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Medicare

Distribution by Scientific Domains
Medical Sciences89%
Humanities and Social Sciences4%
Business, Economics, Finance and Accounting4%
2 Other Domains3%
Distribution within Medical Sciences
Transplantation14%
Health & Social Care13%
Consumer Health General8%
Cardiovascular Disease3%
18 Other Subdomains62%

Terms modified by Medicare

  • medicare beneficiary
  • medicare claim
  • medicare claim data
  • medicare cost
    		•
  • medicare coverage
  • medicare current beneficiary survey
  • medicare data
  • medicare database
    		•
  • medicare expenditure
  • medicare patient
  • medicare payment
  • medicare program
    		•
  • medicare provider
  • medicare recipient
  • medicare reimbursement

    • Selected Abstracts

    Effect of Race and Insurance on Outcome of Pediatric Trauma

    ACADEMIC EMERGENCY MEDICINE, Issue 8 2010
    Wael Hakmeh DO
    ACADEMIC EMERGENCY MEDICINE 2010; 17:809,812 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study sought to determine if insurance or race status affect trauma outcomes in pediatric trauma patients. Methods:, Using the National Trauma Data Bank (NTDB; v6.2), the following variables were extracted: age (0,17 years), payment type (insured, Medicaid/Medicare, or self-pay), race (white, Black/African American, or Hispanic), Injury Severity Score (ISS > 8), type of trauma (blunt or penetrating), and discharge status (alive or dead). Data were analyzed using logistic regression. Results:, Of the 70,781 patient visits analyzed, 67% were insured, 23% were Medicaid/Medicare, and 10% were self-pay. Self-pay patients had higher mortality (11%, compared to Medicaid/Medicare at 5% and insured at 4%; p < 0.001). African Americans and Hispanics also had higher mortality (7 and 6%) compared to whites (4%; p < 0.001). Self-pay patients more likely suffered penetrating trauma than insured patients (12% vs. 4%; p < 0.001), and mortality for penetrating trauma self-pay patients was 29%, compared to only 11% for penetrating trauma insured patients (p < 0.001). The mortality rate varied from a low of 3% for insured whites, to 18% for self-pay African Americans. Logistic regression (including race, insurance status, injury type, and ISS) revealed that African Americans and Hispanics both had an increased risk of death compared to whites (African American odds ratio [OR] = 1.37, Hispanic OR = 1.20). Medicaid/Medicare patients had a slightly increased risk of death with OR = 1.14, but self-pay patients were almost three times more likely to die (adjusted OR = 2.92). Conclusions:, After controlling for ISS and type of injury, mortality disparity exists for uninsured, African American, and Hispanic pediatric trauma patients. Although the reasons for this are unclear, efforts to decrease these disparities are needed. [source]

    Anemia and Cost in Medicare Patients With Congestive Heart Failure

    CONGESTIVE HEART FAILURE, Issue 6 2006
    Craig A. Solid MS
    The objective of this study was to examine the total cost to Medicare associated with the presence of anemia in congestive heart failure (CHF) patients. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify anemia, CHF, and comorbid conditions in 2002, and total Medicare costs were calculated for 2003. The mean patient age was 77.8 years. Anemia, present in 32% of CHF patients, was associated with older age, female sex, non-white race, and increasing burden of comorbidity. The total per-member-per-month cost in 2003 was $1781.01 among CHF patients with anemia in the preceding year compared with $1142.38 for CHF patients without anemia, a ratio of 1.56 (95% confidence interval, 1.5589,1.5592). When adjustment was made for baseline demographic factors and comorbid conditions, the corresponding ratio was 1.25 (95% confidence interval, 1.2546,1.2548). Anemia, a common association of CHF in elderly patients, is an antecedent association of increased societal medical expenditure. [source]

    Frequency of Seborrheic Keratosis Biopsies in the United States: A Benchmark of Skin Lesion Care Quality and Cost Effectiveness

