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  1. 32 CFR 728.61 - Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 5 2010-07-01 2010-07-01 false Medicare beneficiaries. 728.61 Section 728.61... § 728.61 Medicare beneficiaries. (a) Care authorized. Emergency hospitalization and other emergency... Disabled (Medicare) who reside in the 50 United States and the District of Columbia, Guam, Puerto Rico,...

  2. Medicare extra: a comprehensive benefit option for Medicare beneficiaries.

    PubMed

    Davis, Karen; Moon, Marilyn; Cooper, Barbara; Schoen, Cathy

    2005-01-01

    The proposed Part E, Medicare Extra, outlined in this paper adds a comprehensive benefit option to Medicare, eliminating the need for beneficiaries to purchase a private drug plan and Medigap supplemental coverage. Financed by a budget-neutral beneficiary premium, it has the advantages of greater simplicity, efficiency, and value without adding to federal costs. Beneficiaries now enrolled in Medigap plans would save money, as could employers by choosing a lower-cost alternative to current retiree health plans. Eliminating some of the excess payments to Medicare Advantage plans would yield savings that could be used to help finance premium subsidies for low-income beneficiaries.

  3. Sources of drug coverage among Medicare beneficiaries with ESRD.

    PubMed

    Howell, Benjamin L; Powers, Christopher A; Weinhandl, Eric D; St Peter, Wendy L; Frankenfield, Diane L

    2012-05-01

    Despite extensive use of prescription medications in ESRD, relatively little is known about the participation of Medicare ESRD beneficiaries in the Part D program. Here, we quantitated the sources of drug coverage among ESRD beneficiaries and explored the Part D plan preferences of ESRD beneficiaries with regard to deductibles, coverage gaps, and monthly premiums. We obtained data on beneficiary sources of creditable coverage, characteristics of Part D plans, demographics, and residence from the Centers for Medicare and Medicaid Chronic Condition Data Warehouse and identified beneficiaries with ESRD from the US Renal Data System. We found that a substantial proportion (17.0%) of ESRD beneficiaries lacked a known source of creditable drug coverage in 2007 and 64.3% were enrolled in Part D. Of those enrolled, 72% received the Medicare Part D low-income subsidy. ESRD beneficiaries who enrolled in standalone Part D plans without the assistance of the low-income subsidy tended to prefer more comprehensive coverage options. In conclusion, more outreach is needed to ensure that beneficiaries who lack coverage obtain the coverage they need and that ESRD beneficiaries join the best plans for managing their disease and accompanying comorbid conditions.

  4. Medicare Accountable Care Organizations: Beneficiary Assignment Update.

    PubMed

    Vaughn, Thomas; MacKinney, A Clinton; Mueller, Keith J; Ullrich, Fred; Zhu, Xi

    2016-06-01

    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services (CMS) Accountable Care Organization (ACO) regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Overall, the regulatory changes are intended to (1) encourage ACOs to participate in two-sided risk contracts, (2) increase the likelihood that beneficiaries are assigned to the physician (and ACO) from whom they receive most of their primary care services, and (3) make it easier for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to participate in ACOs. Understanding ACO beneficiary assignment policies is critical for ACO in managing their panel of ACO providers and beneficiaries. PMID:27416650

  5. Medicare Accountable Care Organizations: Beneficiary Assignment Update.

    PubMed

    Vaughn, Thomas; MacKinney, A Clinton; Mueller, Keith J; Ullrich, Fred; Zhu, Xi

    2016-06-01

    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services (CMS) Accountable Care Organization (ACO) regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Overall, the regulatory changes are intended to (1) encourage ACOs to participate in two-sided risk contracts, (2) increase the likelihood that beneficiaries are assigned to the physician (and ACO) from whom they receive most of their primary care services, and (3) make it easier for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to participate in ACOs. Understanding ACO beneficiary assignment policies is critical for ACO in managing their panel of ACO providers and beneficiaries.

  6. Should healthy Medicare beneficiaries postpone enrollment in Medicare Part D?

    PubMed

    Atherly, Adam; Dowd, Bryan

    2009-08-01

    We compare estimated lifetime out-of-pocket prescription drug expenditures on outpatient prescription drugs, premiums and late enrollment penalties for healthy 65-year-old Medicare beneficiaries if they (a) purchase Part D as soon as they are eligible versus (b) waiting until they contract a drug-intensive condition. Using data from the Medicare Current Beneficiary Survey, a representative sample of the Medicare population, we estimate the annual probability that a healthy 65-year-old will transition to a drug-intensive health state or death. We then use Monte Carlo simulations to estimate expected lifetime prescription drug spending with and without drug insurance. We find that for the statutory minimum benefit policy with a $30 per month premium, lifetime expected expenditures are about 10% higher for women and 6.5% higher for men if healthy beneficiaries postpone enrollment in Part D. Eliminating the late enrollment penalty would create a significant cost advantage for postponed enrollment, particularly for men. Under current rules, the financial advantage of early enrollment coupled with the reduction in risk associated with purchasing Part D plans and potential utility gains from insurance-induced drug consumption, suggests that immediate purchase of Part D is the optimal choice for Medicare beneficiaries.

  7. Pharmacotherapy in Medicare Beneficiaries With Atrial Fibrillation

    PubMed Central

    Piccini, Jonathan P.; Mi, Xiaojuan; DeWald, Tracy A.; Go, Alan S.; Hernandez, Adrian F.; Curtis, Lesley H.

    2013-01-01

    Background There are limited data regarding national patterns of pharmacotherapy for atrial fibrillation (AF) among older patients. Drug exposure data are now captured for Medicare beneficiaries enrolled in prescription drug plans. Objective To describe pharmacotherapy for AF among Medicare beneficiaries. Methods Using a 5% national sample of Medicare claims data, we compared demographic characteristics, comorbidity, and treatment patterns according to Medicare Part D status among patients with prevalent AF in 2006 and 2007. Results In 2006, 27,174 patients (29.3%) with prevalent AF were enrolled in Medicare Part D. In 2007, enrollment increased to 45,711 (49.1%). Most enrollees were taking rate control agents (74.0% in 2007). β-Blocker use was higher in those with concomitant AF and heart failure and increased with higher CHADS2 scores (P < .001). Antiarrhythmic use was 18.7% in 2006 and 19.1% in 2007, with amiodarone accounting for more than 50%. Class Ic drugs were used in 3.2% of patients in 2007. Warfarin use was less than 60% and declined with increasing stroke risk (P < .001). Conclusion Pharmacotherapy for AF varied according to comorbidity and underlying risk. Amiodarone was the most commonly prescribed antiarrhythmic agent. Postmarketing surveillance using Medicare Part D claims data linked to clinical data may help inform comparative safety, effectiveness, and net clinical benefit of drug therapy for AF in older patients in real-world settings. PMID:22537885

  8. Medication adherence behaviors of Medicare beneficiaries

    PubMed Central

    Carr-Lopez, Sian M; Shek, Allen; Lastimosa, Janine; Patel, Rajul A; Woelfel, Joseph A; Galal, Suzanne M; Gundersen, Berit

    2014-01-01

    Background Medication adherence is crucial for positive outcomes in the management of chronic conditions. Comprehensive medication consultation can improve medication adherence by addressing intentional and unintentional nonadherence. The Medicare Part D prescription drug benefit has eliminated some cost barriers. We sought to examine variables that impact self-reported medication adherence behaviors in an ambulatory Medicare-beneficiary population and to identify the factors that influence what information is provided during a pharmacist consultation. Methods Medicare beneficiaries who attended health fairs in northern California were offered medication therapy management (MTM) services during which demographic, social, and health information, and responses to survey questions regarding adherence were collected. Beneficiaries were also asked which critical elements of a consultation were typically provided by their community pharmacist. Survey responses were examined as a function of demographic, socioeconomic, and health-related factors. Results Of the 586 beneficiaries who were provided MTM services, 575 (98%) completed the adherence questions. Of responders, 406 (70%) reported taking medications “all of the time”. Of the remaining 169 (30%), the following reasons for nonadherence were provided: 123 (73%) forgetfulness; 18 (11%) side effects; and 17 (10%) the medication was not needed. Lower adherence rates were associated with difficulty paying for medication, presence of a medication-related problem, and certain symptomatic chronic conditions. Of the 532 who completed survey questions regarding the content of a typical pharmacist consultation, the topics included: 378 (71%) medication name and indication; 361 (68%) administration instructions; 307 (58%) side effects; 257 (48%) missed-dose instructions; and 245 (46%) interactions. Subsidy recipients and non-English speakers were significantly less likely to be counseled on drug name, indication, and side

  9. Impact of Medicare Managed Care Market Withdrawal on Beneficiaries

    PubMed Central

    Booske, Bridget C.; Lynch, Judith; Riley, Gerald

    2002-01-01

    The 2001 Survey of Involuntary Disenrollees was conducted to investigate the impact of Medicare+Choice (M+C) plan withdrawals on Medicare beneficiaries. Eighty-four percent of a total of 4,732 beneficiaries whose Medicare managed care (MMC) plan stopped serving them at the end of 2000 responded to the survey Their responses indicated that the withdrawal of plans from Medicare affected beneficiaries in terms of concerns about getting and paying for care, increased payments for premiums and out-of-pocket costs, and changes in health care arrangements. Of particular concern were the impacts on those in vulnerable subgroups such as the disabled, less educated, and minorities. PMID:12545601

  10. Medicare spending by beneficiaries with various types of supplemental insurance.

    PubMed

    Khandker, R K; McCormack, L A

    1999-06-01

    The authors analyzed Medicare spending by elderly noninstitutionalized Medicare beneficiaries with and without supplemental insurance such as Medigap, employer-sponsored plans, and Medicaid. Use of a detailed survey of Medicare beneficiaries and their Medicare health insurance claims enabled the authors to control for health status, chronic conditions, functional limitations, and other factors that explain spending variations across supplemental insurance categories. The authors found that supplemental insurance was associated with a higher probability and level of Medicare spending, particularly for Part B services. Beneficiaries with both Medigap and employer plans had the highest levels of spending ceteris paribus, suggesting a possible moral hazard effect of insurance. Findings from this study are discussed in the context of the overall financing of health care for the elderly. PMID:10373721

  11. Lower Rehospitalization Rates among Rural Medicare Beneficiaries with Diabetes

    ERIC Educational Resources Information Center

    Bennett, Kevin J.; Probst, Janice C.; Vyavaharkar, Medha; Glover, Saundra H.

    2012-01-01

    Purpose: We estimated the 30-day readmission rate of Medicare beneficiaries with diabetes, across levels of rurality. Methods: We merged the 2005 Medicare Chronic Conditions 5% sample data with the 2007 Area Resource File. The study population was delimited to those with diabetes and at least 1 hospitalization in the year. Unadjusted readmission…

  12. Medicare beneficiaries more likely to receive appropriate ambulatory services in HMOs than in traditional medicare.

    PubMed

    Ayanian, John Z; Landon, Bruce E; Zaslavsky, Alan M; Saunders, Robert C; Pawlson, L Gregory; Newhouse, Joseph P

    2013-07-01

    With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. We also found that Medicare HMO physicians were rated less favorably by their patients than were physicians in traditional Medicare in 2003; however, by 2009 the opposite was true. Not-for-profit, larger, and older Medicare HMOs performed consistently more favorably on clinical measures and ratings of care than for-profit, smaller, and newer HMOs. Our results suggest that the positive effects of more-integrated delivery systems on the quality of ambulatory care in Medicare HMOs may outweigh the potential incentives to restrict care under capitated payments.

  13. Use of Hospitalists by Medicare Beneficiaries: A National Picture

    PubMed Central

    Pete Welch, W; Stearns, Sally C; Cuellar, Alison E; Bindman, Andrew B

    2014-01-01

    Objective To describe the characteristics of hospitalists serving Medicare beneficiaries. Data Sources Medicare claims from 2009 and 2011 merged with the Provider Enrollment, Chain, and Ownership System file for physician characteristics. Study Design Our construction of the Medicare Data on Physician Practice and Specialty (MD-PPAS) enabled identification of hospitalists based on the attending physician for Medicare admissions (medical and surgical) in 2009 and 2011. Principal Findings In 2011, hospitalists constituted 13.3% of physicians who designated their specialty as primary care and 4.4% of all physicians serving Medicare beneficiaries. Compared to other physicians, hospitalists were more likely to be female, under forty, and in large practices. More than a quarter of Medicare admissions had a hospitalist as the attending physician, though the rate was substantially higher for medical than surgical admissions (31.8% versus 11.3%). Between 2009 and 2011, the percentage of medical admissions with a hospitalist as the attending physician increased by roughly a quarter (from 25.7% to 31.8%). Conclusions This analysis provides a more current and complete estimate of the use of hospitalists by the Medicare population than is available from prior studies. The ability to identify hospitalists from claims data will facilitate research on the impact of hospitalist use on quality and cost. PMID:24967149

  14. Behavioral risk factor surveillance of aged Medicare beneficiaries, 1995.

    PubMed

    Arday, D R; Arday, S L; Bolen, J; Rhodes, L; Chin, J; Minor, P

    1997-01-01

    The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing State-based telephone survey of adults, administered through State health departments. The survey estimates health status and the prevalence of various risk factors among respondents, who include both fee-for-service and managed care Medicare beneficiaries. In this article the authors present an overview of the BRFSS and report 1995 regional results among respondents who were 65 years of age or over and who had health insurance. The advantages and disadvantages of using the BRFSS as a tool to monitor beneficiary health status and risk factors are also discussed.

  15. Predictability of Prescription Drug Expenditures for Medicare Beneficiaries

    PubMed Central

    Wrobel, Marian V.; Doshi, Jalpa; Stuart, Bruce C.; Briesacher, Becky

    2003-01-01

    MCBS data are used to analyze the predictability of drug expenditures by Medicare beneficiaries. Predictors include demographic characteristics and measures of health status, the majority derived using CMS' diagnosis cost group/hierarchical condition category (DCG/HCC) risk-adjustment methodology. In prospective models, demographic variables explained 5 percent of the variation in drug expenditures. Adding health status measures raised this figure between 10 and 24 percent of the variation depending on the model configuration. Adding lagged drug expenditures more than doubled predictive power to 55 percent. These results are discussed in the context of forecasting, and risk adjustment for the proposed new Medicare drug benefit. PMID:15124376

  16. Characteristics of Medicare Advantage and Fee-for-Service Beneficiaries Upon Enrollment in Medicare at Age 65.

    PubMed

    Miller, Eric A; Decker, Sandra L; Parker, Jennifer D

    2016-01-01

    Previous research has found differences in characteristics of beneficiaries enrolled in Medicare fee-for-service versus Medicare Advantage (MA), but there has been limited research using more recent MA enrollment data. We used 1997-2005 National Health Interview Survey data linked to 2000-2009 Medicare enrollment data to compare characteristics of Medicare beneficiaries before their initial enrollment into Medicare fee-for-service or MA at age 65 and whether the characteristics of beneficiaries changed from 2006 to 2009 compared with 2000 to 2005. During this period of MA growth, the greatest increase in enrollment appears to have come from those with no chronic conditions and men.

  17. Characteristics of Medicare Advantage and Fee-for-Service Beneficiaries Upon Enrollment in Medicare at Age 65.

    PubMed

    Miller, Eric A; Decker, Sandra L; Parker, Jennifer D

    2016-01-01

    Previous research has found differences in characteristics of beneficiaries enrolled in Medicare fee-for-service versus Medicare Advantage (MA), but there has been limited research using more recent MA enrollment data. We used 1997-2005 National Health Interview Survey data linked to 2000-2009 Medicare enrollment data to compare characteristics of Medicare beneficiaries before their initial enrollment into Medicare fee-for-service or MA at age 65 and whether the characteristics of beneficiaries changed from 2006 to 2009 compared with 2000 to 2005. During this period of MA growth, the greatest increase in enrollment appears to have come from those with no chronic conditions and men. PMID:27232684

  18. Weighted Health Status in the Medicare Population: Development of the Weighted Index for the Medicare Current Beneficiary Survey (WHIMCBS).

    ERIC Educational Resources Information Center

    Doctor, Jason N.; Chan, Leighton; MacLehose, Richard F.; Patrick, Donald L.

    2001-01-01

    Developed an approach to constructing an aggregate index of health at the population level with data from Medicare beneficiaries using the 1991 (n=12,667), 1995 (n=15,590), and 1997 (n=17,058) Medicare Current Beneficiary Survey (MCBS). Findings suggest that in addition to mortality, morbidity appears to play a significant role in years of healthy…

  19. Risk of Musculoskeletal Injuries, Fractures, and Falls in Medicare Beneficiaries With Disorders of Binocular Vision

    PubMed Central

    Pineles, Stacy L.; Repka, Michael X.; Yu, Fei; Lum, Flora; Coleman, Anne L.

    2015-01-01

    Importance Disorders of binocular vision are increasingly prevalent among fee-for-service Medicare beneficiaries 65 years or older. Visual impairment is a recognized risk factor for fractures. Despite the association of visual impairment and fracture risk, to our knowledge, no study has examined the influence that disorders of binocular vision (strabismus, amblyopia, diplopia, and nystagmus) may have on musculoskeletal injury and fracture risk in the elderly population. Objective To evaluate associations between disorders of binocular vision and musculoskeletal injury, fracture, and falls in the elderly. Design, Setting, and Participants A retrospective study of 10-year (2002-2011) musculoskeletal injury, fracture, or fall prevalence in a 5% random sample of Medicare Part B fee-for-service claims for beneficiaries with disorders of binocular vision. Participants included Medicare beneficiaries living in the general community who were 65 years or older with at least 1 year of Medicare Part B enrollment. Exposures Diagnosis of a disorder of binocular vision. Main outcomes and measures Ten-year prevalence of musculoskeletal injury, fracture, or fall in individuals with and without disorders of binocular vision. Analyses were adjusted for age, sex, race/ethnicity, region of residence, systemic and ocular comorbidities, and duration of follow-up. Results There were 2 196 881 Medicare beneficiaries identified. Of these, 99 525 (4.5%) had at least 1 reported disorder of binocular vision (strabismus, 2.3%; diplopia, 2.2%; amblyopia, 0.9%; and nystagmus, 0.2%). During the 10-year study period, there were 1 272 948 (57.9%) patients with documented musculoskeletal injury, fracture, or fall. The unadjusted odds ratio (OR) for the association between disorders of binocular vision and any of the 3 injury types was 2.23 (95% CI, 2.20-2.27; P < .001). The adjusted OR was 1.27 (95% CI, 1.25-1.29; P < .001). Conclusions and Relevance Medicare beneficiaries with a disorder of

  20. How health reform legislation will affect Medicare beneficiaries.

    PubMed

    Guterman, Stuart; Davis, Karen; Stremikis, Kristof

    2010-03-01

    Despite criticism that health reform legislation will result in cuts to Medicare, the bills passed by the House of Representatives and the Senate, as well as President Obama's proposal, contain provisions that would strengthen the program by reducing costs for prescription drugs, expanding coverage for preventive care, providing more help for low-income beneficiaries, and supporting accessible, coordinated, and comprehensive care that effectively responds to patients' needs. The legislation also would help to extend the program's fiscal solvency--for nine years, under the Senate bill. This issue brief examines the provisions in the pending legislation and how each one would work to improve benefits, extend the fiscal solvency of the Medicare Hospital Insurance Trust Fund, reduce pressure on the federal budget, and contribute to moving the health care system toward better access to care, improved quality, and greater efficiency. PMID:20297561

  1. The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural America

    ERIC Educational Resources Information Center

    Weingarten, Joseph P.; Brittman, Susan; Hu, Wenrong; Przybyszewski, Chris; Hammond, Judith M.; FitzGerald, Dawn

    2006-01-01

    Context: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level. Purpose: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities. Methods: Medicare beneficiaries with diabetes aged 18-75 were…

