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The Permanente Journal 2020Previous research has reported switching from traditional Medicare (TM) to Medicare Advantage (MA) plans increased from 2006 to 2011 at the aggregate level, and...
INTRODUCTION
Previous research has reported switching from traditional Medicare (TM) to Medicare Advantage (MA) plans increased from 2006 to 2011 at the aggregate level, and switching from MA plans to TM also increased. However, little is known about switching behavior among individuals with specific chronic diseases.
OBJECTIVE
To examine disease-specific switching patterns between TM and MA to understand the impact on MA plans.
METHODS
Using the 2006 to 2012 Medicare Current Beneficiary Survey, we examined disease-specific switching rates between TM and MA and disease-specific ratios of mean baseline total Medicare expenditures of beneficiaries remaining in the same plan (stayers) vs those switching to another plan (switchers), respectively. We focused on beneficiaries with 1 or more of 10 incident diagnoses.
RESULTS
Beneficiaries with a new diagnosis of Alzheimer disease and related dementias, hypertension, and psychiatric disorders had relatively high rates of switching into MA plans and low rates of switching out of MA plans. Among those with new diagnoses of psychiatric disorders and diabetes, more costly beneficiaries (those with higher costs) switched into MA plans. For cancer, more costly beneficiaries remained in MA plans.
CONCLUSION
Together, these results suggest that MA plans may have not only higher caseloads but also a more costly case mix of beneficiaries with certain diseases than historically was the case. Our findings can help inform MA plans to understand their beneficiaries' disease burden and prepare for provision of relevant services.
Topics: Aged; Chronic Disease; Female; Health Expenditures; Humans; Male; Medicare; Medicare Part C; United States
PubMed: 31852048
DOI: 10.7812/TPP/19.059 -
The American Journal of Hospice &... Aug 2019As the Medicare program struggles to control expenditures, there is increased focus on opportunities to manage patient populations more efficiently and at a lower cost....
As the Medicare program struggles to control expenditures, there is increased focus on opportunities to manage patient populations more efficiently and at a lower cost. A major source of expense for the Medicare program is beneficiaries at end of life. Estimates of the percentage of Medicare costs that arise from patients in the last year of life differ, ranging from 13% to 25%, depending on methods and assumptions. We analyze the most recently available Medicare Limited Data Set to update prior studies of end-of-life costs and examine different methods of performing this calculation. Based upon these findings, we conclude that higher estimates that take into account the spending over the 12 months leading up to death more accurately reflect the full cost of a patient's last year of life. Comparing current year costs of decedents with Medicare's current year costs understates the full budgetary impact of end-of-life patients. Because risk-taking entities such as Medicare Advantage plans and Accountable Care Organizations (ACOs) need to reduce costs while improving the quality of care, they should initiate programs to better manage the care of patients with serious or advanced illness. We also calculate costs for beneficiaries dying in different settings and conclude that more effective use of palliative care and hospice benefits offers a lower cost, higher quality alternative for patients at end of life.
Topics: Accountable Care Organizations; Centers for Medicare and Medicaid Services, U.S.; Female; Health Expenditures; Hospice Care; Humans; Male; Medicare; Medicare Part C; Models, Economic; Terminal Care; United States
PubMed: 30884954
DOI: 10.1177/1049909119836204 -
Clinical Imaging Oct 2020Medicaid reimbursements for physician services are determined by each state. However, how these reimbursements vary between states, and how these reimbursements vary in...
BACKGROUND
Medicaid reimbursements for physician services are determined by each state. However, how these reimbursements vary between states, and how these reimbursements vary in comparison to Medicare reimbursements is unknown for musculoskeletal radiology studies.
OBJECTIVE
To evaluate the variability in Medicaid and Medicare physician reimbursements for musculoskeletal imaging studies between states.
METHODS
We evaluated the Medicare and Medicaid physician reimbursements for the most commonly performed musculoskeletal radiology studies (15 radiographs and 10 MRIs) based on Medicare's 2017 National Summary Data File. Medicare and Medicaid reimbursements for these studies were compared by dollar difference (difference in reimbursement in dollars between Medicare and Medicaid). State-wide variability in these reimbursements was quantified by the coefficient of variation (COV) and by the dollar difference in reimbursement amounts. Medicaid and Medicare reimbursement rates were compared using a paired t-test, since the data was paired by state.
RESULTS
The mean Medicaid reimbursement rates were lower for musculoskeletal radiographs (p < 0.05) but higher for musculoskeletal MRI studies than the Medicare rates (p < 0.05). As hypothesized, there was variation in both Medicare and Medicaid imaging reimbursements between states, however, the variation was substantially higher for Medicaid reimbursements. We found the Medicare reimbursement COV between states was 0.07 for all imaging studies, whereas the Medicaid reimbursement COV between states varied from 0.23 to 0.55 for radiographs and from 0.31 to 0.45 for MRIs.
DISCUSSION
The data show that there is mild, but constant variation across imaging studies in Medicare reimbursement for musculoskeletal imaging studies between states. However, there is more variation in the Medicaid reimbursements across imaging studies and between states. More appropriate reimbursement may increase access to care for Medicaid patients.