    DERMATOLOGIC SURGERY, Issue 8 2003
    Maria I. Duque MD
    Background. Most seborrheic keratoses may be readily clinically differentiated from skin cancer, but occasional lesions resemble atypical melanocytic neoplasms. Objective. To evaluate the frequency, cost, and intensity of procedures performed that result in the removal and histopathologic evaluation of seborrheic keratoses. Methods. Episodes of surgical removal of lesions that were identified as seborrheic keratoses by histologic identification were determined using Medicare Current Beneficiary Survey data from 1998 to 1999. These episodes were defined by a histopathology procedure code that is associated with a diagnosis code for seborrheic keratosis. We then identified what procedure(s) generated the histopathology specimen. Biopsy and shave procedures were considered "low intensity," whereas excision and repair procedures were considered "high intensity." Results. Dermatologists managed 85% of all episodes of seborrheic keratoses. Dermatologists managed 89% of seborrheic keratosis episodes using low-intensity procedures compared with 51% by other specialties. For nondermatologists, 46% of the treatment cost ($9 million) to Medicare was generated from high-intensity management compared with 15% by dermatologists ($6 million). Conclusion. There is a significant difference in the management of suspicious pigmented lesions between dermatologists and other specialists. This affects both the cost and quality of care. [source]

    Profiles in Patient Safety: Antibiotic Timing in Pneumonia and Pay-for-performance

    ACADEMIC EMERGENCY MEDICINE, Issue 7 2006
    Jesse M. Pines MD
    The delivery of antibiotics within four hours of hospital arrival for patients who are admitted with pneumonia, as mandated by the Joint Commission for the Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services, has gained considerable attention recently because of the plan to implement pay-for-performance for adherence to this standard. Although early antibiotic administration has been associated with improved survival for patients with pneumonia in two large retrospective studies, the effect on actual patient care and outcomes for patients with pneumonia and other emergency department patients of providing financial incentives and disincentives to hospitals for performance on this measure currently is unknown. This article provides an in-depth case-based description of the evidence behind antibiotic timing in pneumonia, discusses potential program effects, and analyzes how the practical implementation of pay-for-performance for pneumonia conforms to American Medical Association guidelines on pay-for-performance. [source]

    Association between Insurance Status and Admission Rate for Patients Evaluated in the Emergency Department

    ACADEMIC EMERGENCY MEDICINE, Issue 11 2003
    Jennifer Prah Ruger PhD
    Abstract Objectives: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. Methods: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for underinsured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. Results: Compared with the other insured group, underinsured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed underinsured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Underinsured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. Conclusions: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference. [source]

    ALL CHILDREN ARE NOT CREATED EQUAL: PRWORA'S UNCONSTITUTIONAL RESTRICTION ON IMMIGRANT CHILDREN'S ACCESS TO FEDERAL HEALTH CARE PROGRAMS

    FAMILY COURT REVIEW, Issue 3 2006
    Hyejung Janet Shin
    The lack of health insurance for children is a serious problem in the United States, especially for those children in families that earn too little to get private health insurance and too much to qualify for Medicare. Even within this subclass of children, immigrant children are particularly vulnerable to the problems faced by lack of health care. Nevertheless, with the passage of the Personal Responsibility and Work Reconciliation Act (PRWORA) by Congress, equality interests of low-income immigrant children are undermined when immigrant children are denied federal benefits for the first 5 years of residency in the United States. The first part of this Note examines the importance of child health care and the long-term problems with uninsured children, especially with uninsured immigrant children and pregnant women. The next part introduces Medicaid as well as State Children's Health Insurance Program, a supplemental federal program designed to increase health care coverage to all children, while contrasting these programs in light of the restrictive anti-immigrant PRWORA provisions. The third part explains the passage of PRWORA, its anti-immigrant provisions, and how these provisions prevent needy immigrant children from receiving federally funded health care. Then, the fourth part uses both the Equal Protection Clause of the Fourteenth Amendment and the Due Process Clause of the Fifth Amendment to argue the unconstitutionality of the anti-immigrant provisions. Finally, the last part lays out the recommendation to amend the Social Security Act so that the PRWORA barriers can be removed and recent immigrant children can receive federally funded health care. [source]

    The Financial Accountability of Australia's Medicare System: A Generational Accounting Analysis

    FINANCIAL ACCOUNTABILITY & MANAGEMENT, Issue 2 2001
    Paul J. M. Klumpes
    The financial sustainability of publicly funded health care systems is sensitive to the demographics of ageing populations, which have a significant bearing on their financial management, accountability and reporting of their financial performance. This paper examines historical and current trends in demographic structure of Australia's population that are likely to impact on the financial management and accountability practices affecting Australia'suniversal public health care system (,Medicare'). The pay-as-you-go financed funding status of Medicare as represented under both currently required, cash-based accounting principles and proposed accrual-based accounting principles are criticised for not recognising the obligations of the Australian government under Medicare. An alternative system of generational accounting is proposed that projects the financial management costs of Medicare. Data are taken from both historical trends in expenditure and ageing as well as projected demographics. The analysis implies that there is significant intergenerational-inequity in the funding of Medicare, which is not recognised under accrual-based accounting principles that are now being used to evaluate the financial accountability and performance of government entities. [source]