  2. Effect of Communication Disability on Satisfaction with Health Care: A Survey of Medicare Beneficiaries

    ERIC Educational Resources Information Center

    Hoffman, Jeanne M.; Yorkston, Kathryn M.; Shumway-Cook, Anne; Ciol, Marcia A.; Dudgeon, Brian J.; Chan, Leighton

    2005-01-01

    Purpose: To examine the prevalence and characteristics of community-dwelling Medicare beneficiaries reporting a communication disability and the relationship between that disability and dissatisfaction with medical care. Method: A total of 12,769 Medicare Current Beneficiary Survey respondents age 65 and older in 2001 were categorized by level of…

  3. Self-Reported Cancer Screening among Elderly Medicare Beneficiaries: A Rural-Urban Comparison

    ERIC Educational Resources Information Center

    Fan, Lin; Mohile, Supriya; Zhang, Ning; Fiscella, Kevin; Noyes, Katia

    2012-01-01

    Purpose: We examined the rural-urban disparity of screening for breast cancer and colorectal cancer (CRC) among the elder Medicare beneficiaries and assessed rurality's independent impact on receipt of screening. Methods: Using 2005 Medicare Current Beneficiary Survey, we applied weighted logistic regression to estimate the overall rural-urban…

  4. New challenges to medicare beneficiary access to mAbs

    PubMed Central

    Wilson, Andrew

    2009-01-01

    Precision binding of monoclonal antibodies (mAbs) to biological targets, their relative clinical success, and expansion of indications following initial approval, are distinctive clinical features. The relatively high cost of mAbs, together with the absence of a regulatory pathway to generics, stand out as distinctive economic features. Based on both literature review and primary data collection we enumerated mAb original approvals, supplemental indications and off-label uses, assessed payer formulary management of mAbs, and determined new challenges to Medicare beneficiary access to mAbs. We found that the FDA has approved 22 mAbs and 30 supplemental indications pertaining to the originally approved mAbs. In addition, there are 46 off-label use citations in officially recognized pharmaceutical compendia. Across Part B carriers and Part D plans, we found considerable variation in terms of coverage and conditions of reimbursement related to on- and off-label uses of mAbs. Our results point to four major challenges facing mAb developers, health care providers, Medicare beneficiaries, payers and policymakers. These include administrative price controls, coverage variation, projected shift from physician- to self-administered mAbs, and comparative effectiveness. We suggest more systematic use of “coverage with evidence development” as a means of optimally addressing these challenges. PMID:20046575

  5. Rapid reengineering of acute medical care for Medicare beneficiaries: the Medicare innovations collaborative.

    PubMed

    Leff, Bruce; Spragens, Lynn H; Morano, Barbara; Powell, Jennifer; Bickert, Terri; Bond, Christy; DeGolia, Peter; Malone, Michael; Glew, Catherine; McCrystle, Sindy; Allen, Kyle; Siu, Albert L

    2012-06-01

    In 2009 we described a geriatric service line or "portfolio" model of acute care-based models to improve care and reduce costs for high-cost Medicare beneficiaries with multiple chronic conditions. In this article we report the early results of the Medicare Innovations Collaborative, a collaborative program of technical assistance and peer-to-peer exchange to promote the simultaneous adoption of multiple complex care models by hospitals and health systems. We found that organizations did in fact adopt and implement multiple complex care models simultaneously; that these care models were appropriately integrated and adapted so as to enhance their adoptability within the hospital or health care system; and that these processes occurred rapidly, in less than one year. Members indicated that the perceived prestige of participation in the collaborative helped create incentives for change among their systems' leaders and was one of the top two reasons for success. The Medicare Innovations Collaborative approach can serve as a model for health service delivery change, ultimately expanding beyond the acute care setting and into the community and often neglected postacute and long-term care arenas to redesign care for high-cost Medicare beneficiaries.

  6. Rapid reengineering of acute medical care for Medicare beneficiaries: the Medicare innovations collaborative.

    PubMed

    Leff, Bruce; Spragens, Lynn H; Morano, Barbara; Powell, Jennifer; Bickert, Terri; Bond, Christy; DeGolia, Peter; Malone, Michael; Glew, Catherine; McCrystle, Sindy; Allen, Kyle; Siu, Albert L

    2012-06-01

    In 2009 we described a geriatric service line or "portfolio" model of acute care-based models to improve care and reduce costs for high-cost Medicare beneficiaries with multiple chronic conditions. In this article we report the early results of the Medicare Innovations Collaborative, a collaborative program of technical assistance and peer-to-peer exchange to promote the simultaneous adoption of multiple complex care models by hospitals and health systems. We found that organizations did in fact adopt and implement multiple complex care models simultaneously; that these care models were appropriately integrated and adapted so as to enhance their adoptability within the hospital or health care system; and that these processes occurred rapidly, in less than one year. Members indicated that the perceived prestige of participation in the collaborative helped create incentives for change among their systems' leaders and was one of the top two reasons for success. The Medicare Innovations Collaborative approach can serve as a model for health service delivery change, ultimately expanding beyond the acute care setting and into the community and often neglected postacute and long-term care arenas to redesign care for high-cost Medicare beneficiaries. PMID:22665832

  7. Designing health insurance information for the Medicare beneficiary: a policy synthesis.

    PubMed Central

    Davidson, B N

    1988-01-01

    Can Medicare beneficiaries make rational and informed decisions about their coverage under the Medicare program? Recent policy developments in the Medicare program have been based on the theory of competition in medical care. One of the key assumptions of the competitive model is the free flow of adequate information, enabling the consumer to make an informed choice from among the various sellers of a particular product. Options for Medicare beneficiaries in supplementing their basic Medicare coverage include the purchase of private supplementary insurance policies or enrollment in a Medicare HMO. These consumers, in a complex health insurance market, have only limited information available to them because many health plans do not make adequate comparable product information available. Moreover, since the introduction of the Medicare HMO option, the long-range plan for management of the Medicare budget has become based on the large-scale voluntary enrollment of beneficiaries into capitated health plans. The policy instrument that has been used to improve beneficiary decisions on how to supplement Medicare coverage is the informational or educational program. This synthesis presents findings regarding the relative effectiveness of different types of health insurance information programs for the Medicare beneficiary in an effort to promote practical use of the most effective types of information. PMID:3060450

  8. Using the Medicare Current Beneficiary Survey to conduct research on Medicare-eligible veterans.

    PubMed

    Jonk, Yvonne; O'Connor, Heidi; Schult, Tamara; Cutting, Andrea; Feldman, Roger; Ripley, Diane Cowper; Dowd, Bryan

    2010-01-01

    The Medicare Current Beneficiary Survey (MCBS) is a longitudinal, multipurpose panel survey of a nationally representative sample of Medicare beneficiaries sponsored by the Centers for Medicare and Medicaid Services (CMS). The MCBS serves as a comprehensive data source on self-reported health and socioeconomic status, health insurance, healthcare utilization and costs, and patient satisfaction. CMS uses Medicare claims data to validate self-reported Medicare Fee-For-Service (FFS) utilization. Because the Veterans Health Administration (VHA) does not bill for services, CMS imputes VHA costs. This article addresses the quality of the MCBS dataset for conducting research on Medicare-eligible veterans by addressing the sample's representativeness, quality of self-reported data, and accuracy of imputed VHA cost estimates. We compared demographic data from the 1992 and 2001 National Survey of Veterans (NSV) with the MCBS 1992 and 2001 Cost and Use files. We compared self-reported VHA utilization and CMS's imputed costs with VHA administrative datasets. The VHA's Pharmacy Benefits Management (PBM) database is available from fiscal year (FY) 1999 onward, and the VHA Health Economics Resource Center's (HERC) Average Cost datasets are available from FY1998 onward. While the samples were comparable in terms of age, sex, and race, the MCBS respondents were in better health, less likely to be married, and more likely to be widowed than NSV respondents. MCBS underreporting rates were higher for VHA than Medicare outpatient events. Underreporting and differences between CMS's and HERC's costing methodologies contributed to lower MCBS versus VHA administrative person- and event-level costs. Alternatively, average annual VHA prescription costs per capita were higher in the MCBS than in the PBM data. Differences in socioeconomic characteristics of the NSV and MCBS samples may be attributable to differences in sampling methodologies. Higher underreporting rates for VHA versus

  9. The January effect: medication reinitiation among Medicare Part D beneficiaries.

    PubMed

    Kaplan, Cameron; Zhang, Yuting

    2014-11-01

    The Medicare prescription drug program (Part D) standard benefit includes deductible, initial coverage, coverage gap and catastrophic coverage phases. As beneficiaries enter each phase, their out-of-pocket medication costs change discontinuously. The benefit cycle restarts on 1 January of the next year. Taking advantage of variation in drug coverage, we study how individuals reinitiate discontinued medications in response to the non-linear price schedule. Because some beneficiaries who receive low-income subsidies (LIS) have zero or fixed small copayments throughout the year, we perform a difference-in-difference analysis by using the LIS group as a comparison. We find that individuals delay reinitiating important medications in December and are significantly more likely to reinitiate in January than in other months. Although we find some evidence that reinitiation is lower in the final months of the year, it is mostly driven by those who face higher prices due to the coverage gap. Our study suggests that individuals respond more to the current price of medications and do not anticipate future prices as well as theory would suggest.

  10. A Medicare Current Beneficiary Survey-Based Investigation of Alternative Primary Care Models in Nursing Homes: Cost and Utilization Differences.

    PubMed

    Lee, A James; Gautam, Ramraj; Melillo, Karen Devereaux; Abdallah, Lisa M; Remington, Ruth; Van Etten, Deborah; Gore, Rebecca

    2016-05-01

    The current study used the Medicare Current Beneficiary Survey-Based (MCBS) Cost and Use files for 2006-2008 to investigate whether health care costs and service utilization of nursing home residents varied with nurse practitioner (NP) and physician assistant (PA) involvement, compared to the use of medical doctors (MDs) only. The sample included Medicare beneficiaries 65 and older residing in a nursing home for the entire study year (433 annual observations). A generalized estimating equations procedure was used to assess whether health care cost and utilization measures varied by cohort. Point estimates indicated that the annual per-person cost of non-institutional services (total medical cost less the cost of the nursing home itself) was $3,847 and $3,170 more for individuals in the MD-only and MD-dominant cohorts, respectively, compared to those in the NP/PA-dominant cohort. [Res Gerontol Nurs. 2016; 9(3):115-122.].

  11. Ultrasound screening for abdominal aortic aneurysm in medicare beneficiaries.

    PubMed

    Schermerhorn, Marc; Zwolak, Robert; Velazquez, Omaida; Makaroun, Michel; Fairman, Ronald; Cronenwett, Jack

    2008-01-01

    Ultrasound screening for abdominal aortic aneurysm (AAA) has been shown to be beneficial and cost-effective for men aged 65-74. However, most screening studies have been conducted in Europe and Australia, where attendance for screening was higher than the single large U.S. study involving only veterans. The prevalence of AAA in the U.S. general population is not well defined, nor is the best method of recruitment for screening. Letters of invitation for a free screening ultrasound for AAA were sent to 30,000 randomly selected Medicare beneficiaries from the hospital referral region of three university-affiliated hospitals without restriction by age, gender, or comorbidity. Attendance for screening was calculated by age, gender, and travel distance to the screening center. Telephone calls to a random sample of nonresponders were made to determine the reason for failure to attend. Prevalence of AAA by ultrasound and known risk factors for AAA (e.g., age, gender, smoking status) were determined. The attendance rate was 7% (2,005). Attendance was greater with male gender (p < 0.01), younger age (p < 0.05), and decreased travel distance to the screening center (p < 0.05). The primary reasons for failure to attend included incorrect address or vital status, poor health, and lack of interest. Prevalence of previously undetected AAA was 2.8% in men and 0.2% in women. AAA was predicted by smoking status and male gender (p < 0.01 for each). Unselected invitation of Medicare beneficiaries for ultrasound screening for AAA results in a low attendance and low yield of AAA. The prevalence estimates from this study may not reflect the entire Medicare population given the low attendance and may reflect the healthy habits of those most interested in screening. Patients should be selected for screening based on their suitability for repair if an AAA is found as well as their risk factors for AAA. The best method of recruitment for screening of those most at risk for AAA in the United

  12. Ultrasound screening for abdominal aortic aneurysm in medicare beneficiaries.

    PubMed

    Schermerhorn, Marc; Zwolak, Robert; Velazquez, Omaida; Makaroun, Michel; Fairman, Ronald; Cronenwett, Jack

    2008-01-01

    Ultrasound screening for abdominal aortic aneurysm (AAA) has been shown to be beneficial and cost-effective for men aged 65-74. However, most screening studies have been conducted in Europe and Australia, where attendance for screening was higher than the single large U.S. study involving only veterans. The prevalence of AAA in the U.S. general population is not well defined, nor is the best method of recruitment for screening. Letters of invitation for a free screening ultrasound for AAA were sent to 30,000 randomly selected Medicare beneficiaries from the hospital referral region of three university-affiliated hospitals without restriction by age, gender, or comorbidity. Attendance for screening was calculated by age, gender, and travel distance to the screening center. Telephone calls to a random sample of nonresponders were made to determine the reason for failure to attend. Prevalence of AAA by ultrasound and known risk factors for AAA (e.g., age, gender, smoking status) were determined. The attendance rate was 7% (2,005). Attendance was greater with male gender (p < 0.01), younger age (p < 0.05), and decreased travel distance to the screening center (p < 0.05). The primary reasons for failure to attend included incorrect address or vital status, poor health, and lack of interest. Prevalence of previously undetected AAA was 2.8% in men and 0.2% in women. AAA was predicted by smoking status and male gender (p < 0.01 for each). Unselected invitation of Medicare beneficiaries for ultrasound screening for AAA results in a low attendance and low yield of AAA. The prevalence estimates from this study may not reflect the entire Medicare population given the low attendance and may reflect the healthy habits of those most interested in screening. Patients should be selected for screening based on their suitability for repair if an AAA is found as well as their risk factors for AAA. The best method of recruitment for screening of those most at risk for AAA in the United

  13. Reductions in mortality among Medicare beneficiaries following the implementation of Medicare Part D.

    PubMed

    Semilla, April P; Chen, Fang; Dall, Timothy M

    2015-07-01

    Medicare Part D is a prescription drug program that provides seniors and disabled individuals enrolled in Medicare with outpatient drug coverage benefits. Part D has been shown to increase access to medicines and improve medication adherence; however, the effect of Part D on health outcomes has not yet been extensively studied. In this study, we used a published and validated Markov-based microsimulation model to quantify the relationships among medication use, disease incidence and severity, and mortality. Based on the simulation results, we estimate that since the implementation of Part D in 2006, nearly 200,000 Medicare beneficiaries have lived at least 1 year longer. Reductions in mortality have occurred because of fewer deaths associated with medication-sensitive conditions such as diabetes, congestive heart failure, stroke, and myocardial infarction. Improved access to medication through Medicare Part D helps patients improve blood pressure, cholesterol, and blood glucose levels, which in turn can prevent or delay the onset of disease and the incidence of adverse health events, thus reducing mortality. PMID:26295437

  14. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-08

    ... HUMAN SERVICES Administration on Aging Funding Opportunity: Affordable Care Act Medicare Beneficiary...: Availability of funding opportunity announcement. Funding Opportunity Title/Program Name: Affordable Care Act... Protection and Affordable Care Act of 2010 (Affordable Care Act). Catalog of Federal Domestic...

  15. Residential and Health Care Transition Patterns among Older Medicare Beneficiaries over Time

    ERIC Educational Resources Information Center

    Sato, Masayo; Shaffer, Thomas; Arbaje, Alicia I.; Zuckerman, Ilene H.

    2011-01-01

    Purpose: To describe annual care transition patterns across residential and health care settings and assess consistency in care transition patterns across years. Design and Methods: This retrospective cohort study used the Medicare Current Beneficiary Survey (2000-2005). The sample comprised beneficiaries aged 65 years and older (N = 57,684…

  16. Depression and Ambulatory Care Sensitive Hospitalizations among Medicare Beneficiaries with Chronic Physical Conditions

    PubMed Central

    Bhattacharya, Rituparna; Shen, Chan; Sambamoorthi, Usha

    2014-01-01

    Objective We examined the association between depression and hospitalizations for Ambulatory Care Sensitive Conditions (H-ACSC) among Medicare beneficiaries with chronic physical conditions. Methods We used a retrospective longitudinal design using multiple years (2002-2009) of linked fee-for-service Medicare claims and survey data from Medicare Current Beneficiary Survey (MCBS) data to create six longitudinal panels. We followed individuals in each panel for a period of three years; first year served as the baseline and subsequent two years served as the follow-up. We measured depression, chronic physical conditions and other characteristics at baseline and examined H-ACSC at two follow-up. We identified chronic physical conditions from survey data and H-ACSC and depression from fee-for-service Medicare claims.. We analyzed unadjusted and adjusted relationships between depression and the risk of H-ACSC with chi-square tests and logistic regressions. Results Among all Medicare beneficiaries, 9.3% had diagnosed depression. Medicare beneficiaries with depression had higher rates of any H-ACSC as compared to those without depression (13.6% vs 7.7%). Multivariable regression indicated that compared to those without depression, Medicare beneficiaries with depression were more likely to experience any H-ACSC. Conclusions Depression was associated with greater risk of H-ACSC, suggesting that healthcare quality measures may need to include depression as a risk-adjustment variable. PMID:24999083

  17. Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

    ERIC Educational Resources Information Center

    Meng, Hongdao; Friedman, Bruce; Wamsley, Brenda R.; Van Nostrand, Joan F.; Eggert, Gerald M.

    2010-01-01

    Purpose: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. Methods: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19…

  18. Utilization of Post-Acute Care following Distal Radius Fracture among Medicare Beneficiaries

    PubMed Central

    Zhong, Lin; Mahmoudi, Elham; Giladi, Aviram M.; Shauver, Melissa; Chung, Kevin C.; Waljee, Jennifer F.

    2016-01-01

    Purpose To examine the utilization and cost of post-acute care following isolated distal radius fractures (DRF) among Medicare beneficiaries. Methods We examined utilization of post-acute care among Medicare beneficiaries who experienced an isolated DRF (n=38,479) during 2007 using 100% Medicare claims data. We analyzed the effect of patient factors on hospital admission following DRF and the receipt of post-acute care delivered by skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), home healthcare agencies (HHAs), and outpatient OT/PT for the recovery of DRF. Results In this cohort of isolated DRF patients, 1,694 (4.4%) were admitted to hospitals following DRF, and 20% received post-acute care. Women and patients with more comorbid conditions were more likely to require hospital admission. The utilization of post-acute care was higher among women, patients who resided in urban areas, and patients of higher socioeconomic status. The average cost per patient of post-acute care services from IRFs and SNFs ($15,888/patient) was significantly higher than the average cost other aspects of DRF care and accounted for 69% of the total DRF-related expenditure among patients who received inpatient rehabilitation. Conclusions Sociodemographic factors, including sex, socioeconomic status, and age, were significantly correlated with the use of post-acute care following isolated DRFs, and post-acute care accounted for a substantial proportion of the total expenditures related to these common injuries among the elderly. Identifying patients who will derive the greatest benefit from post-acute care can inform strategies to improve the cost-efficiency of rehabilitation and optimize scarce healthcare resources. Level of evidence Therapeutic, III PMID:26527599

  19. Responses to Medicare Drug Costs among Near-Poor versus Subsidized Beneficiaries

    PubMed Central

    Fung, Vicki; Reed, Mary; Price, Mary; Brand, Richard; Dow, William H; Newhouse, Joseph P; Hsu, John

    2013-01-01

    Objective There is limited information on the protective value of Medicare Part D low-income subsidies (LIS). We compared responses to drug costs for LIS recipients with near-poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS. Data Sources/Study Setting Medicare Advantage beneficiaries in 2008. Study Design We examined three drug cost responses using multivariate logistic regression: cost-reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities). Data Collection Telephone interviews in a stratified random sample (N = 1,201, 70 percent response rate). Principal Findings After adjustment, a comparable percentage of unsubsidized near-poor (26 percent) and higher income beneficiaries reported cost-reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost-reducing behaviors (15 percent, p = .019 vs near-poor). Unsubsidized near-poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near-poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015). Conclusions Low-income subsidies provide protection from drug cost-related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors. PMID:23663197

  20. Medicare Beneficiary Counseling Programs: What Are They and Do They Work?

    PubMed Central

    McCormack, Lauren A.; Schnaier, Jenny A.; Lee, A. James; Garfinkel, Steven A.

