Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration.

    Stason, William B; Ritter, Grant A; Martin, Timothy; Prottas, Jeffrey; Tompkins, Christopher; Shepard, Donald S

    2016-01-01

    Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head. The demonstration was conducted in 2005-2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework. Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa. The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.

  5. Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration.

    William B Stason

    Full Text Available Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS conditions affecting the back, limbs, neck, or head.The demonstration was conducted in 2005-2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework.Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa.The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.

  6. Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration

    Stason, William B.; Ritter, Grant A; Prottas, Jeffrey; Tompkins, Christopher; Shepard, Donald S.

    2016-01-01

    Background Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head. Methods The demonstration was conducted in 2005–2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework. Results Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa. Conclusion The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased. PMID:26928221

  7. Cost-effectiveness analysis of allopurinol versus febuxostat in chronic gout patients: a U.S. payer perspective.

    Gandhi, Pranav K; Gentry, William M; Ma, Qinli; Bottorff, Michael B

    2015-02-01

    Gout is a chronic inflammatory condition associated with poor urate metabolism. Xanthine oxidase inhibitors such as allopurinol and febuxostat are recommended to reduce uric acid levels and to prevent gout attacks in adult patients. Under budget-driven constraints, health care payers are faced with the broader challenge of assessing the economic value of these agents for formulary placement. However, the economic value of allopurinol versus febuxostat has not be assessed in patients with gout over a 5-year time period in the United States. To evaluate the cost-effectiveness of allopurinol versus febuxostat in adult patients with gout over a 5-year time period from a U.S. health care payer's perspective. A Markov model was developed to compare the total direct costs and success of serum uric acid (sUA) level reduction associated with allopurinol and febuxostat. Treatment success was defined as patient achievement of a sUA level less than  6 mg/dL (0.36 mmol/L) at 6 months. Event probabilities were based on published phase III randomized clinical trials and included long-term sequelae from open-label extension studies. A hypothetical cohort of 1,000 adult gout patients with sUA levels of ≥ 8 mg/dL (0.48 mmol/L) who had received either allopurinol 300 mg or febuxostat 80 mg at model entry transitioned among the 4 health states defined by treatment success, treatment failure and switch, treatment dropout, and death. The length of each Markov cycle was 6 months. Costs were gathered from the RED BOOK, Medicare fee schedules, Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, and for a limited number of inputs, expert consultation. Direct costs included treatment drug costs, costs for prophylaxis drugs, diagnostic laboratory tests, and the treatment and management of acute gout flare. Resource utilization was based on clinical evidence and expert consultation. All costs were inflated to 2014 U.S. dollars and were discounted at 3% in the base case

  8. Spillover effects of Medicare fee reductions: evidence from ophthalmology.

    Mitchell, Jean M; Hadley, Jack; Gaskin, Darrell J

    2002-09-01

    Relatively little research has examined physicians' supply responses to Medicare fee cuts especially whether fee reductions for specific procedures have "spillover" effects that cause physicians to increase the supply of other services they provide. In this study we investigate whether ophthalmologist changed their provision of non-cataract services to Medicare patients over the time period 1992-1994, when the Medicare Fee Schedule (MFS) resulted in a 17.4% reduction in the average fee paid for a cataract extraction. Following the McGuire-Pauly model of physician behavior (McGuire and Pauly, 1991), we estimated a supply function for non-cataract procedures that included three price variables (own-price, a Medicare cross-price and a private cross-price) and an income effect. The Medicare cross-price and income variables capture spillover effects. Consistent with the model's predictions, we found that the Medicare cross-price is significant and negative, implying that a 10% reduction in the fee for a cataract extraction will cause ophthalmologists to supply about 5% more non-cataract services. Second, the income variable is highly significant, but its impact on the supply of non-cataract services is trivial. The suggests that physicians behave more like profit maximizing firms than target income seekers. We also found that the own-price and the private cross-price variables are highly significant and have the expected positive and negative effects on the volume of non-cataract services respectively. Our results demonstrate the importance of evaluating volume responses to fee changes for the array of services the physician performs, not just the procedure whose fee has been reduced. Focusing only on the procedure whose fee has been cut will yield an incomplete picture of how fee reductions for specific procedures affect physician supply decisions.

  9. Primary Payer at DX: Issues with Collection and Assessment of Data Quality.

    Sherman, Recinda L; Williamson, Laura; Andrews, Patricia; Kahn, Amy

    2016-01-01

    An individual's access to health insurance influences the amount and type of health services a patient receives for prevention and treatment, and, ultimately, influences survival. The North American Association of Central Cancer Registries (NAACCR) Item #630, Primary Payer at DX, is a required field intended to document health insurance status for the purpose of supporting patterns-of-care studies and other research. However, challenges related to the uniformity of collection and availability of data needed to populate this field diminish the value of the Primary Payer at DX data. A NAACCR taskforce worked on issues surrounding the collection of Primary Payer at DX; including proposing a crosswalk between Primary Payer at DX and the new Public Health Payment Typology standard, often available in hospital discharge databases. However, there are issues with compatibility between coding systems, intent of data collection, timelines for coding insurance, and changes in insurance coverage (partly due to the Affordable Care Act) that continue to complicate the collection and use of Primary Payer at DX data.

  10. Changes in Payer Mix and Physician Reimbursement After the Affordable Care Act and Medicaid Expansion

    Jones, Christine D.; Scott, Serena J.; Anoff, Debra L.; Pierce, Read G.; Glasheen, Jeffrey J.

    2015-01-01

    Although uncompensated care for hospital-based care has fallen dramatically since the implementation of the Affordable Care Act and Medicaid expansion, the changes in hospital physician reimbursement are not known. We evaluated if payer mix and physician reimbursement by encounter changed between 2013 and 2014 in an academic hospitalist practice in a Medicaid expansion state. This was a retrospective cohort study of all general medicine inpatient admissions to an academic hospitalist group in 2013 and 2014. The proportion of encounters by payer and reimbursement/inpatient encounter were compared in 2013 versus 2014. A sensitivity analysis determined the relative contribution of different factors to the change in reimbursement/encounter. Among 37 540 and 40 397 general medicine inpatient encounters in 2013 and 2014, respectively, Medicaid encounters increased (17.3% to 30.0%, P reimbursement/encounter increased 4.2% from $79.98/encounter in 2013 to $83.36/encounter in 2014 (P reimbursement for encounter type by payer accounted for −0.7%, 0.8%, 2.0%, and 2.3% of the reimbursement change, respectively. From 2013 to 2014, Medicaid encounters increased, and uninsured and private payer encounters decreased within our hospitalist practice. Reimbursement/encounter also increased, much of which could be attributed to a change in payer mix. Further analyses of physician reimbursement in Medicaid expansion and non-expansion states would further delineate reimbursement changes that are directly attributable to Medicaid expansion. PMID:26310500

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

    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

  12. Paying Medicare Advantage plans by competitive bidding: how much competition is there?

    Biles, Brian; Pozen, Jonah; Guterman, Stuart

    2009-08-01

    Private health plans that enroll Medicare beneficiaries--known as Medicare Advantage (MA) plans--are being paid $11 billion more in 2009 than it would cost to cover these beneficiaries in regular fee-for-service Medicare. To generate Medicare savings for offsetting the costs of health reform, the Obama Administration has proposed eliminating these extra payments to private insurers and instituting a competitive bidding system that pays MA plans based on the bids they submit. This study examines the concentration of enrollment among MA plans and the degree to which firms offering MA plans actually face competition. The results show that in the large majority of U.S. counties, MA plan enrollment is highly concentrated in a small number of firms. Given the relative lack of competition in many markets as well as the potential impact on traditional Medicare, the authors call for careful consideration of a new system for setting MA plan payments.

  13. Relative efficacy of drugs: an emerging issue between regulatory agencies and third-party payers.

    Eichler, Hans-Georg; Bloechl-Daum, Brigitte; Abadie, Eric; Barnett, David; König, Franz; Pearson, Steven

    2010-04-01

    Drug regulatory agencies have traditionally assessed the quality, safety and efficacy of drugs, and the current paradigm dictates that a new drug should be licensed when the benefits outweigh the risks. By contrast, third-party payers base their reimbursement decisions predominantly on the health benefits of the drug relative to existing treatment options (termed relative efficacy; RE). Over the past decade, the role of payers has become more prominent, and time-to-market no longer means time-to-licensing but time-to-reimbursement. Companies now have to satisfy the sometimes divergent needs of both regulators and payers, and to address RE during the pre-marketing stages. This article describes the current political background to the RE debate and presents the scientific and methodological challenges as they relate to RE assessment. In addition, we explain the impact of RE on drug development, and speculate on future developments and actions that are likely to be required from key players.

  14. Shift in U.S. payer responsibility for the acute care of violent injuries after the Affordable Care Act: Implications for prevention.

    Coupet, Edouard; Karp, David; Wiebe, Douglas J; Kit Delgado, M

    2018-03-28

    Investment in violence prevention programs is hampered by lack of clearly identifiable stakeholders with a financial stake in prevention. We determined the total annual charges for the acute care of injuries from interpersonal violence and the shift in financial responsibility for these charges after the Medicaid expansion from the Affordable Care Act in 2014. We analyzed all emergency department (ED) visits from 2009 to 2014 with diagnosis codes for violent injury in the Nationwide Emergency Department Sample (NEDS). We used sample weights to estimate total charges with adjusted generalized linear models to estimate charges for the 15% of ED visits with missing charge data. We then calculated the share attributable by payer and determined the difference in proportion by payer from 2013 to 2014. Between 2009 and 2013, the uninsured accounted for 28.2-31.3% of annual charges for the acute care of violent injury, while Medicaid was responsible for a similar amount (29.0-31.0%). In 2014, there were $10.7 billion in total charges for violent injury. Medicaid assumed the greatest share, 39.8% (95% CI: 38.0-41.5%, $3.5-5.1 billion), while the uninsured accounted for 23.6% (95% CI: 22.2-24.9%, $2.0-3.0 billion), and Medicare accounted for 7.8% (95% CI: 7.7-8.0%, $0.7-1.0 billion). After Medicaid expansion, taxpayers are now accountable for nearly half of the $10.7 billion in annual charges for the acute care of violent injury in the U.S. These findings highlight the benefit to state Medicaid programs of preventing interpersonal violence. Published by Elsevier Inc.

  15. Variations in Medicare Reimbursement in Radiation Oncology: An Analysis of the Medicare Provider Utilization and Payment Data Set.

    Vu, Charles C; Lanni, Thomas B; Robertson, John M

    2016-04-01

    The purposes of this study were to summarize recently published data on Medicare reimbursement to individual radiation oncologists and to identify the causes of variation in Medicare reimbursement in radiation oncology. The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF), which details nearly all services provided by radiation oncologists in 2012, was used for this study. The data were filtered and analyzed by physician and by billing code. Statistical analysis was performed to identify differences in reimbursements based on sex, rurality, billing of technical services, or location in a certificate of need (CON) state. There were 4135 radiation oncologists who received a total of $1,499,625,803 in payments from Medicare in 2012. Seventy-five percent of radiation oncologists were male. The median reimbursement was $146,453. The code with the highest total reimbursement was 77418 (radiation treatment delivery intensity modulated radiation therapy [IMRT]). The most commonly billed evaluation and management (E/M) code for new visits was 99205 (49%). The most commonly billed E/M code for established visits was 99213 (54%). Forty percent of providers billed none of their new office visits using 99205 (the highest E/M billing code), whereas 34% of providers billed all of their new office visits using 99205. For the 1510 radiation oncologists (37%) who billed technical services, median Medicare reimbursement was $606,008, compared with $93,921 for all other radiation oncologists (Preimbursement. The billing of technical services, with their high capital and labor overhead requirements, limits any comparison in reimbursement between individual radiation oncologists or between radiation oncologists and other specialists. Male sex and rural practice location are independent predictors of higher total Medicare reimbursements. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. The economic impact of improving phosphate binder therapy adherence and attainment of guideline phosphorus goals in hemodialysis patients: a Medicare cost-offset model.

    Ramakrishnan, Karthik; Braunhofer, Peter; Newsome, Britt; Lubeck, Deborah; Wang, Steven; Deuson, Jennifer; Claxton, Ami J

    2014-12-01

    Hyperphosphatemia (serum phosphorus >5.5 mg/dL) in hemodialysis patients is a key factor in mineral and bone disorders and is associated with increased hospitalization and mortality risks. Treatment with oral phosphate binders offers limited benefit in achieving target serum phosphorus concentrations due to high daily pill burden (7-10 pills/day) and associated poor medication adherence. The economic value of improving phosphate binder adherence and increasing percent time in range (PTR) for target phosphorus concentrations has not been previously assessed in dialysis patients. The current retrospective analysis was conducted to summarize health care cost savings to United States (US) payers associated with improved phosphate binder adherence and increased PTR for target phosphorus concentrations in adult end-stage renal disease (ESRD) patients receiving hemodialysis therapy. Phosphate binder adherence and PTR were derived from hemodialysis patients who were treated at a large dialysis organization between January 2007 and December 2011. Cost model inputs were derived from US Renal Data System data between July 2007 and December 2009. A cost-offset model was constructed to estimate monthly and annual incremental health care costs (total Medicare; inpatient, outpatient, and Medicare Part B) associated with different levels of phosphate binder adherence and PTR. Model inputs included number of ESRD patients, population adherence to phosphate binders, PTR associated with adherence to phosphate binders, and per-patient per-month cost associated with PTR. A base case model estimated monthly and annual costs of phosphate binder therapy in the population using estimated model inputs. The estimated adherence rate was used to determine number of patients in compliant and noncompliant groups. Monthly costs were calculated as the sum of per-patient per-month cost times the number of patients in adherent and nonadherent groups. Annual costs were monthly costs times 12 and

  17. 77 FR 29647 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    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...

  18. The Medicare Annual Wellness Visit.

    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.

  19. 78 FR 10610 - TRICARE; Demonstration Project for Participation in Maryland Multi-Payer Patient Centered Medical...

    2013-02-14

    ... National Committee on Quality Assurance Patient Centered Medical Home (PPC-PCMH) recognition criteria... quality improvements. TMA Defense Health Cost Assessment and Evaluation (DHCAPE) staff will calculate... Maryland Multi-Payer Patient Centered Medical Home Program (MMPCMHP) Demonstration AGENCY: Department of...

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

    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

  1. Impact of the New Jersey all-payer rate-setting system: an analysis of financial ratios.

    Rosko, M D

    1989-01-01

    Although prospective payment may contain costs, many analysts are concerned about the unintended consequences of rate regulation. This article presents the results of a case-study analysis of the New Jersey rate-setting programs during the period 1977-1985. Using measures of profitability, liquidity, and leverage, data for New Jersey, the Northeast, and the United States as a whole are used to contrast the impact of two forms of prospective payment. After attempting alternative cost-containment methods, the New Jersey Department of Health implemented an all-payer system in which prospective rates of compensation were established for DRGs. The new rate-setting system was designed to control costs, improve access to care, maintain quality of services, ensure financial viability of efficient providers, and limit the payment differentials associated with cost shifting. The results of this study have a number of implications for the evaluation of all-payer rate regulation. First, although the New Jersey all-payer system was more successful than the partial-payer program in restraining the rate of increase in cost per case, savings were achieved without adversely affecting the viability of regulated hospitals. Second, the large differentials among payers that were associated with the partial-payer program were reduced dramatically by the all-payer program. Third, using the financial position of inner-city hospitals relative to suburban hospitals as a measure of equity, the all-payer system appeared to be a fairer method of regulating rates.

  2. Payer and Pharmaceutical Manufacturer Considerations for Outcomes-Based Agreements in the United States.

    Brown, Joshua D; Sheer, Rich; Pasquale, Margaret; Sudharshan, Lavanya; Axelsen, Kirsten; Subedi, Prasun; Wiederkehr, Daniel; Brownfield, Fred; Kamal-Bahl, Sachin

    2018-01-01

    Considerable interest exists among health care payers and pharmaceutical manufacturers in designing outcomes-based agreements (OBAs) for medications for which evidence on real-world effectiveness is limited at product launch. To build hypothetical OBA models in which both payer and manufacturer can benefit. Models were developed for a hypothetical hypercholesterolemia OBA, in which the OBA was assumed to increase market access for a newly marketed medication. Fixed inputs were drug and outcome event costs from the literature over a 1-year OBA period. Model estimates were developed using a range of inputs for medication effectiveness, medical cost offsets, and the treated population size. Positive or negative feedback to the manufacturer was incorporated on the basis of expectations of drug performance through changes in the reimbursement level. Model simulations demonstrated that parameters had the greatest impact on payer cost and manufacturer reimbursement. Models suggested that changes in the size of the population treated and drug effectiveness had the largest influence on reimbursement and costs. Despite sharing risk for potential product underperformance, manufacturer reimbursement increased relative to having no OBA, if the OBA improved market access for the new product. Although reduction in medical costs did not fully offset the cost of the medication, the payer could still save on net costs per patient relative to having no OBA by tying reimbursement to drug effectiveness. Pharmaceutical manufacturers and health care payers have demonstrated interest in OBAs, and under a certain set of assumptions both may benefit. Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

  3. Payer Negotiations in the New Healthcare Environment: How to Prepare for and Succeed in a Value-Based World.

    Howrigon, Ron

    2016-01-01

    Because of their involvement with the Affordable Care exchanges, the national insurance companies have reported significant financial losses. As a result, there will soon be significant payer pressure to reduce medical expenses. To succeed in future negotiations with the payers, medical practices must understand the needs of the payers and then play to those needs. The author is a former managed care executive with more than 25 years of experience managing provider networks and implementing payer strategies for some of the largest payers in the United States. In this article, he outlines important things medical practices should be doing to prepare for the new world of value-based contracting. Medical practices that embrace this change and work hard to evolve with the future are the ones that are going to survive and succeed.

  4. Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service.

    Huckfeldt, Peter J; Escarce, José J; Rabideau, Brendan; Karaca-Mandic, Pinar; Sood, Neeraj

    2017-01-01

    Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health. Project HOPE—The People-to-People Health Foundation, Inc.

  5. Estimating anesthesia and surgical procedure times from medicare anesthesia claims.

    Silber, Jeffrey H; Rosenbaum, Paul R; Zhang, Xuemei; Even-Shoshan, Orit

    2007-02-01

    Procedure times are important variables that often are included in studies of quality and efficiency. However, due to the need for costly chart review, most studies are limited to single-institution analyses. In this article, the authors describe how well the anesthesia claim from Medicare can estimate chart times. The authors abstracted information on time of induction and entrance to the recovery room ("anesthesia chart time") from the charts of 1,931 patients who underwent general and orthopedic surgical procedures in Pennsylvania. The authors then merged the associated bills from claims data supplied from Medicare (Part B data) that included a variable denoting the time in minutes for the anesthesia service. The authors also investigated the time from incision to closure ("surgical chart time") on a subset of 1,888 patients. Anesthesia claim time from Medicare was highly predictive of anesthesia chart time (Kendall's rank correlation tau = 0.85, P < 0.0001, median absolute error = 5.1 min) but somewhat less predictive of surgical chart time (Kendall's tau = 0.73, P < 0.0001, median absolute error = 13.8 min). When predicting chart time from Medicare bills, variables reflecting procedure type, comorbidities, and hospital type did not significantly improve the prediction, suggesting that errors in predicting the chart time from the anesthesia bill time are not related to these factors; however, the individual hospital did have some influence on these estimates. Anesthesia chart time can be well estimated using Medicare claims, thereby facilitating studies with vastly larger sample sizes and much lower costs of data collection.

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

    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

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

    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

  8. Is expanding Medicare coverage cost-effective?

    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.

  9. Real-World Evidence: Useful in the Real World of US Payer Decision Making? How? When? And What Studies?

    Malone, Daniel C; Brown, Mary; Hurwitz, Jason T; Peters, Loretta; Graff, Jennifer S

    2018-03-01

    To examine how real-world evidence (RWE) is currently perceived and used in managed care environments, especially to inform pharmacy and therapeutic (P&T) committee decisions, to assess which study factors (e.g., data, design, and funding source) contribute to RWE utility in decisions, and to identify barriers to consideration of RWE studies in P&T decision making. We conducted focus groups/telephone-based interviews and surveys to understand perceptions of RWE and assess awareness, quality, and relevance of two high-profile examples of published RWE studies. A purposive sample comprised 4 physicians, 15 pharmacists, and 1 researcher representing 18 US health plans and health system organizations. Participants reported that RWE was generally used, or useful, to inform safety monitoring, utilization management, and cost analysis, but less so to guide P&T decisions. Participants were not aware of the two sample RWE studies but considered both studies to be valuable. Relevant research questions and outcomes, transparent methods, study quality, and timely results contribute to the utility of published RWE. Perceived organizational barriers to the use of published RWE included lack of skill, training, and timely study results. Payers recognize the value of RWE, but use of such studies to inform P&T decisions varies from organization to organization and is limited. Relevance to payers, timeliness, and transparent methods were key concerns with RWE. Participants recognized the need for continuing education on evaluating and using RWE to better understand the study methods, findings, and applicability to their organizations. Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

  10. Use of Oritavancin in Moderate-to-Severe ABSSSI Patients Requiring IV Antibiotics: A U.S. Payer Budget Impact Analysis.

    Jensen, Ivar S; Wu, Elizabeth; Fan, Weihong; Lodise, Thomas P; Nicolau, David P; Dufour, Scott; Cyr, Philip L; Sulham, Katherine A

    2016-06-01

    It is estimated that acute bacterial skin and skin structure infections (ABSSSI) account for nearly 10% of hospital admissions and 3.4-3.8 million emergency department visits per year in the United States. Analyses of hospital discharge records indicate 74% of ABSSSI admissions involve empiric treatment with methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics. Analysis has shown that payer costs could be reduced if moderate-to-severe ABSSSI patients were treated to a greater extent in the observational unit followed by discharge to outpatient parenteral antibiotic therapy (OPAT). Oritavancin is a lipoglycopeptide antibiotic with bactericidal activity against gram-positive bacteria, including MRSA. To estimate the impact on a U.S. payer's budget of using single-dose oritavancin in ABSSSI patients with suspected MRSA involvement who are indicated for intravenous antibiotics. A decision analytic model based on current clinical practice was developed to estimate the economic value of decreased hospital resource consumption by using single-dose oritavancin over a 1-year time horizon. Use of antibiotics was informed by an analysis of the Premier Research Database. Demographic and clinical data were derived from a targeted literature review. Emergency department, observation, laboratory, and administration costs used were Medicare National Limitation amounts. Drug costs were 2014 wholesale acquisition costs. For a hypothetical U.S. payer with 1,000,000 members, it is expected that approximately 14,285 members per year will be diagnosed with ABSSSI severe enough to indicate intravenous antibiotics with MRSA activity. Based on this simulation, use of single-dose oritavancin in 26% of these patients was estimated to reduce the number of inpatient admissions, reduce length of stay for patients requiring admission, and reduce the number of days a patient needs to receive daily infusions in the OPAT clinic. The total patient days decreased from 171,125 to 133

  11. The Medicare Cost Report and the limits of hospital accountability: improving financial accounting data.

    Kane, N M; Magnus, S A

    2001-02-01

    Health policy makers, legislators, providers, payers, and a broad range of other players in the health care market routinely seek information on hospital financial performance. Yet the data at their disposal are limited, especially since hospitals' audited financial statements--the "gold standard" in hospital financial reporting--are not publicly available in many states. As a result, the Medicare Cost Report (MCR), filed annually by most U.S. hospitals in order to receive payment for treating Medicare patients, has become the primary public source of hospital financial information. However, financial accounting elements in the MCR are unreliable, poorly defined, and lacking in critical detail. Comparative analyses of MCRs and matched, audited financial statements reveal long-standing problems with the MCR's data, including major differences in reported profits; variations in the reporting of both revenues and expenses; an absence of relevant details, such as charity care, bad debt, operating versus nonoperating income, and affiliate transactions; an inconsistent classification of changes in net assets; and a failure to provide cash flow statements. Because of these problems, MCR financial data give only a limited and often inaccurate picture of the financial position of hospitals. Audited financial statements provide a more complete perspective, enabling analysts to address important questions left unanswered by the MCR data. Regulatory action is needed to create a national database of financial information based upon audited statements.

  12. Older women's health and financial vulnerability: implications of the Medicare benefit structure.

    Sofaer, S; Abel, E

    1990-01-01

    Elderly women and men have different patterns of disease and utilize health services differently. This essay examines the extent to which Medicare covers the specific conditions and services associated with women and men. Elderly women experience higher rates of poverty than elderly men; consequently, elderly women are especially likely to be unable to pay high out-of-pocket costs for health care. Using a new method for simulating out-of-pocket costs, the Illness Episode Approach, the essay shows that Medicare provides better coverage for illnesses which predominate among men than for those which predominate among women. In addition, women on Medicare who supplement their basic coverage by purchasing a typical private insurance "Medigap" policy do not receive as much of an advantage from their purchases as do men. The calculations also show that the Medicare Catastrophic Coverage Act would have had little impact on the gender gap in financial vulnerability.