    Estimating lifetime or episode-of-illness costs under censoring

    HEALTH ECONOMICS, Issue 9 2010
    Anirban Basu
    Abstract Many analyses of healthcare costs involve use of data with varying periods of observation and right censoring of cases before death or at the end of the episode of illness. The prominence of observations with no expenditure for some short periods of observation and the extreme skewness typical of these data raise concerns about the robustness of estimators based on inverse probability weighting (IPW) with the survival from censoring probabilities. These estimators also cannot distinguish between the effects of covariates on survival and intensity of utilization, which jointly determine costs. In this paper, we propose a new estimator that extends the class of two-part models to deal with random right censoring and for continuous death and censoring times. Our model also addresses issues about the time to death in these analyses and separates the survival effects from the intensity effects. Using simulations, we compare our proposed estimator to the inverse probability estimator, which shows bias when censoring is large and covariates affect survival. We find our estimator to be unbiased and also more efficient for these designs. We apply our method and compare it with the IPW method using data from the Medicare,SEER files on prostate cancer. Copyright © 2010 John Wiley & Sons, Ltd. [source]

    Predicting risk selection following major changes in medicare

    HEALTH ECONOMICS, Issue 4 2008
    Steven D. Pizer
    Abstract The Medicare Modernization Act of 2003 created several new types of private insurance plans within Medicare, starting in 2006. Some of these plan types previously did not exist in the commercial market and there was great uncertainty about their prospects. In this paper, we show that statistical models and historical data from the Medicare Current Beneficiary Survey can be used to predict the experience of new plan types with reasonable accuracy. This lays the foundation for the analysis of program modifications currently under consideration. We predict market share, risk selection, and stability for the most prominent new plan type, the stand-alone Medicare prescription drug plan (PDP). First, we estimate a model of consumer choice across Medicare insurance plans available in the data. Next, we modify the data to include PDPs and use the model to predict the probability of enrollment for each beneficiary in each plan type. Finally, we calculate mean-adjusted actual spending by plan type. We predict that adverse selection into PDPs will be substantial, but that enrollment and premiums will be stable. Our predictions correspond well to actual experience in 2006. Copyright © 2007 John Wiley & Sons, Ltd. [source]

    Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics

    HEALTH SERVICES RESEARCH, Issue 5p1 2010
    Chuan-Fen Liu
    Objective. To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. Data Sources/Study Setting. VA administrative and Medicare claims data from 2001 to 2004. Study Design. Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. Principal Findings. A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3,4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). Conclusions. Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care. [source]

    Dementia and Medicare at Life's End

    HEALTH SERVICES RESEARCH, Issue 2 2008
    Vicki L. Lamb
    Objective. To determine the effect of a diagnosis of Alzheimer's disease or related dementias (ADRD), and the timing of first ADRD diagnosis, on Medicare expenditures at end of life. Data Sources. Monthly Medicare payment data for the 5 years before death linked to the National Long-Term Care Survey (NLTCS) for decedents between 1996 and 2000 (N=4,899). Data Extraction Methods. Medicare payment data for the 5 years before death were used to compare 5-year and 6-month intervals of expenditures (total and six subcategories of services) for persons with and without a diagnosis of ADRD during the last 5 years of life, controlling for age, gender, race, education, comorbidities, and nursing home status. Covariate matching was used. Principal Findings. On average, ADRD diagnosis was not significantly associated with excess Medicare payments over the last 5 years of life. Regarding the timing of ADRD diagnosis, there were no significant 5-year total expenditure differences for persons diagnosed with dementia more than 1 year before death. Payment differences by 6-month intervals were highly sensitive to timing of ADRD diagnosis, with the highest differences occurring around the time of diagnosis. There were reduced, non-significant, or negative total payment differences after the initial diagnosis for those diagnosed at least 1 year before death. Only those diagnosed with ADRD in the last year of life had significantly higher Medicare payments during the last 12 months of life, primarily for acute care services. Conclusions. ADRD has a smaller impact on total Medicare expenditures than previously reported in controlled studies. The significant differences occur primarily around the time of diagnosis. Although rates of dementia are increasing per se, our results suggest that long-term (1+ year) ADRD diagnoses do not contribute to greater total Medicare costs at the end of life. [source]