    1996-01-01

    Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs utilize a volunteer-based and locally-sponsored support system to deliver free and unbiased counseling on the Medicare program and related health insurance issues. This article discusses the effectiveness of the ICA model. Because the ICA programs serve as a vital link between HCFA and its beneficiaries, information about the programs' success may be useful to HCFA and other policymakers during this era of consumer information. PMID:10165027

  1. Cost-sharing, physician utilization, and adverse selection among Medicare beneficiaries with chronic health conditions.

    PubMed

    Hoffman, Geoffrey

    2015-02-01

    Pooled data from the 2007, 2009, and 2011/2012 California Health Interview Surveys were used to compare the number of self-reported annual physician visits among 36,808 Medicare beneficiaries ≥65 in insurance groups with differential cost-sharing. Adjusted for adverse selection and a set of health covariates, Medicare fee-for-service (FFS) only beneficiaries had similar physician utilization compared with HMO enrollees but fewer visits compared with those with supplemental (1.04, p = .001) and Medicaid (1.55, p = .003) coverage. FFS only beneficiaries in very good or excellent health had fewer visits compared with those of similar health status with supplemental (1.30, p = .001) or Medicaid coverage (2.15, p = .002). For subpopulations with several chronic conditions, FFS only beneficiaries also had fewer visits compared with beneficiaries with supplemental or Medicaid coverage. Observed differences in utilization may reflect efficient and necessary physician utilization among those with chronic health needs.

  2. Variations Among Medicare Beneficiaries Living in Different Settings: Demographics, Health Status, and Service Use.

    PubMed

    Degenholtz, Howard B; Park, Mijung; Kang, Yihuang; Nadash, Pamela

    2016-07-01

    Older people with complex health issues and needs for functional support are increasingly living in different types of residential care environments as alternatives to nursing homes. This study aims to compare the demographics and health-care expenditures of Medicare beneficiaries by the setting in which they live: nursing homes, residential care settings, and at home using data from the 2002 to 2010 Medicare Current Beneficiary Study (MCBS), a nationally representative survey of the Medicare population. All Medicare beneficiaries aged 65 years or older who participated in the fall MCBS interview (years 2002-2010) and were alive for the full year (N = 83,507) were included in the sample. We found that there is a gradient in health status, physical and cognitive functioning, and health-care use and spending across settings. Minority elderly are overrepresented in facilities and underrepresented in alternative living settings.

  3. Viva la Vida: helping Latino Medicare beneficiaries with diabetes live their lives to the fullest.

    PubMed

    Olson, Rebecca; Sabogal, Fabio; Perez, Ana

    2008-02-01

    Viva la Vida (Live Your Life) is a call to action for older Latinos to take charge of their diabetes and live life to the fullest. Lumetra, California's federally designated Medicare quality improvement organization, developed the Viva la Vida project to improve diabetes care among Latino Medicare beneficiaries in 4 Southern California counties. After researching barriers to good diabetes care among Latino seniors, Lumetra designed a multifaceted program targeting health care providers and Medicare beneficiaries through bilingual, low-literacy health education materials and tools, community and provider partnerships, and the mass media. The project succeeded in helping to reduce the disparity in glycosylated hemoglobin testing between White and Latino Medicare beneficiaries in the 4 program counties. PMID:18172150

  4. The Validity of Race and Ethnicity in Enrollment Data for Medicare Beneficiaries

    PubMed Central

    Zaslavsky, Alan M; Ayanian, John Z; Zaborski, Lawrence B

    2012-01-01

    Objective To assess the validity of race/ethnicity in Medicare databases for studies of racial/ethnic disparities. Data Sources The 2010 Medicare Consumer Assessments of Healthcare Providers and Systems (CAHPS®) survey was linked to Medicare enrollment data and local area characteristics from the 2000 Census. Study Design Race/ethnicity was cross-tabulated for CAHPS and Medicare data. Within each self-reported category, demographic, geographic, health, and health care variables were compared between those that were and were not similarly identified in Medicare data. Data Collection Methods The Medicare CAHPS survey included 343,658 responses from elderly participants (60 percent response rate). Data were weighted for sampling and nonresponse to be representative of the national population of elderly Medicare beneficiaries. Principal Findings Self-reported Hispanics, Asians, Pacific Islanders, and American Indians were underidentified in Medicare enrollment data. Individuals in these groups who were identified in Medicare data tended to be more strongly identified with their group, poorer, and in worse health and to report worse health care experiences than those who were not so identified. Conclusions Self-reported members of racial and ethnic groups other than Whites and Blacks who are identified in Medicare data differ substantially from those who are not so identified. These differences should be considered in assessments of disparities in health and health care among Medicare beneficiaries. PMID:22515953

  5. Evaluating the Initiation of Novel Oral Anticoagulants in Medicare Beneficiaries

    PubMed Central

    Baik, Seo Hyon; Hernandez, Inmaculada; Zhang, Yuting

    2016-01-01

    BACKGROUND As alternatives to warfarin, 2 novel oral anticoagulants (NOACs), dabigatran and rivaroxaban, were approved in 2010 and 2011 to prevent stroke and other thromboembolic events in patients with atrial fibrillation. It is unclear how patient characteristics are associated with the initiation of anticoagulants. OBJECTIVE To evaluate how patient demographics, clinical characteristics, types of insurance, and patient out-of-pocket spending affect the initiation of warfarin and 2 NOACs—dabigatran and rivaroxaban. METHODS We used pharmacy claims data from a 5% random sample of Medicare beneficiaries to identify patients who were newly diagnosed with atrial fibrillation between October 1, 2010, and October 31, 2012, and who were prescribed an oral anticoagulant within 60 days of diagnosis. We identified key predictors of initiation of NOACs using a multinomial logistic regression model with generalized logit link. RESULTS Patients who were black and who had a history of acute myocardial infarction, stroke or transient ischemic attack, chronic kidney disease, or congestive heart failure were significantly associated with lower odds of receiving NOACs compared with warfarin. Age greater than 65 years, a history of hypertension, and use of nonsteroidal anti-inflammatory drugs were positively associated with the initiation of NOACs. Rivaroxaban was most likely to be initiated among women, followed by warfarin and dabigatran. Individuals receiving a low-income subsidy were more likely to initiate warfarin than NOACs, even though they paid little copayment. Individuals with supplemental Part D drug coverage, such as national Programs for All-Inclusive Care for the Elderly or employer-sponsored plans, were more likely to initiate NOACs compared with warfarin. CONCLUSIONS We found that race, sex, type of Part D plans, and some clinical conditions were associated with the initiation of NOACs relative to warfarin. But patient demographic and clinical characteristics did

  6. Health care expenditures associated with skeletal fractures among Medicare beneficiaries, 1999-2005.

    PubMed

    Kilgore, Meredith L; Morrisey, Michael A; Becker, David J; Gary, Lisa C; Curtis, Jeffrey R; Saag, Kenneth G; Yun, Huifeng; Matthews, Robert; Smith, Wilson; Taylor, Allison; Arora, Tarun; Delzell, Elizabeth

    2009-12-01

    Fractures impose substantial burdens, in terms of both costs and health, on individuals and health care systems. This is particularly true for older Americans and the Medicare system. The objective of this study was to estimate the costs of care associated with selected fractures among Medicare beneficiaries. This was a retrospective, person-level, pre/postfracture analysis using administrative data. The study used Medicare claims data from 1999 through 2005 for a 5% sample of Medicare beneficiaries. The subjects included Medicare beneficiaries, >or=65 yr of age, who had at least 13 mo of both Parts A and B coverage and not enrolled in Medicare Advantage and who experienced a closed fracture of the hip, femur, pelvis, tibia/fibula, ankle, distal forearm, nondistal radius/ulna, humerus, clavicle, spine, or wrist, or any fracture of the distal forearm or ankle during the years 2000 through 2005. The main outcome measures were incremental (greater than baseline) and attributable (directly associated) payments for Medicare-covered services for the first 6 mo after incident fractures. Incremental payments ranged from $7788 (95% CI, $7550-$8025) for distal forearm fractures to $31,310 (95% CI, $31,073-$31,547) for open hip fractures; the attributable payments for distal forearm and hip fractures were $1856 and $18,734, respectively. Fractures are associated with substantial increases in health services utilization and costs among Medicare beneficiaries, but significant proportions of those costs are not directly attributable to fracture treatment. Further research is needed to ascertain other health conditions that are driving costs for Medicare beneficiaries after fractures.

  7. Inpatient Utilization and Costs for Medicare Fee-for-Service Beneficiaries with Heart Failure

    PubMed Central

    Fitch, Kathryn; Pelizzari, Pamela M.; Pyenson, Bruce

    2016-01-01

    Background Although the medical and economic burden of heart failure in the United States is already substantial, it will likely grow as the population ages and life expectancy increases. Not surprisingly, most of the heart failure burden is borne by individuals aged ≥65 years, many of whom are in the Medicare population. The population-based utilization and costs of inpatient care for Medicare beneficiaries with heart failure are not well understood by payers and providers. Objective To create a real-world view of utilization and costs associated with inpatient admissions, readmissions, and admissions to skilled nursing facilities among Medicare fee-for-service (FFS) beneficiaries with heart failure. Methods The study used the 2011 and 2012 Medicare 5% sample limited data set to perform a retrospective analysis of claims data. The look-back year that was used to identify certain patient characteristics was 2011, and 2012 was the analysis period for the study. Beneficiaries with heart failure were defined as those who had ≥1 acute inpatient, emergency department, nonacute inpatient, or outpatient claims in 2012 containing an International Classification of Diseases, Ninth Revision code for heart failure. To be included in the study, beneficiaries with heart failure had to have eligibility for ≥1 months in 2012 and in all 2011 months, with Part A and Part B eligibility in all the study months, and no enrollment in an HMO (Medicare Advantage plan). Utilization of inpatient admissions, inpatient readmissions, and skilled nursing facility admissions in 2012 were reported for Medicare FFS beneficiaries with heart failure and for all Medicare FFS beneficiaries. The costs for key metrics included all allowed Medicare payments in 2012 US dollars. Results The 2012 Medicare FFS population for this study consisted of 1,461,935 patients (1,301,545 without heart failure; 160,390 with heart failure); the heart failure prevalence was 11%. The Medicare-allowed cost per

  8. The private health insurance choices of medicare beneficiaries: how much does price matter?

    PubMed

    Rice, Thomas; Jacobson, Gretchen; Cubanski, Juliette; Neuman, Tricia

    2014-12-01

    This article presents, critiques, and analyzes the influence of prices on insurance choices made by Medicare beneficiaries in the Medicare Advantage, Part D, and Medigap markets. We define price as health insurance premiums for the Medicare Advantage and Medigap markets, and total out-of-pocket costs (including premiums and cost sharing) for the Part D market. In Medicare Advantage and Part D, prices only partly explain insurance choices. Enrollment decisions also may be influenced by other factors such as the perceived quality of the higher-premium plans, better provider networks, lower cost-sharing for services, more generous benefits, and a preference for certain brand-name products. In contrast, the one study available on the Medigap market concludes that price appears to be associated with plan selection. This may be because Medigap benefits are fully standardized, making it easier for beneficiaries to compare alternative policies. The article concludes by discussing policy options available to Medicare.

  9. Additional reductions in Medicare spending growth will likely require shifting costs to beneficiaries.

    PubMed

    Chernew, Michael E

    2013-05-01

    Policy makers have considerable interest in reducing Medicare spending growth. Clarity in the debate on reducing Medicare spending growth requires recognition of three important distinctions: the difference between public and total spending on health, the difference between the level of health spending and rate of health spending growth, and the difference between growth per beneficiary and growth in the number of beneficiaries in Medicare. The primary policy issue facing the US health care system is the rate of spending growth in public programs, and solving that problem will probably require reforms to the entire health care sector. The Affordable Care Act created a projected trajectory for Medicare spending per beneficiary that is lower than historical growth rates. Although opportunities for one-time savings exist, any long-term savings from Medicare, beyond those already forecast, will probably require a shift in spending from taxpayers to beneficiaries via higher beneficiary premium contributions (overall or via means testing), changes in eligibility, or greater cost sharing at the point of service.

  10. Racial and ethnic differences in hospitalization rates among aged Medicare beneficiaries, 1998.

    PubMed

    Eggers, P W; Greenberg, L G

    2000-01-01

    Efforts to study racial variations in access to health care for minorities other than black persons have been hampered by a paucity of data. The Health Care Financing Administration (HCFA) has made efforts in the past few years to enhance the racial codes on the Medicare enrollment files to include Hispanic, Asian American, and Native American designations. This study examines hospitalization rates by these more detailed racial/ethnic groupings. The results show black, Hispanic, and Native American aged beneficiaries compared with white beneficiaries have higher hospitalization rates. Asian American beneficiaries have lower hospitalization rates. Rates of revascularization--coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA)--are lower for black, Hispanic, and Native American beneficiaries compared with white beneficiaries, while rates for Asian Americans are similar to rates for white beneficiaries.

  11. Racial and Ethnic Differences in Hospitalization Rates Among Aged Medicare Beneficiaries, 1998.

    PubMed

    Eggers, Paul W; Greenberg, Linda G

    2000-01-01

    Efforts to study racial variations in access to health care for minorities other than black persons have been hampered by a paucity of data. The Health Care Financing Administration (HCFA) has made efforts in the past few years to enhance the racial codes on the Medicare enrollment files to include Hispanic, Asian American, and Native American designations. This study examines hospitalization rates by these more detailed racial/ethnic groupings. The results show black, Hispanic, and Native American aged beneficiaries compared with white beneficiaries have higher hospitalization rates. Asian American beneficiaries have lower hospitalization rates. Rates of revascularization-coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA)-are lower for black, Hispanic, and Native American beneficiaries compared with white beneficiaries, while rates for Asian Americans are similar to rates for white beneficiaries.

  12. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... amounts and national Medicare program payment amounts. 419.41 Section 419.41 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM... Calculation of national beneficiary copayment amounts and national Medicare program payment amounts. (a)...

  13. Supplemental coverage associated with more rapid spending growth for Medicare beneficiaries.

    PubMed

    Golberstein, Ezra; Walsh, Kayo; He, Yulei; Chernew, Michael E

    2013-05-01

    Lowering both Medicare spending and the rate of Medicare spending growth is important for the nation's fiscal health. Policy makers in search of ways to achieve these reductions have looked at the role that supplemental coverage for Medicare beneficiaries plays in Medicare spending. Supplemental coverage makes health care more affordable for beneficiaries but also makes beneficiaries insensitive to the cost of their care, thereby increasing the demand for care. Ours is the first empirical study to investigate whether supplemental Medicare coverage is associated with higher rates of spending growth over time. We found that supplemental insurance coverage was associated with significantly higher rates of overall spending growth. Specifically, employer-sponsored and self-purchased supplemental coverage were associated with annual total spending growth rates of 7.17 percent and 7.18 percent, respectively, compared to 6.08 percent annual growth for beneficiaries without supplemental coverage. Results for Medicare program spending were more equivocal, however. Our results are consistent with the belief that current trends away from generous employer-sponsored supplemental coverage and efforts to restrict the generosity of supplemental coverage may slow spending growth. PMID:23650320

  14. Psychometric properties of an instrument to assess Medicare beneficiaries' prescription drug plan experiences.

    PubMed

    Martino, Steven C; Elliott, Marc N; Cleary, Paul D; Kanouse, David E; Brown, Julie A; Spritzer, Karen L; Heller, Amy; Hays, Ron D

    2009-01-01

    Using data from 335,249 Medicare beneficiaries who responded to the 2007 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, along with data from 22 cognitive interviews, we investigated the reliability and validity of an instrument designed to assess beneficiaries' experiences with their prescription drug plans. Composite measures derived from the instrument had acceptable internal consistency and sufficient plan-level reliability to inform consumer choice, quality improvement, and payor oversight. These measures were positively associated with members' overall rating of the plan and their willingness to recommend the plan. Moreover, each was independently useful in predicting beneficiaries' global ratings of their plan. This instrument can be an important tool for helping beneficiaries to choose a plan that best meets their needs. PMID:19544934

  15. End of Life Medicare and Medicaid Expenditures for Dually Eligible Beneficiaries

    PubMed Central

    Liu, Korbin; Wiener, Joshua M.; Niefeld, Marlene R.

    2006-01-01

    In 1995, combined Medicare and Medicaid spending in the last year of life for dually eligible beneficiaries was more than $40,000 per beneficiary Medicaid's share, primarily for long-term care (LTC), constituted about 40 percent of the total. Beneficiaries under age 65, Black persons, and individuals who died in a hospital had higher than average expenditures. The vast majority (86 percent) received some form of supportive services (nursing home, home care, hospice services). It is critical that policy deliberations consider both acute and LTC use concurrently because of their extensive use by dually eligible beneficiaries, as well as the interaction of the two funding sources (Medicare and Medicaid) that cover them. PMID:17290660

  16. Regional variation in the denial of reimbursement for bone mineral density testing among US Medicare beneficiaries.

    PubMed

    Curtis, Jeffrey R; Laster, Andrew J; Becker, David J; Carbone, Laura; Gary, Lisa C; Kilgore, Meredith L; Matthews, Robert; Morrisey, Michael A; Saag, Kenneth G; Tanner, S Bobo; Delzell, Elizabeth

    2008-01-01

    Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician's office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age > or =65 yr with part A+B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.

  17. Following the Money: Factors Associated with the Cost of Treating High-Cost Medicare Beneficiaries

    PubMed Central

    Reschovsky, James D; Hadley, Jack; Saiontz-Martinez, Cynthia B; Boukus, Ellyn R

    2011-01-01

    Objective To identify factors associated with the cost of treating high-cost Medicare beneficiaries. Data Sources A national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004–2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources. Study Design Using 12 months of claims data from 2005 to 2006, the sample was divided into predicted high-cost (top quartile) and lower cost beneficiaries using a risk-adjustment model. For each group, total annual standardized costs of care were regressed on beneficiary, usual source of care physician, practice, and market characteristics. Principal Findings Among high-cost beneficiaries, health was the predominant predictor of costs, with most physician and practice and many market factors (including provider supply) insignificant or weakly related to cost. Beneficiaries whose usual physician was a medical specialist or reported inadequate office visit time, medical specialist supply, provider for-profit status, care fragmentation, and Medicare fees were associated with higher costs. Conclusions Health reform policies currently envisioned to improve care and lower costs may have small effects on high-cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for “bending the cost curve.” PMID:21306368

  18. Beneficiary complaints, provider numbers and carrier shopping: Medicare contractor operations.

    PubMed

    Kusserow, R P

    1991-11-01

    The number of Medicare claims processed annually will double in the next 10 years, making it imperative that contractors review claims accurately and ensure that payments are made only for medically necessary, high-quality care. Effective identification and prosecution of fraud and abuse in the Medicare program will depend on a cooperative effort between Medicare contractors, the Health Care Financing Administration, and the Office of Inspector General.

  19. Health and Health Care of Medicare Beneficiaries in 2030

    PubMed Central

    Gaudette, Étienne; Tysinger, Bryan; Cassil, Alwyn; Goldman, Dana P.