  13. Medicare Provider Utilization and Payment Data - Outpatient

    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...

  14. Basic Stand Alone Medicare Inpatient Claims PUF

    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...

  15. Medicare Provider Payment Data - Home Health Agencies

    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...

  16. Medicare Referring Provider (DMEPOS) Data CY2013

    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...

  17. Medicare Provider Payment Data - Skilled Nursing Facilities

    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...

  18. Medicare Provider Analysis and Review (MEDPAR)

    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...

  19. Medicare Referring Provider DMEPOS PUF CY2013

    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...

  20. Medicare Provider Utilization and Payment Data - Inpatient

    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)...

  1. Medicare Geographic Variation - Public Use File

    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...

  2. Medicare Demonstration Projects and Evaluation Reports

    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...

  3. Enhancing Medicares Hospital Acquired Conditions Policy

    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...

  4. Appeals - Redetermination by a Medicare Contractor

    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...

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

    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...

  6. Medicare Preventive Services Quick Reference Tool

    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...

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

    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...

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

    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...

  9. Costs and Clinical Quality Among Medicare Beneficiaries..

    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,...

  10. Medicare Provider Data - Physician and Other Supplier

    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...

  11. Geographic Variation in Medicare Spending Dashboard

    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...

  12. Medicare Prescription Drug Coverage - General Information

    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...

  13. Medicare Part D Opioid Drug Mapping Tool

    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...

  14. Flu shots and the characteristics of unvaccinated elderly Medicare beneficiaries.

    Lochner, Kimberly A; Wynne, Marc

    2011-12-21

    Data from the Medicare Current Beneficiary Survey, 2009. • Overall, 73% of Medicare beneficiaries aged 65 years and older reported receiving a flu shot for the 2008 flu season, but vaccination rates varied by socio-demographic characteristics. Flu vaccination was lowest for beneficiaries aged 65-74 years old, who were non-Hispanic Blacks and Hispanics, were not married, had less than a high school education, or who were eligible for Medicaid (i.e., dual eligibles). • Healthcare utilization and personal health behavior were also related to vaccination rates, with current smokers and those with no hospitalizations or physician visits being less likely to be vaccinated. • Among those beneficiaries who reported receiving a flu shot, 59% received it in a physician's office or clinic, with the next most common setting being in the community (21%); e.g., grocery store, shopping mall, library, or church. • Among those beneficiaries who did not receive a flu shot, the most common reasons were beliefs that the shot could cause side effects or disease (20%), that they didn't think the shot could prevent the flu (17%), or that the shot wasn't needed (16%). Less than 1% reported that they didn't get the flu shot because of cost. Elderly persons (aged 65 years and older) are at increased risk of complications from influenza, with the majority of influenza-related hospitalizations and deaths occurring among the elderly (Fiore et al., 2010). Most physicians recommend their elderly patients get a flu shot each year, and many hospitals inquire about elderly patient's immunization status upon admission, providing a vaccination if requested. The importance of getting a flu shot is underscored by the Department of Health and Human Services' Healthy People initiative, which has set a vaccination goal of 90% for the Nation's elderly by the year 2020 (Department of Health and Human Services [DHHS], 2011). Although all costs related to flu shots are covered by Medicare, requiring

  15. A successful Charter challenge to medicare? Policy options for Canadian provincial governments.

    Flood, Colleen M; Thomas, Bryan

    2018-03-26

    In September 2016, a case went to trial in British Columbia that seeks to test the constitutionality of provincial laws that (1) ban private health insurance for medically necessary hospital and physician services; (2) ban extra-billing (physicians cannot charge patients more than the public tariff); and (3) require physicians to work solely for the public system or 'opt-out' and practice privately. All provinces have similar laws that have been passed to meet the requirements of federal legislation, the Canada Health Act (and thus qualify for federal funds). Consequently, a finding of unconstitutionality of one or more of these laws could have a very significant impact on the future of Canada's single-payer system ('medicare'). However, should the court find that a particular law is not in compliance with the Canadian Charter of Rights and Freedoms, the baton is then passed back to the government which may respond with other laws or policies that they believe to be constitutionally compliant. The ultimate impact of any successful Charter challenge to laws protecting medicare from privatization will thus significantly depend on how Canadian governments respond. Provincial governments could allow privatization to undercut equity and access, or they could respond creatively with new legal and policy solutions to both improve equity and access and tackle some of the problems that have long bedeviled Canadian medicare. This paper provides an understanding - grounded in comparative health systems evidence - of law and policy options available to Canadian lawmakers for limiting two-tier care in the wake of any successful challenge to existing laws. The paper presents the results of a large inter-disciplinary, comparative study, started in 2015, that systematically reviewed the legal and broader regulatory schemes used to regulate the public/private divide in 15 Organization for Economic Co-Operation and Development countries with a particular eye to what the effect of

  16. Financial Performance of Rural Medicare ACOs.

    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. Association between payer mix and costs, revenues and profitability: a cross-sectional study of Lebanese hospitals.

    Saleh, S; Ammar, W; Natafgi, N; Mourad, Y; Dimassi, H; Harb, H

    2015-09-08

    This study aimed to examine the association between the payer mix and the financial performance of public and private hospitals in Lebanon. The sample comprised 24 hospitals, representing the variety of hospital characteristics in Lebanon. The distribution of the payer mix revealed that the main sources of revenue were public sources (61.1%), out-of-pocket (18.4%) and private insurance (18.2%). Increases in the percentage of revenue from public sources were associated with lower total costs and revenues, but not profit margins. An inverse association was noted between increased revenue from private insurance and profitability, attributed to increased costs. Increased percentage of out of- pocket payments was associated with lower costs and higher profitability. The study provides evidence that payer mix is associated with hospital costs, revenues and profitability. This should initiate/inform discussions between public and private payers and hospitals about the level of payment and its association with hospital sector financial viability.

  18. Functional impairment and hospital readmission in Medicare seniors.

    Greysen, S Ryan; Stijacic Cenzer, Irena; Auerbach, Andrew D; Covinsky, Kenneth E

    2015-04-01

    Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment. To assess the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors. We created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22,289 Medicare hospitalizations from January 1, 2000, through December 31, 2010. Outcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission. Patients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4% were female, 84.9% were white, 89.6% reported 3 or more comorbidities, and 86.0% had 1 or more hospitalizations in the previous year. Overall, 48.3% had some level of functional impairment before admission, and 15.5% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95% CI, 0.94-1.20), 14.4% with difficulty with 1 or more

  19. 77 FR 16841 - Medicare Program; Solicitation for Proposals for the Medicare Graduate Nurse Education...

    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...

  20. Eight reasons payer interoperability and data sharing are essential in ACOs. Interoperability standards could be a prerequisite to measuring care.

    Mookencherry, Shefali

    2012-01-01

    It makes strategic and business sense for payers and providers to collaborate on how to take substantial cost out of the healthcare delivery system. Acting independently, neither medical groups, hospitals nor health plans have the optimal mix of resources and incentives to significantly reduce costs. Payers have core assets such as marketing, claims data, claims processing, reimbursement systems and capital. It would be cost prohibitive for all but the largest providers to develop these capabilities in order to compete directly with insurers. Likewise, medical groups and hospitals are positioned to foster financial interdependence among providers and coordinate the continuum of patient illnesses and care settings. Payers and providers should commit to reasonable clinical and cost goals, and share resources to minimize expenses and financial risks. It is in the interest of payers to work closely with providers on risk-management strategies because insurers need synergy with ACOs to remain cost competitive. It is in the interest of ACOs to work collaboratively with payers early on to develop reasonable and effective performance benchmarks. Hence, it is essential to have payer interoperability and data sharing integrated in an ACO model.

  1. Management of sacroiliac joint disruption and degenerative sacroiliitis with nonoperative care is medical resource-intensive and costly in a United States commercial payer population

    Ackerman, Stacey J; Polly, David W; Knight, Tyler; Holt, Tim; Cummings, John

    2014-01-01

    Introduction Low back pain is common and originates in the sacroiliac (SI) joint in 15%–30% of cases. Traditional SI joint disruption/degenerative sacroiliitis treatments include nonoperative care or open SI joint fusion. To evaluate the usefulness of newly developed minimally-invasive technologies, the costs of traditional treatments must be better understood. We assessed the costs of nonoperative care for SI joint disruption to commercial payers in the United States (US). Methods A retrospective study of claim-level medical resource use and associated costs used the MarketScan® Commercial Claims and Encounters as well as Medicare Supplemental Databases of Truven Healthcare. Patients with a primary ICD-9-CM diagnosis code for SI joint disruption (720.2, 724.6, 739.4, 846.9, or 847.3), an initial date of diagnosis from January 1, 2005 to December 31, 2007 (index date), and continuous enrollment for ≥1 year before and 3 years after the index date were included. Claims attributable to SI joint disruption with a primary or secondary ICD-9-CM diagnosis code of 71x.xx, 72x.xx, 73x.xx, or 84x.xx were identified; the 3-year medical resource use-associated reimbursement and outpatient pain medication costs (measured in 2011 US dollars) were tabulated across practice settings. A subgroup analysis was performed among patients with lumbar spinal fusion. Results The mean 3-year direct, attributable medical costs were $16,196 (standard deviation [SD] $28,592) per privately-insured patient (N=78,533). Among patients with lumbar spinal fusion (N=434), attributable 3-year mean costs were $91,720 (SD $75,502) per patient compared to $15,776 (SD $27,542) per patient among patients without lumbar spinal fusion (N=78,099). Overall, inpatient hospitalizations (19.4%), hospital outpatient visits and procedures (14.0%), and outpatient pain medications (9.6%) accounted for the largest proportion of costs. The estimated 3-year insurance payments attributable to SI joint disruption

  2. Medicare managed care plan performance: a comparison across hospitalization types.

    Basu, Jayasree; Mobley, Lee Rivers

    2012-01-01

    The study evaluates the performance of Medicare managed care (Medicare Advantage [MA]) Plans in comparison to Medicare fee-for-service (FFS) Plans in three states with historically high Medicare managed care penetration (New York, California, Florida), in terms of lowering the risks of preventable or ambulatory care sensitive conditions (ACSC) hospital admissions and providing increased referrals for admissions for specialty procedures. Using 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP-SID) of the Agency for Healthcare Research and Quality, ACSC admissions are compared with 'marker' admissions and 'referral-sensitive' admissions, using a multinomial logistic regression approach. The year 2004 represents a strategic time to test the impact of MA on preventable hospitalizations, because the HMOs dominated the market composition in that time period. MA enrollees in California experienced 22% lower relative risk (RRR= 0.78, p<0.01), those in Florida experienced 16% lower relative risk (RRR= 0.84, p<0.01), while those in New York experienced 9% lower relative risk (RRR=0.91, p<0.01) of preventable (versus marker) admissions compared to their FFS counterparts. MA enrollees in New York experienced 37% higher relative risk (RRR=1.37, p<0.01) and those in Florida had 41% higher relative risk (RRR=1.41, p<0.01)-while MA enrollees in California had 13% lower relative risk (RRR=0.87, p<0.01)-of referral-sensitive (versus marker) admissions compared to their FFS counterparts. While MA plans were associated with reductions in preventable hospitalizations in all three states, the effects on referral-sensitive admissions varied, with California experiencing lower relative risk of referral-sensitive admissions for MA plan enrollees. The lower relative risk of preventable admissions for MA plan enrollees in New York and Florida became more pronounced after accounting for selection bias.

  3. Health Expenditure Growth under Single-Payer Systems: Comparing South Korea and Taiwan.

    Cheng, Shou-Hsia; Jin, Hyun-Hyo; Yang, Bong-Min; Blank, Robert H

    2018-05-03

    Achieving universal health coverage has been an important goal for many countries worldwide. However, the rapid growth of health expenditures has challenged all nations, both those with and without such universal coverage. Single-payer systems are considered more efficient for administrative affairs and may be more effective for containing costs than multipayer systems. However, South Korea, which has a typical single-payer scheme, has almost the highest growth rate in health expenditures among industrialized countries. The aim of the present study is to explicate this situation by comparing South Korea with Taiwan. This study analyzed statistical reports published by government departments in South Korea and Taiwan from 2001 to 2015, including population and economic statistics, health statistics, health expenditures, and social health insurance reports. Between 2001 and 2015, the per capita national health expenditure (NHE) in South Korea grew 292%, whereas the corresponding growth of per capita NHE in Taiwan was only 83%. We find that the national health insurance (NHI) global budget cap in Taiwan may have restricted the growth of health expenditures. Less comprehensive benefit coverage for essential diagnosis/treatment services under the South Korean NHI program may have contributed to the growth of out-of-pocket payments. The expansion of insurance coverage for vulnerable individuals may also contribute to higher growth in NHE in South Korea. Explicit regulation of health care resource distribution may also lead to more limited provisioning and utilization of health services in Taiwan. Under analogous single-payer systems, South Korea had a much higher growth in health spending than Taiwan. The annual budget cap for total reimbursement, more comprehensive coverage for essential diagnosis and treatment services, and the regulation of health care resource distribution are important factors associated with the growth of health expenditures. Copyright © 2018

  4. Medicare and Medicaid fraud and abuse regulations.

    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.

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

    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

  6. Managed care and inpatient mortality in adults: effect of primary payer.

    Hines, Anika L; Raetzman, Susan O; Barrett, Marguerite L; Moy, Ernest; Andrews, Roxanne M

    2017-02-08

    Because managed care is increasingly prevalent in health care finance and delivery, it is important to ascertain its effects on health care quality relative to that of fee-for-service plans. Some stakeholders are concerned that basing gatekeeping, provider selection, and utilization management on cost may lower quality of care. To date, research on this topic has been inconclusive, largely because of variation in research methods and covariates. Patient age has been the only consistently evaluated outcome predictor. This study provides a comprehensive assessment of the association between managed care and inpatient mortality for Medicare and privately insured patients. A cross-sectional design was used to examine the association between managed care and inpatient mortality for four common inpatient conditions. Data from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases for 11 states were linked to data from the American Hospital Association Annual Survey Database. Hospital discharges were categorized as managed care or fee for service. A phased approach to multivariate logistic modeling examined the likelihood of inpatient mortality when adjusting for individual patient and hospital characteristics and for county fixed effects. Results showed different effects of managed care for Medicare and privately insured patients. Privately insured patients in managed care had an advantage over their fee-for-service counterparts in inpatient mortality for acute myocardial infarction, stroke, pneumonia, and congestive heart failure; no such advantage was found for the Medicare managed care population. To the extent that the study showed a protective effect of privately insured managed care, it was driven by individuals aged 65 years and older, who had consistently better outcomes than their non-managed care counterparts. Privately insured patients in managed care plans, especially older adults, had better outcomes than those in fee-for-service plans

  7. Can health promotion programs save Medicare money?

    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

  8. Economic burden of hospitalizations of Medicare beneficiaries with heart failure

    Kilgore M

    2017-05-01

    Full Text Available Meredith Kilgore,1 Harshali K Patel,2 Adrian Kielhorn,2 Juan F Maya,2 Pradeep Sharma1 1Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, 2Amgen, Inc., Thousand Oaks, CA, USA Objective: The objective of this study was to assess the costs associated with the hospitalization and the cumulative 30-, 60-, and 90-day readmission rates in a cohort of Medicare beneficiaries with heart failure (HF.Methods: This was a retrospective, observational study based on data from the national 5% sample of Medicare beneficiaries. Inpatient data were gathered for Medicare beneficiaries with at least one HF-related hospitalization between July 1, 2005, and December 31, 2011. The primary end point was the average per-patient cost of hospitalization for individuals with HF. Secondary end points included the cumulative rate of hospitalization, the average length of hospital stay, and the cumulative 30-, 60-, and 90-day readmission rates.Results: Data from 63,678 patients with a mean age of 81.8 years were included in the analysis. All costs were inflated to $2,015 based on the medical care component of the Consumer Price Index. The mean per-patient cost of an HF-related hospitalization was $14,631. The mean per-patient cost of a cardiovascular (CV-related or all-cause hospitalization was $16,000 and $15,924, respectively. The cumulative rate of all-cause hospitalization was 218.8 admissions per 100 person-years, and the median length of stay for HF-related, CV-related, and all-cause hospitalizations was 5 days. Also, 22.3% of patients were readmitted within 30 days, 33.3% were readmitted within 60 days, and 40.2% were readmitted within 90 days.Conclusion: The costs associated with hospitalization for Medicare beneficiaries with HF are substantial and are compounded by a high rate of readmission. Keywords: heart failure, Medicare, health economics, hospitalization, costs

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

    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-Medicaid Enrollee Profiles (State and National)

    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...

  11. Medicare Post-Acute Care Episodes and Payment Bundling

    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...

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

    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...

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

    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...

  14. Medicare Beneficiary Knowledge of the Part D Program

    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...

  15. Medicare and Medicaid Trends in Health Care Sectors

    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...

  16. Measuring Coding Intensity in the Medicare Advantage Program

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

    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...

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

    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...

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

    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...

  20. 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.

    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.

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

    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.

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

    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.

  3. Cost savings and enhanced hospice enrollment with a home-based palliative care program implemented as a hospice-private payer partnership.

    Kerr, Christopher W; Donohue, Kathleen A; Tangeman, John C; Serehali, Amin M; Knodel, Sarah M; Grant, Pei C; Luczkiewicz, Debra L; Mylotte, Kathleen; Marien, Melanie J

    2014-12-01

    In the United States, 5% of the population is responsible for nearly half of all health care expenditures, with a large concentration of spending driven by individuals with expensive chronic conditions in their last year of life. Outpatient palliative care under the Medicare Hospice Benefit excludes a large proportion of the chronically ill and there is widespread recognition that innovative strategies must be developed to meet the needs of the seriously ill while reducing costs. This study aimed to evaluate the impact of a home-based palliative care program, implemented through a hospice-private payer partnership, on health care costs and utilization. This was a prospective, observational database study where insurance enrollment and claims data were analyzed. The study population consisted of Home Connections (HC) program patients enrolled between January 1, 2010 and December 31, 2012 who subsequently expired (n=149) and who were also Independent Health members. A control group (n=537) was derived using propensity-score matching. The primary outcome variable was overall costs within the last year of life. Costs were also examined at six months, three months, one month, and two weeks. Inpatient, outpatient, ancillary, professional, and pharmacy costs were compared between the two groups. Medical service utilization and hospice enrollment and length of stay were also evaluated. Cost savings were apparent in the last three months of life—$6,804 per member per month (PMPM) cost for palliative care participants versus $10,712 for usual care. During the last two weeks of life, total allowed PMPM was $6,674 versus $13,846 for usual care. Enhanced hospice entry (70% versus 25%) and longer length of stay in hospice (median 34 versus 9 days) were observed. Palliative care programs partnered with community hospice providers may achieve cost savings while helping provide care across the continuum.

  4. Why Hospitals and Payers are Recommending Home Care Upon Discharge Instead of SNF or Traditional Home Health Services--Alternative Payment Model Hospital Incentives Aligning with Patient Choice.

    Luke, Josh

    2016-01-01

    Seniors and other hospital patients in the United States have traditionally had the option of being discharged to a skilled nursing facility (convalescent home) for post-acute services, or home with nursing and therapy services provided in the home setting. Traditionally, these home based services have been referred to as "home health." As more Americans have retired, home health services have expanded and are readily accessible. This growth put tremendous stress on the Medicare fund which pays for senior care services. However, "Home Care," which traditionally has been viewed as non-medical home based services, has also become a booming industry for the cost conscious in recent years as more Americans reach retirement age. With the passing of the Affordable Care Act in 2010, providers and payers are now finding themselves responsible for post-acute care and continuous patient health, so cost efficient solutions for post-acute care are thriving. For the first time in history, American hospitals and Insurers are recognizing Home Care as an effective model that achieves the Triple Aim of Health Care reform. Home Care, which is no longer completely non-medical services, has proven to be an integral part of the care continuum for seniors in recent years and is now becoming a viable solution for keeping patients well, while still honoring their desire to age and heal at home. This paper analyzes the benefits and risks of home care and provides a clear understanding as to why American hospitals are emphasizing SNF Avoidance and skipping home health, opting instead to refer patients directly to home care as the preferred discharge solution in a value based model.

  5. 75 FR 46833 - 45th Anniversary of Medicare and Medicaid

    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...

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

    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…

  7. Linking individual medicare health claims data with work-life claims and other administrative data.

    Mokyr Horner, Elizabeth; Cullen, Mark R

    2015-09-30

    Researchers investigating health outcomes for populations over age 65 can utilize Medicare claims data, but these data include no direct information about individuals' health prior to age 65 and are not typically linkable to files containing data on exposures and behaviors during their worklives. The current paper is a proof-of-concept, of merging employers' administrative data and private, employment-based health claims with Medicare data. Characteristics of the linked data, including sensitivity and specificity, are evaluated with an eye toward potential uses of such linked data. This paper uses a sample of former manufacturing workers from an industrial cohort as a test case. The dataset created by this integration could be useful to research in areas such as social epidemiology and occupational health. Medicare and employment administrative data were linked for a large cohort of manufacturing workers (employed at some point during 1996-2008) who transitioned onto Medicare between 2001-2009. Data on work-life health, including biometric indicators, were used to predict health at age 65 and to investigate the concordance of employment-based insurance claims with subsequent Medicare insurance claims. Chronic diseases were found to have relatively high levels of concordance between employment-based private insurance and subsequent Medicare insurance. Information about patient health prior to receipt of Medicare, including biometric indicators, were found to predict health at age 65. Combining these data allows for evaluation of continuous health trajectories, as well as modeling later-life health as a function of work-life behaviors and exposures. It also provides a potential endpoint for occupational health research. This is the first harmonization of its kind, providing a proof-of-concept. The dataset created by this integration could be useful for research in areas such as social epidemiology and occupational health.

  8. 76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

    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...

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

    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.

  10. Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data.

    Kim, Hyunjee; McConnell, K John; Sun, Benjamin C

    2017-08-01

    The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.

  11. Success under duress: policies and practices managers view as keys to profitability in five California hospitals with challenging payer mix.

    Rundall, Thomas; Oberlin, Shelley; Thygesen, Brian; Janus, Katharina

    2012-01-01

    Hospitals with a challenging payer mix (CPM)-high proportions of uninsured and Medicaid patients and a low proportion of commercially insured patients-are an important source of care for low-income, uninsured people. Achieving profitability is difficult for CPM hospitals. From 2005 through 2008, only one-third of 67 CPM hospitals in California reported positive total margins. In-depth group interviews were completed with the management leadership teams of a diverse group of five profitable CPM hospitals to identify the management strategies and practices that the hospitals' leadership teams credited for their financial success. Twelve management policy and practice topics were identified. Four of the policies and practices that managers identified involve organizational actions to increase hospital revenue or operational efficiency. These factors are consistent with those identified in previous research. However, managers also identified eight factors not previously revealed in research on hospital profitability, including management policies and practices that establish the organizational culture, workforce, relationships, monitoring systems, and governance necessary to ensure that hospital employees and affiliated physicians support and successfully implement organizational actions necessary to achieve profitability.

  12. Can health promotion programs save Medicare money?

    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

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

    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...

  14. Payers' experiences with confidential pharmaceutical price discounts: A survey of public and statutory health systems in North America, Europe, and Australasia.

    Morgan, Steven G; Vogler, Sabine; Wagner, Anita K

    2017-04-01

    Institutional payers for pharmaceuticals worldwide appear to be increasingly negotiating confidential discounts off of the official list price of pharmaceuticals purchased in the community setting. We conducted an anonymous survey about experiences with and attitudes toward confidential discounts on patented pharmaceuticals in a sample of high-income countries. Confidential price discounts are now common among the ten health systems that participated in our study, though some had only recently begun to use these pricing arrangements on a routine basis. Several health systems had used a wide variety of discounting schemes in the past two years. The most frequent discount received by participating health systems was between 20% and 29% of official list prices; however, six participants reported their health system received one or more discount over the past two years that was valued at 60% or more of the list prices. On average, participants reported that confidential discounts were more common, complex, and significant for specialty pharmaceuticals than for primary care pharmaceuticals. Participants had a more favorable view of the impact of confidential discount schemes on their health systems than on the global marketplace. Overall, the frequency, complexity, and scale of confidential discounts being routinely negotiated suggest that the list prices for medicines bear limited resemblance to what many institutional payers actually pay. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

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

    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.

  16. Card index of coal user-payers in the system of accounting and analysis of coal marketing

    Czapka, D

    1980-01-01

    A card index of coal users-payers was formed on the basis of an existing card file of payers which functions in development of an earlier subsystem of financial accounting of coal users by means of a corresponding reorganization of the available set of data and supplementing it with new data on users. The card index performs a monitor and address function. Checked and refined data are input in subsequent technological cycles of data conversion. The structure of the card file, its functions, realization conditions with output of necessary following results are examined.

