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Medicare Program (medicare + program)
Selected AbstractsDriven to Tiers: Socioeconomic and Racial Disparities in the Quality of Nursing Home CareTHE MILBANK QUARTERLY, Issue 2 2004VINCENT MOR Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition. [source] The Effect of Benefits, Premiums, and Health Risk on Health Plan Choice in the Medicare ProgramHEALTH SERVICES RESEARCH, Issue 4p1 2004Adam 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] The Costs of Decedents in the Medicare Program: Implications for Payments to Medicare+Choice PlansHEALTH SERVICES RESEARCH, Issue 1 2004Melinda 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] US Health Care Reform and Transplantation, Part II: Impact on the Public Sector and Novel Health Care Delivery SystemsAMERICAN JOURNAL OF TRANSPLANTATION, Issue 10 2010D. A. Axelrod The Patient Protection and Affordable Care Act passed in 2010 will result in dramatic expansion of publically funded health insurance coverage for low-income individuals. It is estimated that of the 32 million newly insured, 16 million will obtain coverage through expansion of the Medicaid Program, and the remaining 16 million will purchase coverage through their employer or newly legislated insurance exchanges. While the Act contains numerous provisions to improve access to private insurance as discussed in Part I of this analysis, public sector coverage will significantly be affected. The cost of health care reform will be borne disproportionately by Medicare, which faces nearly $500 billion in cuts to be identified by a new independent board. Transplant centers should be concerned about the impact of the reform on the financial aspects of transplantation. In addition, this legislation also utilizes the Medicare Program to drive reform of the health care delivery system, by encouraging the development of integrated Accountable Care Organizations, experimentation with new ,models' of health care delivery, and expanded support for Comparative Effectiveness Research. Transplant providers, including transplant centers and physicians/surgeons need to lead this movement, drawing on our experience providing comprehensive multidisciplinary care under global budgets with publically reported outcomes. [source] Access to Health Care Services for the Disabled ElderlyHEALTH SERVICES RESEARCH, Issue 3p1 2006Donald H. Taylor Jr. Objective. To determine whether difficulty walking and the strategies persons use to compensate for this deficit influenced downstream Medicare expenditures. Data Source. Secondary data analysis of Medicare claims data (1999,2000) for age-eligible Medicare beneficiaries (N=4,997) responding to the community portion of the 1999 National Long Term Care Survey (NLTCS). Study Design. Longitudinal cohort study. Walking difficulty and compensatory strategy were measured at the 1999 NLTCS, and used to predict health care use as measured in Medicare claims data from the survey date through year-end 2000. Data Extraction. Respondents to the 1999 community NLTCS with complete information on key explanatory variables (walking difficulty and compensatory strategy) were linked with Medicare claims to define outcome variables (health care use and cost). Principal Findings. Persons who reported it was very difficult to walk had more downstream home health visits (1.1/month, p<.001), but fewer outpatient physician visits (,0.16/month, p<.001) after controlling for overall disease burden. Those using a compensatory strategy for walking also had increased home health visits/month (0.55 for equipment, 1.0 for personal assistance, p<.001 for both) but did not have significantly reduced outpatient visits. Persons reporting difficulty walking had increased downstream Medicare costs ranging from $163 to $222/month (p<.001) depending upon how difficult walking was. Less than half of the persons who used equipment to adapt to walking difficulty had their difficulty fully compensated by the use of equipment. Persons using equipment that fully compensated their difficulty used around $300/month less in Medicare-financed costs compared with those with residual difficulty. Conclusions. Difficulty walking and use of compensatory strategies are correlated with the use of Medicare-financed services. The potential impact on the Medicare program is large, given how common such limitations are among the elderly. [source] Do Rural Elders Have Limited Access to Medicare Hospice Services?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2004Beth A. Virnig PhD Objectives:, To examine whether there are urban-rural differences in use of the Medicare hospice benefit before death and whether those differences suggest that there is a problem with access to hospice care for rural Medicare beneficiaries. Design:, Observational study using 100% of Medicare enrollment, hospice, and hospital claims data. Setting:, Inpatient hospitals and hospices. Participants:, Persons aged 65 and older in the Medicare program who died in 1999. Measurements:, Rates of hospice use before death and in-hospital death rates were calculated. Results:, In 1999, there were 1.76 million deaths of Medicare beneficiaries aged 65 and older. Hospice services were used by 365,700 of these beneficiaries. Rates of hospice care before death were negatively associated with degree of rurality. The lowest rate of hospice use, 