    The Effects of Health Sector Market Factors and Vulnerable Group Membership on Access to Alcohol, Drug, and Mental Health Care

    HEALTH SERVICES RESEARCH, Issue 3p1 2007
    Susan E. Stockdale
    Objective. This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics. Data Sources. Wave 2 data (2000,2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997,1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources. Study Design. The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored. Principal Findings. Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration. Conclusions. Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization. [source]

    The Effect of Benefits, Premiums, and Health Risk on Health Plan Choice in the Medicare Program

    HEALTH SERVICES RESEARCH, Issue 4p1 2004
    Adam Atherly
    Objective. To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan. Data Source. Individual data from the Medicare Current Beneficiary Survey were combined with plan-level data from Medicare Compare. Study Design. Health plan choices, including the Medicare+Choice/Fee-for-Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit. Principal Findings. Premiums have a significant effect on plan selection, with an estimated out-of-pocket premium elasticity of ,0.134 and an insurer-perspective elasticity of ,4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage. Conclusions. Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics. [source]

    Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life

    HEALTH SERVICES RESEARCH, Issue 2 2004
    Amber E. Barnato
    Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source]

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

    HEALTH SERVICES RESEARCH, Issue 1 2004
    Melinda Beeuwkes Buntin
    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 risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. [source]

    Medical Expenditures during the Last Year of Life: Findings from the 1992,1996 Medicare Current Beneficiary Survey

    HEALTH SERVICES RESEARCH, Issue 6 2002
    Donald R Hoover
    Objective. To compare medical expenditures for the elderly (65 years old) over the last year of life with those for nonterminal years. Data Source. From the 1992,1996 Medicare Current Beneficiary Survey (MCBS) data from about ten thousand elderly persons each year. Study Design. Medical expenditures for the last year of life and nonterminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. Data Collection. The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four-month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. Principal Findings. From 1992 to 1996, mean annual medical expenditures (1996 dollars) for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for nonterminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death. However, non-Medicare last-year-of-life expenditures were higher and Medicare last-year-of-life expenditures were lower for those dying at older ages. Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures. Conclusions. While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end-of-life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care. [source]

    Dementia services in Canada

    INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 9 2010
    Kenneth Rockwood
    Canadians with dementia have access to Medicare, a universal, single payer healthcare program. Implementation of Medicare is through the provinces and territories, giving variation in the level of care available. At present, there is no national strategy for dementia, although a recent report from the Alzheimer Society of Canada is expected to catalyze one. Most dementia care is provided by primary care practitioners, with three specialties (geriatric psychiatry, geriatric medicine and neurology) providing consultant expertise. Primary care reforms are aimed at developing a more coordinated approach to the complex needs of people with dementia, and have especially emphasized education of providers. Any national strategy is expected to underscore prevention and research, the latter building on Canada's strong contribution to this international undertaking. Copyright © 2010 John Wiley & Sons, Ltd. [source]

    Pneumonia and Influenza Hospitalizations in Elderly People with Dementia

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2009
    Elena N. Naumova PhD
    OBJECTIVES: To compare the demographic and geographic patterns of pneumonia and influenza (P&I) hospitalizations in older adults with dementia with those of the U.S. population and to examine the relationship between healthcare accessibility and P&I. DESIGN: Observational study using historical medical claims from the Centers for Medicare and Medicaid Services (CMS) and CMS records supplemented with information derived from other large national sources. SETTING: Retrospective analysis of medical records uniformly collected over a 5-year period with comprehensive national coverage. PARTICIPANTS: A study population representative of more than 95% of all people aged 65 and older residing in the continental United States. MEASUREMENTS: Six million two hundred seventy-seven thousand six hundred eighty-four records of P&I between 1998 and 2002 were abstracted, and county-specific outcomes for hospitalization rates of P&I, mean length of hospital stay, and percentage of deaths occurring in a hospital setting were estimated. Associations with county-specific elderly population density, percentage of nursing home residents, median household income per capita, and rurality index were assessed. RESULTS: Rural and poor counties had the highest rate of P&I and percentage of influenza. Patients with dementia had a lower frequency of influenza diagnosis, a shorter length of hospital stay, and 1.5 times as high a rate of death as the national average. CONCLUSION: The results suggest strong disparities in healthcare practices in rural locations and vulnerable populations; infrastructure, proximity, and access to healthcare are significant predictors of influenza morbidity and mortality. These findings have important implications for influenza vaccination, testing, and treatment policies and practices targeting the growing fraction of patients with cognitive impairment. [source]