    2016-01-01

    On Medicare’s 50th anniversary, we use the Future Elderly Model (FEM) – a microsimulation model of health and economic outcomes for older Americans – to generate a snapshot of changing Medicare demographics and spending between 2010 and 2030. During this period, the baby boomers, who began turning 65 and aging into Medicare in 2011, will drive Medicare demographic changes, swelling the estimated US population aged 65 or older from 39.7 million to 67.0 million. Among the risks for Medicare sustainability, the size of the elderly population in the future likely will have the highest impact on spending but is easiest to forecast. Population health and the proportion of the future elderly with disabilities are more uncertain, though tools such as the FEM can provide reasonable forecasts to guide policymakers. Finally, medical technology breakthroughs and their effect on longevity are most uncertain and perhaps riskiest. Policymakers will need to keep these risks in mind if Medicare is to be sustained for another 50 years. Policymakers may also want to monitor the equity of Medicare financing amid signs that the program’s progressivity is declining, resulting in higher-income people benefiting relatively more from Medicare than lower-income people. PMID:27127455

  20. 42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... services for Medicare beneficiaries. (a) Conditions for payment of claims for ordered covered imaging and clinical laboratory services and items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)—(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To...

  1. 42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... services for Medicare beneficiaries. (a) Conditions for payment of claims for ordered covered imaging and clinical laboratory services and items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)—(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To...

  2. 42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... services for Medicare beneficiaries. (a) Conditions for payment of claims for ordered covered imaging and clinical laboratory services and items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)—(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To...

  3. Is There Disparity in Physician Service Use? A Comparison of Hispanic and White Medicare Beneficiaries

    ERIC Educational Resources Information Center

    Chen, Li-Mei

    2010-01-01

    This article investigates general physician service use by a national sample of non-Hispanic white and Hispanic Medicare beneficiaries age 65 and older. Using the health behavior model as the conceptual framework, Oaxaca decomposition multivariate analyses were conducted to examine predictors for contact with a physician and the number of…

  4. Patterns of Depression Treatment in Medicare Beneficiaries with Depression after Traumatic Brain Injury.

    PubMed

    Albrecht, Jennifer S; Kiptanui, Zippora; Tsang, Yuen; Khokhar, Bilal; Smith, Gordon S; Zuckerman, Ilene H; Simoni-Wastila, Linda

    2015-08-15

    There are no clinical guidelines addressing the management of depression after traumatic brain injury (TBI). The objectives of this study were to (1) describe depression treatment patterns among Medicare beneficiaries with a diagnosis of depression post-TBI; (2) compare them with depression treatment patterns among beneficiaries with a diagnosis of depression pre-TBI; and (3) quantify the difference in prevalence of use. We conducted a retrospective analysis of Medicare beneficiaries hospitalized with TBI during 2006-2010. We created two cohorts: beneficiaries with a new diagnosis of depression pre-TBI (n=4841) and beneficiaries with a new diagnosis of depression post-TBI (n=4668). We searched for antidepressant medications in Medicare Part D drug event files and created variables indicating antidepressant use in each 30-day period after diagnosis of depression. We used provider specialty and current procedural terminology to identify psychotherapy in any location. We used generalized estimating equations to quantify the effect of TBI on receipt of depression treatment during the year after diagnosis of depression. Average monthly prevalence of antidepressant use was 42% among beneficiaries with a diagnosis of depression pre-TBI and 36% among those with a diagnosis post-TBI (p<0.001). Beneficiaries with a diagnosis of depression post-TBI were less likely to receive antidepressants compared with a depression diagnosis pre-TBI (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.82, 0.92). There was no difference in receipt of psychotherapy between the two groups (OR 1.08; 95% CI 0.93, 1.26). Depression after TBI is undertreated among older adults. Knowledge about reasons for this disparity and its long-term effects on post-TBI outcomes is limited and should be examined in future work.

  5. Patterns of Depression Treatment in Medicare Beneficiaries with Depression after Traumatic Brain Injury

    PubMed Central

    Kiptanui, Zippora; Tsang, Yuen; Khokhar, Bilal; Smith, Gordon S.; Zuckerman, Ilene H.; Simoni-Wastila, Linda

    2015-01-01

    Abstract There are no clinical guidelines addressing the management of depression after traumatic brain injury (TBI). The objectives of this study were to (1) describe depression treatment patterns among Medicare beneficiaries with a diagnosis of depression post-TBI; (2) compare them with depression treatment patterns among beneficiaries with a diagnosis of depression pre-TBI; and (3) quantify the difference in prevalence of use. We conducted a retrospective analysis of Medicare beneficiaries hospitalized with TBI during 2006–2010. We created two cohorts: beneficiaries with a new diagnosis of depression pre-TBI (n=4841) and beneficiaries with a new diagnosis of depression post-TBI (n=4668). We searched for antidepressant medications in Medicare Part D drug event files and created variables indicating antidepressant use in each 30-day period after diagnosis of depression. We used provider specialty and current procedural terminology to identify psychotherapy in any location. We used generalized estimating equations to quantify the effect of TBI on receipt of depression treatment during the year after diagnosis of depression. Average monthly prevalence of antidepressant use was 42% among beneficiaries with a diagnosis of depression pre-TBI and 36% among those with a diagnosis post-TBI (p<0.001). Beneficiaries with a diagnosis of depression post-TBI were less likely to receive antidepressants compared with a depression diagnosis pre-TBI (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.82, 0.92). There was no difference in receipt of psychotherapy between the two groups (OR 1.08; 95% CI 0.93, 1.26). Depression after TBI is undertreated among older adults. Knowledge about reasons for this disparity and its long-term effects on post-TBI outcomes is limited and should be examined in future work. PMID:25526613

  6. Chronic health conditions in Medicare beneficiaries 65 years and older with HIV infection

    PubMed Central

    Friedman, Eleanor E.; Duffus, Wayne A.

    2016-01-01

    Objectives To examine sociodemographic factors and chronic health conditions of people living with HIV (PLWHIV/HIV+) at least 65 years old and compare their chronic disease prevalence with beneficiaries without HIV. Design National fee-for-service Medicare claims data (parts A and B) from 2006 to 2009 were used to create a retrospective cohort of beneficiaries at least 65 years old. Methods Beneficiaries with an inpatient or skilled nursing facility claim, or outpatient claims with HIV diagnosis codes were considered HIV+. HIV+ beneficiaries were compared with uninfected beneficiaries on demographic factors and on the prevalence of hypertension, hyperlipidemia, ischemic heart disease, rheumatoid arthritis/osteoarthritis, and diabetes. Odds ratios (OR), 95% confidence intervals (CIs), and P values were calculated. Adjustment variables included age, sex, race/ethnicity, end stage renal disease (ESRD), and dual Medicare–Medicaid enrollment. Chronic conditions were examined individually and as an index from zero to all five conditions. Results Of 29 060 418 eligible beneficiaries, 24 735 (0.09%) were HIV+. HIV+ beneficiaries were more likely to be Hispanic, African-American, male, and younger (P > 0.0001) and were 1.5–2.1 times as likely to have a chronic disease [diabetes (adjusted OR) 1.51, 95% CI (1.47, 1.55):rheumatoid arthritis/osteoarthritis 2.14, 95% CI (2.08, 2.19)], and 2.4–7 times as likely to have 1–5 comorbid chronic conditions [1 condition (adjusted OR) 2.38, 95% CI (2.21, 2.57): 5 conditions 7.07, 95% CI (6.61, 7.56)]. Conclusion Our results show that PLWHIV at least 65 years old are at higher risk of comorbidities than other fee-for-service Medicare beneficiaries. This finding has implications for the cost and health management of PLWHIV 65 years and older. PMID:27478988

  7. Geographic Access to Health Care for Rural Medicare Beneficiaries

    ERIC Educational Resources Information Center

    Chan, Leighton; Hart, L. Gary; Goodman, David C.

    2006-01-01

    Context: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. Purpose: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in…

  8. Hospital choice by rural medicare beneficiaries: does hospital ownership matter?--a Colorado case.

    PubMed

    Roh, Chul-Young; Lee, Keon-Hyung

    2006-01-01

    About 45 percent of rural patients in Colorado bypassed their local rural hospitals during the 1990s. The effect of this phenomenon is a reduction in occupancy rates and a decrease in the competitiveness of rural hospitals, thereby ultimately causing rural hospitals to close and adversely affecting the communities that they were designed to serve. This study tests whether hospital ownership affects hospital choice by patients after controlling for institutional and individual dimensions. A conditional logistic regression is used to analyze Colorado Inpatient Discharge Data (CIDD) on 85,529 patients in addition to hospital data. Rural Medicare beneficiaries are influenced to choose a particular hospital by a combination of hospital characteristics (the number of beds, the number of services, accreditation, ownership type, and distance from patient residence) and patient characteristics (medical condition, age, gender, race, and total charge for services). Increasing rural hospitals' survivability, collaborating with other rural hospitals, expanding the number of available services, making strategic alliance with other providers are possible strategies that may help ward off encroachment by urban competitors. PMID:16583743

  9. Parkinson's Disease and Home Healthcare Use and Expenditures among Elderly Medicare Beneficiaries

    PubMed Central

    Bhattacharjee, Sandipan; Metzger, Aaron; Tworek, Cindy; Wei, Wenhui; Pan, Xiaoyun; Sambamoorthi, Usha

    2015-01-01

    This study estimated excess home healthcare use and expenditures among elderly Medicare beneficiaries (age ≥ 65 years) with Parkinson's disease (PD) compared to those without PD and analyzed the extent to which predisposing, enabling, need factors, personal health choice, and external environment contribute to the excess home healthcare use and expenditures among individuals with PD. A retrospective, observational, cohort study design using Medicare 5% sample claims for years 2006-2007 was used for this study. Logistic regressions and Ordinary Least Squares regressions were used to assess the association of PD with home health use and expenditures, respectively. Postregression nonlinear and linear decomposition techniques were used to understand the extent to which differences in home healthcare use and expenditures among elderly Medicare beneficiaries with and without PD can be explained by individual-level factors. Elderly Medicare beneficiaries with PD had higher home health use and expenditures compared to those without PD. 27.5% and 18% of the gap in home health use and expenditures, respectively, were explained by differences in characteristics between the PD and no PD groups. A large portion of the differences in home healthcare use and expenditures remained unexplained. PMID:26090265

  10. Reducing Cancer Screening Disparities in Medicare Beneficiaries Through Cancer Patient Navigation

    PubMed Central

    Braun, Kathryn L.; Thomas, William L.; Domingo, Jermy-Leigh B.; Allison, Amanda L.; Ponce, Avette; Kamakana, P. Haunani; Brazzel, Sandra S.; Aluli, N. Emmett; Tsark, JoAnn U.

    2016-01-01

    Significant racial disparities in cancer mortality are seen between Medicare beneficiaries. A randomized controlled trial tested the use of lay navigators (care managers) to increase cancer screening of Asian and Pacific Islander Medicare beneficiaries. The study setting was Moloka‘i General Hospital on the island of Moloka‘i, Hawai‘i, which was one of six sites participating in the Cancer Prevention and Treatment Demonstration sponsored by the Centers for Medicare and Medicaid Services. Between 2006 and 2009, 488 Medicare beneficiaries (45% Hawaiian, 35% Filipino, 11% Japanese, 8% other) were randomized to have a navigator help them access cancer screening services (experimental condition, n = 242) or cancer education (control condition, n = 246). Self-reported data on screening participation were collected at baseline and exit from the study, and differences were tested using chi-square. Groups were similar in demographic characteristics and baseline screening prevalence of breast, cervical, prostate, and colorectal cancers. At study exit, 57.0% of women in the experimental arm and 36.4% of controls had had a Papanicolaou test in the past 24 months (P = .001), 61.7% of women in the experimental arm and 42.4% of controls had had a mammogram in the past 12 months (P = .003), 54.4% of men in the experimental arm and 36.0% of controls had had a prostate-specific antigen test in the past 12 months (P = .008), and 43.0% of both sexes in the experimental arm and 27.2% of controls had had a flexible sigmoidoscopy or colonoscopy in the past 5 years (P < .001). Findings suggest that navigation services can increase cancer screening in Medicare beneficiaries in groups with significant disparities. PMID:25640884

  11. Access to cancer drugs in Medicare Part D: formulary placement and beneficiary cost sharing in 2006.

    PubMed

    Bowman, Jennifer; Rousseau, Amy; Silk, David; Harrison, Catherine

    2006-01-01

    The Medicare Part D benefit expands the universe of cancer drugs and biologics that Medicare may cover. Individual Part D plans have discretion to determine their formularies and cost sharing for drugs within federal guidelines. This paper analyzes differences in coverage and cost sharing for cancer drugs among these plans. We find that many cancer drugs, including brand-name products, are covered by almost all plans, although prior authorization might limit access to some. In addition, many plans charge a relatively low copayment for most cancer drugs. These findings suggest that Part D could greatly expand beneficiaries' access to cancer treatments.

  12. How prevalent and costly are Choosing Wisely low-value services? Evidence from Medicare beneficiaries.

    PubMed

    Collado, Megan

    2014-10-01

    (1) Through the Choosing Wisely initiative, medical specialty societies identified non-indicated cardiac testing in low-risk patients and short-interval dual-energy X-ray absorptiometry (DXA) or bone density testing as low-value care. (2) Nationally, 13 percent of low-risk Medicare beneficiaries received non-indicated cardiac tests, and 10 percent of DXAs reimbursed by Medicare were administered at inappropriately short intervals. There is significant geographic variation in the provision of these services. (2) Carefully designed policy and payment changes will likely prove most effective in reducing low-value care.

  13. Functional health outcomes as a measure of health care quality for Medicare beneficiaries.

    PubMed Central

    Bierman, A S; Lawrence, W F; Haffer, S C; Clancy, C M

    2001-01-01

    OBJECTIVE: the Medicare Health Outcomes Survey (HOS), a new quality measure in the Health Plan Employer Data and Information Set, is designed to assess physical and mental functional health outcomes of Medicare beneficiaries enrolled in Medicare+Choice organizations. We discuss the rationale for the HOS measure together with methodologic challenges in its use and interpretation, using descriptive data from the baseline Medicare HOS to illustrate some of these challenges. DATA SOURCES/STUDY DESIGN: The 1999 Cohort 2 Medicare HOS baseline data were used for a cross-sectional descriptive analysis. A random sample of 1,000 beneficiaries from each health plan with a Medicare+Choice contract was surveyed (N = 156,842; 282 organizations included in these analyses) . PRINCIPAL FINDINGS: The HOS measure is designed to assess a previously unmeasured dimension of quality. Plan-level variation was seen across all baseline measures of sociodemographic characteristics and illness burden. At the individual level socioeconomic position as measured by educational attainment was strongly associated with functional status. The least educated beneficiaries had the highest burden of illness on all measures examined, and there was a consistent and significant gradient in health and functional status across all levels of education. In analyses stratified by race and ethnicity, socioeconomic gradients in f un ct ion persist ed. CONCLUSIONS Despite limitations, by focusing at t en t ion on the need to improve functional health out comes among elderly Medicare beneficiaries enrolled in Medicare+Choice, the HOS can serve as an important new tool to support efforts to improve health care quality. The HOS provides valuable information at the federal, state, and health plan levels that can be used to identify, prioritize, and evaluate quality improvement interventions and monitor progress for the program overall as well as for vulnerable subgroups. To interpret the HOS as a quality measure

  14. An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries.

    PubMed

    Roblin, Douglas W; Howard, David H; Junling Ren; Becker, Edmund R

    2011-04-01

    In service industries other than health care, unit employees who report a favorable service climate--characterized by commitment to a team concept and intrateam interactions that are supportive, collegial, and collaborative--have high levels of consumer satisfaction and work unit productivity. The authors evaluated whether similar primary care team (PCT) functioning influenced the short-term future health (SF-36) of elderly Medicare beneficiaries (N = 991) in a group model managed care organization (MCO). PCT functioning was assessed by surveys of practitioners and support staff on the MCO's 14 primary care practices and included measures of perceived task delegation, role collaboration, patient orientation, and team ownership. On average, patient physical and emotional health declined over 2 years. Medicare beneficiaries empanelled to relatively high functioning PCTs had significantly better physical and emotional health at 2 years following baseline assessment than those empanelled to relatively low functioning PCTs.

  15. Differences between generalists and mental health specialists in the psychiatric treatment of Medicare beneficiaries.

    PubMed Central

    Ettner, S L; Hermann, R C; Tang, H

    1999-01-01

    OBJECTIVE: To examine differences between the general medical and mental health specialty sectors in the expenditure and treatment patterns of aged and disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder. DATA SOURCES: Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply from the Area Resources File and the American Psychological Association. STUDY DESIGN: Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of services received, whether or not the patient was hospitalized for a psychiatric disorder, the length of the psychiatric care episode, the intensity of service use, and satisfaction with care. We compared these outcomes for beneficiaries who did and did not receive mental health specialty services during the episode, using multiple regression analyses to adjust for observable population differences. We also performed sensitivity analyses using instrumental variables techniques to reduce the potential bias arising from unmeasured differences in patient case mix across sectors. PRINCIPAL FINDINGS: Relative to beneficiaries treated only in the general medical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater intensity; among the persons who were disabled, they were due primarily to longer episodes. Some evidence was also found of higher satisfaction with care among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker. CONCLUSIONS: Mental health care provided to Medicare beneficiaries in the general medical sector does not appear to substitute perfectly for

  16. Postdischarge Environmental and Socioeconomic Factors and the Likelihood of Early Hospital Readmission among Community-Dwelling Medicare Beneficiaries

    ERIC Educational Resources Information Center

    Arbaje, Alicia I.; Wolff, Jennifer L.; Yu,Qilu; Powe, Neil R.; Anderson, Gerard F.; Boult, Chad

    2008-01-01

    Purpose: This study attempts to determine the associations between postdischarge environmental (PDE) and socioeconomic (SES) factors and early readmission to hospitals. Design and Methods: This study was a cohort study using the 2001 Medicare Current Beneficiary Survey and Medicare claims for the period from 2001 to 2002. The participants were…

  17. Cognition and Take-up of Subsidized Drug Benefits by Medicare Beneficiaries

    PubMed Central

    Kuye, Ifedayo O.; Frank, Richard G.; McWilliams, J. Michael

    2013-01-01

    Importance Take-up of the Medicare Part D low-income subsidy (LIS) by eligible beneficiaries has been low despite the attractive drug coverage it offers at no cost to beneficiaries and outreach efforts by the Social Security Administration. Objective To examine the role of beneficiaries’ cognitive abilities in explaining this puzzle. Design and Setting Analysis of survey data from the nationally representative Health and Retirement Study. Participants Elderly Medicare beneficiaries who were likely eligible for the LIS, excluding Medicaid and Supplemental Security Income recipients, who automatically receive the subsidy without applying. Main Outcomes and Measures Using survey assessments of overall cognition and numeracy from 2006–2010, we examined how cognitive abilities were associated with self-reported Part D enrollment, awareness of the LIS, and application for the LIS. We also compared out-of-pocket drug spending and premium costs between LIS-eligible beneficiaries who did and did not report receipt of the LIS. Analyses were adjusted for sociodemographic characteristics, household income and assets, health status, and presence of chronic conditions. Results Compared with LIS-eligible beneficiaries in the top quartile of overall cognition, those in the bottom quartile were significantly less likely to report Part D enrollment (adjusted rate, 63.5% vs. 52.0%; P=0.002), LIS awareness (58.3% vs. 33.3%; P=0.001), and LIS application (25.5% vs. 12.7%; P<0.001). Lower numeracy was also associated with lower rates of Part D enrollment (P=0.03) and LIS application (P=0.002). Reported receipt of the LIS was associated with significantly lower annual out-of-pocket drug spending (adjusted mean difference, −$256; P=0.02) and premium costs (−$273; P=0.02). Conclusions and Relevance Among Medicare beneficiaries likely eligible for the Part D LIS, poorer cognition and numeracy were associated with lower reported take-up. Current educational and outreach efforts

  18. Changes in Health Care Spending and Quality for Medicare Beneficiaries Associated with a Commercial ACO Contract

    PubMed Central

    McWilliams, J. Michael; Landon, Bruce E.; Chernew, Michael E.