Topics: Humans; Insurance, Health, Reimbursement; Medicaid; Medicare; Physicians; Radiology; United States
PubMed: 32454392
DOI: 10.1016/j.clinimag.2020.04.032 -
Health Affairs (Project Hope) Apr 2019
Topics: Delivery of Health Care; Global Health; Health Policy; Humans; Medicare; Periodicals as Topic; Policy Making; Practice Patterns, Physicians'; Quality Improvement; United States
PubMed: 30933605
DOI: 10.1377/hlthaff.2019.00368 -
JAMA Internal Medicine Sep 2017Nearly 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....
IMPORTANCE
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.
OBJECTIVE
To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans.
DESIGN, SETTING, AND PARTICIPANTS
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.
EXPOSURES
Enrollment in an MA plan.
MAIN OUTCOMES AND MEASURES
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.
RESULTS
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 (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%).
CONCLUSIONS AND RELEVANCE
Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.
Topics: Health Care Costs; Health Expenditures; Humans; Insurance, Health, Reimbursement; Insurance, Physician Services; Medicare; Medicare Part C; Needs Assessment; United States
PubMed: 28692718
DOI: 10.1001/jamainternmed.2017.2679 -
American Journal of Clinical Pathology Apr 2021Quantifying pathologist participation in Medicare services may be informative for the prediction of future workforce needs and reimbursement.
OBJECTIVES
Quantifying pathologist participation in Medicare services may be informative for the prediction of future workforce needs and reimbursement.
METHODS
A retrospective examination was performed of pathologist professional (Part B) Medicare billings and payments from 2012 to 2017. The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File was the primary data source.
RESULTS
From 2012 to 2017, there was an increase (3.7%; 11,215 up to 11,627) in pathologists providing Medicare Part B services. Female pathologists increased from 36.10% to 40.8% of pathologists during this time period. Normalized per pathologist, there was an increase (7.8%; 1,382 up to 1,489) in beneficiaries served as well as an increase (4.1%; 2,442 up to 2,543) in services performed. The top 10 pathology Part B services performed in a facility were all surgical pathology. Although services increased, the overall payment of Part B pathology services decreased (3%; $996,519,358 down to $966,615,856) during the study period.
CONCLUSIONS
Although there is increasing pathologist participation in Medicare, the workload per pathologist has increased.
Topics: Aged; Female; Humans; Medicare; Pathologists; Retrospective Studies; Sex Factors; United States; Workforce
PubMed: 33210114
DOI: 10.1093/ajcp/aqaa167 -
Journal of Health Politics, Policy and... Aug 2021Medicare initiatives have been instrumental in improving care delivery and payment as exemplified by its role in broadly expanding the use of telehealth during the...
Medicare initiatives have been instrumental in improving care delivery and payment as exemplified by its role in broadly expanding the use of telehealth during the COVID-19 pandemic. Medicare innovations have been adopted or adapted in Medicaid and by private payers, while Medicare Advantage plans successfully compete with traditional Medicare only because their payment rates are tied by regulation to those in the traditional Medicare program. However, Medicare has not succeeded in implementing new, value-based payment approaches that also would serve as models for other payers, nor has Medicare succeeded in improving quality by relying on public reporting of measured performance. It is increasingly clear that burdensome attention to measurement and reporting distracts from what could be successful efforts to actually improve care through quality improvement programs, with Medicare leading in partnership with providers, other payers, and patients. Although Congress is unlikely to adopt President Biden's proposals to decrease the eligibility age for Medicare or to adopt a public option based on Medicare prices and payment methods in the marketplaces, the Biden administration has an opportunity to provide overdue, strategic direction to the pursuit of value-based payments and to replace failed pay-for-performance with provider-managed projects to improve quality and reduce health disparities.
Topics: Delivery of Health Care; Health Policy; Humans; Medicare; Quality Improvement; Reimbursement Mechanisms; Telemedicine; United States
PubMed: 33493320
DOI: 10.1215/03616878-8970838 -
JAMA Health Forum Oct 2022
Topics: Aged; Humans; Kidney Failure, Chronic; Medicare; United States
PubMed: 36206008
DOI: 10.1001/jamahealthforum.2022.3500 -
Annals of Family Medicine Nov 2017Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care...
PURPOSE
Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers.
METHODS
To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value.
RESULTS
Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation.
CONCLUSIONS
Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.
Topics: Humans; Insurance Claim Review; Medicare; Physician Incentive Plans; Primary Health Care; Quality of Health Care; United States
PubMed: 29133491
DOI: 10.1370/afm.2153 -
The American Journal of Managed Care Sep 2021Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced...
Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced alternative payment models (APMs). Many of these models will continue to be voluntary because they either are in early stages or have not yet proven their effectiveness. The models that have proven their effectiveness should become permanent, comprising the new way that providers are paid in the Medicare program. Either way, getting today's high performers into those programs and keeping them engaged to continue to innovate and set new benchmarks is as important as attracting and improving the performance of poorer performers. That will require a shift in Medicare's policy on pricing and evaluating APMs.
Topics: Aged; Humans; Medicare; United States
PubMed: 34533910
DOI: 10.37765/ajmc.2021.88624