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BMC Health Services Research Feb 2018To estimate changes in the cost and utilization of Medicare among beneficiaries over age 65 who have been impacted by a natural disaster, we merged publically available...
BACKGROUND
To estimate changes in the cost and utilization of Medicare among beneficiaries over age 65 who have been impacted by a natural disaster, we merged publically available county-level Medicare claims for the years 2008-2012 with Federal Emergency Management Agency (FEMA) data related to disasters in each U.S. County from 2007 to 2012.
METHODS
Fixed-effects generalized linear models were used to calculate change in per capita costs standardized by region and utilization per 1000 beneficiaries at the county level. Aggregate county demographic characteristics of Medicare participants were included as predictors of change in county-level utilization and cost. FEMA data was used to determine counties that experienced no, some, high, and extreme hazard exposure. FEMA data was merged with claims data to create a balanced panel dataset from 2008 to 2012.
RESULTS
In general, both cost and utilization of Medicare services were higher in counties with more hazard exposure. However, utilization of home health services was lower in counties with more hazard exposure.
CONCLUSIONS
Additional research using individual-level data is needed to address limitations and determine the impacts of the substitution of services (e.g., inpatient rehabilitation for home health) that may be occurring in disaster affected areas during the post-disaster period.
Topics: Aged; Disasters; Eligibility Determination; Female; Frail Elderly; Health Services Research; Health Services for the Aged; Humans; Insurance Claim Review; Male; Medicare; United States
PubMed: 29415716
DOI: 10.1186/s12913-018-2900-9 -
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 -
Federal Register Dec 2018Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO)...
Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017. Final rules.
Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. The policies included in this final rule provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. This final rule also provides new tools to support coordination of care across settings and strengthen beneficiary engagement; and ensure rigorous benchmarking. In this final rule, we also respond to public comments we received on the extreme and uncontrollable circumstances policies for the Shared Savings Program that were used to assess the quality and financial performance of ACOs that were subject to extreme and uncontrollable events, such as Hurricanes Harvey, Irma, and Maria, and the California wildfires, in performance year 2017, including the applicable quality data reporting period for performance year 2017.
Topics: Accountable Care Organizations; Benchmarking; Cost Savings; Disasters; Fee-for-Service Plans; Forecasting; Health Policy; Humans; Medicare; Medicare Part A; Medicare Part B; Quality Assurance, Health Care; United States
PubMed: 30596411
DOI: No ID Found -
Health Services Research Apr 2017To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation.
OBJECTIVE
To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation.
DATA SOURCES/STUDY SETTING
Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files.
STUDY DESIGN
We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time.
DATA COLLECTION/EXTRACTION METHODS
Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas.
PRINCIPAL FINDINGS
In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time.
CONCLUSIONS
Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.
Topics: Economics, Hospital; Health Care Costs; Hospitals; Humans; Medicare; Medicare Part A; Prospective Payment System; United States
PubMed: 27060973
DOI: 10.1111/1475-6773.12490 -
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 -
Health Affairs (Project Hope) Jun 2018We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's... (Comparative Study)
Comparative Study
We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost. These findings suggest that while both voluntary and mandatory approaches can play a role in engaging hospitals in bundled payment, mandatory programs can produce more robust, generalizable evidence. Either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payment programs.
Topics: Arthroplasty, Replacement; Databases, Factual; Episode of Care; Female; Health Expenditures; Humans; Insurance, Health; Male; Mandatory Programs; Medicare; Orthopedics; Outcome Assessment, Health Care; Patient Care Bundles; Retrospective Studies; Statistics, Nonparametric; United States
PubMed: 29863929
DOI: 10.1377/hlthaff.2017.1358 -
Inquiry : a Journal of Medical Care... 2019The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of...
The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of delivering better care at lower cost. Policymakers must reverse this trend and ensure parity between traditional Medicare and MA rather than encourage it through legislation that only benefits MA. Furthermore, as discussions of expanding health insurance coverage through Medicare intensify, policymakers should explore what version of Medicare they wish to expand.
Topics: Humans; Medicare; Medicare Part C; Privatization; United States
PubMed: 31382843
DOI: 10.1177/0046958019867612 -
Health Services Research Apr 2022To examine the effects of hospital membership in affiliation networks-franchise-like networks sponsored by high-quality health systems in which affiliate hospitals pay...
OBJECTIVE
To examine the effects of hospital membership in affiliation networks-franchise-like networks sponsored by high-quality health systems in which affiliate hospitals pay an annual fee for access to sponsor's operational and clinical resources-on clinical quality, patient experience ratings, and financial performance of affiliates and their competitors.
DATA SOURCES
Network membership data from press releases and websites of four sponsors (Mayo Clinic, Cleveland Clinic, MD Anderson, Memorial Sloan Kettering), American Hospital Association's Annual Survey, Centers for Medicare & Medicaid Services' Hospital Compare, and Healthcare Cost Report Information System, all for 2005-2016.
STUDY DESIGN
We used a quasi-experimental design and estimated hospital-level regressions with hospital-fixed effects. Dependent variables were measures of clinical quality, patient experience, and financial performance. Independent variables included an indicator for affiliate versus nonaffiliate and fixed effects for hospital characteristics and year. To analyze effects on competitors, we repeated analyses by comparing hospitals in the same county as an affiliate to nonaffiliated, noncompetitor hospitals.
DATA COLLECTION
Membership was obtained through press releases and network websites then linked across datasets by name and Medicare's identification number.
PRINCIPAL FINDINGS
Across networks, affiliates (N = 199) experienced insignificant clinical quality changes but increased net income by $38,500 and operating margin by 6.6% (p values = 0.01-0.08) compared to nonaffiliates. Multispecialty affiliates improved on no measures. Cancer-specific affiliates improved their net income ($96,900) and operating margin (3.6%; p-values < 0.05). Affiliates' competitors experienced mixed changes in clinical measures relative to hospitals without affiliates in market (p-value < 0.05) but no financial effects. Affiliation was not associated with patient experience ratings for affiliates nor competitors.
CONCLUSIONS
Despite quality-focused missions, affiliation networks are not guaranteed to improve public measures of quality in affiliated hospitals, although hospitals in these communities improve financially. Future research should assess the conditions and mechanisms by which affiliation improves quality consistently and which forms of quality.
Topics: Aged; Hospitals; Humans; Medicare; Surveys and Questionnaires; United States
PubMed: 34490641
DOI: 10.1111/1475-6773.13876 -
Inquiry : a Journal of Medical Care... 2019High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower...
High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services' (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.
Topics: Aged; Economic Competition; Financial Management; Humans; Medicaid; Medicare; Nursing Homes; Quality of Health Care; United States
PubMed: 30739512
DOI: 10.1177/0046958018825061 -
American Family Physician Nov 1998Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing... (Review)
Review
Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.
Topics: Continuity of Patient Care; Durable Medical Equipment; Family Practice; Home Care Services; Humans; Medicare; Physician's Role; Referral and Consultation; Reimbursement Mechanisms; United States
PubMed: 9824958
DOI: No ID Found