    2013-01-01

    Importance In a multi-payer system, new payment incentives implemented by one insurer for an accountable care organization (ACO) may affect spending and quality of care for another insurer’s enrollees served by the ACO. Such “spillover” effects reflect the extent of organizational efforts to reform care delivery and can contribute to the total impact of ACOs. Objective We examined whether the Blue Cross Blue Shield (BCBS) of Massachusetts’ Alternative Quality Contract (AQC), an early commercial ACO initiative associated with reduced spending and improved quality for BCBS enrollees, was also associated with changes in spending and quality for Medicare beneficiaries, who were not covered by the AQC. Design and Exposure Quasi-experimental comparisons from 2007–2010 of Medicare beneficiaries served by 11 provider organizations entering the AQC in 2009 or 2010 (intervention group) vs. beneficiaries served by other providers (control group). Using a difference-in-differences approach, we estimated changes in spending and quality for the intervention group in the first and second years of exposure to the AQC relative to concurrent changes for the control group. Regression and propensity-score methods were used to adjust for differences in sociodemographic and clinical characteristics. Participants and Setting Elderly fee-for-service Medicare beneficiaries in Massachusetts (1,761,325 person-years). Main Outcome Measures The primary outcome was total quarterly medical spending per beneficiary. Secondary outcomes included spending by setting and type of service, 5 process measures of quality, potentially avoidable hospitalizations, and 30-day readmissions. Results Before entering the AQC, total quarterly spending for the intervention group was $150 (95% CI, $25–$274) higher than for the control group and rose at a similar rate. In year 2 of the intervention group’s exposure to the AQC, this difference was reduced to $51 (95% CI, −$109–$210; P=0

  19. BBA impacts on hospital residents, finances, and Medicare subsidies.

    PubMed

    Cromwell, Jerry; Adamache, Walter; Drozd, Edward M

    2006-01-01

    Concern over rapidly rising Medicare expenditures prompted Congress to pass the 1997 Balanced Budget Act (BBA) that included provisions reducing graduate medical education (GME) payments and capped the growth in residents for payment purposes. Using Medicare cost reports through 2001, we find that both actual and capped residents continued to grow post-BBA. While teaching hospital total margins declined, GME payment reductions of approximately 17 percent had minimal impact on revenue growth (-0.5 percent annually). Four years after BBA, residents remained a substantial line of business for nearly one-half of teaching hospitals with Medicare effective marginal subsidies exceeding resident stipends by nearly $50,000 on average. Coupled with an estimated replacement cost of over $100,000 per resident, it is not surprising that hospitals accepted nearly 4,000 residents beyond their allowable payment caps in just 4 years post-BBA.

  20. Trends in the Diagnosis and Outcomes of Traumatic Carotid and Vertebral Artery Dissections among Medicare Beneficiaries

    PubMed Central

    Newhall, Karina; Gottlieb, Daniel J.; Stone, David H.; Goodney, Philip P.

    2016-01-01

    Background Early identification of carotid and vertebral artery dissections has been advocated to reduce stroke among trauma patients. We sought to characterize trends in the diagnosis of traumatic carotid and vertebral artery dissections and association changes in stroke rate among Medicare beneficiaries. Methods Using Medicare claims, we created a cohort of 5,961 beneficiaries admitted with a new traumatic carotid or vertebral artery dissection from 2001 to 2012. We calculated rates of stroke during hospitalization and 90 days of discharge. We calculated rates of carotid imaging using computed tomography-angiography, carotid duplex, and plain angiography index hospitalization. To study concurrent secular trends, we created a secondary cohort of patients admitted after any traumatic injury from 2001 to 2012 and determined rates of stroke and carotid imaging within this cohort. Results From 2001 to 2012, incidence of traumatic carotid dissection increased 72% among Medicare beneficiaries (1.1–1.76 per 100,000 patients; rate ratio [RR], 1.72; 95% CI, 1.6–1.9, P < 0.001). Among patients diagnosed with traumatic carotid or vertebral artery dissections, the combined in-hospital and 90-day stroke rate did not change significantly (4.9% in 2001; 5.2% in 2012; RR, 1.06; 95% CI, 0.93–1.20; P = 0.094). Likewise, there was little change in mortality (10.3%; RR, 1.01; 95% CI, 0.95–1.06; P = 0.88). Among all trauma patients, the use of computed tomography angiography has increased 16-fold (2–35 per 100,000 patients; RR, 16.7; 95% CI, 13–19; P < 0.0001). Conclusions Despite increased diagnosis of carotid or vertebral artery dissection, there has been little change in stroke risk among trauma patients. Efforts to more effectively target imaging and treatment for these patients are necessary. PMID:27371360

  1. Epidemiology and Outcomes of Community Acquired Clostridium difficile Infections in Medicare Beneficiaries

    PubMed Central

    Collins, Courtney E; Ayturk, M Didem; Flahive, Julie M; Emhoff, Timothy A; Anderson, Frederick A; Santry, Heena P

    2014-01-01

    Background The incidence of community-acquired Clostridium difficile (CACD) is increasing in the US. Many CACD infections occur in the elderly who are predisposed to poor outcomes. We aimed to describe the epidemiology and outcomes of CACD in a nationally representative sample of Medicare beneficiaries. Study Design We queried a 5% random sample of Medicare beneficiaries (2009–2011 Part A inpatient and Part D prescription drug claims, N=864,604) for any hospital admission with a primary ICD-9 diagnosis code for C. difficile (008.45). We examined patient sociodemographic and clinical characteristics, pre-admission exposure to oral antibiotics, prior treatment with oral vancomycin or metronidazole, inpatient outcomes (colectomy, ICU stay, length of stay, mortality), and subsequent admissions for C. difficile. Results A total of 1566 (0.18%) patients were admitted with CACD. Of these, 889(56.8%) received oral antibiotics within 90 days of admission. Few were being treated with oral metronidazole (N=123, 7.8%) or vancomycin (N=13, 0.8%) at the time of admission. While 223(14%) patients required ICU admission, few (N=15, 1%) underwent colectomy. Hospital mortality was 9%. Median length of stay (LOS) among survivors was 5 days (IQR 3–8). One- fifth of survivors were re-admitted with C. difficile with a median follow up time of 393 days (IQR 129–769). Conclusions Nearly half of Medicare beneficiaries admitted with CACD have no recent antibiotic exposure. High mortality and re-admission rates suggest that the burden of C. difficile on patients and the healthcare system will increase as the US population ages. Additional efforts at primary prevention and eradication may be warranted. PMID:24755188

  2. Mind the Gap: Why Closing the Doughnut Hole Is Insufficient for Increasing Medicare Beneficiary Access to Oral Chemotherapy

    PubMed Central

    Keating, Nancy L.

    2016-01-01

    Purpose Orally administered anticancer medications are among the fastest growing components of cancer care. These medications are expensive, and cost-sharing requirements for patients can be a barrier to their use. For Medicare beneficiaries, the Affordable Care Act will close the Part D coverage gap (doughnut hole), which will reduce cost sharing from 100% in 2010 to 25% in 2020 for drug spending above $2,960 until the beneficiary reaches $4,700 in out-of-pocket spending. How much these changes will reduce out-of-pocket costs is unclear. Methods We used the Medicare July 2014 Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information Files from the Centers for Medicare & Medicaid Services for 1,114 stand-alone and 2,230 Medicare Advantage prescription drug formularies, which represent all formularies in 2014. We identified orally administered anticancer medications and summarized drug costs, cost-sharing designs used by available plans, and the estimated out-of-pocket costs for beneficiaries without low-income subsidies who take a single drug before and after the doughnut hole closes. Results Little variation existed in formulary design across plans and products. The average price per month for included products was $10,060 (range, $5,123 to $16,093). In 2010, median beneficiary annual out-of-pocket costs for a typical treatment duration ranged from $6,456 (interquartile range, $6,433 to $6,482) for dabrafenib to $12,160 (interquartile range, $12,102 to $12,262) for sunitinib. With the assumption that prices remain stable, after the doughnut hole closes, beneficiaries will spend approximately $2,550 less. Conclusion Out-of-pocket costs for Medicare beneficiaries taking orally administered anticancer medications are high and will remain so after the doughnut hole closes. Efforts are needed to improve affordability of high-cost cancer drugs for beneficiaries who need them. PMID:26644524

  3. Type of Multimorbidity and Patient-Doctor Communication and Trust among Elderly Medicare Beneficiaries

    PubMed Central

    Shen, Chan; Sambamoorthi, Nethra; Kelly, Kimberly

    2016-01-01

    Background. Effective communication and high trust with doctor are important to reduce the burden of multimorbidity in the rapidly aging population of the US. However, the association of multimorbidity with patient-doctor communication and trust is unknown. Objective. We examined the relationship between multimorbidity and patient-doctor communication and trust among the elderly. Method. We used the Medicare Current Beneficiary Survey (2012) to analyze the association between multimorbidity and patient-doctor communication and trust with multivariable logistic regressions that controlled for patient's sociodemographic characteristics, health status, and satisfaction with care. Results. Most elderly beneficiaries reported effective communication (87.5–97.5%) and high trust (95.4–99.1%) with their doctors. The elderly with chronic physical and mental conditions were less likely than those with only physical conditions to report effective communication with their doctor (Adjusted Odds Ratio [95% Confidence Interval] = 0.80 [0.68, 0.96]). Multimorbidity did not have a significant association with patient-doctor trust. Conclusions. Elderly beneficiaries had high trust in their doctors, which was not affected by the presence of multimorbidity. Elderly individuals who had a mental condition in addition to physical conditions were more likely to report ineffective communication. Programs to improve patient-doctor communication with patients having cooccurring chronic physical and mental health conditions may be needed. PMID:27800181

  4. Trends in Antihypertensive Medication Discontinuation and Low Adherence Among Medicare Beneficiaries Initiating Treatment From 2007 to 2012.

    PubMed

    Tajeu, Gabriel S; Kent, Shia T; Kronish, Ian M; Huang, Lei; Krousel-Wood, Marie; Bress, Adam P; Shimbo, Daichi; Muntner, Paul

    2016-09-01

    Low antihypertensive medication adherence is common. During recent years, the impact of low medication adherence on increased morbidity and healthcare costs has become more recognized, leading to interventions aimed at improving adherence. We analyzed a 5% sample of Medicare beneficiaries initiating antihypertensive medication between 2007 and 2012 to assess whether reductions occurred in discontinuation and low adherence. Discontinuation was defined as having no days of antihypertensive medication supply for the final 90 days of the 365 days after initiation. Low adherence was defined as having a proportion of days covered <80% during the 365 days after initiation among beneficiaries who did not discontinue treatment. Between 2007 and 2012, 41 135 Medicare beneficiaries in the 5% sample initiated antihypertensive medication. Discontinuation was stable during the study period (21.0% in 2007 and 21.3% in 2012; P-trend=0.451). Low adherence decreased from 37.4% in 2007 to 31.7% in 2012 (P-trend<0.001). After multivariable adjustment, the relative risk of low adherence for beneficiaries initiating treatment in 2012 versus in 2007 was 0.88 (95% confidence interval, 0.83-0.92). Low adherence was more common among racial/ethnic minorities, beneficiaries with Medicaid buy-in (an indicator of low income), and those with polypharmacy, and was less common among females, beneficiaries initiating antihypertensive medication with multiple classes or a 90-day prescription fill, with dementia, a history of stroke, and those who reached the Medicare Part D coverage gap in the previous year. In conclusion, low adherence to antihypertensive medication has decreased among Medicare beneficiaries; however, rates of discontinuation and low adherence remain high. PMID:27432867

  5. Resource Use Trajectories for Aged Medicare Beneficiaries with Complex Coronary Conditions

    PubMed Central

    Federspiel, Jerome J; Stearns, Sally C; D'Arcy, Laura P; Geissler, Kimberley H; Beadles, Christopher A; Crespin, Daniel J; Carey, Timothy S; Rossi, Joseph S; Sheridan, Brett C

    2013-01-01

    Objective To use coronary revascularization choice to illustrate the application of a method simulating a treatment's effect on subsequent resource use. Data Sources Medicare inpatient and outpatient claims from 2002 to 2008 for patients receiving multivessel revascularization for symptomatic coronary disease in 2003–2004. Study Design This retrospective cohort study of 102,877 beneficiaries assessed survival, days in institutional settings, and Medicare payments for up to 6 years following receipt of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Methods A three-part estimator designed to provide robust estimates of a treatment's effect in the setting of mortality and censored follow-up was used. The estimator decomposes the treatment effect into effects attributable to survival differences versus treatment-related intensity of resource use. Principal Findings After adjustment, on average CABG recipients survived 23 days longer, spent an 11 additional days in institutional settings, and had cumulative Medicare payments that were $12,834 higher than PCI recipients. The majority of the differences in institutional days and payments were due to intensity rather than survival effects. Conclusions In this example, the survival benefit from CABG was modest and the resource implications were substantial, although further adjustments for treatment selection are needed. PMID:23347002

  6. Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries?

    PubMed Central

    Snow, R; Babish, J D; McBean, A M

    1995-01-01

    To learn whether the risk of revaccination in adults should limit its use, the authors investigated whether adverse events requiring hospitalization occurred in a group of Medicare enrollees revaccinated with pneumococcal polysaccharide vaccine. A prospective cohort analysis and case study of revaccinated people involved five percent of all elderly Medicare enrollees from 1985 through 1988, consisting of 66,256 people receiving one dose of vaccine and 1,099 receiving two doses. Comparison was made of the hospitalization rate within 30 days after revaccination and rates of singly vaccinated persons using discharge diagnosis for all those hospitalized during the 30 days after revaccination. No significant difference was found between the hospitalization rate of the revaccinated cohort and comparison group. No adverse reactions attributable to pneumococcal polysaccharide vaccine causing hospitalization were identified among 39 revaccinated persons who were hospitalized within 30 days of revaccination. Revaccination of elderly Medicare beneficiaries does not cause events serious enough to require hospitalization. Vaccination of persons according to the Public Health Service Immunization Practice Advisory Committee guidelines is recommended when the prior immunization status is unknown. PMID:8570826

  7. Medicare Beneficiaries Face Growing Out-Of-Pocket Burden For Specialty Drugs While In Catastrophic Coverage Phase.

    PubMed

    Trish, Erin; Xu, Jianhui; Joyce, Geoffrey

    2016-09-01

    The Affordable Care Act (ACA) includes provisions to reduce Medicare beneficiaries' out-of-pocket spending for prescription drugs by gradually closing the coverage gap between the initial coverage limit and the catastrophic coverage threshold (known as the doughnut hole) beginning in 2011. However, Medicare beneficiaries who take specialty pharmaceuticals could still face a large out-of-pocket burden because of uncapped cost sharing in the catastrophic coverage phase. Using 2008-12 pharmacy claims data from a 20 percent sample of Medicare beneficiaries, we analyzed trends in total and out-of-pocket spending among Medicare beneficiaries who take at least one high-cost specialty drug from the top eight specialty drug classes in terms of spending. Annual total drug spending per specialty drug user studied increased considerably during the study period, from $18,335 to $33,301, and the proportion of expenditures incurred while in the catastrophic coverage phase increased from 70 percent to 80 percent. We observed a 26 percent decrease in mean annual out-of-pocket expenditures incurred below the catastrophic coverage threshold, likely attributable to the ACA's doughnut hole cost-sharing reductions, but increases in mean annual out-of-pocket expenditures incurred while in the catastrophic coverage phase offset these reductions almost entirely. Policy makers should consider implementing limits on patients' out-of-pocket burden. PMID:27605634

  8. Ethnic Disparities in Adherence to Antihypertensive Medications in Medicare Part D Beneficiaries

    PubMed Central

    Holmes, Holly M.; Luo, Ruili; Hanlon, Joseph T.; Elting, Linda S.; Suarez-Almazor, Maria; Goodwin, James S.

    2012-01-01

    BACKGROUND Nonadherence to antihypertensive medication is common and leads to adverse health outcomes. The Medicare Part D prescription drug program has decreased cost and increased access to medications, thus potentially improving medication adherence. OBJECTIVES To determine the level of adherence and characteristics of Part D beneficiaries associated with higher levels of antihypertensive medication adherence. DESIGN Retrospective analysis using Medicare claims and Part D event files for 2007. PARTICIPANTS Medicare Part D enrollees with prevalent uncomplicated hypertension who filled at least one antihypertensive prescription in 2006 and two prescriptions in 2007. MEASUREMENTS Medication adherence was defined by an average Medication Possession Ratio (MPR) of 80% or greater. Potential factors associated with adherence evaluated included age, sex, race/ethnicity, socioeconomic factors, comorbidity, medication use, copay, being in the coverage gap, and number of unique prescribers. RESULTS Among 168,522 Medicare Part D enrollees with prevalent uncomplicated hypertension receiving antihypertensive medicines in 2007, overall adherence was 79.5%. In univariate analysis, adherence varied significantly by most patient factors. In multivariable analysis, decreased odds of adherence persisted for blacks (OR 0.53, 95% CI 0.51–0.55), Hispanics (OR 0.58, 95% CI 0.55–0.61) and other non-white races (OR 0.80 95% CI 0.75–0.85) compared to whites. Increased comorbidity and concurrent medication use were also associated with reduced adherence. Adherence was significantly different across several geographic regions. CONCLUSION We identified a number of associations with patient factors and medication adherence to antihypertensive drugs, with significant differences in adherence by ethnicity. Improving adherence could have significant public health implications and could improve outcomes specific to hypertension as well as improved cost and healthcare utilization. PMID

  9. Changes in Initial Treatment for Prostate Cancer Among Medicare Beneficiaries, 1999-2007

    SciTech Connect

    Dinan, Michaela A.; Robinson, Timothy J.; Zagar, Timothy M.; Scales, Charles D.; Curtis, Lesley H.; Reed, Shelby D.; Lee, W. Robert; Schulman, Kevin A.

    2012-04-01

    Purpose: In the absence of evidence from large clinical trials, optimal therapy for localized prostate cancer remains unclear; however, treatment patterns continue to change. We examined changes in the management of patients with prostate cancer in the Medicare population. Methods and Materials: We conducted a retrospective claims-based analysis of the use of radiation therapy, surgery, and androgen deprivation therapy in the 12 months after diagnosis of prostate cancer in a nationally representative 5% sample of Medicare claims. Patients were Medicare beneficiaries 67 years or older with incident prostate cancer diagnosed between 1999 and 2007. Results: There were 20,918 incident cases of prostate cancer between 1999 and 2007. The proportion of patients receiving androgen deprivation therapy decreased from 55% to 36%, and the proportion of patients receiving no active therapy increased from 16% to 23%. Intensity-modulated radiation therapy replaced three-dimensional conformal radiation therapy as the most common method of radiation therapy, accounting for 77% of external beam radiotherapy by 2007. Minimally invasive radical prostatectomy began to replace open surgical approaches, being used in 49% of radical prostatectomies by 2007. Conclusions: Between 2002 and 2007, the use of androgen deprivation therapy decreased, open surgical approaches were largely replaced by minimally invasive radical prostatectomy, and intensity-modulated radiation therapy replaced three-dimensional conformal radiation therapy as the predominant method of radiation therapy in the Medicare population. The aging of the population and the increasing use of newer, higher-cost technologies in the treatment of patients with prostate cancer may have important implications for nationwide health care costs.

