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JAMA May 2022
Topics: Aged; Humans; Medicare; Patient Care Bundles; Reimbursement Mechanisms; United States
PubMed: 35452088
DOI: 10.1001/jama.2022.6402 -
Annual Review of Public Health Apr 2020Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this... (Review)
Review
Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.
Topics: Aged; Aged, 80 and over; Delivery of Health Care; Female; Humans; Male; Medicare; Reimbursement Mechanisms; United States; Value-Based Health Insurance
PubMed: 32237986
DOI: 10.1146/annurev-publhealth-040119-094327 -
AJR. American Journal of Roentgenology Jan 2021Medicare permits radiologists to bill for trainee work but only in narrowly defined circumstances and with considerable consequences for noncompliance. The purpose of... (Review)
Review
Medicare permits radiologists to bill for trainee work but only in narrowly defined circumstances and with considerable consequences for noncompliance. The purpose of this article is to introduce relevant policy rationale and definitions, review payment requirements, outline documentation and operational considerations for diagnostic and interventional radiology services, and offer practical suggestions for academic radiologists striving to optimize regulatory compliance. As academic radiology departments advance their missions of service, teaching, and scholarship, most rely on residents and fellows to support expanding clinical demands. Given the risks of technical noncompliance, institutional commitment and ongoing education regarding teaching supervision compliance are warranted.
Topics: Humans; Insurance, Health, Reimbursement; Internship and Residency; Medicare; Radiology; United States
PubMed: 33211571
DOI: 10.2214/AJR.20.22887 -
JAMA Jun 2023
Topics: Insurance Benefits; Insurance Coverage; Medicare Part D; United States; Medicare
PubMed: 37140895
DOI: 10.1001/jama.2023.6371 -
The American Journal of Managed Care May 2024Most Medicare beneficiaries obtain supplemental insurance or enroll in Medicare Advantage (MA) to protect against potentially high cost sharing in traditional Medicare...
OBJECTIVES
Most Medicare beneficiaries obtain supplemental insurance or enroll in Medicare Advantage (MA) to protect against potentially high cost sharing in traditional Medicare (TM). We examined changes in Medicare supplemental insurance coverage in the context of MA growth.
STUDY DESIGN
Repeated cross-sectional analysis of the Medicare Current Beneficiary Survey from 2005 to 2019.
METHODS
We determined whether Medicare beneficiaries 65 years and older were enrolled in MA (without Medicaid), TM without supplemental coverage, TM with employer-sponsored supplemental coverage, TM with Medigap, or Medicaid (in TM or MA).
RESULTS
From 2005 to 2019, beneficiaries with TM and supplemental insurance provided by their former (or current) employer declined by approximately half (31.8% to 15.5%) while the share in MA (without Medicaid) more than doubled (13.4% to 35.1%). The decline in supplemental employer-sponsored insurance use was greater for White and for higher-income beneficiaries. Over the same period, beneficiaries in TM without supplemental coverage declined by more than a quarter (13.9% to 10.1%). This decline was largest for Black, Hispanic, and lower-income beneficiaries.
CONCLUSIONS
The rapid rise in MA enrollment from 2005 to 2019 was accompanied by substantial changes in supplemental insurance with TM. Our results emphasize the interconnectedness of different insurance choices made by Medicare beneficiaries.
Topics: Humans; United States; Medicare Part C; Aged; Cross-Sectional Studies; Male; Female; Medicare; Insurance Coverage; Aged, 80 and over; Cost Sharing; Insurance, Medigap
PubMed: 38748929
DOI: 10.37765/ajmc.2024.89539 -
Journal of the American Geriatrics... Dec 2021Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs)...
BACKGROUND
Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs) accountable for 90-day costs of care. Its overall impact on Medicare spending and clinical outcomes is unknown.
METHODS
Retrospective cohort study using Medicare claims from 2012 to 2017. We used an interrupted time-series design to compare participating vs matched control SNFs on total 90-day Medicare payments and payment components (initial SNF stay, readmissions, and outpatient/clinician), case mix (volume, proportion Medicaid, proportion black, number of comorbidities), and clinical outcomes (90-day readmission, mortality and healthy days at home, and length of initial SNF stay), overall and among key subgroups with frailty or dementia, for 47 of the 48 conditions in the program (excluding major lower extremity joint replacement).
RESULTS
Our sample included 1001 participating and 3873 matched control SNFs. At baseline, total Medicare institutional payments were increasing at BPCI SNFs at a rate of $121 per episode per quarter; during the intervention period, payments decreased at a rate of -$398/episode/quarter. Among controls, payments were stable in the baseline period (+$17/episode/quarter) but decreased at -$424/episode/quarter during the intervention period, yielding a nonsignificant difference in slope changes of -$79/episode/quarter (95% confidence interval [CI] -$188, $31, p = 0.16). However, among patients with frailty, spending declined by $620/episode/quarter in the BPCI group, compared with $330/episode/quarter in the non-BPCI group, for a difference in slope changes of -$289 (95% CI -$482, -$96, p = 0.003). There were no differences in the change in slopes in case selection or clinical outcomes overall or in any clinical subgroup.
CONCLUSIONS
SNF participation in BPCI was associated with no overall differential change in total Medicare payments per episode, case selection, or clinical outcomes. Exploratory analyses revealed a decrease in Medicare payments in patients with frailty that may warrant further study.
