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Health Services Research Dec 2017To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs.
OBJECTIVE
To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs.
DATA SOURCES/STUDY SETTING
Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida.
STUDY DESIGN
We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences.
DATA COLLECTION/EXTRACTION METHODS
Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims.
PRINCIPAL FINDINGS
Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons.
CONCLUSIONS
Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Humans; Medicare; Medicare Part C; Medicare Part D; Middle Aged; Patient Satisfaction; Quality Indicators, Health Care; Risk Adjustment; United States; Young Adult
PubMed: 29130269
DOI: 10.1111/1475-6773.12787 -
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 -
Medical Care Aug 2019To develop and validate a measure that estimates individual level poverty in Medicare administrative data that can be used in studies of Medicare claims.
OBJECTIVE
To develop and validate a measure that estimates individual level poverty in Medicare administrative data that can be used in studies of Medicare claims.
DATA SOURCES
A 2008 to 2013 Medicare Current Beneficiary Survey linked to 2008 to 2013 Medicare fee-for-service beneficiary summary file and census data.
STUDY DESIGN AND METHODS
We used the Medicare Current Beneficiary Survey to define individual level poverty status and linked to Medicare administrative data (N=38,053). We partitioned data into a measure derivation dataset and a validation dataset. In the derivation data, we used a logistic model to regress poverty status on measures of dual eligible status, part D low-income subsidy, and demographic and administrative data, and modeled with and without linked census and nursing home data. Each beneficiary receives a predicted poverty score from the model. Performance was evaluated in derivation and validation data and compared with other measures used in the literature. We present a measure for income-only poverty as well as one for income and asset poverty.
PRINCIPAL FINDINGS
A score (predicted probability of income poverty) >0.5 yielded 58% sensitivity, 94% specificity, and 84% positive predictive value in the derivation data; our score yielded very similar results in the validation data. The model's c-statistic was 0.84. Our poverty score performed better than Medicaid enrollment, high zip code poverty, and zip code median income. The income and asset version performed similarly well.
CONCLUSIONS
A poverty score can be calculated using Medicare administrative data for use as a continuous or binary measure. This measure can improve researchers' ability to identify poverty in Medicare administrative data.
Topics: Aged; Aged, 80 and over; Cross-Sectional Studies; Female; Humans; Income; Male; Medicare; Middle Aged; Poverty; Reproducibility of Results; United States
PubMed: 31295189
DOI: 10.1097/MLR.0000000000001154 -
The American Journal of Managed Care Mar 2022To study the association between Medicare's wage index adjustment and the differential use of labor-intensive surgical procedures and medical device-intensive minimally...
OBJECTIVES
To study the association between Medicare's wage index adjustment and the differential use of labor-intensive surgical procedures and medical device-intensive minimally invasive clinical procedures across the United States.
STUDY DESIGN
We combine a conceptual model and an empirical investigation of its predictions, applied to aortic valve replacement, to study the relationship between variation in Medicare wage index payment adjustment across hospital referral regions (HRRs) and the utilization of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in these areas.
METHODS
Using detailed individual Medicare claims data for 2013-2018 and a novel geographical crosswalk to nest information on Medicare's wage index and utilization of TAVR and SAVR, we estimate a mixed effects Poisson regression model across HRRs to test our hypotheses.
RESULTS
We find regional variation in Medicare wage index adjustment levels to be correlated with differential TAVR and SAVR utilization and growth over time. In particular, in HRRs where the wage index is half the national mean there is a 35% decline in the rate of TAVR use and in HRRs where the wage index is 50% higher than the national mean there is a 52% increase in the rate of TAVR use.
CONCLUSIONS
Consistent with our framework and hypothesis, our results highlight the importance of adjusting Medicare hospital inpatient payments for device-intensive procedures. Absent such adjustment, access to appropriate interventions may be reduced in areas with low wage index, and lower reimbursement, when driven by wage index adjustment, may influence the treatment approach selected.
Topics: Aged; Aortic Valve Stenosis; Hospitals; Humans; Medicare; Risk Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome; United States
PubMed: 35404553
DOI: 10.37765/ajmc.2022.88842 -
Health Care Financing ReviewThis year marks the 40th anniversary of the Medicare Program. Medicare has achieved its two basic goals of ensuring access to care for elderly and disabled beneficiaries...
This year marks the 40th anniversary of the Medicare Program. Medicare has achieved its two basic goals of ensuring access to care for elderly and disabled beneficiaries and protecting them from severe financial hardship. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 represents an important improvement by adding prescription drug coverage. Medicare's major future challenge is responding to the retirement of the baby boom generation and rising health care costs. Promising policy options should aim to ensure health and financial security for beneficiaries and proactively use Medicare's purchasing power to achieve greater efficiency and quality in health care for Medicare beneficiaries and all Americans. More policy attention needs to be focused on debating Medicare's future, a more complex issue than even Social Security.
Topics: Adult; Aged; Consumer Behavior; Health Services Accessibility; History, 20th Century; Humans; Insurance, Pharmaceutical Services; Medicare; Middle Aged; United States
PubMed: 17290637
DOI: No ID Found -
Health Services Research Aug 2018To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary...