  10. Patient-Centered Medical Home Features and Health Care Expenditures of Medicare Beneficiaries with Chronic Disease Dyads.

    PubMed

    Philpot, Lindsey M; Stockbridge, Erica L; Padrón, Norma A; Pagán, José A

    2016-06-01

    Three out of 4 Medicare beneficiaries have multiple chronic conditions, and managing the care of this growing population can be complex and costly because of care coordination challenges. This study assesses how different elements of the patient-centered medical home (PCMH) model may impact the health care expenditures of Medicare beneficiaries with the most prevalent chronic disease dyads (ie, co-occurring high cholesterol and high blood pressure, high cholesterol and heart disease, high cholesterol and diabetes, high cholesterol and arthritis, heart disease and high blood pressure). Data from the 2007-2011 Medical Expenditure Panel Survey suggest that increased access to PCMH features may differentially impact the distribution of health care expenditures across health care service categories depending on the combination of chronic conditions experienced by each beneficiary. For example, having no difficulty contacting a provider after regular hours was associated with significantly lower outpatient expenditures for beneficiaries with high cholesterol and diabetes (n = 635; P = 0.038), but it was associated with significantly higher inpatient expenditures for beneficiaries with high blood pressure and high cholesterol (n = 1599; P = 0.015), and no significant differences in expenditures in any category for beneficiaries with high blood pressure and heart disease (n = 1018; P > 0.05 for all categories). However, average total health care expenditures are largely unaffected by implementing the PCMH features considered. Understanding how the needs of Medicare beneficiaries with multiple chronic conditions can be met through the adoption of the PCMH model is important not only to be able to provide high-quality care but also to control costs. (Population Health Management 2016;19:206-211).

  11. Positron emission tomography for initial staging of esophageal cancer among medicare beneficiaries

    PubMed Central

    Varghese, Thomas K.; Flanagan, Meghan R.; Flum, David R.; Shankaran, Veena; Oelschlager, Brant K.; Mulligan, Michael S.; Wood, Douglas E.; Pellegrini, Carlos A.

    2016-01-01

    Background The role of positron emission tomography (PET) in the initial staging of esophageal cancer is to detect occult metastases, but its ability to do so has not been evaluated at the population-level. In 2001, Medicare approved reimbursement of PET for esophageal cancer staging. We hypothesized rapid adoption of PET after 2001 and a coincident increase in the prevalence of stage IV disease. Methods A retrospective cohort study [1997-2009] was conducted of 12,870 Medicare beneficiaries with esophageal cancer using the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. Results PET use increased from <3% before 2001 to 44% in 2009 (post-PET era) (P trend <0.001). Over the same period, the prevalence of stage IV disease also increased (20% in 1997 and 28% in 2009, P trend <0.001). After adjusting for changing patient characteristics over time, the rate of increase in stage IV disease in the post-PET era [relative risk (RR) =1.06; 95% confidence interval (CI), 1.00-1.13] was no different than the rate of increase in the pre-PET era (RR =1.02; 95% CI, 1.02-1.04). Over the entire study period, the prevalence of unrecorded stage decreased by more than half (43% to 18%, adjusted P trend <0.001) with coincident increases in stage 0-III (37% to 53%, adjusted P trend <0.001) as well as stage IV disease. Conclusions The increasing frequency of PET use and stage IV disease over time is more likely explained by improved documentation rather than PET’s ability to detect occult metastases. The absence of compelling population-level impact compliments previous studies, revealing an opportunity to increase value through selective use of PET. PMID:27284472

  12. No association between Centers for Medicare and Medicaid services payments and volume of Medicare beneficiaries or per-capita health care costs for each state.

    PubMed

    Harewood, Gavin C; Alsaffar, Omar

    2015-03-01

    The Centers for Medicare and Medicaid Services recently published data on Medicare payments to physicians for 2012. We investigated regional variations in payments to gastroenterologists and evaluated whether payments correlated with the number of Medicare patients in each state. We found that the mean payment per gastroenterologist in each state ranged from $35,293 in Minnesota to $175,028 in Mississippi. Adjusted per-physician payments ranged from $11 per patient in Hawaii to $62 per patient in Washington, DC. There was no correlation between the mean per-physician payment and the mean number of Medicare patients per physician (r = 0.09), there also was no correlation between the mean per-physician payment and the overall mean per-capita health care costs for each state (r = -0.22). There was a 5.6-fold difference between the states with the lowest and highest adjusted Medicare payments to gastroenterologists. Therefore, the Centers for Medicare and Medicaid Services payments do not appear to be associated with the volume of Medicare beneficiaries or overall per-capita health care costs for each state.

  13. Patterns of erythropoiesis-stimulating agent use among Medicare beneficiaries with myelodysplastic syndromes and consistency with clinical guidelines.

    PubMed

    Davidoff, Amy J; Weiss, Sheila R; Baer, Maria R; Ke, Xuehua; Hendrick, Franklin; Zeidan, Amer; Gore, Steven D

    2013-06-01

    Erythropoiesis-stimulating agents (ESA) are used commonly to reduce symptomatic anemia in patients with myelodysplastic syndromes (MDS). We assessed population-based patterns of ESA use relative to treatment guidelines using data from the Surveillance, Epidemiology, and End Results (SEER) registries, with linked Medicare claims providing detailed treatment data from 2001 through 2005. The study found widespread use (62%) of ESA in Medicare beneficiaries with MDS. Similar ESA use rates regardless of risk status, low frequency (45%) of serum erythropoietin determination prior to ESA initiation, and high prevalence (60.4%) of short-duration ESA episodes suggest clinically important discrepancies between actual practice and guideline-recommended therapy.

  14. Patterns of erythropoiesis-stimulating agent use among Medicare beneficiaries with myelodysplastic syndromes and consistency with clinical guidelines.

    PubMed

    Davidoff, Amy J; Weiss, Sheila R; Baer, Maria R; Ke, Xuehua; Hendrick, Franklin; Zeidan, Amer; Gore, Steven D

    2013-06-01

    Erythropoiesis-stimulating agents (ESA) are used commonly to reduce symptomatic anemia in patients with myelodysplastic syndromes (MDS). We assessed population-based patterns of ESA use relative to treatment guidelines using data from the Surveillance, Epidemiology, and End Results (SEER) registries, with linked Medicare claims providing detailed treatment data from 2001 through 2005. The study found widespread use (62%) of ESA in Medicare beneficiaries with MDS. Similar ESA use rates regardless of risk status, low frequency (45%) of serum erythropoietin determination prior to ESA initiation, and high prevalence (60.4%) of short-duration ESA episodes suggest clinically important discrepancies between actual practice and guideline-recommended therapy. PMID:23523473

  15. A Medicare current beneficiary survey-based investigation of alternative primary care models in nursing homes: functional ability and health status outcomes.

    PubMed

    Abdallah, Lisa M; Van Etten, Deborah; Lee, A James; Melillo, Karen Devereaux; Remington, Ruth; Gautam, Ramraj; Gore, Rebecca J

    2015-01-01

    This study assessed how the health status and functioning of Medicare beneficiaries residing in nursing homes varies systematically with nurse practitioners (NPs) and physician assistants (PAs) providing primary care services. A secondary analysis was conducted using data from the 2006, 2007, and 2008 Medicare Current Beneficiary Surveys. The study sample included 433 participant-year observations within one of three cohorts: (a) medical doctor (MD)-only, those who received primary care services exclusively from a physician; (b) MD-dominant, those who received some primary care services from an NP or PA, but those visits accounted for less than one half of total primary care visits; and (c) NP/PA-dominant, those who received more than one half of their primary care visits from an NP or PA. Participants in the MD-only cohort had significantly less orientation and independence in activities of daily living compared to participants in the NP/PA-dominant cohort. Other study variables did not vary significantly by practice model. Although the study provides some evidence that NP/PA involvement is associated with improved functioning, it is premature to draw strong inferences.

  16. Trends in Warfarin Monitoring Practices Among New York Medicare Beneficiaries, 2006-2011.

    PubMed

    Triller, Darren M; Wymer, Susan; Meek, Patrick D; Hylek, Elaine M; Ansell, Jack E

    2015-10-01

    Anticoagulation with warfarin requires frequent evaluation of the international normalized ratio (INR), and less invasive testing devices are available for use by clinicians at the point-of-care (POC) and by patients who self-test (PST). Despite commercial availability and positive results of published studies, evidence suggests that adoption of less invasive (POC/PST) testing in the United States is slow. Considering the equivalence of results and logistical advantages of POC/PST testing, slow uptake may indicate a gap in quality of care warranting evaluation and possibly intervention. This study used Medicare fee for service claims data to explore the uptake of POC/PST INR monitoring across New York State over a 6 year time frame (2006-11), with additional analyses based on beneficiary age, sex, race and ethnicity and income by county. In 2006, only 28.3% of 103,410 analyzable beneficiaries presumed to be chronic warfarin users based on INR testing patterns were monitored by POC/PST, and increased to only 37.6% by 2011. Utilization of POC/PST testing varied widely by county (baseline range 1.2-89.4%), and uptake of these testing modalities in New York State was significantly lower among the very elderly, women, and ethnic minorities. We hypothesize that poor penetration of these less invasive INR testing modalities into highly populated New York City and barriers to POC utilization in long term care facilities may account for a portion of the variability in INR testing patterns observed in this study. However, additional research is needed to further explore whether disparities in warfarin monitoring practices exist. PMID:26198584

  17. Trends in Warfarin Monitoring Practices Among New York Medicare Beneficiaries, 2006-2011.

    PubMed

    Triller, Darren M; Wymer, Susan; Meek, Patrick D; Hylek, Elaine M; Ansell, Jack E

    2015-10-01

    Anticoagulation with warfarin requires frequent evaluation of the international normalized ratio (INR), and less invasive testing devices are available for use by clinicians at the point-of-care (POC) and by patients who self-test (PST). Despite commercial availability and positive results of published studies, evidence suggests that adoption of less invasive (POC/PST) testing in the United States is slow. Considering the equivalence of results and logistical advantages of POC/PST testing, slow uptake may indicate a gap in quality of care warranting evaluation and possibly intervention. This study used Medicare fee for service claims data to explore the uptake of POC/PST INR monitoring across New York State over a 6 year time frame (2006-11), with additional analyses based on beneficiary age, sex, race and ethnicity and income by county. In 2006, only 28.3% of 103,410 analyzable beneficiaries presumed to be chronic warfarin users based on INR testing patterns were monitored by POC/PST, and increased to only 37.6% by 2011. Utilization of POC/PST testing varied widely by county (baseline range 1.2-89.4%), and uptake of these testing modalities in New York State was significantly lower among the very elderly, women, and ethnic minorities. We hypothesize that poor penetration of these less invasive INR testing modalities into highly populated New York City and barriers to POC utilization in long term care facilities may account for a portion of the variability in INR testing patterns observed in this study. However, additional research is needed to further explore whether disparities in warfarin monitoring practices exist.

  18. Cost-related Nonadherence by Medication Type among Medicare Part D Beneficiaries with Diabetes

    PubMed Central

    Williams, Jessica; Steers, W. Neil; Ettner, Susan L.; Mangione, Carol M.; Duru, O. Kenrik

    2013-01-01

    Background Despite the rollout of Medicare Part D, cost-related non-adherence (CRN) among older adults remains a problem. Objectives To examine the rate and correlates of self-reported CRN among a population of older persons with diabetes. Research Design Cross-sectional. Subjects 1,264 Part D patients with diabetes, who entered the coverage gap in 2006. Measures Initial administrative medication lists were verified in computer-assisted telephone interviews, in which participants brought their medication bottles to the phone. Medications were classified into cardiometabolic (diabetes, hypertension, cholesterol-lowering), symptom relief, and “other.” Participants were asked if they had any cost-related non-adherence during 2006, and if so to which medication/s. We used the person-medication dyad as the unit of analysis, and tested a multivariate random effects logistic regression model to analyze the correlates of CRN. Results Approximately 16% of participants reported any CRN. CRN was more frequent for cholesterol-lowering medications [Relative risk 1.54, 95%CI 1.01-2.32] compared to medications taken for symptom relief. CRN was reported less frequently with increasing age above 75 years, compared to patients between 65 and 69. In addition, compared to those with incomes >$40,000, CRN risk for those with incomes <$25,000 was markedly higher [RR 3.05, 95%CI 1.99-4.65]. Conclusions In summary, we found high rates of CRN among Medicare beneficiaries with diabetes, particularly those with lower incomes. We observed more frequent CRN for cholesterol-lowering medications as compared to medications for symptom relief. Efforts to ensure medication affordability for this population will be important in boosting adherence to key medications. PMID:23032359

  19. Evaluation of a high-risk case management pilot program for Medicare beneficiaries with Medigap coverage.

    PubMed

    Hawkins, Kevin; Parker, Paula M; Hommer, Cynthia E; Bhattarai, Gandhi R; Huang, Jinghua; Wells, Timothy S; Ozminkowski, Ronald J; Yeh, Charlotte S

    2015-04-01

    The objective was to evaluate the 3-year experience of a high-risk case management (HRCM) pilot program for adults with an AARP Medicare Supplement (Medigap) Insurance Plan. Participants were provided in-person visits as well as telephonic and mailed services to improve care coordination from December 1, 2008, to December 31, 2011. Included were adults who had an AARP Medigap Insurance Plan, resided in 1 of 5 pilot states, and had a Hierarchical Condition Category score>3.74, or were referred into the program. Propensity score weighting was used to adjust for case-mix differences among 2015 participants and 7626 qualified but nonparticipating individuals. Participants were in the program an average of 15.4 months. After weighting, multiple regression analyses were used to estimate differences in quality of care and health care expenditures between participants and nonparticipants. Increased duration in the program was associated with fewer hospital readmissions. Additionally, participants were significantly more likely to have recurring office visits and recommended laboratory tests. The program demonstrated $7.7 million in savings over the 3 years, resulting in a return on investment of $1.40 saved for every dollar spent on the program. Savings increased each year from 2009 to 2011 and with longer length of engagement. The majority of savings were realized by the federal Medicare program. This study focused on quality of care and savings for an HRCM program designed solely for Medicare members with Medicare Supplement coverage. This program had a favorable impact on quality of care and demonstrated savings over a 3-year period.

  20. Cost-related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and 2000

    PubMed Central

    Wilson, Ira B; Rogers, William H; Chang, Hong; Safran, Dana Gelb

    2005-01-01

    Objective To report rates of cost-related skipping of medications and other treatments, assess correlates of skipping, examine changes in skipping between 1998 and 2000, and identify factors associated with changes in skipping. Design, Setting, and Participants Cross-sectional and longitudinal analyses of surveys of a probability sample of Medicare beneficiaries in 13 states in 1998 and 2000. Main Outcome Measure Self-reported rates of skipping medications and other treatments. Results Cost-related skipping rates increased from 9.5% in 1998 to 13.1% in 2000. In separate multivariable models using 1998 and 2000 data, higher out-of-pocket costs, lower physician-patient relationship quality, low income, and lacking prescription drug coverage were associated with more skipping (P<.05 for all). Better physical and mental health, and greater age were associated with less skipping (P<.05). HMO membership was not associated with higher rates of skipping in 1998 (P=.84), but was in 2000 (P<.0004). In longitudinal analyses, increased medication costs and HMO membership were associated with the observed increase cost-related skipping between 1998 and 2000. Conclusions Cost-related skipping was associated with several factors, including drug coverage, poverty, poor health, and physician-patient relationship quality. The important role of physician-patient relationships in cost-related skipping has not been shown previously. Physicians should be aware of these risk factors for cost-related skipping, and initiate dialogue about problems paying for prescription medications and other treatments. PMID:16050880

  1. Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries

    PubMed Central

    2011-01-01

    Background Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines. Methods The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop. Results The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline. Conclusions Both the additive and

  2. Association between age and use of intensive care among surgical Medicare beneficiaries

    PubMed Central

    Wunsch, Hannah; Gershengorn, Hayley B.; Guerra, Carmen; Rowe, John; Li, Guohua

    2013-01-01

    Purpose To determine the role age plays in use of intensive care for patients who have major surgery. Materials and Methods Retrospective cohort study examining the association between age and admission to an intensive care unit (ICU) for all Medicare beneficiaries aged 65 or older who had a hospitalization for one of five surgical procedures: esophagectomy, cystectomy, pancreaticoduodenectomy (PD), elective open abdominal aortic aneurysm repair (open AAA), and elective endovascular AAA repair (endo AAA) from 2004–08. The primary outcome was admission to an ICU. Secondary outcomes were complications and hospital mortality. We used multi-level mixed-effects logistic regression to adjust for other patient and hospital-level factors associated with each outcome. Results The percentage of hospitalized patients admitted to ICU ranged from 41.3% for endo AAA to 81.5% for open AAA. In-hospital mortality also varied, from 1.1% for endo AAA to 6.8% for esophagectomy. After adjusting for other factors, age was associated with admission to ICU for cystectomy (Adjusted Odds Ratio (AOR) 1.56 (95% CI 1.36–1.78) for age 80–84+; 2.25 (1.85–2.75) age 85+ compared with age 65–69), PD (AOR 1.26 (1.06–1.50) age 80–84; 1.49 (1.11–1.99) age 85+) and esophagectomy (AOR 1.26 (1.02–1.55) age 80–84; 1.28 (0.91–1.80) age 85+). Age was not associated with use of intensive care for open or endo AAA. Older age was associated with increases in complication rates and in-hospital mortality for all five surgical procedures. Conclusions The association between age and use of intensive care was procedure-specific. Complication rates and in-hospital mortality increased with age for all five surgical procedures. PMID:23787024

  3. The Complex Relationship Between Quality and Resource Use Among Medicare Fee-for-Service Beneficiaries with Diabetes.

    PubMed

    Xu, Wendy Yi; Abraham, Jean; Marmor, Schelomo; Knutson, David; Virnig, Beth A

    2016-02-01

    This study examines the relationship between Healthcare Effectiveness Data and Information Set-based diabetes quality measures and resource use for evaluation and management (E&M), inpatient facility, and surgical procedure services for a national sample of Medicare fee-for-service beneficiaries in 1685 Hospital Service Areas. Using multivariate regression analyses, the study findings suggest that higher rates of beneficiaries' receipt of HbA1c, low-density lipoprotein cholesterol, and retinal eye exam tests ("composite quality") during the year is inversely related to average inpatient resource use. However, no association is found between composite quality and E&M services, suggesting that quality improvement with respect to increased rates of testing could be achieved without significant increases in resource use.

  4. 75 FR 75884 - Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-07

    ... in the Federal Register at http://www.gpoaccess.gov/fr/index.html . Background Medicare prescription... Medicare prescription drug coverage premiums, when they go into effect on January 1, 2011. DATES:...

  5. Big Data, Little Data, and Care Coordination for Medicare Beneficiaries with Medigap Coverage.

    PubMed

    Ozminkowski, Ronald J; Wells, Timothy S; Hawkins, Kevin; Bhattarai, Gandhi R; Martel, Charles W; Yeh, Charlotte S

    2015-06-01

    Most healthcare data warehouses include big data such as health plan, medical, and pharmacy claims information for many thousands and sometimes millions of insured individuals. This makes it possible to identify those with multiple chronic conditions who may benefit from participation in care coordination programs meant to improve their health. The objective of this article is to describe how large databases, including individual and claims data, and other, smaller types of data from surveys and personal interviews, are used to support a care coordination program. The program described in this study was implemented for adults who are generally 65 years of age or older and have an AARP(®) Medicare Supplement Insurance Plan (i.e., a Medigap plan) insured by UnitedHealthcare Insurance Company (or, for New York residents, UnitedHealthcare Insurance Company of New York). Individual and claims data were used first to calculate risk scores that were then utilized to identify the majority of individuals who were qualified for program participation. For efficient use of time and resources, propensity to succeed modeling was used to prioritize referrals based upon their predicted probabilities of (1) engaging in the care coordination program, (2) saving money once engaged, and (3) receiving higher quality of care. To date, program evaluations have reported positive returns on investment and improved quality of healthcare among program participants. In conclusion, the use of data sources big and small can help guide program operations and determine if care coordination programs are working to help older adults live healthier lives.