15.2% of deaths, was seen in rural areas not adjacent to an urban area. The highest rate of use, 22.2% of deaths, was seen in urban areas. Rural areas adjacent to urban areas had an intermediate level of hospice use (17.0% of deaths). Hospices based in rural areas had a smaller number of elderly patients each year than hospices based in urban areas (P<.001) and were more likely to have very low volumes (average daily census of three patients or less). Conclusion:, The consistently lower use of Medicare hospice services before death and smaller sizes of rural hospices suggest that the combination of Medicare hospice payment policies and hospice volumes are problematic for rural hospices. Adjusting Medicare payment policies might be a critical step to assure availability of hospice services forterminally ill beneficiaries regardless of where they live. [source] Who Are the Uninsured Elderly in the United States?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2004James W. Mold MD Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade. [source] Health Insurance Literacy of Older AdultsJOURNAL OF CONSUMER AFFAIRS, Issue 2 2009LAUREN McCORMACK We developed an instrument to measure dimensions of health insurance literacy reflecting familiarity with health insurance terminology and proficiency with the Medicare program. The instrument's items were based on a conceptual framework integrating the financial and health insurance literacy fields and were fielded in a national survey of older adults. We found that overall levels of health insurance literacy were low to moderate. The oldest adults, those with lower education and income, and those with poorer health had lower levels of health insurance literacy. The items demonstrated good psychometric properties and construct validity. They are a promising way to measure selected aspects of health insurance literacy. [source] Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional StaffTHE JOURNAL OF RURAL HEALTH, Issue 3 2005Keith J. Mueller PhD ABSTRACT: Sweeping changes to the Medicare program embodied in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), including a new prescription drug benefit, changes in payment policies, and reform of the Medicare managed-care program, have major implications for rural health care. The most efficient mechanism for research to affect policy is to provide policy makers with information on issues about which they have voiced concern. The Rural Policy Research Institute's Health Panel conducted 2 focus groups with 16 congressional staff in September 2004 to identify a set of researchable questions concerning the impact of the MMA on rural health care. This paper presents research questions in the following areas that staff identified as having the highest priority: access to health plans and pharmacy services, beneficiary outreach and enrollment, technology capacity, provider payment policy, and demonstration projects. [source] The Growing Pains of Integrated Health Care for the Elderly: Lessons from the Expansion of PACETHE MILBANK QUARTERLY, Issue 2 2004DIANE L. GROSS The early success of the demonstration Program of All-Inclusive Care for the Elderly (PACE) led to its designation as a permanent Medicare program in 1997. But the growth in the number of programs and enrollment has lagged and does not meet expectations. This article offers insights into the mechanisms influencing the expansion of PACE, from information obtained in interviews and surveys of administrators, medical directors, and financial officers in 27 PACE programs. Sixteen barriers to expansion were found, including competition, PACE model characteristics, poor understanding of the program among referral sources, and a lack of financing for expansion. This experience offers important lessons for providing integrated health care to the frail elderly. [source] American Society of Transplant Surgeons Transplant Center Outcomes Requirements,A Threat to InnovationAMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2009M. M. Abecassis The transplant center regulations recently published by the Centers for Medicare and Medicaid (CMS) mandate that observed program-specific survival outcomes to fall within expected risk-adjusted outcomes. Meeting these outcomes is essential to continued participation in the Medicare program. Both donor and recipient variables not considered in current risk adjustment models can result in inferior outcomes and therefore may cause an overestimation of transplant center expected performance, precluding participation in the federally funded Medicare program. We reviewed the most recent four reporting periods published by the Scientific Registry for Transplant Recipients on their public website. We identified kidney, liver and heart transplant programs that were flagged for having outcomes statistically lower than expected as well as those that failed to meet CMS criteria. We also analyzed whether center volumes correlated with outcomes in these centers. We highlight the need for mitigating factors that could justify inferior outcomes under specific circumstances. Failure to reach consensus on such a mechanism for appeal may result in risk-averse behavior by transplant centers with respect to innovation and therefore hamper the ability to advance the field of transplantation. We propose a methodology that may address this emerging dilemma. [source] | ||||||||||