    Use of Medicare and Department of Veterans Affairs Health Care by Veterans with Dementia: A Longitudinal Analysis

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2009
    Carolyn W. Zhu PhD
    The objectives of this study were to examine longitudinal patterns of Department of Veterans Affairs (VA),only use, dual VA and Medicare use, and Medicare-only use by veterans with dementia. Data on VA and Medicare use were obtained from VA administrative datasets and Medicare claims (1998,2001) for 2,137 male veterans who, in 1997, used some VA services, had a formal diagnosis of Alzheimer's disease or vascular dementia in the VA, and were aged 65 and older. Generalized ordered logit models were used to estimate the effects of patient characteristics on use group over time. In 1998, 41.7% of the sample were VA-only users, 55.4% were dual users, and 2.9% were Medicare-only users. By 2001, 30.4% were VA-only users, 51.5% were dual users, and 18.1% were Medicare-only users. Multivariate results show that greater likelihood of Medicare use was associated with older age, being white, being married, having higher education, having private insurance or Medicaid, having low VA priority level, and living in a nursing home or dying during the year. Higher comorbidities were associated with greater likelihood of dual use as opposed to any single system use. Alternatively, number of functional limitations was associated with greater likelihood of Medicare-only use and less likelihood of VA-only use. These results imply that different aspects of veterans' needs have differential effects on where they seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure that patients receive high-quality care, especially patients with multiple comorbidities. [source]

    The Effect of Transitioning to Medicare Part D Drug Coverage in Seniors Dually Eligible for Medicare and Medicaid

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2008
    William H. Shrank MD
    OBJECTIVES: To evaluate medication use, out-of-pocket spending, and medication switching during the transition period for patients dually eligible for Medicaid and Medicare (dual eligibles). DESIGN: Time-trend analysis, using segmented linear regression. SETTING: Patient-level pharmacy dispensing data from January 2005 to December 2006 from a large pharmacy chain with stores in 34 states. PARTICIPANTS: Dual eligibles aged 65 and older. MEASUREMENTS: Changes in utilization, patient copayments, and medication switching were analyzed using interrupted time trend analyses. Utilization and spending were evaluated for five study drugs: clopidogrel, proton pump inhibitors (PPIs), warfarin, and statins (essential drugs covered by Part D plans) and benzodiazepines (not covered through Part D but potentially covered through Medicaid). RESULTS: Drug use for 13,032 dual eligibles was evaluated. There was no significant effect of the transition to Medicare Part D on use of all study drugs, including the uncovered benzodiazepines. Cumulative reductions were seen in copayments for all covered drugs after implementation of Part D, ranging from 25% annually for PPIs to 53% for warfarin, but there was a larger increase in copayments, 91% annually, for benzodiazepines after the transition. The rate of switching medications was 3.0 times as great for the PPIs after implementation of Part D than before implementation, but there was no significant change in the other study drug classes. CONCLUSION: These findings in a single, large pharmacy chain indicate that the transition plan for dual eligibles led to less medication discontinuation and switching than many had expected. The substantially greater cost sharing for benzodiazepines highlights the importance of implementing a thoughtful transition plan when executing such a national policy. [source]

    Healthcare Costs of Acute and Chronic Pain Associated with a Diagnosis of Herpes Zoster

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2007
    Robert H. Dworkin PhD
    OBJECTIVES: To determine the healthcare costs of acute and chronic pain associated with herpes zoster. DESIGN: Retrospective cohort analysis. SETTING: Inpatient and outpatient care. PARTICIPANTS: Patients were selected from Medicare, commercial insurance, and Medicaid claims databases if they had a diagnosis of herpes zoster or postherpetic neuralgia (PHN) or were prescribed analgesics after a diagnosis of herpes zoster (possible PHN) and were matched to controls for demographic and clinical factors using propensity scores. MEASUREMENTS: One-year excess healthcare expenditures attributable to herpes zoster pain or PHN were calculated for inpatient, outpatient, and prescription drug services. RESULTS: For the Medicare cohort, the average excess cost per patient was $1,300 in the year after a diagnosis of herpes zoster with 30 days or fewer of analgesic use and ranged from $2,200 to $2,300 per patient with PHN or possible PHN. Patients with possible PHN were 53% more prevalent than patients with PHN in the Medicare cohort and accounted for half of all excess expenditures. Findings were similar in the younger cohorts with commercial insurance and Medicaid except that costs attributable to PHN and possible PHN were higher, and patients with possible PHN were three to five times as prevalent as patients with PHN. CONCLUSION: Healthcare costs associated with PHN were substantially greater than those associated with herpes zoster pain that resolved within 30 days. The data suggest that as many as 80% of patients with PHN may not be diagnosed with PHN and that these patients account for at least half of PHN expenditures. [source]