  6. Big Data, Little Data, and Care Coordination for Medicare Beneficiaries with Medigap Coverage.

    PubMed

    Ozminkowski, Ronald J; Wells, Timothy S; Hawkins, Kevin; Bhattarai, Gandhi R; Martel, Charles W; Yeh, Charlotte S

    2015-06-01

    Most healthcare data warehouses include big data such as health plan, medical, and pharmacy claims information for many thousands and sometimes millions of insured individuals. This makes it possible to identify those with multiple chronic conditions who may benefit from participation in care coordination programs meant to improve their health. The objective of this article is to describe how large databases, including individual and claims data, and other, smaller types of data from surveys and personal interviews, are used to support a care coordination program. The program described in this study was implemented for adults who are generally 65 years of age or older and have an AARP(®) Medicare Supplement Insurance Plan (i.e., a Medigap plan) insured by UnitedHealthcare Insurance Company (or, for New York residents, UnitedHealthcare Insurance Company of New York). Individual and claims data were used first to calculate risk scores that were then utilized to identify the majority of individuals who were qualified for program participation. For efficient use of time and resources, propensity to succeed modeling was used to prioritize referrals based upon their predicted probabilities of (1) engaging in the care coordination program, (2) saving money once engaged, and (3) receiving higher quality of care. To date, program evaluations have reported positive returns on investment and improved quality of healthcare among program participants. In conclusion, the use of data sources big and small can help guide program operations and determine if care coordination programs are working to help older adults live healthier lives. PMID:27447434

  7. On Medicare But At Risk: A State-Level Analysis of Beneficiaries Who Are Underinsured or Facing High Total Cost Burdens.

    PubMed

    Schoen, Cathy; Solís-Román, Claudia; Huober, Nick; Kelchner, Zachary

    2016-05-01

    Medicare provides essential health coverage for older and disabled adults, yet it does not limit out-of-pocket costs for covered benefits and excludes dental, hearing, and longer-term care. The resulting out-of-pocket costs can add up to a substantial share of income. Based on U.S. Census surveys, nearly a quarter of Medicare beneficiaries (11.5 million) were underinsured in 2013–14, meaning they spent a high share of their income on health care. Adding premiums to medical care expenses, we find that 16 percent of beneficiaries (8 million) spent 20 percent or more of their income on insurance plus care. At the state level, the proportion of beneficiaries underinsured ranged from 16 percent to 32 percent, while the proportion with a high total cost burden ranged from 11 percent to 26 percent. Low-income beneficiaries were most at risk. The findings underscore the need to assess beneficiary impacts of any proposal to redesign Medicare. PMID:27214925

  8. On Medicare But At Risk: A State-Level Analysis of Beneficiaries Who Are Underinsured or Facing High Total Cost Burdens.

    PubMed

    Schoen, Cathy; Solís-Román, Claudia; Huober, Nick; Kelchner, Zachary

    2016-05-01

    Medicare provides essential health coverage for older and disabled adults, yet it does not limit out-of-pocket costs for covered benefits and excludes dental, hearing, and longer-term care. The resulting out-of-pocket costs can add up to a substantial share of income. Based on U.S. Census surveys, nearly a quarter of Medicare beneficiaries (11.5 million) were underinsured in 2013–14, meaning they spent a high share of their income on health care. Adding premiums to medical care expenses, we find that 16 percent of beneficiaries (8 million) spent 20 percent or more of their income on insurance plus care. At the state level, the proportion of beneficiaries underinsured ranged from 16 percent to 32 percent, while the proportion with a high total cost burden ranged from 11 percent to 26 percent. Low-income beneficiaries were most at risk. The findings underscore the need to assess beneficiary impacts of any proposal to redesign Medicare.

  9. Patient Satisfaction, Empowerment, and Health and Disability Status Effects of a Disease Management-Health Promotion Nurse Intervention among Medicare Beneficiaries with Disabilities

    ERIC Educational Resources Information Center

    Friedman, Bruce; Wamsley, Brenda R.; Liebel, Dianne V.; Saad, Zabedah B.; Eggert, Gerald M.

    2009-01-01

    Purpose: To report the impact on patient and informal caregiver satisfaction, patient empowerment, and health and disability status of a primary care-affiliated disease self-management-health promotion nurse intervention for Medicare beneficiaries with disabilities and recent significant health services use. Design and Methods: The Medicare…

  10. Service use and costs for Medicare beneficiaries in risk-based HMOs and CMPs: some interim results from the National Medicare Competition Evaluation.

    PubMed Central

    Rossiter, L F; Nelson, L M; Adamache, K W

    1988-01-01

    The Health Care Financing Administration (HCFA) initiated the Medicare Competition Demonstration in 1982 in anticipation of congressional intent to establish a national program. Interim results on the 1984 service use and cost experience of the health maintenance organizations (HMOs) and competitive medical plans (CMPs) participating in the demonstrations indicate that Medicare enrollees in the demonstration experienced a median of 1,951 hospital days per 1,000 person years, 57 per cent of the median of 3,432 days per 1,000 in the local markets from which the plans drew enrollment. Independent practice association (IPA) HMOs experienced higher hospital use rates than staff and group model HMOs. These comparisons are not adjusted for various risk factors, the absence of which were likely to favor the demonstration plans. Plans with lower hospital service use were federally qualified and had been operating for more than five years. The median total annual revenue per enrollee across all plans was $2,312, compared to median annual expenses per enrollee of $2,250. The distribution of median annual expenses per enrollee by major category of expense was: institutional expenses ($1,038/enrollee), medical expenses ($720/enrollee), supplemental services expenses ($154/enrollee), and administrative and other expenses ($295/enrollee). Future analysis, using beneficiary-level data, will examine the impact of the demonstration and the nature and extent of evident biased selection and will compare the quality of care in the demonstrations to that in the fee-for-service sector. PMID:3291622

  11. Potential impact of pharmacist interventions to reduce cost for Medicare Part D beneficiaries.

    PubMed

    Thatcher, Erin E; Vanwert, Elizabeth M; Erickson, Steven R

    2013-06-01

    The objective was to determine the impact of simulated pharmacist interventions on out-of-pocket cost, time to coverage gap, and cost per patient to the Medicare Part D program using actual patient cases from an adult general medicine clinic. Medication profiles of 100 randomly selected Medicare-eligible patients from a university-affiliated general internal medicine clinic were reviewed by a pharmacist to identify opportunities to cost-maximize the patients' therapies based on the plan. An online Part-D calculator, Aetna Medicare Rx Essentials, was used as the standard plan to determine medication cost and time to gap. The primary analysis was comparison of the patients' pre-review and post-review out-of-pocket cost, time to coverage gap, and cost to Medicare. A total of 65 patients had at least 1 simulated pharmacist cost intervention. The most common intervention was substituting for a less costly generic, followed by substituting a generic for a brand name. Projected patient cost savings was $476 per year. The average time to coverage gap was increased by 0.7 ±1.2 months. This study illustrates that the pharmacists may be able to reduce cost to some patients as well as to the Medicare Part D program.

  12. Potential impact of pharmacist interventions to reduce cost for Medicare Part D beneficiaries.

    PubMed

    Thatcher, Erin E; Vanwert, Elizabeth M; Erickson, Steven R

    2013-06-01

    The objective was to determine the impact of simulated pharmacist interventions on out-of-pocket cost, time to coverage gap, and cost per patient to the Medicare Part D program using actual patient cases from an adult general medicine clinic. Medication profiles of 100 randomly selected Medicare-eligible patients from a university-affiliated general internal medicine clinic were reviewed by a pharmacist to identify opportunities to cost-maximize the patients' therapies based on the plan. An online Part-D calculator, Aetna Medicare Rx Essentials, was used as the standard plan to determine medication cost and time to gap. The primary analysis was comparison of the patients' pre-review and post-review out-of-pocket cost, time to coverage gap, and cost to Medicare. A total of 65 patients had at least 1 simulated pharmacist cost intervention. The most common intervention was substituting for a less costly generic, followed by substituting a generic for a brand name. Projected patient cost savings was $476 per year. The average time to coverage gap was increased by 0.7 ±1.2 months. This study illustrates that the pharmacists may be able to reduce cost to some patients as well as to the Medicare Part D program. PMID:23178417

  13. The Economic Burden of Ischemic Stroke and Major Hemorrhage in Medicare Beneficiaries with Nonvalvular Atrial Fibrillation: A Retrospective Claims Analysis

    PubMed Central

    Fitch, Kathryn; Broulette, Jonah; Kwong, Winghan Jacqueline

    2014-01-01

    Background Understanding the economic implications of oral anticoagulation therapy requires careful consideration of the risks and costs of stroke and major hemorrhage. The majority of patients with atrial fibrillation (AF) are aged ≥65 years, so focusing on the Medicare population is reasonable when discussing the risk for stroke. Objective To examine the relative economic burden associated with stroke and major hemorrhage among Medicare beneficiaries who are newly diagnosed with nonvalvular atrial fibrillation (NVAF). Methods This study was a retrospective analysis of a 5% sample of Medicare claims data for patients with NVAF from 2006 to 2008. Patients with NVAF without any claims of AF during the 12 months before the first (index) claim for AF in 2007 (baseline period) were identified and were classified into 4 cohorts during a 12-month follow-up period after the index date. These cohorts included (1) no claims for ischemic stroke or major hemorrhage (without stroke or hemorrhage); (2) no claims for ischemic stroke and ≥1 claims for major hemorrhage (hemorrhage only); (3) ≥1 claims for ischemic stroke and no major hemorrhage claims (stroke only); and (4) ≥1 claims each for ischemic stroke and for major hemorrhage (stroke and hemorrhage). The 1-year mean postindex total all-cause healthcare costs adjusted by the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (HCC) score were compared among the study cohorts. Results: Of the 9455 eligible patients included in this study, 3% (N = 261) of the patients had ischemic stroke claims only, 3% (N = 276) had hemorrhage claims only, and <1% (N = 13) had both during the follow-up period. The unadjusted follow-up healthcare costs were $63,781 and $64,596 per patient for the ischemic stroke only and the hemorrhage only cohorts, respectively, compared with $35,474 per patient for those without hemorrhage or stroke claims. After adjustment for HCC risk score, the mean incremental costs for

  14. 42 CFR 424.507 - Ordering and referring covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... ordered or referred by a resident or an intern, the claim must identify the teaching physician as the... referred by a resident or an intern, the claim must identify the teaching physician as the ordering or... intern, the claim must identify the teaching physician as the ordering or referring physician. The...

  15. 42 CFR 424.507 - Ordering and referring covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... ordered or referred by a resident or an intern, the claim must identify the teaching physician as the... referred by a resident or an intern, the claim must identify the teaching physician as the ordering or... intern, the claim must identify the teaching physician as the ordering or referring physician. The...

  16. The Association of Ambulatory Care with Breast Cancer Stage at Diagnosis Among Medicare Beneficiaries

    PubMed Central

    Keating, Nancy L; Landrum, Mary Beth; Ayanian, John Z; Winer, Eric P; Guadagnoli, Edward

    2005-01-01

    OBJECTIVE Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis. DESIGN Retrospective cohort study using cancer registry and Medicare claims data. PATIENTS Population-based sample of 11,291 women aged ≥67 diagnosed with breast cancer during 1995 to 1996. MEASUREMENTS AND MAIN RESULTS Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P≥.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P <.001). The rate of advanced cancer also decreased with increasing number of visits (P <.001). CONCLUSIONS Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits. PMID:15693926

  17. Medicare

    MedlinePlus

    ... receiving health services. . . . . . . . . 15 If you have other health insurance. . . . . . . . . . . 15 Contacting Social Security Visit our website At ... 2048 What is Medicare? Medicare is our country’s health insurance program for people age 65 or older. People ...

  18. Medicare

    Cancer.gov

    The Centers for Medicare & Medicaid Services administers Medicare, a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease.

  19. Medicare

    MedlinePlus

    ... quality measures for nursing homes Learn more Address change/Medicare card issue? Lost or incorrect Medicare card? Select your card issue Select your card issue... Change your name or address Replace a lost or ...

  20. Medicare

    MedlinePlus

    Medicare is the U.S. government's health insurance program for people age 65 or older. Some people under age 65 can qualify for Medicare, too. They include those with disabilities, permanent kidney ...

  1. Medicare Hospital Charges in the Last Year of Life: Distribution by Quarter for Rural and Urban Nursing Home Decedents with Cognitive Impairment

    ERIC Educational Resources Information Center

    Gessert, Charles E.; Haller, Irina V.

    2008-01-01

    Background: Medicare beneficiaries incur 27%-30% of lifetime charges in the last year of life; most charges occur in the last quarter. Factors associated with high end-of-life Medicare charges include less advanced age, non-white race, absence of advance directive, and urban residence. Methods: We analyzed Medicare hospital charges in the last…

  2. BENEFITS IMPROVEMENT AND PROTECTION ACT’S IMPACT ON TRANSPLANTATION RATES AMONG ELDERLY MEDICARE BENEFICIARIES WITH END-STAGE RENAL DISEASE

    PubMed Central

    Mullins, C. Daniel; Jain, Rahul; Weir, Matthew R.; Franey, Christine S.; Shih, Ya-Chen Tina; Pradel, Françoise G.; Bikov, Kaloyan; Bartlett, Stephen T.

    2012-01-01

    Background The Benefits Improvement and Protection Act (BIPA) expanded Medicare coverage for post-transplant immunosuppresants for elderly patients and others eligible for Medicare beyond their ESRD status, yet retained the three year limit for patients eligible solely because of ESRD status. Our objective was to determine BIPA’s impact on renal transplantation among elderly patients (age 65+) affected by BIPA. Methods Medicare claims and the United States Renal Data System Standard Analysis Files were used to analyze the likelihood of transplantation among elderly patients, all of whom were affected by BIPA, versus the non-elderly, many of whom were unaffected by BIPA. A difference-in-differences approach and generalized logistic regressions were used to estimate BIPA’s impact. Results Analysis of data for 632,904 ESRD Medicare beneficiaries who met inclusion/exclusion criteria suggest that BIPA made elderly patients more likely (Relative Likelihood = 1.36 (95% CI: 1.32 – 1.41)) to have a transplant. The likelihood for non-elderly patients decreased following BIPA (Relative Likelihood = 0.93 (95% CI: 0.92 – 0.94)). Conclusion Transplantation rates increased among those elderly patients, all of whom were affected by BIPA by extending immunosuppressant coverage under BIPA. These results suggest that removing financial barriers to post-transplant care may positively impacts transplantation rates, yet raise questions regarding whether the law shifted transplants from younger to older patients. PMID:23314351

  3. Particulate Air Pollution and the Rate of Hospitalization for Congestive Heart Failure among Medicare Beneficiaries in Pittsburgh, Pennsylvania.

    PubMed Central

    Wellenius, Gregory A.; Bateson, Thomas F.; Mittleman, Murray A.; Schwartz., Joel

    2006-01-01

    We used a case-crossover approach to evaluate the association between ambient air pollution and the rate of hospitalization for congestive heart failure (CHF) among Medicare recipients (age ≥ 65) residing in Allegheny County (Pittsburgh area), PA, during 1987–1999. We also explored effect modification by age, gender, and specific secondary diagnoses. During follow-up, there were 55,019 admissions with a primary diagnosis of CHF. We found that particulate matter with aerodynamic diameter ≤ 10 μm (PM10), carbon monoxide (CO), nitrogen dioxide (NO2), and sulfur dioxide – but not ozone – were positively and significantly associated with the rate of admission on the same day in single-pollutant models. The strongest associations were observed with CO, NO2 and PM10. The associations with CO and NO2 were the most robust in two-pollutant models, remaining statistically significant even after adjusting for other pollutants. Patients with a recent myocardial infarction were at greater risk of particulate-related admission, but there was otherwise no significant effect modification by age, gender, or other secondary diagnoses. These results suggest that short-term elevations in air pollution from traffic-related sources may trigger acute cardiac decompensation of heart failure patients and that those with certain comorbid conditions may be more susceptible to these effects. PMID:15901623

  4. Regulations regarding income-related monthly adjustment amounts to Medicare beneficiaries' prescription drug coverage premiums. Interim final rule with request for comments.

    PubMed

    2010-12-01

    We are adding a new subpart to our regulations, which contains the rules we will apply to determine the income-related monthly adjustment amount for Medicare prescription drug coverage premiums. This new subpart implements changes made to the Social Security Act (Act) by the Affordable Care Act. These rules parallel the rules in subpart B of this part, which describes the rules we apply when we determine the income-related monthly adjustment amount for certain Medicare Part B (medical insurance) beneficiaries. These rules describe the new subpart; what information we will use to determine whether you will pay an income-related monthly adjustment amount and the amount of the adjustment when applicable; when we will consider a major life-changing event that results in a significant reduction in your modified adjusted gross income; and how you can appeal our determination about your income-related monthly adjustment amount. These rules will allow us to implement the provisions of the Affordable Care Act on time that relate to the income-related monthly adjustment amount for Medicare prescription drug coverage premiums, when they go into effect on January 1, 2011.

  5. The Impact of Home Health Length of Stay and Number of Skilled Nursing Visits on Hospitalization among Medicare-Reimbursed Skilled Home Health Beneficiaries

    PubMed Central

    O'Connor, Melissa; Hanlon, Alexandra; Naylor, Mary D.; Bowles, Kathryn H.

    2015-01-01

    The implementation of the Home Health Prospective Payment System in 2000 led to a dramatic reduction in home health length of stay and number of skilled nursing visits among Medicare beneficiaries. While policy leaders have focused on the rising costs of home health care, its potential underutilization and the relationship between service use and patient outcomes including hospitalization rates have not been rigorously examined. A secondary analysis of five Medicare-owned assessment and claims data sets for the year 2009 was conducted among two independently randomly selected samples of Medicare-reimbursed home health recipients (each n=31,485) to examine the relationship between home health length of stay or number of skilled nursing visits and hospitalization rates within 90 days of discharge from home health. Patients who had a home health length of stay of at least 22 days or received at least 4 skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits. Additional study is needed to clarify the best way to structure home health services and determine readiness for discharge to reduce hospitalization among this chronically ill population. In the mean time, the findings of this study suggest that home health providers should consider the benefits of at least four SNV and/or a home health LOS of 22 days or longer. PMID:25990046

  6. Regulations regarding income-related monthly adjustment amounts to Medicare beneficiaries' prescription drug coverage premiums. Interim final rule with request for comments.

    PubMed

    2010-12-01

    We are adding a new subpart to our regulations, which contains the rules we will apply to determine the income-related monthly adjustment amount for Medicare prescription drug coverage premiums. This new subpart implements changes made to the Social Security Act (Act) by the Affordable Care Act. These rules parallel the rules in subpart B of this part, which describes the rules we apply when we determine the income-related monthly adjustment amount for certain Medicare Part B (medical insurance) beneficiaries. These rules describe the new subpart; what information we will use to determine whether you will pay an income-related monthly adjustment amount and the amount of the adjustment when applicable; when we will consider a major life-changing event that results in a significant reduction in your modified adjusted gross income; and how you can appeal our determination about your income-related monthly adjustment amount. These rules will allow us to implement the provisions of the Affordable Care Act on time that relate to the income-related monthly adjustment amount for Medicare prescription drug coverage premiums, when they go into effect on January 1, 2011. PMID:21137594

  7. Underweight, Markers of Cachexia, and Mortality in Acute Myocardial Infarction: A Prospective Cohort Study of Elderly Medicare Beneficiaries

    PubMed Central

    Bucholz, Emily M.; Krumholz, Hannah A; Krumholz, Harlan M.