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

    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.

  18. How alternative payment models in emergency medicine can benefit physicians, payers, and patients.

    Harish, Nir J; Miller, Harold D; Pines, Jesse M; Zane, Richard D; Wiler, Jennifer L

    2017-06-01

    While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system. Copyright © 2017 Elsevier Inc. All rights reserved.

  19. Financing care for the uninsured: the dilemma vexes New Jersey hospitals and payers.

    Wells, E V

    1996-05-01

    New Jersey's diverse constituencies and special interest groups don't usually agree on a public policy issue. However, almost everyone in the public policy arena agrees that hospitals should treat people who show up in emergency departments with problems requiring medical attention. For over a decade, Garden State policymakers, payers, and providers have faced the dilemma of excess demand on hospitals that treat the uninsured. This demand has risen due to increasing health care costs, development of costly technology, state deregulation of hospital payments, and employers' reluctance to insure workers and their families coupled with a mobile workforce holding part-time and seasonal jobs. The fiscal solvency of inner-city hospitals is threatened yet the problem continues to elude resolution.

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

    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.

  1. The Payer and Patient Cost Burden of Open Breast Conserving Procedures Following Percutaneous Breast Biopsy.

    Kimball, Chloe C; Nichols, Christine I; Vose, Joshua G

    2018-01-01

    Percutaneous core-needle biopsy (PCNB) is the standard of care to biopsy and diagnose suspicious breast lesions. Dependent on histology, many patients require additional open procedures for definitive diagnosis and excision. This study estimated the payer and patient out-of-pocket (OOP) costs, and complication risk, among those requiring at least 1 open procedure following PCNB. This retrospective study used the Truven Commercial database (2009-2014). Women who underwent PCNB, with continuous insurance, and no history of cancer, chemotherapy, radiation, or breast surgery in the prior year were included. Open procedures were defined as open biopsy or lumpectomy. Study follow-up ended at chemotherapy, radiation, mastectomy, or 90 days-whichever occurred first. In total, 143 771 patients (mean age 48) met selection criteria; 85.1% underwent isolated PCNB, 12.4% one open procedure, and 2.5% re-excision. Incidence of complications was significantly lower among those with PCNB alone (9.2%) vs 1 open procedure (15.6%) or re-excision (25.3%, P  open procedure vs PCNB alone (US $17 125 vs US $3935, P  open procedure vs PCNB alone (US $1527 vs US $669), and US $247 greater for re-excision vs 1 procedure. A meaningful proportion of patients underwent open procedure(s) following PCNB which was associated with increased complication risk and costs to both the payer and the patient. These results suggest a need for technologies to reduce the proportion of cases requiring open surgery and, in some cases, re-excision.

  2. Challenges around Access to and Cost of Life-Saving Medications after Allogeneic Hematopoietic Cell Transplantation for Medicare Patients.

    Farnia, Stephanie; Ganetsky, Alex; Silver, Alicia; Hwee, Theresa; Preussler, Jaime; Griffin, Joan; Khera, Nandita

    2017-08-01

    Hematopoietic cell transplantation (HCT) is an expensive, medically complicated, and potentially life-threatening therapy for multiple hematologic and nonhematologic disorders with a prolonged trajectory of recovery. Similar to financial issues in other cancer treatments, adverse financial consequences of HCT are emerging as an important issue and may be associated with poor quality of life and increased distress in HCT survivors. Prescription medicine coverage for HCT for Medicare and some Medicaid beneficiaries, especially in the long-term, remains suboptimal because of inadequate payer formularies or prohibitive copays. With an increasing number of older patients undergoing HCT and improvement in the overall survival after HCT, the problem of financial burden faced by Medicare beneficiaries with fixed incomes is going to worsen. In this article, we describe the typical financial burden borne by HCT recipients based on estimated copayment amounts attached to the categories of key medications as elucidated through 2 case studies. We also suggest some possible solutions for consideration to help these patients and families get through the HCT by minimizing the financial burden from essential medications needed during the post-HCT period. Copyright © 2017 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

  3. The payers perspective on MIH-CP programs. How to make a case for funding your project.

    Zavadsky, Matt

    2015-07-01

    Here are some key points to consider when engaging in conversations with potential payers for EMS-based MIH-CP programs. The realignment of fiscal incentives within the healthcare system has created an environment that encourages providers and payers to work together to right-size utilization. Providers and payers are often unaware of the true value EMS agencies can bring to their patients through proactive and innovative patient navigation services. You need to tell them--or, better yet, show them. You may need to do a small demonstration project with a handful of patients to prove you can make a difference. In order to understand the new environment, you need to become well-versed in healthcare metrics, specifically as they relate to the partners to whom you'll be proposing. Be sure you know things like readmission rates and penalties, value-based purchasing penalties, HCAHPS scores, MSPB and other motivating factors you. can use to help build the business case for your audience. For many in EMS, crafting partnerships for. payment of services not related to ambulance transport is a new and scary thing. Hopefully the examples provided here from payers paying for MIH services have demonstrated that their perspective is not much different from ours. We are all trying to do the right things for our patients, improve their experience of care and reduce the cost of the healthcare system.

  4. HIE sustainability secrets. NeHC report shares HIE success stories of alternate revenue streams and payer buy-in.

    Prestigiacomo, Jennifer

    2011-11-01

    Getting effective stakeholder engagement, including that of payers, and creating innovative value-added services that provide alternate revenue streams beyond basic subscription services, are just a couple of the common traits of the flourishing health information exchanges profiled in the sustainability report released in August by the National eHealth Collaborative.

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

    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

  6. How End-Stage Renal Disease Patients Manage the Medicare Part D Coverage Gap

    Kovacs, Pamela J.; Perkins, Nathan; Nuschke, Elizabeth; Carroll, Norman

    2012-01-01

    Medicare Part D was enacted to help elderly and disabled individuals pay for prescription drugs, but it was structured with a gap providing no coverage in 2010 between $2,830 and $6,440. Patients with end-stage renal disease (ESRD) are especially likely to be affected due to high costs of dialysis-related drugs and the importance of adherence for…

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

    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.

  8. Bariatric Surgery Coverage: a Comprehensive Budget Impact Analysis from a Payer Perspective.

    Palli, Swetha R; Rizzo, John A; Heidrich, Natalie

    2018-06-01

    The objective of this study was to estimate a payer's budget impact of bariatric surgery coverage under (1) unrestricted, (2) budget-restricted ($500,000/year), and (3) quantity-restricted (100/year) medical benefit plan scenarios versus non-coverage in general and type 2 diabetes mellitus (T2DM) populations over a 10-year period. Using recently published literature and health technology assessment reports, the model evaluated a hypothetical payer population of 100,000 members under current real-world trends: BMI-defined obesity groups (31.3% normal/underweight, 33% overweight, 20.4% obese, 9% severely obese and 6.3% morbidly obese), T2DM prevalence (6.7-27.5%; 100% for the T2DM model), surgery type (LAGB, BPD/DS, VSG, and RYGB), and differential outcomes (T2DM resolution, costs, and reoperation and complications rates). Assuming a surgery election rate of 1.42% among eligible candidates with a 3% discount rate and 10% annual surgery turnover rate, the model calculated the incremental cost per-member-per-month (PMPM) by estimating the difference in total non-T2DM and T2DM-related expected costs and savings. One-way (± 25%) sensitivity analysis was performed. The impact of covering bariatric surgery under multiple scenarios for a general (or T2DM) population ranged from an additional $0.3 to $3.6 (T2DM: $0.3 to $10.5) PMPM in year 1. Incremental costs diminished over time, breaking even between years 5 and 9 (T2DM: 5-6), and by year 10, cost savings were estimated to be between $1.5 and $4.8 (T2DM: $1.2 and $31.8). Providing bariatric surgery coverage may have a modest short-term budget impact increase but would lead to long-term net cost savings in a general population model. The cost savings were much more pronounced in the T2DM model.

  9. Management of sacroiliac joint disruption and degenerative sacroiliitis with nonoperative care is medical resource-intensive and costly in a United States commercial payer population

    Ackerman SJ

    2014-02-01

    Full Text Available Stacey J Ackerman,1 David W Polly Jr,2 Tyler Knight,3 Tim Holt,4 John Cummings5 1Covance Market Access Services Inc, San Diego, CA, USA; 2University of Minnesota, Orthopaedic Surgery, Minneapolis, MN, USA; 3Covance Market Access Services Inc, Gaithersburg, MD, USA; 4Montgomery Spine Center, Orthopaedic Surgery, Montgomery, AL, USA; 5Community Health Network, Neurosurgery, Indianapolis, IN, USA Introduction: Low back pain is common and originates in the sacroiliac (SI joint in 15%–30% of cases. Traditional SI joint disruption/degenerative sacroiliitis treatments include nonoperative care or open SI joint fusion. To evaluate the usefulness of newly developed minimally-invasive technologies, the costs of traditional treatments must be better understood. We assessed the costs of nonoperative care for SI joint disruption to commercial payers in the United States (US. Methods: A retrospective study of claim-level medical resource use and associated costs used the MarketScan® Commercial Claims and Encounters as well as Medicare Supplemental Databases of Truven Healthcare. Patients with a primary ICD-9-CM diagnosis code for SI joint disruption (720.2, 724.6, 739.4, 846.9, or 847.3, an initial date of diagnosis from January 1, 2005 to December 31, 2007 (index date, and continuous enrollment for ≥1 year before and 3 years after the index date were included. Claims attributable to SI joint disruption with a primary or secondary ICD-9-CM diagnosis code of 71x.xx, 72x.xx, 73x.xx, or 84x.xx were identified; the 3-year medical resource use-associated reimbursement and outpatient pain medication costs (measured in 2011 US dollars were tabulated across practice settings. A subgroup analysis was performed among patients with lumbar spinal fusion. Results: The mean 3-year direct, attributable medical costs were $16,196 (standard deviation [SD] $28,592 per privately-insured patient (N=78,533. Among patients with lumbar spinal fusion (N=434, attributable 3-year

  10. Variation in Medicare Expenditures for Treating Perioperative Complications: The Cost of Rescue.

    Pradarelli, Jason C; Healy, Mark A; Osborne, Nicholas H; Ghaferi, Amir A; Dimick, Justin B; Nathan, Hari

    2016-12-21

    Treating surgical complications presents a major challenge for hospitals striving to deliver high-quality care while reducing costs. Costs associated with rescuing patients from perioperative complications are poorly characterized. To evaluate differences across hospitals in the costs of care for patients surviving perioperative complications after major inpatient surgery. Retrospective cohort study using claims data from the Medicare Provider Analysis and Review files. We compared payments for patients who died vs patients who survived after perioperative complications occurred. Hospitals were stratified using average payments for patients who survived following complications, and payment components were analyzed across hospitals. Administrative claims database of surgical patients was analyzed at hospitals treating Medicare patients nationwide. This study included Medicare patients aged 65 to 100 years who underwent abdominal aortic aneurysm repair (n = 69 207), colectomy for cancer (n = 107 647), pulmonary resection (n = 91 758), and total hip replacement (n = 307 399) between 2009 and 2012. Data analysis took place between November 2015 and March 2016. Clinical outcome of surgery (eg, no complication, complication and death, or complication and survival) and the individual hospital where a patient received an operation. Risk-adjusted, price-standardized Medicare payments for an episode of surgery. Risk-adjusted perioperative outcomes were also assessed. The mean age for Medicare beneficiaries in this study ranged from 74.1 years (pulmonary resection) to 78.2 years (colectomy). The proportion of male patients ranged from 37% (total hip replacement) to 77% (abdominal aortic aneurysm repair), and most patients were white. Among patients who experienced complications, those who were rescued had higher price-standardized Medicare payments than did those who died for all 4 operations. Assessing variation across hospitals, payments for patients

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

    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.

  12. Volume of Requests for Internet Medicare Replacement Cards

    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...

  13. Association Between Race, Neighborhood, and Medicaid Enrollment and Outcomes in Medicare Home Health Care.

    Joynt Maddox, Karen E; Chen, Lena M; Zuckerman, Rachael; Epstein, Arnold M

    2018-02-01

    More than 3 million Medicare beneficiaries use home health care annually, yet little is known about how vulnerable beneficiaries fare in the home health setting. This is particularly important given the recent launch of Medicare's Home Health Value-Based Purchasing model. The objective of this study was to determine odds of adverse clinical outcomes associated with dual enrollment in Medicaid and Medicare as a marker of individual poverty, residence in a low-income ZIP code tabulation area (ZCTA), and black race. Retrospective observational study using individuals-level logistic regression. Home health care. Fee-for-service Medicare beneficiaries from 2012 to 2014. Thirty- and 60-day clinical outcomes, including readmissions, admissions, and emergency department (ED) use. Home health agencies serving a high proportion of dually enrolled, low-income ZCTA, or black beneficiaries were less often high-quality. Dually-enrolled, low-income ZCTA, and Black beneficiaries receiving home health care after hospitalization had higher risk-adjusted odds of 30-day readmission (odds ratio [OR] = 1.08, P home health care without preceding hospitalization had higher 60-day admission (OR = 1.06, P home health services who are dually enrolled, live in a low-income neighborhood, or are black have higher rates of adverse clinical outcomes. These populations may be an important target for quality improvement under Home Health Value-Based Purchasing. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  14. 78 FR 72089 - Medicare, Medicaid, and Children's Health Insurance Programs; Provider Enrollment Application Fee...

    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...

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

    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.

  16. 75 FR 58405 - Medicare Program; Meeting of the Advisory Panel on Medicare Education, October 13, 2010

    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...

  17. 75 FR 3742 - Medicare Program; Meeting of the Advisory Panel on Medicare Education; Cancellation of the...

    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...

  18. 76 FR 59138 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    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...

  19. 75 FR 58407 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    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...

  20. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    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...

  1. 77 FR 59618 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    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...

  2. 76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

    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...

  3. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    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...

  4. 75 FR 52629 - Medicare Program; Establishing Additional Medicare Durable Medical Equipment, Prosthetics...

    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...

  5. 77 FR 69850 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible...

    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...

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

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

    2017-09-01

    Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear. To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans. Retrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries. Enrollment in an MA plan. Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care. The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker

  7. Utilization and growth patterns of sacroiliac joint injections from 2000 to 2011 in the medicare population.

    Manchikanti, Laxmaiah; Hansen, Hans; Pampati, Vidyasagar; Falco, Frank J E

    2013-01-01

      The high prevalence of persistent low back pain and growing number of diagnostic and therapeutic modalities employed to manage chronic low back pain and the subsequent impact on society and the economy continue to hold sway over health care policy. Among the multiple causes responsible for chronic low back pain, the contributions of the sacroiliac joint have been a subject of debate albeit a paucity of research. At present, there are no definitive conservative, interventional or surgical management options for managing sacroiliac joint pain. It has been shown that the increases were highest for facet joint interventions and sacroiliac joint blocks with an increase of 310% per 100,000 Medicare beneficiaries from 2000 to 2011. There has not been a systematic assessment of the utilization and growth patterns of sacroiliac joint injections. Analysis of the growth patterns of sacroiliac joint injections in Medicare beneficiaries from 2000 to 2011. To evaluate the utilization and growth patterns of sacroiliac joint injections. This assessment was performed utilizing Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011. The findings of this assessment in Medicare beneficiaries from 2000 to 2011 showed a 331% increase per 100,000 Medicare beneficiaries with an annual increase of 14.2%, compared to an increase in the Medicare population of 23% or annual increase of 1.9%. The number of procedures increased from 49,554 in 2000 to 252,654 in 2011, or a rate of 125 to 539 per 100,000 Medicare beneficiaries. Among the various specialists performing sacroiliac joint injections, physicians specializing in physical medicine and rehabilitation have shown the most increase, followed by neurology with 1,568% and 698%, even though many physicians from both specialties have been enrolling in interventional pain management and pain management. Even though the numbers were small for nonphysician providers including

  8. Compared to Canadians, U.S. physicians spend nearly four times as much money interacting with payers.

    Zimmerman, Christina

    2011-11-01

    (1) In Canadian office practices, physi­cians spent 2.2 hours per week interacting with payers, nurses spent 2.5 hours, and clerical staff spent 15.9 hours. In U.S. practices, physicians spent 3.4 hours per week interacting with payers, nurses spent 20.6 hours, and clerical staff spent 53.1 hours. (2) Canadian physician practices spent $22,205 per physician per year on interactions with health plans. U.S. physician practices spent $82,975 per physician per year. (3) U.S. physician practices spend $60,770 per physician per year more (approximately four times as much) than their Canadian counterparts.

  9. Economic Evaluation of PCSK9 Inhibitors in Reducing Cardiovascular Risk from Health System and Private Payer Perspectives.

    Alejandro Arrieta

    Full Text Available The introduction of Proprotein covertase subtilisin/kexin type 9 (PCSK9 inhibitors has been heralded as a major advancement in reducing low-density lipoprotein cholesterol levels by nearly 50%. However, concerns have been raised on the added value to the health care system in terms of their costs and benefits. We assess the cost-effectiveness of PCSK9 inhibitors based on a decision-analytic model with existing clinical evidence. The model compares a lipid-lowering therapy based on statin plus PCSK9 inhibitor treatment with statin treatment only (standard therapy. From health system perspective, incremental cost per quality adjusted life years (QALYs gained are presented. From a private payer perspective, return-on-investment and net present values over patient lifespan are presented. At the current annual cost of $14,000 to $15,000, PCSK9 inhibitors are not cost-effective at an incremental cost of about $350,000 per QALY. Moreover, for every dollar invested in PCSK9 inhibitors, the private payer loses $1.98. Our study suggests that the annual treatment price should be set at $4,250 at a societal willingness-to-pay of $100,000 per QALY. However, we estimate the breakeven price for private payer is only $600 per annual treatment. At current prices, our study suggests that PCSK9 inhibitors do not add value to the U.S. health system and their provision is not profitable for private payers. To be the breakthrough drug in the fight against cardiovascular disease, the current price of PCSK9 inhibitors must be reduced by more than 70%.

  10. Payer Perspectives on PCSK9 Inhibitors: A Conversation with Stephen Gorshow, MD, and James T. Kenney, RPh, MBA.

    Mehr, Stanton R

    2016-02-01

    The new proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can have significant budget effects, depending on the breadth of the US Food and Drug Administration (FDA)'s approved labeling. American Health & Drug Benefits asked Stephen Gorshow, MD, Regional Medical Director, UnitedHealthcare, and James T. Kenney, RPh, MBA, Manager, Specialty and Pharmacy Contracts, Harvard Pilgrim Health Care, to participate in a teleconference to better understand how payers are approaching the management of these agents.

  11. Performance-Based Risk-Sharing Arrangements: U.S. Payer Experience.

    Goble, Joseph A; Ung, Brian; van Boemmel-Wegmann, Sascha; Navarro, Robert P; Parece, Andrew

    2017-10-01

    As a result of global concern about rising drug costs, many U.S. payers and European agencies such as the National Health Service have partnered with pharmaceutical companies in performance-based risk-sharing arrangements (PBRSAs) by which manufacturers share financial risk with health care purchasing entities and authorities. However, PBRSAs present many administrative and legal challenges that have minimized successful contract experiences in the United States. To (a) identify drug and disease characteristics and contract components that contribute to successful PBRSA experiences and the primary barriers to PBRSA execution and (b) explore solutions to facilitate contract negotiation and execution. A 37-item, web-based survey instrument (Qualtrics), approximately 20 minutes in duration, was open during July and August 2016. The survey was emailed to 90 pharmacy and medical directors of various health care organizations. Statistical analysis included the Kruskal-Wallis test and chi-square tests to examine differences among payer responses. Survey responses were anonymized and data were aggregated. Twenty-seven individuals completed the survey (30% completion rate). The majority of respondents worked for regional health plans (52%, n = 14), covering at least 1 million lives (63%, n = 17), with at least 7 years of managed care experience (81%, n = 22). A total of 51 PBRSAs were active among respondents at the time of the survey. Easily obtainable and evaluable drug data and medical data were the most important drug and disease attributes for successful PBRSAs, respectively. Pharmacy claims and patient demographic data were assessed as "very easy and inexpensive" to collect. Type and amount of manufacturer payment for drug outcome performance failure, endpoint measurement, and necessary clinical data for drug performance measurement were all critical factors for successful PBRSAs. Standardized contract templates and transparent contract financial risk evaluation and

  12. Physician trainees' decision making and information processing: choice size and Medicare Part D.

    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.

  13. Myths and memes about single-payer health insurance in the United States: a rebuttal to conservative claims.

    Geyman, John P

    2005-01-01

    Recent years have seen the rapid growth of private think tanks within the neoconservative movement that conduct "policy research" biased to their own agenda. This article provides an evidence-based rebuttal to a 2002 report by one such think tank, the Dallas-based National Center for Policy Analysis (NCPA), which was intended to discredit 20 alleged myths about single-payer national health insurance as a policy option for the United States. Eleven "myths" are rebutted under eight categories: access, cost containment, quality, efficiency, single-payer as solution, control of drug prices, ability to compete abroad (the "business case"), and public support for a single-payer system. Six memes (self-replicating ideas that are promulgated without regard to their merits) are identified in the NCPA report. Myths and memes should have no place in the national debate now underway over the future of a failing health care system, and need to be recognized as such and countered by experience and unbiased evidence.

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

    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.

  15. 78 FR 6272 - Rules Relating to Additional Medicare Tax; Correction

    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...

  16. Understanding Trends in Medicare Spending, 2007-2014.

    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.

  17. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    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...

  18. Variation in Payment Rates under Medicare's Inpatient Prospective Payment System.

    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.

  19. 20 CFR 404.1018b - Medicare qualified government employment.

    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...

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

    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

  1. Do Medicare Advantage Plans Select Enrollees in Higher Margin Clinical Categories?

    Newhouse, Joseph P.; McWilliams, J. Michael; Price, Mary; Huang, Jie; Fireman, Bruce; Hsu, John

    2013-01-01

    The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or Average Revenue/Average Cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans’ margins for these 48 conditions are correlated (r=0.39, pincentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC’s in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation of high margin HCC’s in Medicare more generally. These results do not permit a conclusion on overall social efficiency, but we note that selection according to margin could be socially efficient. In addition, our findings suggest there are omitted interaction terms in the risk adjustment model that Medicare currently uses. PMID:24308879

  2. Rising Prices of Targeted Oral Anticancer Medications and Associated Financial Burden on Medicare Beneficiaries.

    Shih, Ya-Chen Tina; Xu, Ying; Liu, Lei; Smieliauskas, Fabrice

    2017-08-01

    Purpose The high cost of oncology drugs threatens the affordability of cancer care. Previous research identified drivers of price growth of targeted oral anticancer medications (TOAMs) in private insurance plans and projected the impact of closing the coverage gap in Medicare Part D in 2020. This study examined trends in TOAM prices and patient out-of-pocket (OOP) payments in Medicare Part D and estimated the actual effects on patient OOP payments of partial filling of the coverage gap by 2012. Methods Using SEER linked to Medicare Part D, 2007 to 2012, we identified patients who take TOAMs via National Drug Codes in Part D claims. We calculated total drug costs (prices) and OOP payments per patient per month and compared their rates of inflation with general health care prices. Results The study cohort included 42,111 patients who received TOAMs between 2007 and 2012. Although the general prescription drug consumer price index grew at 3% per year over 2007 to 2012, mean TOAM prices increased by nearly 12% per year, reaching $7,719 per patient per month in 2012. Prices increased over time for newly and previously launched TOAMs. Mean patient OOP payments dropped by 4% per year over the study period, with a 40% drop among patients with a high financial burden in 2011, when the coverage gap began to close. Conclusion Rising TOAM prices threaten the financial relief patients have begun to experience under closure of the coverage gap in Medicare Part D. Policymakers should explore methods of harnessing the surge of novel TOAMs to increase price competition for Medicare beneficiaries.

