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Nursing Management Oct 1996Guidelines recently issued by the Health Care Financing Administration (HCFA) explicity allow health maintenance organizations (HMOs) with a Medicare risk contract to...
Guidelines recently issued by the Health Care Financing Administration (HCFA) explicity allow health maintenance organizations (HMOs) with a Medicare risk contract to sell a point-of-service (POS) benefit to their Medicare members. For an additional charge, these HMO members will now be allowed to go out-of-network for certain medical services.
Topics: Centers for Medicare and Medicaid Services, U.S.; Choice Behavior; Guidelines as Topic; Health Maintenance Organizations; Humans; Medicare; Point-of-Care Systems; United States
PubMed: 9287732
DOI: No ID Found -
Medicare & Medicaid Research Review 2014This work provides descriptive statistics on hospice users. It also explores the magnitude of relative resource use during hospice episodes and whether such patterns...
OBJECTIVE
This work provides descriptive statistics on hospice users. It also explores the magnitude of relative resource use during hospice episodes and whether such patterns vary by episode length for patients who only use routine home care as compared to those who use multiple levels of hospice care. Examining resource use for hospice users who require different hospice levels of care within an episode versus solely routine home care provides insight to the varied resource use associated with the different patient populations (i.e., those who may require steady routine home care across the entire episode versus those who require varied levels of care across the episode).
DATA SOURCE
The analyses were based on a longitudinal analytic file that was constructed from 100% of Medicare claims for hospice users with completed episodes spanning September 1, 2008 through the end of calendar year 2011. In examining resource use for routine home care users and all levels of hospice care, the analyses were restricted to single episode decedents who began their hospice episode on or after April 1, 2010 and whose date of death was on or before December 31, 2011. Daily wage-weighted visit units (WWVUs) were calculated for each patient during their hospice stay. In order to compute a WWVU, one-fourth of the Bureau of Labor Statistics hourly wage rate for each visit discipline (i.e., skilled nursing, medical social services, home health aide, and an average for therapies) was multiplied by the corresponding number of visit units reported on hospice claims.
PRINCIPAL FINDINGS
Using enhanced data on the intensity of service use, the results confirm previous research that suggested a curved pattern to service use during a hospice episode. For several measures of resource intensity, service use is more intensive during the initial days in the episode and for the last few days prior to death relative to the middle days of the episode. The pattern becomes more pronounced as episodes increase in length, but is otherwise a similar curve when compared by diagnosis. Thus, the results provide useful information for potential policy discussions about Medicare hospice reform.
Topics: Aged; Aged, 80 and over; Alzheimer Disease; Dementia; Hospice Care; Humans; Insurance Coverage; Longitudinal Studies; Male; Medicare; Middle Aged; Neoplasms; United States
PubMed: 25097798
DOI: 10.5600/mmrr.004.02.b03 -
Health Services Research Aug 2018To examine the effects of Medicare's revised ambulatory surgery center (ASC) payment schedule on overall payments for outpatient surgery.
OBJECTIVES
To examine the effects of Medicare's revised ambulatory surgery center (ASC) payment schedule on overall payments for outpatient surgery.
DATA SOURCES
Twenty percent sample of national Medicare beneficiaries.
STUDY DESIGN
We conducted a pre-post study of Medicare beneficiaries who underwent outpatient surgery in a hospital outpatient department (HOPD), ASC, or physician office between 2004 and 2011. Specifically, we used multivariable regression to compare temporal trends in outpatient surgery before and after implementation of Medicare's revised payment schedule in 2008, which reduced ASC facility payments to roughly two-thirds that of HOPDs. Our outcome measures included overall Medicare payments, utilization rates, per beneficiary spending, and average episode payments for outpatient surgery.
PRINCIPAL FINDINGS
Between the last quarters of 2007 and 2008, overall Medicare payments for outpatient surgery grew by $334 million-an amount nearly three times higher than would have been expected without the policy change (p < .001 for the difference). While utilization rates of outpatient surgery were attenuated, per beneficiary spending and average surgical episode payments increased by 10.4 percent and 7.8 percent, respectively, over the same period. By the end of 2011, Medicare payments for outpatient surgery reached $5.1 billion. Without the policy change, they would have totaled only $4.1 billion.