    Long-Term Acute Care: A Review of the Literature

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2007
    Manuel A. Eskildsen MD
    Long-term acute care (LTAC) represents a rapidly growing category of Medicare providers, but little is known about its quality, outcomes, and cost-effectiveness. Its defining characteristic, as set by Medicare, is an average length of stay of greater than 25 days. Modern LTAC emerged in the early 1980s as a setting for the weaning of ventilator-dependent patients. The industry has developed greatly in the last few years, with for-profit corporations dominating the field, and as Medicare expenditures have grown, new payment systems have emerged to limit spiraling costs. Although LTAC is mainly known for providing chronic ventilator weaning, the case mix is varied. The majority of outcome studies in this setting have been done on pulmonary patients, with fewer data available on nonventilator patients. This article analyzes studies of LTAC that are currently available, discusses some of the public policy issues surrounding this level of care, and suggests a research agenda, including a role for the field of geriatrics. [source]

    Epidemiology of Medicare Abuse: The Example of Power Wheelchairs

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2007
    James S. Goodwin MD
    OBJECTIVES: To determine the effect of neighborhood ethnic composition on power wheelchair prescriptions. DESIGN: The 5% noncancer sample of Medicare recipients in the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database, from 1994 to 2001. SETTING: SEER regions. PARTICIPANTS: Individuals covered by Medicare living in SEER regions without a cancer diagnosis. MEASUREMENTS: Individual characteristics (age, sex, ethnicity, justifying diagnosis, and comorbidity), primary diagnoses, neighborhood characteristics (percentage black, percentage Hispanic, percentage with <12 years education, and median income), and SEER region. RESULTS: The rate of power wheelchair prescriptions was 33 times greater in 2001 than in 1994, with a shift over time from justifying diagnoses more closely tied to mobility impairment, such as strokes, to less-specific medical diagnoses, such as osteoarthritis. In multilevel, multivariate analyses, individuals living in neighborhoods with higher percentages of blacks or Hispanics were more likely to receive power wheelchairs (odds ratios=1.09 for each 10% increase in black residents and 1.23 for each 10% increase in Hispanic residents) after controlling for ethnicity and other characteristics at the individual level. CONCLUSION: These results support allegations that marketers promoting power wheelchairs have specifically targeted minority neighborhoods. [source]

    Multimorbidity and Survival in Older Persons with Colorectal Cancer

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2006
    Cary P. Gross MD
    OBJECTIVES: To ascertain the effect of common chronic conditions on mortality in older persons with colorectal cancer. DESIGN: Retrospective cohort study. SETTING: Population-based cancer registry. PARTICIPANTS: Patients in the Surveillance Epidemiology and End Results,Medicare linked database who were aged 67 and older and had a primary diagnosis of Stage 1 to 3 colorectal cancer during 1993 through 1999. MEASUREMENTS: Chronic conditions were identified using claims data, and vital status was determined from the Medicare enrollment files. After estimating the adjusted hazard ratios for mortality associated with each condition using a Cox model, the population attributable risk (PAR) was calculated for the full sample and by age subgroup. RESULTS: The study sample consisted of 29,733 patients, 88% of whom were white and 55% were female. Approximately 9% of deaths were attributable to congestive heart failure (CHF; PAR =9.4%, 95% confidence interval (CI) =8.4,10.5%), more than 5% were attributable to chronic obstructive pulmonary disease (COPD; PAR =5.3%, 95% CI=4.7,6.6%), and nearly 4% were attributable to diabetes mellitus (PAR =3.9%, 95% CI=3.1,4.8%). The PAR associated with CHF increased with age, from 6.3% (95% CI=4.4,8.8%) in patients aged 67 to 70 to 14.5% (95% CI=12.0,17.5%) in patients aged 81 to 85. Multiple conditions were common. More than half of the patients who had CHF also had diabetes mellitus or COPD. The PAR associated with CHF alone (4.29%, 95% CI=3.68,4.94%) was similar to the PAR for CHF in combination with diabetes mellitus (3.08, 95% CI=2.60,3.61%) or COPD (3.93, 95% CI=3.41,4.54%). CONCLUSION: A substantial proportion of deaths in older persons with colorectal cancer can be attributed to CHF, diabetes mellitus, and COPD. Multimorbidity is common and exerts a substantial effect on colorectal cancer survival. [source]