  3. Atrial fibrillation, stroke, and anticoagulation in Medicare beneficiaries: trends by age, sex, and race, 1992-2010.

    Shroff, Gautam R; Solid, Craig A; Herzog, Charles A

    2014-06-03

    We evaluated temporal trends in ischemic stroke and warfarin use among demographic subsets of the US Medicare population that are not well represented in randomized trials of warfarin for stroke prevention in nonvalvular atrial fibrillation (AF). One-year cohorts of Medicare-primary payer patients (1992-2010) were created using the Medicare 5% sample. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify AF and ischemic and hemorrhagic stroke; ≥ 3 consecutive prothrombin time claims were used to identify warfarin use. Ischemic stroke rates (per 1000 patient-years) decreased markedly from 1992 to 2010. Among women, rates decreased from 37.1 to 13.6 for ages 65 to 74 years, from 55.2 to 16.5 for ages 74 to 84, and from 66.9 to 22.9 for age ≥ 85; warfarin use increased 31% to 59%, 27% to 63%, and 15% to 49%, respectively. Among men, rates decreased from 33.8 to 11.7 for ages 65 to 74 years, from 49.2 to 13.8 for ages 75 to 84, and from 51.5 to 18.0 for age ≥ 85; warfarin use increased 34% to 63%, 28% to 66%, and 15% to 55%, respectively. Rates decreased from 47.0 to 14.8 for whites and 73.0 to 29.3 for blacks; warfarin use increased 27% to 61% and 19% to 52%, respectively. In all age categories, the thromboembolic risk (CHADS [congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke]) score was significantly higher among women (versus men) and blacks (versus whites). Ischemic stroke rates among Medicare AF patients decreased significantly in all demographic subpopulations from 1992-2010, coincident with increasing warfarin use. Ischemic stroke rates remained higher and warfarin use rates remained lower for women and blacks with AF, groups whose baseline CHADS scores were higher. © 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

  4. Costs and clinical quality among Medicare beneficiaries: associations with health center penetration of low-income residents.

    Sharma, Ravi; Lebrun-Harris, Lydie A; Ngo-Metzger, Quyen

    2014-01-01

    Determine the association between access to primary care by the underserved and Medicare spending and clinical quality across hospital referral regions (HRRs). Data on elderly fee-for-service beneficiaries across 306 HRRs came from CMS' Geographic Variation in Medicare Spending and Utilization database (2010). We merged data on number of health center patients (HRSA's Uniform Data System) and number of low-income residents (American Community Survey). We estimated access to primary care in each HRR by "health center penetration" (health center patients as a proportion of low-income residents). We calculated total Medicare spending (adjusted for population size, local input prices, and health risk). We assessed clinical quality by preventable hospital admissions, hospital readmissions, and emergency department visits. We sorted HRRs by health center penetration rate and compared spending and quality measures between the high- and low-penetration deciles. We also employed linear regressions to estimate spending and quality measures as a function of health center penetration. The high-penetration decile had 9.7% lower Medicare spending ($926 per capita, p=0.01) than the low-penetration decile, and no different clinical quality outcomes. Compared with elderly fee-for-service beneficiaries residing in areas with low-penetration of health center patients among low-income residents, those residing in high-penetration areas may accrue Medicare cost savings. Limited evidence suggests that these savings do not compromise clinical quality.

  5. The bribery statute: a new weapon against Medicare fraud.

    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.

  6. MIPPA: First Broad Changes to Medicare Part D Plan Operations.

    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.

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

    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.

  8. Transgender Medicare Beneficiaries and Chronic Conditions: Exploring Fee-for-Service Claims Data

    Guerino, Paul; Ewald, Erin; Laffan, Alison M.

    2017-01-01

    Abstract Purpose: Data on the health and well-being of the transgender population are limited. However, using claims data we can identify transgender Medicare beneficiaries (TMBs) with high confidence. We seek to describe the TMB population and provide comparisons of chronic disease burden between TMBs and cisgender Medicare beneficiaries (CMBs), thus laying a foundation for national level TMB health disparity research. Methods: Using a previously validated claims algorithm based on ICD-9-CM codes relating to transsexualism and gender identity disorder, we identified a cohort of TMBs using Medicare Fee-for-Service (FFS) claims data. We then describe the demographic characteristics and chronic disease burden of TMBs (N = 7454) and CMBs (N = 39,136,229). Results: Compared to CMBs, a greater observed proportion of TMBs are young (under age 65) and Black, although these differences vary by entitlement. Regardless of entitlement, TMBs have more chronic conditions than CMBs, and more TMBs have been diagnosed with asthma, autism spectrum disorder, chronic obstructive pulmonary disease, depression, hepatitis, HIV, schizophrenia, and substance use disorders. TMBs also have higher observed rates of potentially disabling mental health and neurological/chronic pain conditions, as well as obesity and other liver conditions (nonhepatitis), compared to CMBs. Conclusion: This is the first systematic look at chronic disease burden in the transgender population using Medicare FFS claims data. We found that TMBs experience multiple chronic conditions at higher rates than CMBs, regardless of Medicare entitlement. TMBs under age 65 show an already heavy chronic disease burden which will only be exacerbated with age. PMID:29125908

  9. Cost to primary care practices of responding to payer requests for quality and performance data.

    Halladay, Jacqueline R; Stearns, Sally C; Wroth, Thomas; Spragens, Lynn; Hofstetter, Sara; Zimmerman, Sheryl; Sloane, Philip D

    2009-01-01

    We wanted to determine how much it costs primary care practices to participate in programs that require them to gather and report data on care quality indicators. Using mixed quantitative-qualitative methods, we gathered data from 8 practices in North Carolina that were selected purposively to be diverse by size, ownership, type, location, and medical records. Formal practice visits occurred between January 2008 and May 2008. Four quality-reporting programs were studied: Medicare's Physician Quality Reporting Initiative (PQRI), Community Care of North Carolina (CCNC), Bridges to Excellence (BTE), and Improving Performance in Practice (IPIP). We estimated direct costs to the practice and on-site costs to the quality organization for implementation and maintenance phases of program participation. Major expenses included personnel time for planning, training, registry maintenance, visit coding, data gathering and entry, and modification of electronic systems. Costs per full-time equivalent clinician ranged from less than $1,000 to $11,100 during program implementation phases and ranged from less than $100 to $4,300 annually during maintenance phases. Main sources of variation included program characteristics, amount of on-site assistance provided, experience and expertise of practice personnel, and the extent of data system problems encountered. The costs of a quality-reporting program vary greatly by program and are important to anticipate and understand when undertaking quality improvement work. Incentives that would likely improve practice participation include financial payment, quality improvement skills training, and technical assistance with electronic system troubleshooting.

  10. Executive function, episodic memory, and Medicare expenditures.

    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.

  11. Medicare Part D and Portfolio Choice.

    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.

  12. Identifying the Transgender Population in the Medicare Program

    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

  13. Medication adherence and Medicare expenditure among beneficiaries with heart failure.

    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.

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

    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.

  15. Home Health Agency Characteristics and Quality Outcomes for Medicare Beneficiaries With Rehabilitation-Sensitive Conditions.

    Mroz, Tracy M; Meadow, Ann; Colantuoni, Elizabeth; Leff, Bruce; Wolff, Jennifer L

    2018-06-01

    To examine associations between organizational characteristics of home health agencies (eg, profit status, rehabilitation therapy staffing model, size, and rurality) and quality outcomes in Medicare beneficiaries with rehabilitation-sensitive conditions, conditions for which occupational, physical, and/or speech therapy have the potential to improve functioning, prevent or slow substantial decline in functioning, or increase ability to remain at home safely. Retrospective analysis. Home health agencies. Fee-for-service beneficiaries (N=1,006,562) admitted to 9250 Medicare-certified home health agencies in 2009. Not applicable. Institutional admission during home health care, community discharge, and institutional admission within 30 days of discharge. Nonprofit (vs for-profit) home health agencies were more likely to discharge beneficiaries to the community (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.33) and less likely to have beneficiaries incur institutional admissions within 30 days of discharge (OR, .93; 95% CI, .88-.97). Agencies in rural (vs urban) counties were less likely to discharge patients to the community (OR, .83; 95% CI, .77-.90) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.24; 95% CI, 1.18-1.30) and within 30 days of discharge (OR, 1.15; 95% CI, 1.10-1.22). Agencies with contract (vs in-house) therapy staff were less likely to discharge beneficiaries to the community (OR, .79, 95% CI, .70-.91) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.09; 95% CI, 1.03-1.15) and within 30 days of discharge (OR, 1.17; 95% CI, 1.07-1.28). As payers continue to test and implement reimbursement mechanisms that seek to reward value over volume of services, greater attention should be paid to organizational factors that facilitate better coordinated, higher quality home health care for beneficiaries who may benefit from rehabilitation. Copyright © 2017

  16. 42 CFR 460.90 - PACE benefits under Medicare and Medicaid.

    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...

  17. 42 CFR 411.53 - Basis for conditional Medicare payment in no-fault cases.

    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...

  18. Use of Bone Scan During Initial Prostate Cancer Workup, Downstream Procedures, and Associated Medicare Costs

    Falchook, Aaron D. [Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (United States); Salloum, Ramzi G. [Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina (United States); Hendrix, Laura H. [Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (United States); Chen, Ronald C., E-mail: ronald_chen@med.unc.edu [Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (United States); Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (United States); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (United States)

    2014-06-01

    Purpose: For patients with a high likelihood of having metastatic disease (high-risk prostate cancer), bone scan is the standard, guideline-recommended test to look for bony metastasis. We quantified the use of bone scans and downstream procedures, along with associated costs, in patients with high-risk prostate cancer, and their use in low- and intermediate-risk patients for whom these tests are not recommended. Methods and Materials: Patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with prostate cancer from 2004 to 2007 were included. Prostate specific antigen (PSA), Gleason score, and clinical T stage were used to define D'Amico risk categories. We report use of bone scans from the date of diagnosis to the earlier of treatment or 6 months. In patients who underwent bone scans, we report use of bone-specific x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans, and bone biopsy within 3 months after bone scan. Costs were estimated using 2012 Medicare reimbursement rates. Results: In all, 31% and 48% of patients with apparent low- and intermediate-risk prostate cancer underwent a bone scan; of these patients, 21% underwent subsequent x-rays, 7% CT, and 3% MRI scans. Bone biopsies were uncommon. Overall, <1% of low- and intermediate-risk patients were found to have metastatic disease. The annual estimated Medicare cost for bone scans and downstream procedures was $11,300,000 for low- and intermediate-risk patients. For patients with apparent high-risk disease, only 62% received a bone scan, of whom 14% were found to have metastasis. Conclusions: There is overuse of bone scans in patients with low- and intermediate-risk prostate cancers, which is unlikely to yield clinically actionable information and results in a potential Medicare waste. However, there is underuse of bone scans in high-risk patients for whom metastasis is likely.

  19. Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.

    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.

  20. 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.

    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.

  1. Direct and indirect costs for adverse drug events identified in medical records across care levels, and their distribution among payers.

    Natanaelsson, Jennie; Hakkarainen, Katja M; Hägg, Staffan; Andersson Sundell, Karolina; Petzold, Max; Rehnberg, Clas; Jönsson, Anna K; Gyllensten, Hanna

    2017-11-01

    Adverse drug events (ADEs) cause considerable costs in hospitals. However, little is known about costs caused by ADEs outside hospitals, effects on productivity, and how the costs are distributed among payers. To describe the direct and indirect costs caused by ADEs, and their distribution among payers. Furthermore, to describe the distribution of patient out-of-pocket costs and lost productivity caused by ADEs according to socio-economic characteristics. In a random sample of 5025 adults in a Swedish county, prevalence-based costs for ADEs were calculated. Two different methods were used: 1) based on resource use judged to be caused by ADEs, and 2) as costs attributable to ADEs by comparing costs among individuals with ADEs to costs among matched controls. Payers of costs caused by ADEs were identified in medical records among those with ADEs (n = 596), and costs caused to individual patients were described by socio-economic characteristics. Costs for resource use caused by ADEs were €505 per patient with ADEs (95% confidence interval €345-665), of which 38% were indirect costs. Compared to matched controls, the costs attributable to ADEs were €1631, of which €410 were indirect costs. The local health authorities paid 58% of the costs caused by ADEs. Women had higher productivity loss than men (€426 vs. €109, p = 0.018). Out-of-pocket costs displaced a larger proportion of the disposable income among low-income earners than higher income earners (0.7% vs. 0.2%-0.3%). We used two methods to identify costs for ADEs, both identifying indirect costs as an important component of the overall costs for ADEs. Although the largest payers of costs caused by ADEs were the local health authorities responsible for direct costs, employers and patients costs for lost productivity contributed substantially. Our results indicate inequalities in costs caused by ADEs, by sex and income. Copyright © 2016 Elsevier Inc. All rights reserved.

  2. Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme.

    Hajati, Farshid; Atlantis, Evan; Bell, Katy J L; Girosi, Federico

    2018-03-08

    We examine the extent to which the adult Australian population on lipid-lowering medications receives the level of high-density lipoprotein cholesterol (HDL-C) testing recommended by national guidelines. We analysed records from 7 years (2008-2014) of the 10% publicly available sample of deidentified, individual level, linked Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) electronic databases of Australia. The PBS data were used to identify individuals on stable prescriptions of lipid-lowering treatment. The MBS data were used to estimate the annual frequency of HDL-C testing. We developed a methodology to address the issue of 'episode coning' in the MBS data, which causes an undercounting of pathology tests. We used a published figure on the proportion of unreported HDL-C tests to correct for the undercounting and estimate the probability that an HDL-C test was performed. We judged appropriateness of testing frequency by comparing the HDL-C testing rate to guidelines' recommendations of annual testing for people at high risk for cardiovascular disease. We estimated that approximately 49% of the population on stable lipid-lowering treatment did not receive any HDL-C test in a given year. We also found that approximately 19% of the same population received two or more HDL-C tests within the year. These levels of underutilisation and overutilisation have been changing at an average rate of 2% and -4% a year, respectively, since 2009. The yearly expenditure associated with test overutilisation was approximately $A4.3 million during the study period, while the cost averted because of test underutilisation was approximately $A11.3 million a year. We found that approximately half of Australians on stable lipid-lowering treatment may be having fewer HDL-C testing than recommended by national guidelines, while nearly one-fifth are having more tests than recommended. © Article author(s) (or their employer(s) unless otherwise stated in the text

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

    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...

  4. Medicare-Medicaid Ever-enrolled Trends Report

    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....

  5. State-County Profiles of Medicare-Medicaid dual Benes

    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...

  6. Use of Hospitalists by Medicare Benes, A National Picture

    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...

  7. Basic Stand Alone Medicare Claims Public Use Files

    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...

  8. State and National Profiles of Medicare-Medicaid dual Benes

    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.

  9. Basic Stand Alone Medicare DME Line Items PUF

    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...

  10. Basic Stand Alone Medicare Prescription Drug Events PUF

    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,...

  11. Medicare Data to Calculate Your Primary Service Areas

    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...

  12. Medicare Part D Prescriber Look-up Tool

    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....

  13. Characteristics of otolaryngology claims to Medicare in 2012.

    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.

  14. 75 FR 37971 - Providing Stability and Security for Medicare Reimbursements

    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...

  15. 76 FR 68011 - Medicare Program; Advanced Payment Model

    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.

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

    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.

  17. The National Market for Medicare Clinical Laboratory Testing

    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...

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

    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.

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

    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.

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

    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...

  1. Launching a medicare advantage plan: smart planning saves headaches.

    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.

  2. National Profile of Medicare-Medicaid dual Beneficiaries

    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...

  3. 42 CFR 421.304 - Medicare integrity program contractor functions.

    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...

  4. Medicare Advantage-Part D Contract and Enrollment Data

    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,...

  5. Forging a novel provider and payer partnership in Wisconsin to compensate pharmacists for quality-driven pharmacy and medication therapy management services.

    Trapskin, Kari; Johnson, Curtis; Cory, Patrick; Sorum, Sarah; Decker, Chris

    2009-01-01

    To describe the Wisconsin Pharmacy Quality Collaborative (WPQC), a quality-based network of pharmacies and payers with the common goals of improving medication use and safety, reducing health care costs for payers and patients, and increasing professional recognition and compensation for pharmacist-provided services. Wisconsin between 2006 and 2009. Community (independent, chain, and health-system) pharmacies and private and public health care payers/purchasers with support from the McKesson Corporation. This initiative aligns incentives for pharmacies and payers through implementation of 12 quality-based pharmacy requirements as conditions of pharmacy participation in a practice-advancement pilot. Payers compensate network pharmacies that meet the quality-based requirements for two levels of pharmacy professional services (level 1, intervention-based services; level 2, comprehensive medication review and assessment services). The pilot project is designed to measure the following outcomes: medication-use quality improvements, frequency and types of services provided, drug therapy problems, patient safety, cost savings, identification of factors that facilitate pharmacist participation, and patient satisfaction. The Pharmacy Society of Wisconsin created the WPQC network, which consists of 53 pharmacies, 106 trained pharmacists, 45 student pharmacists, 6 pharmacy technicians, and 2 initial payers. A quality assurance process is followed approximately quarterly to audit the 12 network quality requirements. An evaluation of this collaboration is being conducted. This program demonstrates that collaboration among payers and pharmacists is possible and can result in the development of an incentive-aligned program that stresses quality patient care, standardized services, and professional service compensation for pharmacists. This combination of a quality-based credentialing process with a professional services reimbursement schedule is unique and has the promise to

  6. Chronic Disease Prevalence and Medicare Advantage Market Penetration

    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...

  7. Operating Profitability of For-Profit and Not-for-Profit Florida Community Hospitals During Medicare Policy Changes, 2000 to 2010.

    Langland-Orban, Barbara; Large, John T; Sear, Alan M; Zhang, Hanze; Zhang, Nanhua

    2015-01-01

    Medicare Advantage was implemented in 2004 and the Recovery Audit Contractor (RAC) program was implemented in Florida during 2005. Both increase surveillance of medical necessity and deny payments for improper admissions. The purpose of the present study was to determine their potential impact on for-profit (FP) and not-for-profit (NFP) hospital operating margins in Florida. FP hospitals were expected to be more adversely affected as admissions growth has been one strategy to improve stock performance, which is not a consideration at NFPs. This study analyzed Florida community hospitals from 2000 through 2010, assessing changes in pre-tax operating margin (PTOM). Florida Agency for Health Care Administration data were analyzed for 104 community hospitals (62 FPs and 42 NFPs). Academic, public, and small hospitals were excluded. A mixed-effects model was used to assess the association of RAC implementation, organizational and payer type variables, and ownership interaction effects on PTOM. FP hospitals began the period with a higher average PTOM, but converged with NFPs during the study period. The average Medicare Advantage effect was not significant for either ownership type. The magnitude of the RAC variable was significantly negative for average PTOM at FPs (-4.68) and positive at NFPs (0.08), meaning RAC was associated with decreasing PTOM at FP hospitals only. RAC complements other Medicare surveillance systems that detect medically unnecessary admissions, coding errors, fraud, and abuse. Since its implementation in Florida, average FP and NFP operating margins have been similar, such that the higher margins reported for FP hospitals in the 1990s are no longer evident. © The Author(s) 2015.

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

    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.

  9. Cost effectiveness of endometrial ablation with the NovaSure® system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives

    Miller JD

    2015-01-01

    Full Text Available Jeffrey D Miller,1 Gregory M Lenhart,1 Machaon M Bonafede,1 Cindy M Basinski,2 Andrea S Lukes,3 Kathleen A Troeger4 1Truven Health Analytics, Cambridge, MA, 2Basinski, LLC, Newburgh, IN, 3Carolina Women’s Research and Wellness Center, Durham, NC, 4Hologic, Inc, Marlborough, MA, USA Objectives: Abnormal uterine bleeding (AUB interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure® system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives. Methods: A health state transition (semi-Markov model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy. Results: Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial and $3,000 (Medicaid; cost savings versus hysterectomy were $6,500 (commercial and $8,900 (Medicaid. Coinciding with a 43%–71% reduction in need for re-ablation, there were 69%–88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities

  10. Quality of Care Improves for Patients with Diabetes in Medicare Shared Savings Accountable Care Organizations: Organizational Characteristics Associated with Performance.

    Fraze, Taressa K; Lewis, Valerie A; Tierney, Emily; Colla, Carrie H

    2017-12-06

    Accountable care organizations (ACOs), a primary care-centric delivery and payment model, aim to promote integrated population health, which may improve care for those with chronic conditions such as diabetes. Research has shown that, overall, the ACO model is effective at reducing costs, but there is substantial variation in how effective different types of ACOs are at impacting costs and improving care delivery. This study examines how ACO organizational characteristics - such as composition, staffing, care management, and experiences with health reform - were associated with quality of care delivered to patients with diabetes. Secondary data were analyzed retrospectively to examine Medicare Shared Savings Program (MSSP) ACOs' performance on diabetes metrics in the first 2 years of ACO contracts. Ordinary least squares was used to analyze 162 MSSP ACOs with publicly available performance data and the National Survey of ACOs. ACOs improved performance significantly for patients with diabetes between contract years 1 and 2. In year 1, also having a private payer contract and an increased number of services within the ACO were positively associated with performance, while having a community health center or a hospital were negatively associated with performance. Better performance in year 1 was negatively associated with improved performance in year 2. This study found that ACOs substantively improved diabetes management within initial contract years. ACOs may need different types of support throughout their contracts to ensure continued improvements in performance.

  11. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States commercial payer population: potential economic implications of a new minimally invasive technology

    Ackerman, Stacey J; Polly, David W; Knight, Tyler; Schneider, Karen; Holt, Tim; Cummings, John

    2014-01-01

    Introduction Low back pain is common and treatment costly with substantial lost productivity and lost wages in the working-age population. Chronic low back pain originating in the sacroiliac (SI) joint (15%–30% of cases) is commonly treated with nonoperative care, but new minimally invasive surgery (MIS) options are also effective in treating SI joint disruption. We assessed whether the higher initial MIS SI joint fusion procedure costs were offset by decreased nonoperative care costs from a US commercial payer perspective. Methods An economic model compared the costs of treating SI joint disruption with either MIS SI joint fusion or continued nonoperative care. Nonoperative care costs (diagnostic testing, treatment, follow-up, and retail pharmacy pain medication) were from a retrospective study of Truven Health MarketScan® data. MIS fusion costs were based on the Premier’s Perspective™ Comparative Database and professional fees on 2012 Medicare payment for Current Procedural Terminology code 27280. Results The cumulative 3-year (base-case analysis) and 5-year (sensitivity analysis) differentials in commercial insurance payments (cost of nonoperative care minus cost of MIS) were $14,545 and $6,137 per patient, respectively (2012 US dollars). Cost neutrality was achieved at 6 years; MIS costs accrued largely in year 1 whereas nonoperative care costs accrued over time with 92% of up front MIS procedure costs offset by year 5. For patients with lumbar spinal fusion, cost neutrality was achieved in year 1. Conclusion Cost offsets from new interventions for chronic conditions such as MIS SI joint fusion accrue over time. Higher initial procedure costs for MIS were largely offset by decreased nonoperative care costs over a 5-year time horizon. Optimizing effective resource use in both nonoperative and operative patients will facilitate cost-effective health care delivery. The impact of SI joint disruption on direct and indirect costs to commercial insurers, health

  12. Routine medicare and radiation exposure. Introductory remarks

    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.)

  13. 76 FR 48563 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-January Through March 2011...

    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...

  14. Can a More User-Friendly Medicare Plan Finder Improve Consumers' Selection of Medicare Plans?

    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.

  15. Medicare capitation model, functional status, and multiple comorbidities: model accuracy

    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

  16. Medicare charge-receipt data: results for South Dakota.

    Lamfers, Randall; Miller, Nathan; Nettleman, Mary D

    2013-10-01

    The 2013 release of 2011 financial information by the Centers for Medicare and Medicaid Services (CMS) caused concern because some hospitals had charges that appeared to be exorbitantly high compared to reimbursement rates. Charges and receipts for South Dakota were compared to national data. The study was restricted to nine discharge codes likely to be seen by an adult hospitalist service. South Dakota hospitals had a lower charge-to-receipt ratio than the national average (p Dakota was 2.74 compared to 3.75 nationally. South Dakota charged 29 percent less for these discharge codes and received 3 percent lower reimbursement than the national average. The relatively low charge-to-receipt ratio and low charges in South Dakota are encouraging. Unfortunately, the only South Dakotans likely to be asked to pay full charges are the uninsured, who thus face bills that are much higher than insurance companies pay for the insured population. This leaves uninsured patients and hospitals with trying to negotiate discounts or waivers on an individual basis, which is an inefficient and problematic approach for both parties.

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

    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.

  18. Making capitated Medicare work for women: policy and research challenges.

    Bierman, A S; Clancy, C M

    2000-01-01

    Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.

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

    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.