CONCLUSIONS
Despite lessening demand, reduced ASC facility payments did not curb spending for outpatient surgery. In fact, overall payments actually increased following the policy change, driven by higher average episode payments.
Topics: Aged; Ambulatory Surgical Procedures; Female; Health Expenditures; Humans; Male; Medicare; Socioeconomic Factors; United States
PubMed: 29194621
DOI: 10.1111/1475-6773.12807 -
The New England Journal of Medicine Nov 2018
Topics: Health Expenditures; Medicare; United States
PubMed: 30382701
DOI: 10.1056/NEJMc1811049 -
National Journal Jun 1998
Topics: Aged; Centers for Medicare and Medicaid Services, U.S.; Chronology as Topic; Computer Systems; Contract Services; Humans; Insurance, Health, Reimbursement; Medicare; Problem Solving; Software; Time; United States
PubMed: 10181059
DOI: No ID Found -
American Journal of Medical Quality :... 1995Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets.... (Review)
Review
Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets. This research offers an in-depth description of how to systematically transform raw inpatient and ambulatory claims data into useful information for health care management and research using the Health Care Financing Administration's National Claims History file as an example. The topics covered include: (a) understanding the contents and architecture of claims data, (b) creating analytic files from raw claims, (c) technical innovations for health policy studies, (d) assessing data accuracy, (d) the costs of using claims data, and (e) ensuring confidentiality. In summary, claims data are found to have great potential for quality of care analysis. As in any analysis, careful development of a database is required for scientific research. The methods outlined in this study offer health data novices as well as experienced analysts a series of strategies to maximize the value of claims data for health policy analysis.
Topics: Aged; Aged, 80 and over; Centers for Medicare and Medicaid Services, U.S.; Databases, Factual; Female; Humans; Information Systems; Insurance Claim Reporting; Insurance Claim Review; Male; Medicare; Quality of Health Care; United States; Utilization Review
PubMed: 8547795
DOI: 10.1177/0885713X9501000402 -
Home Healthcare Nurse Feb 2000This article presents an overview of changes in Medicare's payment system and their effect on home healthcare from a nursing standpoint, and makes policy recommendations... (Review)
Review
This article presents an overview of changes in Medicare's payment system and their effect on home healthcare from a nursing standpoint, and makes policy recommendations for nurses. Home health care utilization, the Balanced Budget Act 1997, the effect of changes in Medicare reimbursement (on beneficiaries and providers), and transition to the new PPS system are discussed. Suggested strategies agencies can use, and how home care nurses can get involved in policy recommendations are presented.
Topics: Community Health Nursing; Home Care Services; Medicare; Organizational Innovation; Reimbursement Mechanisms; United States
PubMed: 11040643
DOI: 10.1097/00004045-200002000-00011 -
Issue Brief (George Washington... Dec 2012Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term...
Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.
Topics: Delivery of Health Care; Forecasting; Health Care Reform; Home Care Services; Hospitals, Convalescent; Humans; Medicare; Medicare Payment Advisory Commission; Patient Protection and Affordable Care Act; Rehabilitation Centers; Reimbursement Mechanisms; Skilled Nursing Facilities; Subacute Care; United States
PubMed: 23240150
DOI: No ID Found -
Health Services Research Apr 2018To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy.
OBJECTIVE
To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy.
DATA SOURCES/STUDY SETTING
Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD).
STUDY DESIGN
We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities.
DATA COLLECTION
We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims.
PRINCIPAL FINDINGS
MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts.
CONCLUSIONS
Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.
Topics: Adult; Aged; Female; Health Expenditures; Hemodialysis Units, Hospital; Hemodialysis, Home; Humans; Insurance, Health, Reimbursement; Kidney Failure, Chronic; Male; Medicare; Middle Aged; Regression Analysis; United States
PubMed: 28105639
DOI: 10.1111/1475-6773.12650 -
Neurology Apr 2015
Topics: Humans; Medicare; Neurology; Physicians
PubMed: 25832666
DOI: 10.1212/WNL.0000000000001529