    Socioeconomic Status and Survival in Older Patients with Melanoma

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2006
    Carlos A. Reyes-Ortiz MD
    OBJECTIVES: To determine the association between socioeconomic status (SES) and survival in older patients with melanoma. DESIGN: Retrospective cohort study. SETTING: Surveillance, Epidemiology and End Results (SEER): a population-based cancer registry covering 14% of the U.S. population. PARTICIPANTS: Twenty-three thousand sixty-eight patients aged 65 and older with melanoma between 1988 and 1999. MEASUREMENTS: Outcome was melanoma-specific survival. Main independent variable was SES (measured as census tract median household income) taken from the SEER-Medicare linked data. RESULTS: Subjects residing in lower-income areas (,$30,000/y) had lower 5-year survival rates (88.5% vs 91.1%, P<.001) than subjects residing in higher-income areas (>$30,000/y). In Cox proportional hazard models, higher income was associated with lower risk of death from melanoma (hazard ratio=0.88, 95% confidence interval=0.79,0.98, P=.02) after adjusting for sociodemographics, stage at diagnosis, thickness, histology, anatomic site, and comorbidity index. There was an interaction effect between SES and ethnicity and survival from melanoma. For whites and nonwhites (all other ethnic groups), 5-year survival rates increased as income increased, although the effect was greater for nonwhites (77.6% to 90.1%, 1st to 5th quintiles, P=.01) than for whites (89.0% to 91.9%, 1st to 5th quintiles, P<.001). CONCLUSION: Older subjects covered by Medicare residing in lower-SES areas had poorer melanoma survival than those residing in higher-SES areas. Further research is needed to determine whether low SES is associated with late-stage disease biology and poorer early detection of melanoma. [source]

    The Effects of a Variant of the Program for All-inclusive Care of the Elderly on Hospital Utilization and Outcomes

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2006
    Robert L. Kane MD
    OBJECTIVES: To compare the effects of the Wisconsin Partnership Program (WPP) on hospital, emergency department (ED), and nursing home utilization with those of traditional care. DESIGN: Quasi-experimental longitudinal cohort design. SETTING: Selected counties in Wisconsin. PARTICIPANTS: WPP elderly enrollees and two matched control groups consisting of frail older people enrolled in fee-for-service insurance plans, Medicare, and Medicaid and receiving home- and community-based waiver services, one from the same geographic area as the WPP and another from a location in the state where the WPP was not offered. MEASUREMENTS: Data came from administrative records. Regression and survival analyses were adjusted for case-mix variables. RESULTS: No significant differences in hospital utilization, ED visits, preventable hospitalizations, risk of entry into nursing homes, or mortality were found. WPP enrollees had more contact with care providers than did controls. CONCLUSION: WPP did not dramatically alter the pattern of care. Part of the weak effect may be attributable to the small numbers of WPP cases per participating physician. [source]

    Evaluation of Nationally Mandated Drug Use Reviews to Improve Patient Safety in Nursing Homes: A Natural Experiment

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2005
    Becky Briesacher PhD
    Objectives: To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes. Design: Quasi-experimental, longitudinal study. Setting: Data source is the 1997,2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. Participants: Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664). Measurements: Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications. Results: In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3,30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8,25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4,26.4) and 18.0% in ALFs (95% CI=15.6,20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1,27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7,21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0,22.0) and 15.6% of ALF residents (95% CI=15.2,15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without. Conclusion: Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy. [source]