  20. Algorithms to Identify Statin Intolerance in Medicare Administrative Claim Data.

    Colantonio, Lisandro D; Kent, Shia T; Huang, Lei; Chen, Ligong; Monda, Keri L; Serban, Maria-Corina; Manthripragada, Angelika; Kilgore, Meredith L; Rosenson, Robert S; Muntner, Paul

    2016-10-01

    To compare characteristics of patients with possible statin intolerance identified using different claims-based algorithms versus patients with high adherence to statins. We analyzed 134,863 Medicare beneficiaries initiating statins between 2007 and 2011. Statin intolerance and discontinuation, and high adherence to statins, defined by proportion of days covered ≥80 %, were assessed during the 365 days following statin initiation. Definition 1 of statin intolerance included statin down-titration or discontinuation with ezetimibe initiation, having a claim for a rhabdomyolysis or antihyperlipidemic event followed by statin down-titration or discontinuation, or switching between ≥3 types of statins. Definition 2 included beneficiaries who met Definition 1 and those who down-titrated statin intensity. We also analyzed beneficiaries who met Definition 2 of statin intolerance or discontinued statins. The prevalence of statin intolerance was 1.0 % (n = 1320) and 5.2 % (n = 6985) using Definitions 1 and 2, respectively. Overall, 45,266 (33.6 %) beneficiaries had statin intolerance by Definition 2 or discontinued statins and 55,990 (41.5 %) beneficiaries had high adherence to statins. Compared with beneficiaries with high adherence to statins, those with statin intolerance and who had statin intolerance or discontinued statins were more likely to be female versus male, and black, Hispanic or Asian versus white. The multivariable adjusted odds ratio for statin intolerance by Definitions 1 and 2 comparing patients initiating high versus low/moderate intensity statins were 2.82 (95%CI: 2.42-3.29), and 8.58 (8.07-9.12), respectively, and for statin intolerance or statin discontinuation was 2.35 (2.25-2.45). Definitions of statin intolerance presented herein can be applied to analyses using administrative claims data.

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

    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.

  2. The Cost-effectiveness of Welcome to Medicare Visual Acuity Screening and a Possible Alternative Welcome to Medicare Eye Evaluation Among Persons Without Diagnosed Diabetes Mellitus

    Rein, David B.; Wittenborn, John S.; Zhang, Xinzhi; Hoerger, Thomas J.; Zhang, Ping; Klein, Barbara Eden Kobrin; Lee, Kris E.; Klein, Ronald; Saaddine, Jinan B.

    2013-01-01

    Objective To estimate the cost-effectiveness of visual acuity screening performed in primary care settings and of dilated eye evaluations performed by an eye care professional among new Medicare enrollees with no diagnosed eye disorders. Medicare currently reimburses visual acuity screening for new enrollees during their initial preventive primary care health check, but dilated eye evaluations may be a more cost-effective policy. Design Monte Carlo cost-effectiveness simulation model with a total of 50 000 simulated patients with demographic characteristics matched to persons 65 years of age in the US population. Results Compared with no screening policy, dilated eye evaluations increased quality-adjusted life-years (QALYs) by 0.008 (95% credible interval [CrI], 0.005–0.011) and increased costs by $94 (95% CrI, −$35 to $222). A visual acuity screening increased QALYs in less than 95% of the simulations (0.001 [95% CrI, −0.002 to 0.004) and increased total costs by $32 (95% CrI, −$97 to $159) per person. The incremental cost-effectiveness ratio of a visual acuity screening and an eye examination compared with no screening were $29 000 and $12 000 per QALY gained, respectively. At a willingness-to-pay value of $15 000 or more per QALY gained, a dilated eye evaluation was the policy option most likely to be cost-effective. Conclusions The currently recommended visual acuity screening showed limited efficacy and cost-effectiveness compared with no screening. In contrast, a new policy of reimbursement for Welcome to Medicare dilated eye evaluations was highly cost-effective. PMID:22232367

  3. Strengthening Medicare: Will increasing the bulk-billing rate and supply of general practitioners increase access to Medicare-funded general practitioner services and does rurality matter?

    Day, Susan E; Alford, Katrina; Dunt, David; Peacock, Stuart; Gurrin, Lyle; Voaklander, Don

    2005-01-01

    Background Recent increases in the bulk-billing rate have been taken as an indication that the Federal government's Strengthening Medicare initiative, and particularly the bulk-billing incentives, are 'working'. Given the enduring geographic differences in the supply of general practitioners (GPs) it is timely to reconsider the impact that this increase in the provision of 'free care' will have on access to Medicare-funded GP services in rural and urban areas of Australia. Utilisation has been modelled as two different stochastic processes: the decision to consult and the frequency of consultation. Results In the decision to consult model the supply of FFS GPs is a more important predictor of utilisation than the bulk-billing rate. Paradoxically the modelling predicts that ceteris paribus increases in either GP supply or the bulk-billing rate appear to have perverse effects in some areas by decreasing utilisation. In the frequency of consultation model, GP density is not a predictor and increasing the bulk-billing rate will unambiguously increase the frequency of consultation across all areas. In both models, the positive impacts associated with changes in supply and cost are constrained outside the inner metropolitan area by reduced geographic accessibility to Medicare-funded GP services. The modelling also shows that people are more likely to consult a GP in areas of high socioeconomic disadvantage, although socioeconomic status is not a predictor of frequency of consultation. Conclusion Bulk-billing rates and the supply of FFS GPs are important features of the Australian health care system that are, potentially, amenable to policy manipulation. The implications of this research are that government policies designed to achieve similarity in these characteristics across geographic areas will not result in equity of access because they fail to address problems caused by geographic inaccessibility in rural and remote areas. Attempting to increase bulk-billing rates

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

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

    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

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

    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.

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

    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.

  8. Profile of medical care costs in patients with amyotrophic lateral sclerosis in the Medicare programme and under commercial insurance.

    Meng, Lisa; Bian, Amy; Jordan, Scott; Wolff, Andrew; Shefner, Jeremy M; Andrews, Jinsy

    2018-02-01

    To determine amyotrophic lateral sclerosis (ALS)-associated costs incurred by patients covered by Medicare and/or commercial insurance before, during and after diagnosis and provide cost details. Costs were calculated from the Medicare Standard Analytical File 5% sample claims data from Parts A and B from 2009, 2010 and 2011 for ALS Medicare patients aged ≥70 years (monthly costs) and ≥65 years (costs associated with disability milestones). Commercial insurance patients aged 18-63 years were selected based on the data provided in the Coordination of Benefits field from Truven MarketScan® in 2008-2010. Monthly costs increased nine months before diagnosis, peaked during the index month (Medicare: $10,398; commercial: $9354) and decreased but remained high post-index. Costs generally shifted from outpatient to inpatient and private nursing after diagnosis; prescriptions and durable medical equipment costs were much higher for commercial patients post-diagnosis. Patients appeared to progress to disability milestones more rapidly as their disease progressed in severity (14.4 months to non-invasive ventilation [NIV] vs. 16.6 months to hospice), and their costs increased accordingly (NIV: $58,973 vs. hospice: $76,179). For newly diagnosed ALS patients in the U.S., medical costs are substantial and increase rapidly and substantially with each disability milestone.

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

    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.

  10. 78 FR 308 - Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health...

    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...

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

    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...

  12. 78 FR 46339 - Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Temporary Moratoria...

    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...

  13. 75 FR 73088 - Medicare Program; Application by the American Association for Accreditation of Ambulatory Surgery...

    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...

  14. Diagnosis-Based Risk Adjustment for Medicare Capitation Payments

    Ellis, Randall P.; Pope, Gregory C.; Iezzoni, Lisa I.; Ayanian, John Z.; Bates, David W.; Burstin, Helen; Ash, Arlene S.

    1996-01-01

    Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula. PMID:10172666

  15. The Influence of Co-Morbidity and Other Health Measures on Dental and Medical Care Use among Medicare beneficiaries 2002

    Chen, Haiyan; Moeller, John; Manski, Richard J.

    2011-01-01

    Objective To assess the impact of co-morbidity and other health measures on the use of dental and medical care services among the community-based Medicare population with data from the 2002 Medicare Current Beneficiary Survey. Methods A co-morbidity index is the main independent variable of our study. It includes oral cancer as a co-morbidity condition and was developed from Medicare claims data. The two outcome variables indicate whether a beneficiary had a dental visit during the year and whether the beneficiary had an inpatient hospital stay during the year. Logistic regressions estimated the relationship between the outcome variables and co-morbidity after controlling for other explanatory variables. Results High scores on the co-morbidity index, high numbers of self-reported physical limitations, and fair or poor self-reported health status were correlated with higher hospital use and lower dental care utilization. Similar results were found for other types of medical care including medical provider visits, outpatient care, and prescription drugs. A multiple imputation technique was used for the approximate 20% of the sample with missing claims, but the resulting co-morbidity index performed no differently than the index constructed without imputation. Conclusions Co-morbidities and other health status measures are theorized to play either a predisposing or need role in determining health care utilization. The study’s findings confirm the dominant role of these measures as predisposing factors limiting access to dental care for Medicare beneficiaries and as need factors producing higher levels of inpatient hospital and other medical care for Medicare beneficiaries. PMID:21972460

  16. 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.

    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.

  17. A Longitudinal Analysis of Site of Death: The Effects of Continuous Enrollment in Medicare Advantage Versus Conventional Medicare.

    Chen, Elizabeth Edmiston; Miller, Edward Alan

    2017-09-01

    This study assessed the odds of dying in hospital associated with enrollment in Medicare Advantage (M-A) versus conventional Medicare Fee-for-Service (M-FFS). Data were derived from the 2008 and 2010 waves of the Health and Retirement Study ( n = 1,030). The sample consisted of elderly Medicare beneficiaries who died in 2008-2010 (34% died in hospital, and 66% died at home, in long-term senior care, a hospice facility, or other setting). Logistic regression estimated the odds of dying in hospital for those continuously enrolled in M-A from 2008 until death compared to those continuously enrolled in M-FFS and those switching between the two plans. Results indicate that decedents continuously enrolled in M-A had 43% lower odds of dying in hospital compared to those continuously enrolled in M-FFS. Financial incentives in M-A contracts may reduce the odds of dying in hospital.

  18. 76 FR 78926 - Medicare and Medicaid Programs; Announcement of Application From Hospital Requesting Waiver for...

    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...

  19. 76 FR 26805 - Medicare Program; Hospice Wage Index for Fiscal Year 2012

    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...

  20. 42 CFR 460.168 - Reinstatement in other Medicare and Medicaid programs.

    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...

  1. 75 FR 5599 - Medicare and Medicaid Programs; Announcement of Applications From Hospitals Requesting Waiver for...

    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...

  2. 78 FR 98 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    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...

  3. 77 FR 51539 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    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...

  4. 78 FR 19269 - Medicare and Medicaid Programs; Announcement of Application From a Hospital Requesting Waiver for...

    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...

  5. 78 FR 45231 - Medicare and Medicaid Programs; Initial Approval of Center for Improvement in Healthcare Quality...

    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...

  6. 77 FR 23193 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2; Corrections

    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...

  7. 42 CFR 403.206 - General standards for Medicare supplemental policies.

    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...

  8. 42 CFR 411.204 - Medicare benefits secondary to LGHP benefits.

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare benefits secondary to LGHP benefits. 411... benefits secondary to LGHP benefits. (a) Medicare benefits are secondary to benefits payable by an LGHP for services furnished during any month in which the individual— (1) Is entitled to Medicare Part A benefits...

  9. Senior services in US hospitals and readmission risk in the Medicare population.

    Arbaje, Alicia I; Yu, Qilu; Wang, Jiangxia; Leff, Bruce

    2017-10-01

    There is a little understanding of the association between hospital organizational characteristics and hospital readmissions. We previously developed a Senior Care Services Scale (SCSS) that describes hospital availability of services relevant to the care of older adults. Determine whether hospitals' SCSS scores were associated with risk of readmission among Medicare beneficiaries. Retrospective cohort analysis. Medicare beneficiaries ≥65 years of age (n = 3 553 367), admitted to 5568 US acute-care hospitals in 2006, discharged alive. Medicare data were linked to the American Hospital Association database of hospital characteristics. All-cause non-elective hospital readmission, or death without readmission, within 30 days of hospital discharge. We examined the association between high and low scores of each of two hospital SCSS service groups: inpatient specialty care (IP) and post-acute (PA) community care. There was no association between high IP scores and readmission (RR 1.00, 95% CI 0.98-1.02). Older adults admitted to hospitals with high PA scores had lower risk of experiencing hospital readmission when compared to older adults admitted to hospitals with low PA scores (RR 0.97, 95% CI 0.95-0.98). High PA scores were associated with increased mortality (RR 1.09, 95% CI 1.06-1.13). In sensitivity analyses exploring relationships at 90 days, both the IP and PA subcomponents were associated with older adults' reduced risk of hospital readmission (IP: RR 0.97, 95% CI 0.95-0.99; PA: RR 0.97, 95% CI 0.95-0.99). Senior services at the hospital-level represents a modifiable risk factor with important impact. Employing organization-level characteristics in readmission risk prediction tools should be expanded. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

  10. An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015.

    Wang, David M; Morgan, Frederick C; Besaw, Robert J; Schmults, Chrysalyne D

    2018-01-01

    Analyses of skin cancer procedures adjusted for population changes are needed. To describe trends in skin cancer-related biopsies and procedures in Medicare beneficiaries. An ecological study of Medicare claims for skin biopsies and skin cancer procedures in 2000 to 2015. Biopsies increased 142%, and skin cancer procedures increased 56%. Mohs micrographic surgery (MMS) utilization increased on the head/neck, hands/feet, and genitalia (increasing from 11% to 27% of all treatment procedures) but was low on the trunk/extremities (increasing from 1% to 4%). Adjusted for increased Medicare enrollment (+36%) between 2000 and 2015, the number of biopsies and MMS procedures performed per 1000 beneficiaries increased (from 56 to 99 and from 5 to 15, respectively), whereas the number of excisions and destructions changed minimally (from 18 to 16 and from 19 to 18, respectively). Growth in biopsies and MMS procedures slowed between each time period studied: 4.3 additional biopsies per year and 0.9 additional MMS procedures per year per 1000 beneficiaries between 2000 and 2007, 2.2 and 0.5 more between 2008 and 2011, and 0.5 and 0.3 more between 2012 and 2015, respectively. Medicare claims-level data do not provide patient-level or nonsurgical treatment information. The increased number of skin cancer procedures performed was largely the result of Medicare population growth over time. MMS utilization increased primarily on high- and medium-risk and functionally and cosmetically significant locations where tissue sparing and maximizing cure are critical. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

  11. Economic impact of new active substance status on EU payers' budgets: example of dimethyl fumarate (Tecfidera(®)) for multiple sclerosis.

    Toumi, Mondher; Jadot, Guy

    2014-01-01

    Recently, collaboration between regulators and payers was set up and was mainly focused on evidence generation along product clinical development. However, neither the regulatory path nor the new active substance status (NASs) was considered. Granting NASs will provide the product with 8 years of data protection and 2 years of market exclusivity during which no generic could enter the market. To review the economic impact (for payers) of NASs granted by the European Medicines Agency (EMA) for dimethyl fumarate (DMF), developed by Biogen and approved for multiple sclerosis (MS) as Tecfidera(®) on 3 February 2014. We reviewed the available DMF-containing products and identified their indication and price through relevant databases and official Web sites. The economic impact of Tecfidera(®) on payers' budgets was calculated assuming NASs was or was not granted. The forecast was identified in Datamonitor. Results identified four products already containing DMF as the main or unique active substance. This would have potentially prevented Tecfidera(®) from being granted NASs. The EMA Committee for Medicinal Products for Human Use (CHMP) denied Tecfidera(®) NASs and, following a company appeal, reversed its position opening as polemic. The impact of that decision has been evaluated at €7 to €10 billion over a 10-year period. NASs is a critical decision because it does have a major budget impact for payers, and it prevents generic competition. Current European Union (EU) regulations on that topic are unclear and open up too many interpretations thus distorting fair trade and affecting payers' bills. Greater clarity and more stringent rules are required to prevent mistrust of this EMA decision.

  12. Impact of managed care on the treatment, costs, and outcomes of fee-for-service Medicare patients with acute myocardial infarction.

    Bundorf, M Kate; Schulman, Kevin A; Stafford, Judith A; Gaskin, Darrell; Jollis, James G; Escarce, José J

    2004-02-01

    To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

  13. 42 CFR 1000.20 - Definitions specific to Medicare.

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Definitions specific to Medicare. 1000.20 Section 1000.20 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS INTRODUCTION; GENERAL DEFINITIONS Definitions § 1000.20 Definitions specific to...

  14. Clinton's 'Medicare for More' Not Such an Easy Cure.

    Kirkner, Richard Mark

    2016-07-01

    The politics of "Medicare for more" are daunting. Not only will Clinton have to defeat Donald Trump in November, she will need to pull enough Democrats into the House and Senate with her-and they will have to be the kind of Democrats who are willing to take on the political risks of health care reform.

  15. Chronic Disease Prevalence and Medicare Advantage Market Penetration

    Bernell, Stephanie Lazarus; Casim, Faizan M.; Wilmott, Jennifer; Pearson, Lindsey; Byler, Caitlin M.; Zhang, Zidong

    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 index that captures multiple diagnoses in one outcome measure (Chronic Disease Severity Index [CDSI]). The MEPS data for 8089 Medicare beneficiaries are merged with MA market penetration data from Centers for Medicare and Medicaid Services (CMS). Ordinary least squares regressions are run with SAS 9.3 to model the effects of MA market penetration on CDSI. The results suggest that each percentage increase in MA market penetration is associated with a greater than 2-point decline in CDSI (lower burden of cardiometabolic chronic disease). Spill-over effects may be driving improvements in the cardiometabolic health of beneficiary populations in counties with elevated levels of MA market penetration. PMID:28462266

  16. 78 FR 6273 - Rules Relating to Additional Medicare Tax

    2013-01-30

    ... DEPARTMENT OF THE TREASURY Internal Revenue Service 26 CFR Parts 1 and 31 [REG-130074-11] RIN 1545-BK54 Rules Relating to Additional Medicare Tax Correction In proposed rule document 2012-29237, appearing on pages 72268- 72277 in the issue of Wednesday, December 5, 2012, make the following correction...

  17. Use of gonioscopy in medicare beneficiaries before glaucoma surgery.

    Coleman, Anne L; Yu, Fei; Evans, Stacy J

    2006-12-01

    The American Academy of Ophthalmology Preferred Practice Patterns for angle closure and open-angle glaucoma (OAG) patients recommends performing bilateral gonioscopy upon initial presentation to evaluate the possibility of narrow angle or angle-closure glaucoma (ACG) and then repeating the examination at least every 5 years. This study aims to assess how commonly eye care providers perform gonioscopy before planned glaucoma surgery in OAG, anatomic narrow angle, and ACG in the Medicare population. Data obtained from a 5% random sample of Medicare beneficiaries undergoing glaucoma surgery in the United States in 1999 were retrospectively reviewed. The proportion of patients with evidence of at least one gonioscopic examination before glaucoma surgery was determined for the period of 1995 to 1999. Demographic and clinical factors potentially influencing the decision to perform gonioscopy were also examined. Overall, gonioscopy is apparently performed in 49% of Medicare beneficiaries during the 4 to 5 years preceding glaucoma surgery. This rate was significantly lower (P gonioscopy rates (P Gonioscopy examination before glaucoma surgery in Medicare beneficiaries is underused, undercoded, and/or miscoded, given current recommendations. Underuse is of particular concern in patients undergoing laser iridotomy as it is the diagnostic test of choice in ACG.

  18. Medicare's Compare databases with a long-term care mission.

    Grimaldi, Paul L

    2004-10-01

    Developed primarily for consumers, Medicare's Compare web sites permit immediate access to information about most nursing homes and home health agencies, including indicators of the quality of care they provide. But hospital staff, too--most notably strategic and discharge planners--can benefit by consulting Compare.

  19. Chronic Disease Prevalence and Medicare Advantage Market Penetration

    Steven W. Howard

    2015-10-01

    Full Text Available 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 index that captures multiple diagnoses in one outcome measure (Chronic Disease Severity Index [CDSI]. The MEPS data for 8089 Medicare beneficiaries are merged with MA market penetration data from Centers for Medicare and Medicaid Services (CMS. Ordinary least squares regressions are run with SAS 9.3 to model the effects of MA market penetration on CDSI. The results suggest that each percentage increase in MA market penetration is associated with a greater than 2-point decline in CDSI (lower burden of cardiometabolic chronic disease. Spill-over effects may be driving improvements in the cardiometabolic health of beneficiary populations in counties with elevated levels of MA market penetration.

  20. 42 CFR 403.205 - Medicare supplemental policy.

    2010-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b)(2) of this section. (1) Policy form. Policy form is the form of health insurance contract that is... contract— (i) Issued under the policy form; and (ii) Held by the policy holder. (c) If the policy otherwise...

  1. Your Medicare Coverage: Durable Medical Equipment (DME) Coverage

    ... 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 ...

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

    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

  3. Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States: A Retrospective Review of a Large Private-Payer Database From 2007 to 2011.

    Erickson, Brandon J; Nwachukwu, Benedict U; Rosas, Sam; Schairer, William W; McCormick, Frank M; Bach, Bernard R; Bush-Joseph, Charles A; Romeo, Anthony A

    2015-07-01

    Overuse injuries to the elbow in the throwing athlete are common. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on both recreational and high-level athletes. There is no current literature regarding the incidence and demographic distribution of this surgical procedure in relation to patient age, location within the Unites States, and sex. To determine the current demographic distribution of UCLR within the US population included in the PearlDiver database. Descriptive epidemiology study. A retrospective analysis of the PearlDiver supercomputer database, a private-payer database, was performed to identify UCLR procedures performed between 2007 and 2011. The Current Procedural Terminology (CPT) code 24346 (reconstruction of the ulnar collateral ligament of the elbow with the use of a tendinous graft) was used. Between 2007 and 2011, a total of 790 patients underwent UCLR. The average (±SD) annual incidence was 3.96 ± 0.38 per 100,000 patients for the overall population but was 22 ± 3.4 for patients aged 15 to 19 years. The overall average annual growth was 4.2%. There were 695 males and 95 females. The 15- to 19-year-old patients accounted for significantly more procedures than any other age group (56.8%; P United States than in any other region (P < .001). The number of procedures significantly increased over time (P = .039). According to this database of a privately insured population, UCLR was performed significantly more in patients aged 15 to 19 than any other age group. The average annual incidence of UCLR per 100,000 people for patients aged 15 to 19 was 22 ± 3.4. Further, this database showed that the number of UCLR procedures is increasing over time. Further work should address risk reduction efforts in this at-risk population. © 2015 The Author(s).

  4. Regulated Medicare Advantage And Marketplace Individual Health Insurance Markets Rely On Insurer Competition.

    Frank, Richard G; McGuire, Thomas G

    2017-09-01

    Two important individual health insurance markets-Medicare Advantage and the Marketplaces-are tightly regulated but rely on competition among insurers to supply and price health insurance products. Many local health insurance markets have little competition, which increases prices to consumers. Furthermore, both markets are highly subsidized in ways that can exacerbate the impact of market power-that is, the ability to set price above cost-on health insurance prices. Policy makers need to foster robust competition in both sectors and avoid designing subsidies that make the market-power problem worse. Project HOPE—The People-to-People Health Foundation, Inc.

  5. Medicare incentive payments for meaningful use of electronic health records: accounting and reporting developments.

    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.

  6. Medicare payments to the neurology workforce in 2012.

    Skolarus, Lesli E; Burke, James F; Callaghan, Brian C; Becker, Amanda; Kerber, Kevin A

    2015-04-28

    Little is known about how neurology payments vary by service type (i.e., evaluation and management [E/M] vs tests/treatments) and compare to other specialties, yet this information is necessary to help neurology define its position on proposed payment reform. Medicare Provider Utilization and Payment Data from 2012 were used. These data included all direct payments to providers who care for fee-for-service Medicare recipients. Total payment was determined by medical specialty and for various services (e.g., E/M, EEG, electromyography/nerve conduction studies, polysomnography) within neurology. Payment and proportion of services were then calculated across neurologists' payment categories. Neurologists comprised 1.5% (12,317) of individual providers who received Medicare payments and were paid $1.15 billion by Medicare in 2012. Sixty percent ($686 million) of the Medicare payment to neurologists was for E/M, which was a lower proportion than primary providers (approximately 85%) and higher than surgical subspecialties (range 9%-51%). The median neurologist received nearly 75% of their payments from E/M. Two-thirds of neurologists received 60% or more of their payment from E/M services and over 20% received all of their payment from E/M services. Neurologists in the highest payment category performed more services, of which a lower proportion were E/M, and performed at a facility, compared to neurologists in lower payment categories. E/M is the dominant source of payment to the majority of neurologists and should be prioritized by neurology in payment restructuring efforts. © 2015 American Academy of Neurology.

  7. Measuring coding intensity in the Medicare Advantage program.

    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. Practice arrangement and medicare physician payment in otolaryngology.