OBJECTIVES
To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms.
DATA SOURCES/STUDY SETTING
Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013).
STUDY DESIGN
We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures.
DATA COLLECTION/EXTRACTION METHODS
We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey.
PRINCIPAL FINDINGS
There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001).
CONCLUSIONS
Physicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.
Topics: Accountable Care Organizations; Benchmarking; Efficiency, Organizational; Humans; Meaningful Use; Medicare; Motivation; Organizational Culture; Patient Safety; Physicians; Quality of Health Care; Regression Analysis; Reimbursement, Incentive; United States
PubMed: 28748535
DOI: 10.1111/1475-6773.12743 -
BMC Health Services Research Jul 2022Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care...
BACKGROUND
Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare's P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare's P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus.
METHODS
We used 2007-2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007-2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients.
RESULTS
Medicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare's P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results.
CONCLUSIONS
Consistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.
Topics: Hospitals; Humans; Inpatients; Medicare; Patient Protection and Affordable Care Act; Quality of Health Care; Reimbursement, Incentive; United States
PubMed: 35902910
DOI: 10.1186/s12913-022-08348-w -
The American Journal of Managed Care Sep 2019To explore whether the Affordable Care Act (ACA)'s Medicare Advantage (MA) payment cuts were associated with changes in enrollees' access to and affordability of... (Comparative Study)
Comparative Study
OBJECTIVES
To explore whether the Affordable Care Act (ACA)'s Medicare Advantage (MA) payment cuts were associated with changes in enrollees' access to and affordability of healthcare relative to traditional Medicare (TM).
STUDY DESIGN
Descriptive analyses of changes in access and affordability in MA relative to TM between 2009 and 2017 and between 2011 and 2017.
METHODS
Respondents who reported Medicare coverage on the National Health Interview Survey were divided into MA and TM enrollees. Using multivariate regression to adjust for demographic, economic, and health status changes over time, we compared changes in healthcare access and affordability for the 2 groups between 2009 and 2017, as the ACA payment cuts were implemented. For some measures, the analysis covers 2011 to 2017.
RESULTS
Between 2009 and 2017, MA respondents did not report statistically significant changes in healthcare access or affordability after adjusting for demographic, socioeconomic, and health status changes in the MA population. There were no statistically significant differences between changes in access and affordability for beneficiaries in MA relative to those in TM over this period.
CONCLUSIONS
Although MA payment cuts were expected to reduce the attractiveness of the MA program to both plans and enrollees, the program's enrollment grew steadily from 2009 to 2017. Over this period, plans reduced their costs for providing Part A and Part B benefits to their enrollees, thereby preserving room for rebates. Our findings show that plans made such cost reductions without significantly affecting enrollees' access to or affordability of care compared with TM beneficiaries.
Topics: Aged; Aged, 80 and over; Costs and Cost Analysis; Female; Forecasting; Health Services Accessibility; Humans; Male; Medicare; Medicare Part C; Patient Protection and Affordable Care Act; United States
PubMed: 31518097
DOI: No ID Found -
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 -
The Milbank Quarterly Mar 2011Hospital cost shifting--charging private payers more in response to shortfalls in public payments--has long been part of the debate over health care policy. Despite the... (Review)
Review
CONTEXT
Hospital cost shifting--charging private payers more in response to shortfalls in public payments--has long been part of the debate over health care policy. Despite the abundance of theoretical and empirical literature on the subject, it has not been critically reviewed and interpreted since Morrisey did so nearly fifteen years ago. Much has changed since then, in both empirical technique and the health care landscape. This article examines the theoretical and empirical literature on cost shifting since 1996, synthesizes the predominant findings, suggests their implications for the future of health care costs, and puts them in the current policy context.
METHODS
The relevant literature was identified by database search. Papers describing policies were considered first, since policy shapes the health care market in which cost shifting may or may not occur. Theoretical works were examined second, as theory provides hypotheses and structure for empirical work. The empirical literature was analyzed last in the context of the policy environment and in light of theoretical implications for appropriate econometric specification.
FINDINGS
Most of the analyses and commentary based on descriptive, industry-wide hospital payment-to-cost margins by payer provide a false impression that cost shifting is a large and pervasive phenomenon. More careful theoretical and empirical examinations suggest that cost shifting can and has occurred, but usually at a relatively low rate. Margin changes also are strongly influenced by the evolution of hospital and health plan market structures and changes in underlying costs.
CONCLUSIONS
Policymakers should view with a degree of skepticism most hospital and insurance industry claims of inevitable, large-scale cost shifting. Although some cost shifting may result from changes in public payment policy, it is just one of many possible effects. Moreover, changes in the balance of market power between hospitals and health care plans also significantly affect private prices. Since they may increase hospitals' market power, provisions of the new health reform law that may encourage greater provider integration and consolidation should be implemented with caution.
Topics: Cost Allocation; Economics, Hospital; Health Policy; History, 20th Century; Humans; Managed Care Programs; Medicare; Models, Economic; Motivation; Prospective Payment System; United States
PubMed: 21418314
DOI: 10.1111/j.1468-0009.2011.00621.x