Topics: Aged; Aged, 80 and over; Case-Control Studies; Diagnosis-Related Groups; Episode of Care; Female; Health Expenditures; Humans; Interrupted Time Series Analysis; Male; Medicare; Outcome Assessment, Health Care; Patient Care Bundles; Reimbursement Mechanisms; Retrospective Studies; Skilled Nursing Facilities; United States
PubMed: 34379323
DOI: 10.1111/jgs.17409 -
The Consultant Pharmacist : the Journal... Nov 2018Chronic care management (CCM) aims to improve health outcomes by enhancing care coordination for patients with multiple chronic conditions. However, few incentives have... (Review)
Review
Chronic care management (CCM) aims to improve health outcomes by enhancing care coordination for patients with multiple chronic conditions. However, few incentives have been provided in recent years for health care professionals to engage in models that improve care coordination. These potential models could help avoid poor health outcomes that lead to hospitalizations and rehospitalizations. Fortunately, in January 2015, under Medicare's physician fee schedule, Medicare began paying separately for CCM services. Qualified health care providers are reimbursed for these coordination of care services. Though pharmacists cannot bill Medicare for these services, they are in a prime position to deliver CCM services and be paid by forming contractual and collaborative partnerships with qualified providers. CCM bridges the gap between fee-for-service and value-based payment models by focusing on care coordination among health care providers.
Topics: Aged; Aged, 80 and over; Chronic Disease; Humans; Medicare Part B; Medication Therapy Management; Pharmacies; Pharmacists; Treatment Outcome; United States
PubMed: 30458904
DOI: 10.4140/TCP.n.2018.611. -
Journal of the American Geriatrics... Aug 2021More than three million Americans turn 65 each year and newly enroll in Medicare, making this one of the most common insurance transitions. Non-Medicare insurance... (Review)
Review
BACKGROUND
More than three million Americans turn 65 each year and newly enroll in Medicare, making this one of the most common insurance transitions. Non-Medicare insurance transitions are associated with changes in health, healthcare utilization and costs. In addition, older Americans have higher morbidity, mortality, healthcare utilization, and healthcare costs than the general population. However, the effect of new Medicare enrollment on these outcomes is unclear.
DESIGN
We conducted a scoping review to rigorously identify the scope of evidence on the association between new Medicare enrollment and health, healthcare utilization and costs.
SETTING
We included English-language, peer-reviewed, studies cataloged in Medline (PubMed) and EconLit from 1998 to 2018.
PARTICIPANTS
Individuals newly enrolling in Medicare.
MEASUREMENTS
We measured health (e.g., self-reported health), healthcare utilization (e.g., provider visits, preventive care, and hospitalizations) and costs (e.g., patient out-of-pocket and health plan spending).
RESULTS
We screened 5265 articles and included 20 articles. New Medicare enrollment was found to increase self-reported health and healthcare utilization overall, as well as reduce disparities across racial and socioeconomic strata. Provider visits, preventive care and hospitalizations all increased. However, patient out-of-pocket spending decreased, and health plan spending also decreased, when Medicare's lower prices were accounted for. Few studies compared outcomes among new Medicare Advantage enrollees with new Medicare fee-for-service enrollees. None of the studies specifically evaluated the effect of new Medicare enrollment on adults with multiple chronic conditions.
CONCLUSION
New Medicare enrollment improves access overall and reduces access disparities. However, the impact of new Medicare enrollment among subgroups defined by insurance coverage type and number of chronic conditions is less clear. Future work should also evaluate the mechanism for increases in hospitalizations.
Topics: Aged; Ambulatory Care; Health Care Costs; Hospitalization; Humans; Medicare; Patient Acceptance of Health Care; United States
PubMed: 33721340
DOI: 10.1111/jgs.17113 -
Annals of Internal Medicine Jul 2019Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.
BACKGROUND
Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.
OBJECTIVE
To compare readmission rates between Medicare Advantage and traditional Medicare.
DESIGN
Retrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS).
SETTING
4748 U.S. acute care hospitals.
PATIENTS
Patients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014.
MEASUREMENTS
30-day readmissions.
RESULTS
Among admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014.
LIMITATION
Potential unobserved differences between populations.
CONCLUSION
The HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries.
PRIMARY FUNDING SOURCE
National Institute on Aging.
Topics: Aged; Female; Heart Failure; Humans; Male; Medicare; Medicare Part C; Myocardial Infarction; Patient Readmission; Pneumonia; Retrospective Studies; United States
PubMed: 31234205
DOI: 10.7326/M18-1795 -
Journal of Hospital Medicine Mar 2015Outpatient versus inpatient status determinations for hospitalized patients impact how hospitals bill Medicare for hospital services. Medicare policies related to status... (Comparative Study)
Comparative Study Review
Outpatient versus inpatient status determinations for hospitalized patients impact how hospitals bill Medicare for hospital services. Medicare policies related to status determinations and the Recovery Audit Contractor (RAC) program charged with postpayment review of such determinations are of increasing concern to hospitals and physicians. We present an overview and discussion of these policies, including the recent 2-midnight rule, the effect on status determinations by the RAC program, and other recent and pertinent legislative and regulatory activity. Finally, we discuss the future direction of Medicare status determination policies and the RAC program, so that physicians and other healthcare providers caring for hospitalized Medicare beneficiaries may better understand these important and dynamic topics.
Topics: Hospitalization; Humans; Inpatients; Medicare; Outpatients; Time Factors; United States
PubMed: 25557865
DOI: 10.1002/jhm.2312