    Cracchiolo, Jennifer; Ridge, John A; Egleston, Brian; Lango, Miriam

    2015-06-01

    Medicare Part B physician payment indicates a cost to Medicare beneficiaries for a physician service and connotes physician clinical productivity. The objective of this study was to determine whether there was an association between practice arrangement and Medicare physician payment. Cross-sectional study. Medicare provider utilization and payment data. Otolaryngologists from 1 metropolitan area were included as part of a pilot study. A generalized linear model was used to determine the effect of practice-specific variables including patient volumes on physician payment. Of 67 otolaryngologists included, 23 (34%) provided services through an independent practice, while others were employed by 1 of 3 local academic centers. Median payment was $58,895 per physician for the year, although some physicians received substantially higher payments. Reimbursements to faculty at 1 academic department were higher than to those at other institutions or to independent practitioners. After adjustments were made for patient volumes, physician subspecialty, and gender, payments to each faculty at Hospital C were 2 times higher than to those at Hospital A (relative ratio [RR] 2.03; 95% CI, 1.27-3.27; P = .003); 2 times higher than to faculty at Hospital B (RR 2.04; 95% CI, 1.4-2.7; P = .0001); and 1.6 times higher than to independent practitioners (RR 1.6; 95% CI, 1.04-2.7; P = .03). Payments to physicians in the other groups were not significantly different. Differences in reimbursement corresponded to an emphasis on procedures over office visits but not Medicare case mix adjustments for patient discharges from associated institutions. Variation in the cost of academic otolaryngology care may be subject in part to institutional factors. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

  9. Growth in HMO share of the Medicare market, 1989-1994.

    Welch, W P

    1996-01-01

    Between 1989 and 1994 the health maintenance organization (HMO) share of the Medicare market grew rapidly. It is still heavily concentrated geographically, however. The most influential factor in this growth is HMO penetration into an area's general health care market. Medicare payment rates and prior Medicare HMO penetration also have an impact, but their effects are much weaker. Thus, payment rate reform is likely to have only a modest impact on Medicare HMO growth in the short term. In the longer term, the HMO share of the Medicare market will continue to grow, because HMO penetration in the general health care market is growing rapidly.

  10. Antihypertensive medication classes used among medicare beneficiaries initiating treatment in 2007-2010.

    Kent, Shia T; Shimbo, Daichi; Huang, Lei; Diaz, Keith M; Kilgore, Meredith L; Oparil, Suzanne; Muntner, Paul

    2014-01-01

    After the 2003 publication of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines, there was a 5-10% increase in patients initiating antihypertensive medication with a thiazide-type diuretic, but most patients still did not initiate treatment with this class. There are few contemporary published data on antihypertensive medication classes filled by patients initiating treatment. We used the 5% random Medicare sample to study the initiation of antihypertensive medication between 2007 and 2010. Initiation was defined by the first antihypertensive medication fill preceded by 365 days with no antihypertensive medication fills. We restricted our analysis to beneficiaries ≥ 65 years who had two or more outpatient visits with a hypertension diagnosis and full Medicare fee-for-service coverage for the 365 days prior to initiation of antihypertensive medication. Between 2007 and 2010, 32,142 beneficiaries in the 5% Medicare sample initiated antihypertensive medication. Initiation with a thiazide-type diuretic decreased from 19.2% in 2007 to 17.9% in 2010. No other changes in medication classes initiated occurred over this period. Among those initiating antihypertensive medication in 2010, 31.3% filled angiotensin-converting enzyme inhibitors (ACE-Is), 26.9% filled beta blockers, 17.2% filled calcium channel blockers, and 14.4% filled angiotensin receptor blockers (ARBs). Initiation with >1 antihypertensive medication class decreased from 25.6% in 2007 to 24.1% in 2010. Patients initiated >1 antihypertensive medication class most commonly with a thiazide-type diuretic and either an ACE-I or ARB. These results suggest that JNC 7 had a limited long-term impact on the choice of antihypertensive medication class and provide baseline data prior to the publication of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults from the Panel Members Appointed to

  11. 78 FR 14689 - Medicare Program; Extension of the Payment Adjustment for Low-volume Hospitals and the Medicare...

    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...

  12. Impact of comorbid conditions in COPD patients on health care resource utilization and costs in a predominantly Medicare population

    Schwab P

    2017-02-01

    comorbidities assessed (except obesity and CKD were associated with higher all-cause costs (mean ratio range: 1.07–1.54, P<0.0001. CHF, sleep apnea, anxiety, and osteoporosis were associated with higher COPD-related costs (mean ratio range: 1.08–1.67, P<0.0001, while CVA, CKD, obesity, osteoarthritis, and type 2 diabetes were associated with lower COPD-related costs.Conclusion: This study confirms that specific comorbidities among COPD patients add significant burden with higher HCRU and costs compared to patients without these comorbidities. Payers may use this information to develop tailored therapeutic interventions for improved management of patients with specific comorbidities. Keywords: COPD, comorbidities, utilization, cost, database, Medicare

  13. Hospital competition and patient-perceived quality of care: Evidence from a single-payer system in Taiwan.

    Chen, Chi-Chen; Cheng, Shou-Hsia

    2010-11-01

    To examine the effects of market competition on patient-perceived quality of care under a single-payer system in Taiwan. Data came from two nationwide surveys conducted on discharged patients and National Health Insurance (NHI) hospital claim datasets in 2002 and 2004. Competition was measured by the Herfindahl-Hirschman Index (HHI). Quality of care was measured by patient-rated hospital performance including interpersonal skills and clinical competence domains. We used the instrumental variable approach to address the endogeneity between competition and patient-perceived quality of care. The results showed that HHI was significantly associated with a decrease in the perceived interpersonal skills (coefficient of -0.460; pcompetition. A similar association was found for the perceived clinical competence (coefficient of -0.457; p=0.001). Quality of care from the patients' perspective is sensitive to the degree of competition. By using patient-reported data, this study provides new evidence concerning competition and quality of care. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

  14. The New Politics of US Health Care Prices: Institutional Reconfiguration and the Emergence of All-Payer Claims Databases.

    Rocco, Philip; Kelly, Andrew S; Béland, Daniel; Kinane, Michael

    2017-02-01

    Prices are a significant driver of health care cost in the United States. Existing research on the politics of health system reform has emphasized the limited nature of policy entrepreneurs' efforts at solving the problem of rising prices through direct regulation at the state level. Yet this literature fails to account for how change agents in the states gradually reconfigured the politics of prices, forging new, transparency-based policy instruments called all-payer claims databases (APCDs), which are designed to empower consumers, purchasers, and states to make informed market and policy choices. Drawing on pragmatist institutional theory, this article shows how APCDs emerged as the dominant model for reforming health care prices. While APCD advocates faced significant institutional barriers to policy change, we show how they reconfigured existing ideas, tactical repertoires, and legal-technical infrastructures to develop a politically and technologically robust reform. Our analysis has important implications for theories of how change agents overcome structural barriers to health reform. Copyright © 2017 by Duke University Press.

  15. Drivers of Medicare Reimbursement for Thoracolumbar Fusion: An Analysis of Data From The Centers For Medicare and Medicaid Services.

    Khanna, Krishn; Padegimas, Eric M; Zmistowski, Benjamin; Howley, Michael; Verma, Kushagra

    2017-11-01

    A retrospective observational study. The purpose of this study is to examine the variation in thoracolumbar fusion (TLF) payment and determine the drivers of this variation. As health care spending continues to increase, variation in surgical procedures reimbursements has come under more scrutiny. TLF is an example of a high-cost, proven-benefit procedure that is often the focus of Centers for Medicare and Medicaid Services (CMS) administrators. There is a wide variation in TLF charges, but the drivers for this variation are not clear. Claims for TLF were identified in the CMS data by analyzing Diagnosis Related Group (DRG) number 460 ("Spinal Fusion Except Cervical without Major Complications or Comorbidities"). Data on factors that may impact cost of care were collected from four sources: the United States Census Bureau, CMS, the Dartmouth Atlas, and WWAMI Rural Health Research Center. These were then grouped into seven categories: quality, supply, demand, substitute treatment availability, patient characteristics, competitive factors, and provider characteristics. Predictive reimbursement models were created from the data using multivariate linear regression to understand the factors that influence TLF reimbursement. There was significant geographic variability in reimbursement. The largest contribution to reimbursement variation came from variables in the demand (ΔR = 13.4%, P reimbursement were provider charges (β = 0.37, P reimbursement in the region (β = 0.19, P reimbursement. There was wide variation in reimbursement for TLF across the U.S. The variables that drive TLF reimbursement variation include supply, demand, and competition. Interestingly, quality of care was not associated with increased TLF reimbursement. N/A.

  16. Billing third party payers for vaccines: state and local health department perspectives.

    Quintanilla, Carlos; Duncan, Lorraine; Luther, Lydia

    2009-01-01

    The cost of adequately immunizing a child has risen steadily with recommendations of new, more expensive vaccines. The Vaccines for Children (VFC) program, a federal entitlement, has continued to fund all recommended vaccines for eligible children. The one other federal vaccine-funding source, Section 317 of the Public Health Service Act, has not kept pace with rising vaccine costs. For local health departments to immunize children not eligible for VFC, but whose families are underinsured or otherwise unable to pay for vaccines, state immunization programs have often relied on Section 317 funds. Recognizing this funding challenge and having learned that children covered by health insurance were being immunized in public clinics with publicly supplied vaccines, the Oregon Immunization Program (OIP) launched a project to expand billing of health plans by local health departments for vaccines administered to covered persons. This has resulted in significant savings of Section 317 funds, allowing the Oregon program to provide more vaccines for high-need persons.

  17. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States commercial payer population: potential economic implications of a new minimally invasive technology

    Ackerman SJ

    2014-05-01

    Full Text Available Stacey J Ackerman,1 David W Polly Jr,2 Tyler Knight,3 Karen Schneider,4 Tim Holt,5 John Cummings Jr6 1Covance Market Access Services Inc., San Diego, CA, USA; 2University of Minnesota, Orthopaedic Surgery, Minneapolis, MN, USA; 3Covance Market Access Services Inc., Gaithersburg, MD, USA; 4Covance Market Access Services Inc., Sydney, Australia; 5Montgomery Spine Center, Orthopedic Surgery, Montgomery, AL, USA; 6Community Health Network, Neurosurgery, Indianapolis, IN, USA Introduction: Low back pain is common and treatment costly with substantial lost productivity and lost wages in the working-age population. Chronic low back pain originating in the sacroiliac (SI joint (15%–30% of cases is commonly treated with nonoperative care, but new minimally invasive surgery (MIS options are also effective in treating SI joint disruption. We assessed whether the higher initial MIS SI joint fusion procedure costs were offset by decreased nonoperative care costs from a US commercial payer perspective. Methods: An economic model compared the costs of treating SI joint disruption with either MIS SI joint fusion or continued nonoperative care. Nonoperative care costs (diagnostic testing, treatment, follow-up, and retail pharmacy pain medication were from a retrospective study of Truven Health MarketScan® data. MIS fusion costs were based on the Premier's Perspective™ Comparative Database and professional fees on 2012 Medicare payment for Current Procedural Terminology code 27280. Results: The cumulative 3-year (base-case analysis and 5-year (sensitivity analysis differentials in commercial insurance payments (cost of nonoperative care minus cost of MIS were $14,545 and $6,137 per patient, respectively (2012 US dollars. Cost neutrality was achieved at 6 years; MIS costs accrued largely in year 1 whereas nonoperative care costs accrued over time with 92% of up front MIS procedure costs offset by year 5. For patients with lumbar spinal fusion, cost neutrality

  18. The economic burden of pulmonary arterial hypertension (PAH) in the US on payers and patients.

    Sikirica, Mirko; Iorga, Serban R; Bancroft, Tim; Potash, Jesse

    2014-12-24

    Pulmonary arterial hypertension (PAH) is a rare condition that can ultimately lead to right heart failure and death. In this study we estimated the health care costs and resource utilization associated with PAH in a large US managed care health plan. Subjects with claims-based evidence of PAH from 1/1/2004 to 6/30/2010 (identification period) were selected. To be included in the final PAH study sample, subjects were required to have ≥2 claims with a primary PH diagnosis; ≥2 claims with a PAH related-diagnosis (connective tissue diseases, congenital heart diseases, portal hypertension); and ≥1 claim with evidence of a PAH-indicated medication. The earliest date of a claim with evidence of PAH-indicated medication during the identification period was set as the index date. Health care costs and resource utilization were compared between an annualized baseline period and a 12 month follow-up period. 504 PAH subjects were selected for the final study cohort. Estimated average total health care costs were approximately 16% lower in the follow-up period compared to the baseline period (follow-up costs = $98,243 [SD = 110,615] vs. baseline costs = $116,681 [SD = 368,094], p PAH had substantively high health care costs. Medical costs appeared to decrease following PAH medication use, but with a concomitant increase in pharmacy costs.

  19. Impact of Superstorm Sandy on Medicare Patients’ Utilization of Hospitals and Emergency Departments

    Benoit Stryckman

    2017-09-01

    Full Text Available Introduction: National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy’s 2012 landfall in New Jersey (NJ. Methods: This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116. Outcome measures were pre-storm discharges (or transfers, average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission. Results: In the pre-storm week, hospital transfers from skilled nursing facilities (SNF increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional “surge” patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%. Conclusion: Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events.

  20. Impact of Superstorm Sandy on Medicare Patients' Utilization of Hospitals and Emergency Departments.

    Stryckman, Benoit; Walsh, Lauren; Carr, Brendan G; Hupert, Nathaniel; Lurie, Nicole

    2017-10-01

    National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy's 2012 landfall in New Jersey (NJ). This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED) and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission. In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional "surge" patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%). Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events.

  1. Impact of Superstorm Sandy on Medicare Patients’ Utilization of Hospitals and Emergency Departments

    Stryckman, Benoit; Walsh, Lauren; Carr, Brendan G.; Hupert, Nathaniel; Lurie, Nicole

    2017-01-01

    Introduction National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy’s 2012 landfall in New Jersey (NJ). Methods This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED) and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission. Results In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional “surge” patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%). Conclusion Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events. PMID:29085534

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

    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."

  3. Evaluation of Patient Migration Patterns and Related Health Care Costs Within a National Medicare Advantage Prescription Drug Plan After Implementation of an Oxycodone HCl Extended-Release Access Restriction.

    Chen, Chi-Chang; De, Ajita P; Sweet, Brian; Wade, Rolin L

    2017-08-01

    Health plans use formulary restrictions (e.g., prior authorization, step therapy, tier change, nonformulary status) in an effort to control cost and promote quality, safety, and appropriate prescription utilization. Some Medicare payers perceive that the inclusion of certain agents, such as branded oxycodone HCl extended-release tablets (OERs), on their formularies is associated with attracting high-cost members to the plan. To evaluate disenrollment rates, patient migration, and subsequent health care costs among OER users who disenrolled from a national Medicare Advantage Prescription Drug plan (study-MAPD) in the plan year following OER nonformulary restriction. A retrospective, longitudinal cohort study using IMS pharmacy and medical claims data between July 1, 2011, and December 31, 2014, was conducted. In the study-MAPD, adults aged ≥ 18 years who were chronic OER users with ≥ 2 OER claims 6 months before the nonformulary restriction date on January 1, 2013 (index date) and with continuous activity in pharmacy and medical claims for 6 months pre- and post-index were included in the study. Comparison years of 2012 and 2014 prerestriction/postrestriction were selected. All groups were followed for 6 months postindex. Year-to-year disenrollment rates of OER patients and the overall plan, as well as patient characteristics and costs of those who disenrolled from and those who remained with the plan, were measured. Costs were compared using a difference-in-differences approach. This study identified 2,935 eligible OER users from the study-MAPD population after imposing nonformulary restrictions on OERs on January 1, 2013. Mean age was 62.1 years, and 59.8% were female. The mean Charlson Comorbidity Index score was 1.83 for those 1,001 patients with medical claims data. For comparison years 2012 (prerestriction) and 2014 (postrestriction), 2,248 and 2,222 OER patients were identified, respectively. Patient characteristics were similar across patient cohorts in

  4. The Independent Medicare Advisory Committee: death panel or smart governing?

    Coleman, Robert

    2011-01-01

    This comment explores whether health care reform legislation establishes an administrative body effectively charged with the rationing of health care resources; insofar as it establishes a presidentially appointed Independent Medicare Advisory Committee (IMAC). IMAC would be charged with "making two annual reports dictating updated rates for Medicare providers including physicians, hospitals, skilled nursing facilities, home health, and durable medical equipment." IMAC's recommendations would be implemented nationally, subject to a Congressional vote. Congress would be granted a thirty-day window to achieve a simple majority for or against the IMAC recommendations. Part I is an introduction. Part II of this article covers the history of American health care. It lays out the federal government's evolving role in the arena of public health and health care, starting in the mid-nineteenth century and continues up to the present day. Part III examines the existing process by which Medicare spending is controlled. This part focuses on the administrative procedures that control Medicare reimbursements. Part IV examines IMAC. This part discusses IMAC's statutory provisions and the administrative transparency laws IMAC would be bound to follow. The close of this part, draws on three analogies as a gauge for how IMAC will operate: Senator Tom Daschle's Federal Health Board (FHB) proposal; the administrative oversight of the Federal Reserve; and the United Kingdom's National Institute for Health and Clinical Excellence (NICE). Part V creates a snapshot of the U.S. health care system as it operates today. This part emphasizes cost, quality, and accessibility of health care, with comparisons to international and state-run health care systems. Throughout this article there are a number of words, phrases, and agencies that have been given acronyms. For convenience, an index of these acronyms is provided in an appendix following the article.

  5. Measuring Quality of Care Under Medicare and Medicaid

    Jencks, Stephen F.

    1995-01-01

    The Health Care Financing Administration's (HCFA) approach to measuring quality of care uses an accepted definition of quality, explicit domains of measurement, and a formal validation procedure that includes face validity, construct validity, reliability, clinical validation, and tests for usefulness. The indicators of quality for Medicare and Medicaid patients span the range of service types, medical conditions, and payment systems and rest on a variety of data systems. Some have already be...

  6. Promoting pneumococcal immunizations among rural Medicare beneficiaries using multiple strategies.

    Johnson, Elizabeth A; Harwell, Todd S; Donahue, Peg M; Weisner, M'liss A; McInerney, Michael J; Holzman, Greg S; Helgerson, Steven D

    2003-01-01

    Vaccine-preventable diseases among adults are major contributing causes of morbidity and mortality in the United States. However, adult immunizations continue to be underutilized in both urban and rural areas. To evaluate the effectiveness of a community-wide education campaign and mailed reminders promoting pneumococcal immunizations to rural Medicare beneficiaries. We implemented a community-wide education campaign, and mailed reminders were sent to Medicare beneficiaries in 1 media market in Montana to increase pneumococcal immunizations. In a second distinct media market, mailed reminders only were sent to beneficiaries. The proportion of respondents aged 65 years and older aware of pneumococcal immunizations increased significantly from baseline to follow-up among respondents both in the education-plus-reminder (63% to 78%, P = 0.04) and the reminder-only (64% to 74%, P = 0.05) markets. Overall from 1998 to 1999, there was a 3.7-percentage-point increase in pneumococcal immunization claims for Medicare beneficiaries in the education-plus-reminder market and a 1.5-percentage-point increase in the reminder-only market. Medicare beneficiaries sent reminders in the education-plus-reminder market compared to those in the reminder-only market were more likely to have a claim for pneumococcal immunization in 1999 (odds ratio 1.18, 95% confidence interval 1.08 to 1.28). The results suggest that these quality improvement strategies (community education plus reminders and reminders alone) modestly increased pneumococcal immunization awareness and pneumococcal immunization among rural adults. Mailed reminder exposure was associated with an increased prevalence of pneumococcal immunizations between 1998 and 1999 and was augmented somewhat by the education campaign.

  7. Drug plan design incentives among Medicare prescription drug plans.

    Huskamp, Haiden A; Keating, Nancy L; Dalton, Jesse B; Chernew, Michael E; Newhouse, Joseph P

    2014-07-01

    Medicare Advantage prescription drug plans (MA-PDs) and standalone prescription drug plans (PDPs) face different incentives for plan design resulting from the scope of covered benefits (only outpatient drugs for PDPs versus all drug and nondrug services for Medicare Advantage [MA]/MA-PDs). The objective is to begin to explore how MA-PDs and PDPs may be responding to their different incentives related to benefit design. We compared 2012 PDP and MA-PD average formulary coverage, prior authorization (PA) or step therapy use, and copayment requirements for drugs in 6 classes used commonly among Medicare beneficiaries. We primarily used 2012 Prescription Drug Plan Formulary and Pharmacy Network Files and MA enrollment data. 2011 Truven Health MarketScan claims were used to estimate drug prices and to compute drug market share. Average coverage and PA/step rates, and average copayment requirements, were weighted by plan enrollment and drug market share. MA-PDs are generally more likely to cover and less likely to require PA/step for brand name drugs with generic alternatives than PDPs, and MA-PDs often have lower copayment requirements for these drugs. For brands without generics, we generally found no differences in average rates of coverage or PA/step, but MA-PDs were more likely to cover all brands without generics in a class. We found modest, confirmatory evidence suggesting that PDPs and MA-PDs respond to different incentives for plan design. Future research is needed to understand the factors that influence Medicare drug plan design decisions.

  8. Will Medicare Advantage payment reforms impact plan rebates and enrollment?

    Nicholas, Lauren Hersch

    2014-01-01

    To assess the relationship between Medicare Advantage (MA) plan rebates and enrollment and simulate the effects of Affordable Care Act (ACA) payment reforms. First difference regressions of county-level MA payment and enrollment data from CMS from 2006 to 2010. A $10 decrease in the per member/per month rebate to MA plans was associated with a 0.20 percentage point (0.9%) decrease in MA penetration (P penetration and a 10% decrease in risk score. ACA reforms are predicted to reduce the level of rebates in lower-spending counties, leading to enrollment decreases of 1.7 to 1.9 percentage points in the lowest-spending counties. The simulation predicts that the disenrollment would come from MA enrollees with higher risk scores. MA enrollment responds to availability of supplemental benefits supported by rebates. ACA provisions designed to lower MA spending will predominantly affect Medicare beneficiaries living in counties where MA plans may be unable to offer a comparable product at a price similar to that of traditional Medicare.

  9. Trends in Medicare Reimbursement for Orthopedic Procedures: 2000 to 2016.

    Eltorai, Adam E M; Durand, Wesley M; Haglin, Jack M; Rubin, Lee E; Weiss, Arnold-Peter C; Daniels, Alan H

    2018-03-01

    Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [Orthopedics. 2018; 41(2):95-102.]. Copyright 2018, SLACK Incorporated.

  10. Saving tax payers' money

    Staak, Thorsten; Günzel, Franziska

    this aim. To resolve this existing dichotomy between the motivation and the practical design of public intervention is the goal of this paper. To this end, we develop, using the Analytical Hierarchy Process, a decision tool, which incorporates the market failure theory as its foundation. With this study......, we contribute to the public policy research by introducing a new multi-attributive decision model as well as to the entrepreneurship arena by introducing the Analytical Hierarchy Process as a methodology that can be used to structure and solve complex public policy decision problems....

  11. What Contributes Most to High Health Care Costs? Health Care Spending in High Resource Patients.

    Pritchard, Daryl; Petrilla, Allison; Hallinan, Shawn; Taylor, Donald H; Schabert, Vernon F; Dubois, Robert W

    2016-02-01

    U.S. health care spending nearly doubled in the decade from 2000-2010. Although the pace of increase has moderated recently, the rate of growth of health care costs is expected to be higher than the growth in the economy for the near future. Previous studies have estimated that 5% of patients account for half of all health care costs, while the top 1% of spenders account for over 27% of costs. The distribution of health care expenditures by type of service and the prevalence of particular health conditions for these patients is not clear, and is likely to differ from the overall population. To examine health care spending patterns and what contributes to costs for the top 5% of managed health care users based on total expenditures. This retrospective observational study employed a large administrative claims database analysis of health care claims of managed care enrollees across the full age and care spectrum. Direct health care expenditures were compared during calendar year 2011 by place of service (outpatient, inpatient, and pharmacy), payer type (commercially insured, Medicare Advantage, and Medicaid managed care), and therapy area between the full population and high resource patients (HRP). The mean total expenditure per HRP during calendar year 2011 was $43,104 versus $3,955 per patient for the full population. Treatment of back disorders and osteoarthritis contributed the largest share of expenditures in both HRP and the full study population, while chronic renal failure, heart disease, and some oncology treatments accounted for disproportionately higher expenditures in HRP. The share of overall expenditures attributed to inpatient services was significantly higher for HRP (40.0%) compared with the full population (24.6%), while the share of expenditures attributed to pharmacy (HRP = 18.1%, full = 21.4%) and outpatient services (HRP = 41.9%, full = 54.1%) was reduced. This pattern was observed across payer type. While the use of physician

  12. Hypertension control after an initial cardiac event among Medicare patients with diabetes mellitus: A multidisciplinary group practice observational study.