    A Cost-Benefit Analysis of External Hip Protectors in the Nursing Home Setting

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2005
    Lisa A. Honkanen MD
    Objectives: To estimate potential cost savings generated by a program of hip protectors in the nursing home from a Medicare perspective. Design: A state-transition Markov model considering short-term and long-term outcomes of hip protectors for a hypothetical nursing home population, stratified by age, sex, and functional status. Costs, transition probabilities between health states, and estimates of hip protectors' effectiveness were derived from published secondary data. Setting: Nursing home facilities in the United States. Participants: Hypothetical cohort of permanent nursing home residents aged 65 and older without a previous hip fracture. Intervention: Program of hip protectors reimbursed by Medicare. Measurements: Number of fractures, life years, and dollars saved. Results: Three pairs of hip protectors replaced annually would result in a weighted average lifetime absolute risk reduction for hip fracture of 8.5%, with net lifetime savings to Medicare of $223 per resident. When the annual cost of hip protectors is less than $151 per person, relative risk of fracture is less than or equal to 0.65 with hip protectors, or adherence is greater than 42%, hip protectors are cost saving to Medicare over a wide range of assumptions. Extrapolating these results to the estimated population of U.S. nursing home residents without a previous hip fracture, Medicare could save $136 million in the first year of a hip-protector reimbursement program. Conclusion: From a Medicare perspective, hip protectors are a cost-saving intervention in the nursing home setting when hip protector effectiveness is less than or equal to 0.65 over the remaining lifetime of subjects. [source]

    Patterns of Utilization for the Minnesota Senior Health Options Program

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2004
    Robert L. Kane MD
    Objectives: To compare the use of medical services provided under the Minnesota Senior Health Options (MSHO) (a special program designed to serve dually eligible older persons) with that provided to controls who received fee-for-service Medicare and Medicaid managed care. Design: Quasi-experimental design using two control groups; separate matched cohort and rolling cross-sectional analyses; regression models used to adjust for case-mix differences. Setting: Urban Minnesota community and nursing home long-term care. Participants: Dually eligible elderly MSHO enrollees in the community and in nursing homes were compared with two sets of controls; one was drawn from nonenrollees living in the same area (control-in) and another from comparable persons living in another urban area where the program was not available (control-out). Cohorts living in the community and in nursing homes were included. Measurements: Use of hospitals and emergency rooms, physician visits. Results: In the community cohort, there were no significant differences in hospital admission rates or in hospital days. MSHO enrollees had significantly fewer preventable hospital admissions and significantly fewer preventable emergency services than the control-in group. MSHO nursing home enrollees had significantly fewer hospital admissions than either control group with or without adjustment at 12 and 18 months. MSHO enrollees had significantly fewer hospital days and preventable hospitalizations than the control-in group. MSHO enrollees had significantly fewer emergency room visits and preventable emergency room visits than either control group. Conclusion: In general, the results of this evaluation are mixed but favor MSHO. The effect of MSHO was stronger for nursing home enrollees than community enrollees. The lower rate of preventable hospitalizations and emergency room visits of MSHO enrollees suggests that MSHO affected the process of care by providing more of some types of preventive and community-care services for community residents. [source]

    Nursing Home Characteristics and Potentially Preventable Hospitalizations of Long-Stay Residents

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2004
    Orna Intrator PhD
    Objectives: To examine the association between having a nurse practitioner/physician assistant (NP/PA) on staff, other nursing home (NH) characteristics, and the rate of potentially preventable/avoidable hospitalizations of long-stay residents, as defined using a list of ambulatory care,sensitive (ACS) diagnoses. Design: Cross-sectional prospective study using Minimum Data Set (MDS) assessments, Centers for Medicare and Medicaid Services inpatient claims and eligibility records, On-line Survey Certification Automated Records, (OSCAR) and Area Resource File (ARP). Setting: Freestanding urban NHs in Maine, Kansas, New York, and South Dakota. Participants: Residents of 663 facilities with a quarterly or annual MDS assessment in the 2nd quarter of 1997, who had a prior MDS assessment at least 160 days before, and who were not health maintenance organization members throughout 1997 (N=54,631). Measurements: A 180-day multinomial outcome was defined as having any hospitalization with primary ACS diagnosis, otherwise having been hospitalized, otherwise died, and otherwise remained in the facility. Results: Multilevel models show that facilities with NP/PAs were associated with lower hospitalization rates for ACS conditions (adjusted odds ratio (AOR)=0.83), but not with other hospitalizations. Facilities with more physicians were associated with higher ACS hospitalizations (ACS, AOR=1.14, and non-ACS, AOR=1.10). Facilities providing intravenous therapy, and those that operate a nurses' aide training program were associated with fewer hospitalizations of both types. Conclusion: Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions. [source]