    Chaddha, Ashish; Smith, Maureen A; Palta, Mari; Johnson, Heather M

    2018-04-23

    Patients with diabetes mellitus and cardiovascular disease have a high risk of mortality and/or recurrent cardiovascular events. Hypertension control is critical for secondary prevention of cardiovascular events. The objective was to determine rates and predictors of achieving hypertension control among Medicare patients with diabetes and uncontrolled hypertension after hospital discharge for an initial cardiac event. A retrospective analysis of linked electronic health record and Medicare data was performed. The primary outcome was hypertension control within 1 year after hospital discharge for an initial cardiac event. Cox proportional hazard models assessed sociodemographics, medications, utilization, and comorbidities as predictors of control. Medicare patients with diabetes were more likely to achieve hypertension control when prescribed beta-blockers at discharge or with a history of more specialty visits. Adults ≥ 80 were more likely to achieve control with diuretics. These findings demonstrate the importance of implementing guideline-directed multidisciplinary care in this complex and high-risk population. ©2018 Wiley Periodicals, Inc.

  13. Assessing Measurement Error in Medicare Coverage From the National Health Interview Survey

    Gindi, Renee; Cohen, Robin A.

    2012-01-01

    Objectives Using linked administrative data, to validate Medicare coverage estimates among adults aged 65 or older from the National Health Interview Survey (NHIS), and to assess the impact of a recently added Medicare probe question on the validity of these estimates. Data sources Linked 2005 NHIS and Master Beneficiary Record and Payment History Update System files from the Social Security Administration (SSA). Study design We compared Medicare coverage reported on NHIS with “benchmark” benefit records from SSA. Principal findings With the addition of the probe question, more reports of coverage were captured, and the agreement between the NHIS-reported coverage and SSA records increased from 88% to 95%. Few additional overreports were observed. Conclusions Increased accuracy of the Medicare coverage status of NHIS participants was achieved with the Medicare probe question. Though some misclassification remains, data users interested in Medicare coverage as an outcome or correlate can use this survey measure with confidence. PMID:24800138

  14. Favorable Risk Selection in Medicare Advantage: Trends in Mortality and Plan Exits Among Nursing Home Beneficiaries

    Goldberg, Elizabeth M.; Trivedi, Amal N.; Mor, Vincent; Jung, Hye-Young; Rahman, Momotazur

    2016-01-01

    The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates. PMID:27516452

  15. Patient-Centered Medical Home Features and Health Care Expenditures of Medicare Beneficiaries with Chronic Disease Dyads.

    Philpot, Lindsey M; Stockbridge, Erica L; Padrón, Norma A; Pagán, José A

    2016-06-01

    Three out of 4 Medicare beneficiaries have multiple chronic conditions, and managing the care of this growing population can be complex and costly because of care coordination challenges. This study assesses how different elements of the patient-centered medical home (PCMH) model may impact the health care expenditures of Medicare beneficiaries with the most prevalent chronic disease dyads (ie, co-occurring high cholesterol and high blood pressure, high cholesterol and heart disease, high cholesterol and diabetes, high cholesterol and arthritis, heart disease and high blood pressure). Data from the 2007-2011 Medical Expenditure Panel Survey suggest that increased access to PCMH features may differentially impact the distribution of health care expenditures across health care service categories depending on the combination of chronic conditions experienced by each beneficiary. For example, having no difficulty contacting a provider after regular hours was associated with significantly lower outpatient expenditures for beneficiaries with high cholesterol and diabetes (n = 635; P = 0.038), but it was associated with significantly higher inpatient expenditures for beneficiaries with high blood pressure and high cholesterol (n = 1599; P = 0.015), and no significant differences in expenditures in any category for beneficiaries with high blood pressure and heart disease (n = 1018; P > 0.05 for all categories). However, average total health care expenditures are largely unaffected by implementing the PCMH features considered. Understanding how the needs of Medicare beneficiaries with multiple chronic conditions can be met through the adoption of the PCMH model is important not only to be able to provide high-quality care but also to control costs. (Population Health Management 2016;19:206-211).

  16. Encouraging Medicare Advantage Enrollees to Switch to Higher Quality Plans: Assessing the Effectiveness of a “Nudge” Letter

    Benjamin L. Howell PhD

    2017-04-01

    Full Text Available There are considerable quality differences across private Medicare Advantage insurance plans, so it is important that beneficiaries make informed choices. During open enrollment for the 2013 coverage year, the Centers for Medicare & Medicaid Services sent letters to beneficiaries enrolled in low-quality Medicare Advantage plans (i.e., plans rated less than 3 stars for at least 3 consecutive years by Medicare explaining the stars and encouraging them to reexamine their choices. To understand the effectiveness of these low-cost, behavioral “nudge” letters, we used a beneficiary-level national retrospective cohort and performed multivariate regression analysis of plan selection during the 2013 open enrollment period among those enrolled in plans rated less than 3 stars. Our analysis controls for beneficiary demographic characteristics, health and health care spending risks, the availability of alternative higher rated plan options in their local market, and historical disenrollment rates from the plans. We compared the behaviors of those beneficiaries who received the nudge letters with those who enrolled in similar poorly rated plans but did not receive such letters. We found that beneficiaries who received the nudge letter were almost twice as likely (28.0% [95% confidence interval = 27.7%, 28.2%] vs. 15.3% [95% confidence interval = 15.1%, 15.5%] to switch to a higher rated plan compared with those who did not receive the letter. White beneficiaries, healthier beneficiaries, and those residing in areas with more high-performing plan choices were more likely to switch plans in response to the nudge. Our findings highlight both the importance and efficacy of providing timely and actionable information to beneficiaries about quality in the insurance marketplace to facilitate informed and value-based coverage decisions.

  17. Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act.

    Misra, Arpit; Lloyd, Jennifer T; Strawbridge, Larisa M; Wensky, Suzanne G

    2018-01-01

    To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization. A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005-2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation. Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (pAct provision, the rate increased by about 1% in the first quarter of 2011 (intercept, pAct trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement. Published by Elsevier Inc.

  18. Extra Help with Medicare Prescription Drug Plan Cost (FY 2010-2015)

    Social Security Administration — This file contains information about Social Security determinations of eligibility for Extra Help with Medicare Prescription Drug Plan Costs. Specific data elements...

  19. Market Size and Innovation: Effects of Medicare Part D on Pharmaceutical Research and Development.

    Blume-Kohout, Margaret E; Sood, Neeraj

    2013-01-01

    Recent evidence suggests that Medicare Part D increased prescription drug use among seniors, and increased pharmaceutical firms' revenues from sales. Previous studies also indicate that increases in market size induce pharmaceutical innovation. This paper assesses the impact of the Medicare Part D legislation on pharmaceutical research and development (R&D), using time-series data on the number of drugs entering preclinical and clinical development by therapeutic class and phase. We find that the passage and implementation of Medicare Part D is associated with significant increases in pharmaceutical R&D for therapeutic classes with higher Medicare market share.

  20. An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013.

    Han, Everett; Baisiwala, Shivani; Jain, Atul; Bundorf, M Kate; Pershing, Suzann

    2017-10-01

    To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013. Retrospective, cross-sectional study. A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services. In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013. Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement. Published by Elsevier Inc.

  1. Extra Help with Medicare Prescription Drug Plan Cost (FY 2016 Onward)

    Social Security Administration — This file contains information about Social Security determinations of eligibility for Extra Help with Medicare Prescription Drug Plan Costs. Specific data elements...

  2. Cost effectiveness of tenofovir disoproxil fumarate for the treatment of chronic hepatitis B from a Canadian public payer perspective.

    Dakin, Helen; Sherman, Morris; Fung, Scott; Fidler, Carrie; Bentley, Anthony

    2011-12-01

    Previous research has demonstrated that tenofovir disoproxil fumarate (DF) is the most cost-effective nucleos(t)ide treatment for chronic hepatitis B (CHB) in the UK, Spain, Italy and France. However, to our knowledge, no published studies have yet evaluated the cost effectiveness of any treatments for CHB in a Canadian setting, where relative prices and management of CHB differ from those in Europe. Our objective was to determine the cost effectiveness of tenofovir DF compared with other nucleos(t)ide therapies licensed for CHB in Canada from the perspective of publicly funded healthcare payers. A Markov model was used to calculate the costs and benefits of nucleos(t)ide therapy in three groups of patients with hepatitis B e antigen (HBeAg)-positive and -negative CHB: nucleos(t)ide-naive patients without cirrhosis; nucleos(t)ide-naive patients with compensated cirrhosis; and lamivudine-resistant patients. Disease progression was modelled as annual transitions between 18 disease states. Transition probabilities, quality of life and costs were based on published studies. Health benefits were measured in QALYs. The reference year for costs was 2007 and costs and outcomes were discounted at 5% per annum. First-line tenofovir DF was the most effective nucleos(t)ide strategy for managing CHB, generating 6.85-9.39 QALYs per patient. First-line tenofovir DF was also the most cost-effective strategy in all patient subgroups investigated, costing between $Can43,758 and $Can48,015 per QALY gained compared with lamivudine then tenofovir. First-line tenofovir DF strongly dominated first-line entecavir. Giving tenofovir DF monotherapy immediately after lamivudine resistance developed was less costly and more effective than any other active treatment strategy investigated for lamivudine-resistant CHB, including second-line use of adefovir or adefovir + lamivudine. Probabilistic sensitivity analysis demonstrated 50% confidence that first-line tenofovir DF is the most cost

  3. No association between Centers for Medicare and Medicaid services payments and volume of Medicare beneficiaries or per-capita health care costs for each state.

    Harewood, Gavin C; Alsaffar, Omar

    2015-03-01

    The Centers for Medicare and Medicaid Services recently published data on Medicare payments to physicians for 2012. We investigated regional variations in payments to gastroenterologists and evaluated whether payments correlated with the number of Medicare patients in each state. We found that the mean payment per gastroenterologist in each state ranged from $35,293 in Minnesota to $175,028 in Mississippi. Adjusted per-physician payments ranged from $11 per patient in Hawaii to $62 per patient in Washington, DC. There was no correlation between the mean per-physician payment and the mean number of Medicare patients per physician (r = 0.09), there also was no correlation between the mean per-physician payment and the overall mean per-capita health care costs for each state (r = -0.22). There was a 5.6-fold difference between the states with the lowest and highest adjusted Medicare payments to gastroenterologists. Therefore, the Centers for Medicare and Medicaid Services payments do not appear to be associated with the volume of Medicare beneficiaries or overall per-capita health care costs for each state. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

  4. Payday for payers. Compensation of the top execs at investor-owned insurers outpaced that of the leaders at hospitals and specialty care.

    Kutscher, Beth; Barr, Paul; Zigmond, Jessica

    2012-08-13

    Top executives at investor-owned hospital chains saw their compensation packages take a hit last year, amid the debt-ceiling crisis and concerns over how it might affect Medicare. Wayne Smith at Community Health Systems led the pack in that sector, with a $21 million payday, while Trevor Fetter, left, of Tenet, came in a distant second with $10.7 million.

  5. Patient casemix classification for medicare psychiatric prospective payment.

    Drozd, Edward M; Cromwell, Jerry; Gage, Barbara; Maier, Jan; Greenwald, Leslie M; Goldman, Howard H

    2006-04-01

    For a proposed Medicare prospective payment system for inpatient psychiatric facility treatment, the authors developed a casemix classification to capture differences in patients' real daily resource use. Primary data on patient characteristics and daily time spent in various activities were collected in a survey of 696 patients from 40 inpatient psychiatric facilities. Survey data were combined with Medicare claims data to estimate intensity-adjusted daily cost. Classification and Regression Trees (CART) analysis of average daily routine and ancillary costs yielded several hierarchical classification groupings. Regression analysis was used to control for facility and day-of-stay effects in order to compare hierarchical models with models based on the recently proposed payment system of the Centers for Medicare & Medicaid Services. CART analysis identified a small set of patient characteristics strongly associated with higher daily costs, including age, psychiatric diagnosis, deficits in daily living activities, and detox or ECT use. A parsimonious, 16-group, fully interactive model that used five major DSM-IV categories and stratified by age, illness severity, deficits in daily living activities, dangerousness, and use of ECT explained 40% (out of a possible 76%) of daily cost variation not attributable to idiosyncratic daily changes within patients. A noninteractive model based on diagnosis-related groups, age, and medical comorbidity had explanatory power of only 32%. A regression model with 16 casemix groups restricted to using "appropriate" payment variables (i.e., those with clinical face validity and low administrative burden that are easily validated and provide proper care incentives) produced more efficient and equitable payments than did a noninteractive system based on diagnosis-related groups.

  6. Identifying frauds and anomalies in Medicare-B dataset.

    Jiwon Seo; Mendelevitch, Ofer

    2017-07-01

    Healthcare industry is growing at a rapid rate to reach a market value of $7 trillion dollars world wide. At the same time, fraud in healthcare is becoming a serious problem, amounting to 5% of the total healthcare spending, or $100 billion dollars each year in US. Manually detecting healthcare fraud requires much effort. Recently, machine learning and data mining techniques are applied to automatically detect healthcare frauds. This paper proposes a novel PageRank-based algorithm to detect healthcare frauds and anomalies. We apply the algorithm to Medicare-B dataset, a real-life data with 10 million healthcare insurance claims. The algorithm successfully identifies tens of previously unreported anomalies.

  7. The Impact of Medicare Part D on Self-Employment.

    Moulton, Jeremy G; Diebold, Jeffrey C; Scott, John C

    2017-01-01

    We explore the relationship between access to affordable health insurance and self-employment using exogenous variation from the introduction of Medicare Part D that reduced the out-of-pocket cost of prescription drugs and improved health outcomes in a difference-in-differences model using the American Community Survey. We find that our treatment group of individuals aged 65-69 were 0.5 percentage points (or 5%) more likely to be self-employed in relation to a control group aged 60-64.

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

    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.

  9. Developing Medicare Competitive Bidding: A Study of Clinical Laboratories

    Hoerger, Thomas J.; Meadow, Ann

    1997-01-01

    Competitive bidding to derive Medicare fees promises several advantages over administered fee systems. The authors show how incentives for cost savings, quality, and access can be incorporated into bidding schemes, and they report on a study of the clinical laboratory industry conducted in preparation for a bidding demonstration. The laboratory industry is marked by variable concentration across geographic markets and, among firms themselves, by social and economic heterogeneity. The authors conclude that these conditions can be accommodated by available bidding design options and by careful selection of bidding markets. PMID:10180003

  10. Antihypertensive medication classes used among medicare beneficiaries initiating treatment in 2007-2010.

    Shia T Kent

    Full Text Available After the 2003 publication of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 guidelines, there was a 5-10% increase in patients initiating antihypertensive medication with a thiazide-type diuretic, but most patients still did not initiate treatment with this class. There are few contemporary published data on antihypertensive medication classes filled by patients initiating treatment.We used the 5% random Medicare sample to study the initiation of antihypertensive medication between 2007 and 2010. Initiation was defined by the first antihypertensive medication fill preceded by 365 days with no antihypertensive medication fills. We restricted our analysis to beneficiaries ≥ 65 years who had two or more outpatient visits with a hypertension diagnosis and full Medicare fee-for-service coverage for the 365 days prior to initiation of antihypertensive medication. Between 2007 and 2010, 32,142 beneficiaries in the 5% Medicare sample initiated antihypertensive medication. Initiation with a thiazide-type diuretic decreased from 19.2% in 2007 to 17.9% in 2010. No other changes in medication classes initiated occurred over this period. Among those initiating antihypertensive medication in 2010, 31.3% filled angiotensin-converting enzyme inhibitors (ACE-Is, 26.9% filled beta blockers, 17.2% filled calcium channel blockers, and 14.4% filled angiotensin receptor blockers (ARBs. Initiation with >1 antihypertensive medication class decreased from 25.6% in 2007 to 24.1% in 2010. Patients initiated >1 antihypertensive medication class most commonly with a thiazide-type diuretic and either an ACE-I or ARB.These results suggest that JNC 7 had a limited long-term impact on the choice of antihypertensive medication class and provide baseline data prior to the publication of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults from the Panel

  11. Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer.

    Rocque, Gabrielle B; Pisu, Maria; Jackson, Bradford E; Kvale, Elizabeth A; Demark-Wahnefried, Wendy; Martin, Michelle Y; Meneses, Karen; Li, Yufeng; Taylor, Richard A; Acemgil, Aras; Williams, Courtney P; Lisovicz, Nedra; Fouad, Mona; Kenzik, Kelly M; Partridge, Edward E

    2017-06-01

    Lay navigators in the Patient Care Connect Program support patients with cancer from diagnosis through survivorship to end of life. They empower patients to engage in their health care and navigate them through the increasingly complex health care system. Navigation programs can improve access to care, enhance coordination of care, and overcome barriers to timely, high-quality health care. However, few data exist regarding the financial implications of implementing a lay navigation program. To examine the influence of lay navigation on health care spending and resource use among geriatric patients with cancer within The University of Alabama at Birmingham Health System Cancer Community Network. This observational study from January 1, 2012, through December 31, 2015, used propensity score-matched regression analysis to compare quarterly changes in the mean total Medicare costs and resource use between navigated patients and nonnavigated, matched comparison patients. The setting was The University of Alabama at Birmingham Health System Cancer Community Network, which includes 2 academic and 10 community cancer centers across Alabama, Georgia, Florida, Mississippi, and Tennessee. Participants were Medicare beneficiaries with cancer who received care at participating institutions from 2012 through 2015. The primary exposure was contact with a patient navigator. Navigated patients were matched to nonnavigated patients on age, race, sex, cancer acuity (high vs low), comorbidity score, and preenrollment characteristics (costs, emergency department visits, hospitalizations, intensive care unit admissions, and chemotherapy in the preenrollment quarter). Total costs to Medicare, components of cost, and resource use (emergency department visits, hospitalizations, and intensive care unit admissions). In total, 12 428 patients (mean (SD) age at cancer diagnosis, 75 (7) years; 52.0% female) were propensity score matched, including 6214 patients in the navigated group and 6214

  12. Early Hospital Readmission is a Predictor of One-Year Mortality in Community-Dwelling Older Medicare Beneficiaries

    Lum, H.D.; Studenski, S.A.; Degenholtz, H.B.; Hardy, S.E.

    2012-01-01

    BACKGROUND: Hospital readmission within thirty days is common among Medicare beneficiaries, but the relationship between rehospitalization and subsequent mortality in older adults is not known. OBJECTIVE: To compare one-year mortality rates among community-dwelling elderly hospitalized Medicare

  13. DEBT COLLECTION IMPROVEMENT ACT OF 1996: HHS's Centers for Medicare & Medicaid Services Faces Challenges to Fully Implement Certain Key Provisions

    2002-01-01

    This report provides additional detail on the Centers for Medicare & Medicaid Services (CMS)2 progress in implementing the debt-referral requirements of DCIA to collect delinquent Medicare debts and includes several recommendations...

  14. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    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...

  15. 75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

    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...

  16. 42 CFR 460.124 - Additional appeal rights under Medicare or Medicaid.

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Additional appeal rights under Medicare or Medicaid. 460.124 Section 460.124 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH... or Medicaid. A PACE organization must inform a participant in writing of his or her appeal rights...

  17. Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population

    A.B. Knudsen (Amy); I. Lansdorp-Vogelaar (Iris); C.M. Rutter (Carolyn); J.E. Savarino (James); M. van Ballegooijen (Marjolein); K.M. Kuntz (Karen); A. Zauber (Ann)

    2010-01-01

    textabstractBackground The Centers for Medicare and Medicaid Services (CMS) considered whether to reimburse computed tomographic colonography (CTC) for colorectal cancer screening of Medicare enrollees. To help inform its decision, we evaluated the reimbursement rate at which CTC screening could be

  18. 75 FR 52760 - Medicare Program; Listening Session Regarding the Implementation of Section 10332 of the Patient...

    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...

  19. 42 CFR 403.322 - Termination of agreements for Medicare recognition of State systems.

    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...

  20. Trends in Community Pharmacy Counts and Closures before and after the Implementation of Medicare Part D

    Klepser, Donald G.; Xu, Liyan; Ullrich, Fred; Mueller, Keith J.

    2011-01-01

    Purpose: Medicare Part D provided 3.4 million American seniors with prescription drug insurance. It may also have had an unintended effect on pharmacy viability. This study compares trends in the number of pharmacies and rate of pharmacy closures before and after the implementation of Medicare Part D. Methods: This retrospective observational…

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

    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.

  2. 76 FR 24213 - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal...

    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...

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

    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.…

  4. 78 FR 8535 - Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement

    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...

  5. 75 FR 81138 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    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...

  6. 75 FR 76293 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    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...

  7. 76 FR 32085 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

    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...

  8. 77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    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...

  9. 76 FR 9502 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

    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...

  10. 76 FR 59265 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

    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...

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

    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.

  12. 75 FR 44313 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    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...

  13. 75 FR 1843 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program

    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...

  14. Straight chiropractic philosophy as a barrier to Medicare compliance: a discussion of 5 incongruent issues.

    Seaman, David R; Soltys, Jonathan R

    2013-12-01

    The purpose of this commentary is to discuss potential 5 factors within straight chiropractic philosophy and practice that may prevent Medicare compliance. The national Medicare Benefit Policy Manual and the Florida Local Coverage Determination were reviewed to identify documentation and conceptual issues regarding chiropractic practice. Five Medicare positions were contrasted with tenets of straight chiropractic philosophy. Based on Medicare's documentation requirements, Medicare defines subluxation and chiropractic practice from the perspective of treating spinal pain and related functional disability. In contrast, traditional straight chiropractic philosophy is not based on the treatment of spinal pain and disability or other symptomatic presentations. In this context, 5 potential areas of conflict are discussed. The Medicare version of chiropractic practice is not consistent with traditional straight chiropractic philosophy, which may play a role in preventing Medicare compliance. The chiropractic profession may need to consider the fashion in which "philosophy" as it relates to technique and practice is presented to students and doctors to facilitate compliance with the documentation requirements of Medicare.

  15. 78 FR 61191 - Medicare Program; FY 2014 Inpatient Prospective Payment Systems: Changes to Certain Cost...

    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...

  16. Impact of HIV Infection on Medicare Beneficiaries with Lung Cancer

    Lee, J. Y.; Moore, P. C.; Lensing, S. Y.

    2012-01-01

    The incidence of lung cancer among individuals infected with the human immunodeficiency virus (HIV) is elevated compared to that among the general population. This study examines the prevalence of HIV and its impact on outcomes among Medicare beneficiaries who are 65 years of age or older and were diagnosed with non small cell lung cancer (NSCLC) between 1997 and 2008. Prevalence of HIV was estimated using the Poisson point estimate and its 95% confidence interval. Relative risks for potential risk factors were estimated using the log-binomial model. A total of 111,219 Medicare beneficiaries met the study criteria. The prevalence of HIV was 156.4 per 100,000 (95% CI: 140.8 to 173.8) and has increased with time. Stage at NSCLC diagnosis did not vary by HIV status. Mortality rates due to all causes were 44%, 76%, and 88% for patients with stage I/II, III, and IV NSCLC, respectively. Across stages of disease, there was no difference between those who were HIV-infected and those who were not with respect to overall mortality. HIV patients, however, were more likely to die of causes other than lung cancer than their immunocompetent counterparts.

  17. Organizational Attributes Associated With Medicare ACO Quality Performance.

    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.

  18. Impact of changes in Medicare payments on the financial condition of nonprofit hospitals.

    Das, Dhiman

    2013-01-01

    This article examines the implications of revenue changes on the financial condition of nonprofit hos pitals. I examine these implications empirically by studying the effect of changes in Medicare payments in the Balanced Budget Act of 1997. Using data from the Healthcare Cost Report Information System maintained by the Centers for Medicare & Medicaid Services between 1996 and 2004, I show that even though revenue fell significantly, resulting in a decline in profitability, hospitals did not significantly change their capital structure and use of capital. An important implication of this is a higher cost of borrowing for these hospitals, which can affect future capital accumulation and viability. Nonprofit hospitals are a very important part of the healthcare delivery system in the United States. Medicare patients constitute the single largest segment of their revenue sources. Understanding the consequences of the changes in Medicare reimbursement on hospital finances is useful in framing future revisions of Medicare payments.

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

    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

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

    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.

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

    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.

  2. Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications.

    Venkatesh, Arjun K; Mei, Hao; Kocher, Keith E; Granovsky, Michael; Obermeyer, Ziad; Spatz, Erica S; Rothenberg, Craig; Krumholz, Harlan M; Lin, Zhenqui

    2017-04-01

    Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims-based definition, 2) facility claims-based definition, and 3) CMS Research Data Assistance Center (ResDAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other

  3. Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications

    Venkatesh, Arjun K.; Mei, Hao; Kocher, Keith E.; Granovsky, Michael; Obermeyer, Ziad; Spatz, Erica S.; Rothenberg, Craig; Krumholz, Harlan M.; Lin, Zhenqui

    2018-01-01

    Objectives Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. Methods We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims–based definition, 2) facility claims–based definition, and 3) CMS Research Data Assistance Center (ResDAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. Results Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p services in the

  4. Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

    Meng, Hongdao; Friedman, Bruce; Wamsley, Brenda R.; Van Nostrand, Joan F.; Eggert, Gerald M.

    2010-01-01

    Purpose: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. Methods: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19…

  5. 78 FR 57857 - Medicare and Medicaid Programs; Application from the Compliance Team for Initial CMS-Approval of...

    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...

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

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

    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...

  8. Cost-Related Medication Nonadherence and Cost-Saving Behaviors Among Patients With Glaucoma Before and After the Implementation of Medicare Part D.

    Blumberg, Dana M; Prager, Alisa J; Liebmann, Jeffrey M; Cioffi, George A; De Moraes, C Gustavo

    2015-09-01

    Understanding factors that lead to nonadherence to glaucoma treatment is important to diminish glaucoma-related disability. To determine whether the implementation of the Medicare Part D prescription drug benefit affected rates of cost-related nonadherence and cost-reduction strategies in Medicare beneficiaries with and without glaucoma and to evaluate associated risk factors for such nonadherence. Serial cross-sectional study using 2004 to 2009 Medicare Current Beneficiary Survey data linked with Medicare claims. Coding to extract data started in January 2014 and analyses were performed between September and November of 2014. Participants were all Medicare beneficiaries, including those with a glaucoma-related diagnosis in the year prior to the collection of the survey data, those with a nonglaucomatous ophthalmic diagnosis in the year prior to the collection of the survey data, and those without a recent eye care professional claim. Effect of the implementation of the Medicare Part D drug benefit. The change in cost-related nonadherence and the change in cost-reduction strategies. Between 2004 and 2009, the number of Medicare beneficiaries with glaucoma who reported taking smaller doses and skipping doses owing to cost dropped from 9.4% and 8.2% to 2.7% (P cost did not improve in the same period (3.4% in 2004 and 2.1% in 2009; P = .12). After Part D, patients with glaucoma had a decrease in several cost-reduction strategies, namely price shopping (26.2%-15.2%; P cost-related nonadherence measures were female sex, younger age, lower income (implementation of Part D, there was a decrease in the rate that beneficiaries with glaucoma reported engaging in cost-saving measures. Although there was a decline in the rate of several cost-related nonadherence behaviors, patients reporting failure to fill prescriptions owing to cost remained stable. This suggests that efforts to improve cost-related nonadherence should focus both on financial hardship and medical

  9. The costs of heart failure in Poland from the public payer's perspective. Polish programme assessing diagnostic procedures, treatment and costs in patients with heart failure in randomly selected outpatient clinics and hospitals at different levels of care: POLKARD.

    Czech, Marcin; Opolski, Grzegorz; Zdrojewski, Tomasz; Dubiel, Jacek S; Wizner, Barbara; Bolisęga, Dorota; Fedyk-Łukasik, Małgorzata; Grodzicki, Tomasz

    2013-01-01

    Heart failure (HF) is a chronic disease of great clinical and economic significance for both the healthcare system and patients themselves. To determine the consumption of medical resources for treatment and care of HF patients and to estimate the related costs. The study involved 400 primary care practices and 396 specialist outpatient clinics, as well as 259 hospitals at all reference levels. The sample was representative and supplemented with patient interview data. Based on the consumption of particular resources and the unit costs of services in 2011, costs of care for HF patients in Poland were estimated. Separate analyses were conducted depending on the stage of the disease (according to NYHA classification I-IV). The public payer's perspective and a one year time horizon were adopted. Direct annual costs of an HF patient's treatment in Poland may range between PLN 3,373.23 and 7,739.49 (2011), the main cost item being hospitalisation. The total costs for the healthcare system could be as high as PLN 1,703 million, which is 3.16% of the National Health Fund's budget (Ex. rate from 05.03.2012: 1 EUR = 4.14 PLN). The costs of treating heart failure in Poland are high; proper allocation of resources to diagnostic procedures and treatment may contribute to rationalisation of the relevant expenditure.

  10. Associations between adherence and outcomes among older, type 2 diabetes patients: evidence from a Medicare Supplemental database

    Boye KS

    2016-08-01

    Full Text Available Kristina Secnik Boye,1 Sarah E Curtis,1 Maureen J Lage,2 Luis-Emilio Garcia-Perez3 1Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 2HealthMetrics Outcomes Research, LLC, Bonita Springs, FL, 3Global Medical Affairs, Lilly Diabetes, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA Objective: To examine the association between adherence to glucose-lowering agents and patient outcomes, including costs, acute-care resource utilization, and complications, in an older, type 2 diabetic population.Data and methods: The study used Truven’s Medicare Supplemental database from July 1, 2009 to June 30, 2014. Patients aged 65 years or older were included if they had at least two type 2 diabetes diagnoses and received a glucose-lowering agent from July 1, 2010 through June 30, 2011. Multivariable analyses examined the relationships among 3-year patient outcomes and levels of adherence, proxied by the proportion of days covered. Outcomes included all-cause medical costs, diabetes-related medical costs, acute-care resource utilization, and acute complications.Results: In this study (N=123,235, higher adherence was linked to reduced costs and improved health outcomes. For example, comparing an individual with adherence of proportion of days covered <20% to one with proportion of days covered ≥80% illustrates an average saving of $28,824 in total 3-year costs. Furthermore, a 1% increase in adherence among 1,000 patients was associated with all-cause savings of $65,464 over 3 years. The probability of a hospitalization, an emergency room (ER visit, or an acute complication decreased monotonically as adherence levels got higher, as did the number of hospitalizations, ER visits, and days hospitalized (P<0.005.Conclusion: Higher adherence was associated with substantially less need for acute care, as indicated by a lowered probability of hospitalization or ER use, a reduced

  11. Baseline Utilization of Breast Radiotherapy Before Institution of the Medicare Practice Quality Reporting Initiative

    Smith, Benjamin D.; Smith, Grace L.; Roberts, Kenneth B.; Buchholz, Thomas A.

    2009-01-01

    Purpose: In 2007, Medicare implemented the Physician Quality Reporting Initiative (PQRI), which provides financial incentives to physicians who report their performance on certain quality measures. PQRI measure no. 74 recommends radiotherapy for patients treated with conservative surgery (CS) for invasive breast cancer. As a first step in evaluating the potential impact of this measure, we assessed baseline use of radiotherapy among women diagnosed with invasive breast cancer before implementation of PQRI. Methods and Materials: Using the SEER-Medicare data set, we identified women aged 66-70 diagnosed with invasive breast cancer and treated with CS between 2000 and 2002. Treatment with radiotherapy was determined using SEER and claims data. Multivariate logistic regression tested whether receipt of radiotherapy varied significantly across clinical, pathologic, and treatment covariates. Results: Of 3,674 patients, 94% (3,445) received radiotherapy. In adjusted analysis, the presence of comorbid illness (odds ratio [OR] 1.69; 95% confidence interval [CI], 1.19-2.42) and unmarried marital status were associated with omission of radiotherapy (OR 1.65; 95% CI, 1.22-2.20). In contrast, receipt of chemotherapy was protective against omission of radiotherapy (OR 0.25; 95% CI, 0.16-0.38). Race and geographic region did not correlate with radiotherapy utilization. Conclusions: Utilization of radiotherapy following CS was high for patients treated before institution of PQRI, suggesting that at most 6% of patients could benefit from measure no. 74. Further research is needed to determine whether institution of PQRI will affect radiotherapy utilization.

  12. Trends in Hospitalization Rates and Outcomes of Endocarditis among Medicare Beneficiaries

    Bikdeli, Behnood; Wang, Yun; Kim, Nancy; Desai, Mayur M.; Quagliarello, Vincent; Krumholz, Harlan M.

    2015-01-01

    Objectives To determine the hospitalization rates and outcomes of endocarditis among older adults. Background Endocarditis is the most serious cardiovascular infection and is especially common among older adults. Little is known about recent trends for endocarditis hospitalizations and outcomes. Methods Using Medicare inpatient Standard Analytic Files, we identified all Fee-For-Service beneficiaries aged ≥65 years with a principal or secondary diagnosis of endocarditis from 1999-2010. We used Medicare Denominator Files to report hospitalizations per 100,000 person-years. Rates of 30-day and 1-year mortality were calculated using Vital Status Files. We used mixed-effects models to calculate adjusted rates of hospitalization and mortality and to compare the results before and after 2007, when the American Heart Association revised recommendations for endocarditis prophylaxis. Results Overall, 262,658 beneficiaries were hospitalized with endocarditis. The adjusted hospitalization rate increased from 1999-2005, reaching 83.5 per 100,000 person-years in 2005, and declined during 2006-2007. After 2007, the decline continued, reaching 70.6 per 100,000 person-years in 2010. Adjusted 30-day and 1-year mortality rates ranged from 14.2% to 16.5% and from 32.6% to 36.2%, respectively. There were no consistent changes in adjusted rates of 30-day and 1-year mortality after 2007. Trends in rates of hospitalization and outcomes were consistent across demographic subgroups. Adjusted rates of hospitalization and mortality declined consistently in the subgroup with principal diagnosis of endocarditis. Conclusions Our study highlights the high burden of endocarditis among older adults. We did not observe an increase in adjusted rates of hospitalization or mortality associated with endocarditis after publication of the 2007 guidelines. PMID:23994421

  13. Medicare physician payment systems: impact of 2011 schedule on interventional pain management.

    Manchikanti, Laxmaiah; Singh, Vijay; Caraway, David L; Benyamin, Ramsin M; Hirsch, Joshua A

    2011-01-01

    Physicians in the United States have been affected by significant changes in the patterns of medical practice evolving over the last several decades. The recently passed affordable health care law, termed the Patient Protection and Affordable Care Act of 2010 (the ACA, for short) affects physicians more than any other law. Physician services are an integral part of health care. Physicians are paid in the United States for their personal services. This payment also includes the overhead expenses for maintaining an office and providing services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula-based payment, mostly based on the Medicare payment system. Physician services are billed under Part B. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in the Medical Economic Index (MEI). Nevertheless, the policy failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to live up to expectations for operational success. Then, in 1998, the sustainable growth rate (SGR) system was introduced. In 2009, multiple attempts were made by Congress to repeal the formula - rather unsuccessfully. Consequently, the SGR formula continues to hamper physician payments. The mechanism of the SGR includes 3 components that are incorporated into a statutory formula: expenditure targets, growth rate period, and annual adjustments of payment rates for physician services. Further, the relative value of a physician fee schedule

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

    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.

  15. The liberal party and the achievement of national Medicare.

    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.

  16. Medicare home health: a description of total episodes of care.

    Branch, L G; Goldberg, H B; Cheh, V A; Williams, J

    1993-01-01

    The purpose of this study was to present descriptive information on the characteristics of 2,873 Medicare home health clients, to quantify systematically their patterns of service utilization and allowed charges during a total episode of care, and to clarify the bivariate associations between client characteristics and utilization. The model client was female, 75-84 years of age, living with a spouse, and frail based on a variety of indicators. The mean total episode was approximately 23 visits, with allowed charges of $1,238 (1986 dollars). Specific subgroups of clients, defined by their morbidities and frailties, used identifiable clusters of services. Implications for case-mix models and implications for capitation payments under health care reform are discussed.

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

    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.

  18. Medicare's "Global" terrorism: where is the pay for performance?

    Reed, R Lawrence; Luchette, Fred A; Esposito, Thomas J; Pyrz, Karen; Gamelli, Richard L

    2008-02-01

    Medicare and Medicaid Services (CMS) payment policies for surgical operations are based on a global package concept. CMS' physician fee schedule splits the global package into preoperative, intraoperative, and postoperative components of each procedure. We hypothesized that these global package component valuations were often lower than comparable evaluation and management (E&M) services and that billing for E&M services instead of the operation could often be more profitable. Our billing database and Trauma Registry were queried for the operative procedures and hospital lengths of stay for trauma patients during the past 5 years. Determinations of preoperative, intraoperative, and postoperative payments were calculated for 10-day and 90-day global packages, comparing them to CMS payments for comparable E&M codes. Of 90-day and 10-day Current Procedural Terminology codes, 88% and 100%, respectively, do not pay for the comprehensive history and physical that trauma patients usually receive, whereas 41% and 98%, respectively, do not even meet payment levels for a simple history and physical. Of 90-day global package procedures, 70% would have generated more revenue had comprehensive daily visits been billed instead of the operation ($3,057,500 vs. $1,658,058). For 10-day global package procedures, 56% would have generated more revenue with merely problem-focused daily visits instead of the operation ($161,855 vs. $156,318). Medicare's global surgical package underpays E&M services in trauma patients. In most cases, trauma surgeons would fare better by not billing for operations to receive higher reimbursement for E&M services that are considered "bundled" in the global package payment.

  19. Metformin and thiazolidinedione use in Medicare patients with heart failure.

    Masoudi, Frederick A; Wang, Yongfei; Inzucchi, Silvio E; Setaro, John F; Havranek, Edward P; Foody, JoAnne M; Krumholz, Harlan M

    2003-07-02

    According to package inserts, metformin is contraindicated in diabetic patients receiving drug treatment for heart failure therapy, and thiazolidinediones are not recommended in diabetic patients with symptoms of advanced heart failure. Little is known about patterns of use of these antihyperglycemic drugs in diabetic patients with heart failure. To determine the proportions of patients hospitalized with heart failure and concomitant diabetes treated with metformin or thiazolidinediones. Serial cross-sectional measurements using data from retrospective medical record abstraction. Nongovernmental acute care hospitals in the United States. Two nationally representative samples of Medicare beneficiaries hospitalized with the primary diagnosis of heart failure and concomitant diabetes between April 1998 and March 1999 and between July 2000 and June 2001. The prescription of either metformin or a thiazolidinedione at hospital discharge. In the 1998-1999 sample (n = 12 505), 7.1% of patients were discharged with a prescription for metformin, 7.2% with a prescription for a thiazolidinedione, and 13.5% with a prescription for either drug. In the 2000-2001 sample (n = 13 158), metformin use increased to 11.2%, thiazolidinedione use to 16.1%, and use of either drug to 24.4% (Puse of metformin and thiazolidinediones is common and has increased rapidly in Medicare beneficiaries with diabetes and heart failure in direct contrast with explicit warnings against this practice by the Food and Drug Administration. Further studies to establish the safety and effectiveness of this practice are needed to ensure optimal care of patients with diabetes and heart failure.

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

    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

  1. Controlling for Frailty in Pharmacoepidemiologic Studies of Older Adults: Validation of an Existing Medicare Claims-based Algorithm.

    Cuthbertson, Carmen C; Kucharska-Newton, Anna; Faurot, Keturah R; Stürmer, Til; Jonsson Funk, Michele; Palta, Priya; Windham, B Gwen; Thai, Sydney; Lund, Jennifer L

    2018-07-01

    Frailty is a geriatric syndrome characterized by weakness and weight loss and is associated with adverse health outcomes. It is often an unmeasured confounder in pharmacoepidemiologic and comparative effectiveness studies using administrative claims data. Among the Atherosclerosis Risk in Communities (ARIC) Study Visit 5 participants (2011-2013; n = 3,146), we conducted a validation study to compare a Medicare claims-based algorithm of dependency in activities of daily living (or dependency) developed as a proxy for frailty with a reference standard measure of phenotypic frailty. We applied the algorithm to the ARIC participants' claims data to generate a predicted probability of dependency. Using the claims-based algorithm, we estimated the C-statistic for predicting phenotypic frailty. We further categorized participants by their predicted probability of dependency (<5%, 5% to <20%, and ≥20%) and estimated associations with difficulties in physical abilities, falls, and mortality. The claims-based algorithm showed good discrimination of phenotypic frailty (C-statistic = 0.71; 95% confidence interval [CI] = 0.67, 0.74). Participants classified with a high predicted probability of dependency (≥20%) had higher prevalence of falls and difficulty in physical ability, and a greater risk of 1-year all-cause mortality (hazard ratio = 5.7 [95% CI = 2.5, 13]) than participants classified with a low predicted probability (<5%). Sensitivity and specificity varied across predicted probability of dependency thresholds. The Medicare claims-based algorithm showed good discrimination of phenotypic frailty and high predictive ability with adverse health outcomes. This algorithm can be used in future Medicare claims analyses to reduce confounding by frailty and improve study validity.

  2. Factors associated with independent pharmacy owners' satisfaction with Medicare Part D contracts.

    Zhang, Su; Doucette, William R; Urmie, Julie M; Xie, Yang; Brooks, John M

    2010-06-01

    As Medicare Part D contracts apply pressure on the profitability of independent pharmacies, there is concern about their owners' willingness to sign such contracts. Identifying factors affecting independent pharmacy owners' satisfaction with Medicare Part D contracts could inform policy makers in managing Medicare Part D. (1) To identify influences on independent pharmacy owners' satisfaction with Medicare Part D contracts and (2) to characterize comments made by independent pharmacy owners about Medicare Part D. This cross-sectional study used a mail survey of independent pharmacy owners in 15 states comprising 6 Medicare regions to collect information on their most- and least-favorable Medicare Part D contracts, including satisfaction, contract management activities, market position, pharmacy operation, and specific payment levels on brand and generic drugs. Of the 1649 surveys mailed, 296 surveys were analyzed. The regression models for satisfaction with both the least and the most-favorable Part D contracts were significant (Pequity. For the least-favorable contract, influences were negotiation, equity, generic rate bonus, and medication therapy management (MTM) payment. About one-third of the survey respondents made at least 1 comment. The most frequent themes in the comments were that Medicare Part D reimbursement rate is too low (28%) and that contracts are offered without negotiation in a "take it or leave it" manner (20%). Equity, contending, negotiation, generic rate bonus, and MTM payments were identified as the influences of independent pharmacy owners' satisfaction toward Medicare Part D contracts. Generic rate bonus and MTM payment provide additional financial incentives to less financially favorable contracts and, in turn, contribute to independent pharmacy owner's satisfaction toward these contracts. Copyright 2010 Elsevier Inc. All rights reserved.

  3. Doctors as Stewards of medicare, or not: CAMSI, MRG, CDM, DRHC and the thin alphabet soup of physician support.

    Duffin, Jacalyn

    2018-07-01

    Physicians are deeply involved in Canadian medicare because it is through medicare that they are paid. However, from its origins to the present physicians -as a profession - have not been strong supporters of medicare. Fearing loss of income and individual autonomy, they have frequently opposed it with criticisms, strikes, threatened job action and lawsuits. Some opponents are unaware that medicare was a boon to physician income, and many fail to connect medicare with responsibility for improving the health status of the country. This paper will trace physician involvement, support and opposition to medicare from its inception to the present, with special attention to small physician organizations that have supported medicare. It will close with a proposal for how doctors could display greater stewardship.

  4. The economic impact of Medicare Part D on congestive heart failure.

    Dall, Timothy M; Blanchard, Tericke D; Gallo, Paul D; Semilla, April P

    2013-05-01

    Medicare Part D has had important implications for patient outcomes and treatment costs among beneficiaries with congestive heart failure (CHF). This study finds that improved medication adherence associated with expansion of drug coverage under Part D led to nearly $2.6 billion in reductions in medical expenditures annually among beneficiaries diagnosed with CHF and without prior comprehensive drug coverage, of which over $2.3 billion was savings to Medicare. Further improvements in adherence could potentially save Medicare another $1.9 billion annually, generating upwards of $22.4 billion in federal savings over 10 years.

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

    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

  6. MCBS Highlights: Ownership and Average Premiums for Medicare Supplementary Insurance Policies

    Chulis, George S.; Eppig, Franklin J.; Poisal, John A.

    1995-01-01

    This article describes private supplementary health insurance holdings and average premiums paid by Medicare enrollees. Data were collected as part of the 1992 Medicare Current Beneficiary Survey (MCBS). Data show the number of persons with insurance and average premiums paid by type of insurance held—individually purchased policies, employer-sponsored policies, or both. Distributions are shown for a variety of demographic, socioeconomic, and health status variables. Primary findings include: Seventy-eight percent of Medicare beneficiaries have private supplementary insurance; 25 percent of those with private insurance hold more than one policy. The average premium paid for private insurance in 1992 was $914. PMID:10153473

  7. Hospital readmission performance and patterns of readmission: retrospective cohort study of Medicare admissions

    Hsieh, Angela F; Lin, Zhenqiu; Bueno, Héctor; Ross, Joseph S; Horwitz, Leora I; Barreto-Filho, José Augusto; Kim, Nancy; Suter, Lisa G; Bernheim, Susannah M; Drye, Elizabeth E; Krumholz, Harlan M

    2013-01-01

    Objectives To determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions. Design Retrospective cohort study. Setting Medicare beneficiaries in the United States. Participants Patients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09. Main outcome measures Readmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services’ condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had ≥95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers. Results For readmissions in the 30 days after the index admission, there were 320 003 after 1 291 211 admissions for heart failure (4041 hospitals), 102 536 after 517 827 admissions for acute myocardial infarction (2378 hospitals), and 208 438 after 1 135 932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial

  8. 76 FR 52955 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    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...

  9. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    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...

  10. Evaluating the Use of Medicare Part D in the Veteran Population With Spinal Cord Injury/Disorder.

    Hatch, Maya N; Raad, Jason; Suda, Katie; Stroupe, Kevin T; Hon, Alice J; Smith, Bridget M

    2018-02-06

    To examine the different sources of medications, the most common drug classes filled, and the characteristics associated with Medicare Part D pharmacy use in veterans with spinal cord injury/disorder (SCI/D). Retrospective, cross-sectional, observational study. Outpatient clinics and pharmacies. Veterans (N=13,442) with SCI/D using Medicare or Veteran Affairs pharmacy benefits. Not applicable. Characteristics and top 10 most common drug classes were examined in veterans who (1) used VA pharmacies only; (2) used both VA and Medicare Part D pharmacies; or (3) used Part D pharmacies only. Chi-square tests and multinomial logistic regression analyses were used to determine associations between various patient variables and source of medications. Patient level frequencies were used to determine the most common drug classes. A total of 13,442 veterans with SCI/D were analyzed in this study: 11,788 (87.7%) used VA pharmacies only, 1281 (9.5%) used both VA and Part D pharmacies, and 373 (2.8%) used Part D pharmacies only. Veterans older than 50 years were more likely to use Part D pharmacies, whereas those with traumatic injury, or secondary conditions, were less associated with the use of Part D pharmacies. Opioids were the most frequently filled drug class across all groups. Other frequently used drug classes included skeletal muscle relaxants, gastric medications, antidepressants (other category), anticonvulsants, and antilipemics. Approximately 12% of veterans with SCI/D are receiving medication outside the VA system. Polypharmacy in this population of veterans is relatively high, emphasizing the importance of health information exchange between systems for improved care for this medically complex population. Published by Elsevier Inc.

  11. 78 FR 38594 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    2013-06-27

    .... The LTC facility regulations clearly specify what services the facility is required to provide to... professional caregivers and are often paid by third-party payers, such as Medicaid. These facilities are... benefit. In regulations at 42 CFR 418.112(c), we specify what must be included in a written agreement...

  12. 76 FR 26489 - Medicare Program; Hospital Inpatient Value-Based Purchasing Program

    2011-05-06

    ... also be aligned with best practices among other payers and the needs of the end users of the measures... have been subsequently shown to not represent the best clinical practice. We interpreted this provision... of measures, including clinical process of care measures, risk adjusted outcome measures, the HCAHPS...

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

    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.

  14. 76 FR 50224 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    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...

  15. 76 FR 66931 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

    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...

  16. Effect of Long-term Care Use on Medicare and Medicaid...

    U.S. Department of Health & Human Services — Individuals eligible and enrolled simultaneously for Medicare and Medicaid commonly referred to as dual eligible or duals have often been cited as accounting for a...

  17. 77 FR 11130 - Medicare Program; Application by the American Association of Diabetes Educators (AADE) for...

    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...

  18. 78 FR 53149 - Medicare and Medicaid Programs: Continued Approval of American Osteopathic Association/Healthcare...

    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...

  19. Comparison of Rate of Utilization of Medicare Services in Private Versus Academic Cardiology Practice.

    Hovanesyan, Arsen; Rubio, Eduardo; Novak, Eric; Budoff, Matthew; Rich, Michael W

    2017-11-15

    Cardiovascular services are the third largest source of Medicare spending. We examined the rate of cardiovascular service utilization in the community of Glendale, CA, compared with the nearest academic medical center, the University of Southern California. Publicly available utilization data released by Medicare for the years 2012 and 2013 were used to identify all inpatient and outpatient cardiology services provided in each practice setting. The analysis included 19 private and 17 academic cardiologists. In unadjusted analysis, academic physicians performed half as many services per Medicare beneficiary per year as those in private practice: 2.3 versus 4.8, p cardiology practice settings in southern California, medical service utilization per Medicare beneficiary was nearly 2-fold higher in private practice than in the academic setting, suggesting that there may be opportunity for substantially reducing costs of cardiology care in the community setting. Copyright © 2017 Elsevier Inc. All rights reserved.

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

    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...