    2016-01-01

    Background Underweight patients are at higher risk of death after acute myocardial infarction (AMI) than normal weight patients; however, it is unclear whether this relationship is explained by confounding due to cachexia or other factors associated with low body mass index (BMI). This study aimed to answer two questions: (1) does comprehensive risk adjustment for comorbid illness and frailty measures explain the higher mortality after AMI in underweight patients, and (2) is the relationship between underweight and mortality also observed in patients with AMI who are otherwise without significant chronic illness and are presumably free of cachexia? Methods and Findings We analyzed data from the Cooperative Cardiovascular Project, a cohort-based study of Medicare beneficiaries hospitalized for AMI between January 1994 and February 1996 with 17 y of follow-up and detailed clinical information to compare short- and long-term mortality in underweight and normal weight patients (n = 57,574). We used Cox proportional hazards regression to investigate the association of low BMI with 30-d, 1-y, 5-y, and 17-y mortality after AMI while adjusting for patient comorbidities, frailty measures, and laboratory markers of nutritional status. We also repeated the analyses in a subset of patients without significant comorbidity or frailty. Of the 57,574 patients with AMI included in this cohort, 5,678 (9.8%) were underweight and 51,896 (90.2%) were normal weight at baseline. Underweight patients were older, on average, than normal weight patients and had a higher prevalence of most comorbidities and measures of frailty. Crude mortality was significantly higher for underweight patients than normal weight patients at 30 d (25.2% versus 16.4%, p < 0.001), 1 y (51.3% versus 33.8%, p < 0.001), 5 y (79.2% versus 59.4%, p < 0.001), and 17 y (98.3% versus 94.0%, p < 0.001). After adjustment, underweight patients had a 13% higher risk of 30-d death and a 26% higher risk of 17-y death than

  8. Medicare Part D Claims Rejections for Nursing Home Residents, 2006 to 2010

    PubMed Central

    Stevenson, David G.; Keohane, Laura M.; Mitchell, Susan L.; Zarowitz, Barbara J.; Huskamp, Haiden A.

    2013-01-01

    Objectives Much has been written about trends in Medicare Part D formulary design and consumers’ choice of plans, but little is known about the magnitude of claims rejections or their clinical and administrative implications. Our objective was to study the overall rate at which Part D claims are rejected, whether these rates differ across plans, drugs, and medication classes, and how these rejection rates and reasons have evolved over time. Study Design and Methods We performed descriptive analyses of data on paid and rejected Part D claims submitted by 1 large national long-term care pharmacy from 2006 to 2010. In each of the 5 study years, data included approximately 450,000 Medicare beneficiaries living in long-term care settings with approximately 4 million Part D drug claims. Claims rejection rates and reasons for rejection are tabulated for each study year at the plan, drug, and class levels. Results Nearly 1 in 6 drug claims was rejected during the first 5 years of the Medicare Part D program, and this rate has increased over time. Rejection rates and reasons for rejection varied substantially across drug products and Part D plans. Moreover, the reasons for denials evolved over our study period. Coverage has become less of a factor in claims rejections than it was initially and other formulary tools such as drug utilization review, quantity-related coverage limits, and prior authorization are increasingly used to deny claims. Conclusions Examining claims rejection rates can provide important supplemental information to assess plans’ generosity of coverage and to identify potential areas of concern. PMID:23145808

  9. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

    PubMed

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  10. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals. Final rule.

    PubMed

    2016-08-22

    We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2017. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and

  11. Regulations regarding income-related monthly adjustment amounts to Medicare beneficiaries' prescription drug coverage premiums. Final rule.

    PubMed

    2012-07-25

    This final rule adopts, without change, the interim final rule with request for comments we published in the Federal Register on December 7, 2010, at 75 FR 75884. The interim final rule contained the rules that we apply to determine the income-related monthly adjustment amount for Medicare prescription drug coverage (also known as Medicare Part D) premiums. This new subpart implemented changes made to the Social Security Act (Act) by the Affordable Care Act. The interim final rule allowed us to implement the provisions of the Affordable Care Act related to the income-related monthly adjustment amount for Medicare prescription drug coverage premiums when they went into effect on January 1, 2011.

  12. Do disabled elderly Medicare beneficiaries with major depression make less use of a consumer-directed home care voucher benefit?

    PubMed

    Friedman, Bruce; Wamsley, Brenda R; Conwell, Yeates

    2015-01-01

    Older adults with major depression may underutilize consumer-directed long-term care. Systematic underutilization would create disparities in outcomes, undermining program effectiveness. The Medicare Primary and Consumer-Directed Care Demonstration included a consumer-directed indemnity benefit that paid for goods and services not financed by traditional Medicare. Overall and for most categories of goods and services there was little difference in use and expenditures between those with and without major depression. However, among those using the benefit to hire in-home workers, arguably the most important consumer-directed purchase, average spending for workers was about 30% lower for depressed persons. While our findings are generally reassuring for public policy, future research is needed to verify that major depression is associated with less spending on in-home workers.

  13. Cost and effects of performance feedback and nurse case management for medicare beneficiaries with diabetes: a randomized controlled trial.

    PubMed

    Herrin, Jeph; Cangialose, Charles B; Nicewander, David; Ballard, David J

    2007-12-01

    Nurse case management has been shown to improve the quality of diabetes care in closed model health maintenance organizations and Veterans Affairs medical clinics. A randomized controlled trial of a similar intervention within HealthTexas Provider Network, a fee-for-service primary care network in North Texas, demonstrated no benefit in processes of care or clinical outcomes for Medicare diabetes patients. To investigate whether the case management model impacted the cost of diabetes care from the Medicare perspective, we compared the average payments and charges incurred between intervention arms: claims-based audit and feedback; claims- and medical-record-based audit and feedback; and claims- and medical-record-based audit and feedback plus a practice-based diabetes resource nurse. Following adjustment for baseline differences between groups, no significant differences were observed. Thus, within this setting, it appears the nurse case management model produced no improvement in either clinical quality or in costs associated with diabetes from a Medicare perspective.

  14. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for medicare.

    PubMed

    Grabowski, David C; O'Malley, A James

    2014-02-01

    Hospitalizations of nursing home residents are frequent and result in complications, morbidity, and Medicare expenditures of more than a billion dollars annually. The lack of a physician presence at many nursing homes during off hours might contribute to inappropriate hospitalizations. Findings from our controlled study of eleven nursing homes provide the first indications that switching from on-call to telemedicine physician coverage during off hours could reduce hospitalizations and therefore generate cost savings to Medicare in excess of the facility's investment in the service. But those savings were evident only at the study nursing homes that used the telemedicine service to a greater extent, compared to the other study facilities. Telemedicine service providers and nursing home leaders might need to take additional steps to encourage buy-in to the use of telemedicine at facilities with such services. At the same time, closer alignment of the stakeholders that bear the costs of telemedicine and those that might realize savings because of its use could offer further incentives for the adoption of telemedicine.

  15. Effect of an Innovative Medicare Managed Care Program on the Quality of Care for Nursing Home Residents

    ERIC Educational Resources Information Center

    Kane, Robert L.; Flood, Shannon; Bershadsky, Boris; Keckhafer, Gail

    2004-01-01

    Purpose: We sought to assess the quality of care provided by an innovative Medicare+Choice HMO targeted specifically at nursing home residents and employing nurse practitioners to provide additional primary care over and above that provided by physicians. The underlying premise of the Evercare approach is that the additional primary care will…

  16. Racial Differences in Hospice Use and In-Hospital Death among Medicare and Medicaid Dual-Eligible Nursing Home Residents

    ERIC Educational Resources Information Center

    Kwak, Jung; Haley, William E.; Chiriboga, David A.

    2008-01-01

    Purpose: We investigated the role of race in predicting the likelihood of using hospice and dying in a hospital among dual-eligible (Medicare and Medicaid) nursing home residents. Design and Methods: This follow-back cohort study examined factors associated with hospice use and in-hospital death among non-Hispanic Black and non-Hispanic White…

  17. Comparison of estimation methods for creating small area rates of acute myocardial infarction among Medicare beneficiaries in California.

    PubMed

    Yasaitis, Laura C; Arcaya, Mariana C; Subramanian, S V

    2015-09-01

    Creating local population health measures from administrative data would be useful for health policy and public health monitoring purposes. While a wide range of options--from simple spatial smoothers to model-based methods--for estimating such rates exists, there are relatively few side-by-side comparisons, especially not with real-world data. In this paper, we compare methods for creating local estimates of acute myocardial infarction rates from Medicare claims data. A Bayesian Monte Carlo Markov Chain estimator that incorporated spatial and local random effects performed best, followed by a method-of-moments spatial Empirical Bayes estimator. As the former is more complicated and time-consuming, spatial linear Empirical Bayes methods may represent a good alternative for non-specialist investigators. PMID:26291680

  18. Comparison of Estimation Methods for Creating Small Area Rates of Acute Myocardial Infarction Among Medicare Beneficiaries in California

    PubMed Central

    Arcaya, Mariana C.; Subramanian, S.V.

    2016-01-01

    Creating local population health measures from administrative data would be useful for health policy and public health monitoring purposes. While a wide range of options – from simple spatial smoothers to model-based methods – for estimating such rates exists, there are relatively few side-by-side comparisons, especially not with real-world data. In this paper, we compare methods for creating local estimates of acute myocardial infarction rates from Medicare claims data. A Bayesian Monte Carlo Markov Chain estimator that incorporated spatial and local random effects performed best, followed by a method-of-moments spatial Empirical Bayes estimator. As the former is more complicated and time-consuming, spatial linear Empirical Bayes methods may represent a good alternative for non-specialist investigators. PMID:26291680

  19. Medicare Interim Payment System's Impact on Medicare Home Health Utilization

    PubMed Central

    Liu, Korbin; Long, Sharon K.; Dowling, Krista

    2003-01-01

    The Medicare home health interim payment system (IPS) implemented in fiscal year 1998 provided very strong incentives for home health agencies (HHAs) to reduce the number of visits provided to each Medicare user and to avoid those beneficiaries whose Medicare plan of care was likely to exceed the average beneficiary cost limit. We analyzed multiple years of data from the Medicare Current Beneficiary Survey (MCBS) to examine how the IPS affected subgroups of the Medicare population by health and socioeconomic characteristics. We found that the IPS strongly reduced overall utilization, but that few subgroups were disproportionately affected. PMID:14997695

  20. 42 CFR 411.108 - Taking into account entitlement to Medicare.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Medicare the primary payer. An example of this would be informing the beneficiary of the right to accept or..., instructions to bill Medicare first for services furnished to Medicare beneficiaries without stipulating...

  1. Dual Eligibility, Selection of Skilled Nursing Facility, and Length of Medicare Paid Postacute Stay.

    PubMed

    Rahman, Momotazur; Gozalo, Pedro; Tyler, Denise; Grabowski, David C; Trivedi, Amal; Mor, Vincent

    2014-08-01

    Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients' SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.

  2. The Adoption of New Adjuvant Radiation Therapy Modalities Among Medicare Beneficiaries With Breast Cancer: Clinical Correlates and Cost Implications

    SciTech Connect

    Roberts, Kenneth B.; Soulos, Pamela R.; Herrin, Jeph; Yu, James B.; Long, Jessica B.; Dostaler, Edward; and others

    2013-04-01

    Purpose: New radiation therapy modalities have broadened treatment options for older women with breast cancer, but it is unclear how clinical factors, geographic region, and physician preference affect the choice of radiation therapy modality. Methods and Materials: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women diagnosed with stage I-III breast cancer from 1998 to 2007 who underwent breast-conserving surgery. We assessed the temporal trends in, and costs of, the adoption of intensity modulated radiation therapy (IMRT) and brachytherapy. Using hierarchical logistic regression, we evaluated the relationship between the use of these new modalities and patient and regional characteristics. Results: Of 35,060 patients, 69.9% received conventional external beam radiation therapy (EBRT). Although overall radiation therapy use remained constant, the use of IMRT increased from 0.0% to 12.6% from 1998 to 2007, and brachytherapy increased from 0.7% to 9.0%. The statistical variation in brachytherapy use attributable to the radiation oncologist and geographic region was 41.4% and 9.5%, respectively (for IMRT: 23.8% and 22.1%, respectively). Women undergoing treatment at a free-standing radiation facility were significantly more likely to receive IMRT than were women treated at a hospital-based facility (odds ratio for IMRT vs EBRT: 3.89 [95% confidence interval, 2.78-5.45]). No such association was seen for brachytherapy. The median radiation therapy cost per treated patient increased from $5389 in 2001 to $8539 in 2007. Conclusions: IMRT and brachytherapy use increased substantially from 1998 to 2007; overall, radiation therapy costs increased by more than 50%. Radiation oncologists played an important role in treatment choice for both types of radiation therapy, whereas geographic region played a bigger role in the use of IMRT than brachytherapy.

  3. 42 CFR 411.23 - Beneficiary's cooperation.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Beneficiary's cooperation. 411.23 Section 411.23... Medicare Payment: General Provisions § 411.23 Beneficiary's cooperation. (a) If CMS takes action to recover conditional payments, the beneficiary must cooperate in the action. (b) If CMS's recovery action...

  4. 42 CFR 411.23 - Beneficiary's cooperation.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Beneficiary's cooperation. 411.23 Section 411.23... Medicare Payment: General Provisions § 411.23 Beneficiary's cooperation. (a) If CMS takes action to recover conditional payments, the beneficiary must cooperate in the action. (b) If CMS's recovery action...

  5. 42 CFR 422.110 - Discrimination against beneficiaries prohibited.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Discrimination against beneficiaries prohibited. 422.110 Section 422.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422.110...

  6. Making sense of the change in how Medicare Advantage plans are paid.

    PubMed

    Gold, Marsha

    2013-05-01

    The Affordable Care Act has altered payment policy for private Medicare Advantage (MA) plans, with the goal of lowering costs closer to the level in traditional Medicare. Using newly available information on 2009 MA plan costs, this analysis com­pares plans' estimates of per capita costs for providing Parts A and B benefits to their enrollees, on a risk-adjusted basis, against what government data show to be the same costs for traditional Medicare program beneficiaries residing in the same county. It finds that on average, risk-adjusted MA plan costs were 4 percent higher than traditional Medicare costs (104%). Among plan types, only HMOs had lower average costs than traditional Medicare. Among local PPOs and private fee-for service plans, over 75 percent had costs exceeding those in traditional Medicare. The wide variation seen in MA plan costs relative to traditional Medicare suggests there is room for greater efficiency in care delivery.

  7. Ambulatory care sensitive hospitalization rates in the aged Medicare population in Utah, 1990 to 1994: a rural-urban comparison.

    PubMed

    Silver, M P; Babitz, M E; Magill, M K

    1997-01-01

    The objective of this study is to compare the likelihood of hospitalization for conditions that are related to the adequacy and use of ambulatory health care services for Medicare beneficiaries residing in rural and urban regions in Utah. The Health Care Financing Administration's (HCFA) hospital discharge database (Utah hospitals: 1990 to 1994) was used to estimate hospitalization rates (with adjustment for out-of-state admissions) for ambulatory care sensitive conditions. Population estimates were obtained from HCFA beneficiary files. Regional hospitalization rates were obtained through ZIP code matching of the hospital discharge and beneficiary files. Medicare beneficiaries aged 65 and older residing in Utah during 1990 to 1994 are the subjects for the study. The main outcome measures include age and sex-adjusted hospitalization rates by region for the entire state and rate ratio estimates for nonurban regions. The results of the study show that Medicare beneficiaries residing in two rural-frontier regions were more likely than urban beneficiaries to be hospitalized for ambulatory care sensitive conditions. Rate ratio estimates were greater than 1.4 for both regions during the study period. These findings suggest a pattern of an increased burden of avoidable secondary complications and disease progression among Utah Medicare beneficiaries residing in some rural regions. This increased burden may be the result of limitations in the ambulatory care system, medical care provider supply, and/or beneficiary propensity to seek care. Variation in disease prevalence or hospital use patterns for these conditions also may be responsible for all or part of the observed variation in ambulatory care sensitive admission rates.

  8. 42 CFR 424.127 - Payment to the beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Special Conditions: Services Furnished in a Foreign Country § 424.127 Payment to the beneficiary. (a) Conditions for payment of inpatient hospital... amount payable to the beneficiary is determined in accordance with § 424.109(b). (c) Conditions...

  9. 42 CFR 424.53 - Payment to the beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... outside the United States. (e) Services furnished by a supplier if the claim has not been assigned to the... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Payment to the beneficiary. Medicare pays the beneficiary for the following services, if covered, in...

  10. 42 CFR 424.53 - Payment to the beneficiary.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... services furnished outside the United States. (e) Services furnished by a supplier if the claim has not... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... § 424.53 Payment to the beneficiary. Medicare pays the beneficiary for the following services,...

  11. 42 CFR 424.53 - Payment to the beneficiary.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... services furnished outside the United States. (e) Services furnished by a supplier if the claim has not... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... § 424.53 Payment to the beneficiary. Medicare pays the beneficiary for the following services,...

  12. 42 CFR 424.53 - Payment to the beneficiary.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... outside the United States. (e) Services furnished by a supplier if the claim has not been assigned to the... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... Payment to the beneficiary. Medicare pays the beneficiary for the following services, if covered, in...

  13. 42 CFR 424.53 - Payment to the beneficiary.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... services furnished outside the United States. (e) Services furnished by a supplier if the claim has not... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... § 424.53 Payment to the beneficiary. Medicare pays the beneficiary for the following services,...

  14. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... medical and surgical services of physicians furnished to beneficiaries and supervision of interns and... occurs: (1) Physician services furnished to beneficiaries and supervision of interns and residents... interns and residents. (1) Physician services furnished to beneficiaries and supervision of interns...

  15. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... medical and surgical services of physicians furnished to beneficiaries and supervision of interns and... occurs: (1) Physician services furnished to beneficiaries and supervision of interns and residents... interns and residents. (1) Physician services furnished to beneficiaries and supervision of interns...

  16. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... medical and surgical services of physicians furnished to beneficiaries and supervision of interns and... occurs: (1) Physician services furnished to beneficiaries and supervision of interns and residents... interns and residents. (1) Physician services furnished to beneficiaries and supervision of interns...

  17. The Effect of Health Plan Characteristics on Medicare+Choice Enrollment

    PubMed Central

    Dowd, Bryan E; Feldman, Roger; Coulam, Robert

    2003-01-01

    Objective To provide national estimates of the effect of out-of-pocket premiums and benefits on Medicare beneficiaries' choice among managed care health plans. Data Sources/Study Setting The data represent the population of all Medicare+Choice (M+C) plans offered to Medicare beneficiaries in the United States in 1999. Study Design The dependent variable is the log of the ratio of the market share of the jth health plan to the lowest cost plan in the beneficiary's county of residence. The explanatory variables are measures of premiums and benefits in the jth health plan relative to the premiums and benefits in the lowest cost plan. Data Collection Methods The data are from the 1999 Medicare Compare database, and M+C enrollment data from the Centers for Medicare and Medicaid Services (CMS). Principal Findings A $10 increase in an M+C plan's out-of-pocket premium, relative to its competitors, is associated with a decrease of four percentage points in the jth plan's market share (i.e., from 25 to 21 percent), holding the premiums of competing plans constant. Conclusions Although our price elasticity estimates are low, the market share losses associated with small changes in a health plan's premium, relative to its competitors, may be sufficient to discipline premiums in a competitive market. Bidding behavior by plans in the Medicare Competitive Pricing Demonstration supports this conclusion. PMID:12650384

  18. Regions with higher Medicare Part D spending show better drug adherence, but not lower medicare costs for two diseases.

    PubMed

    Stuart, Bruce; Shoemaker, J Samantha; Dai, Mingliang; Davidoff, Amy J

    2013-01-01

    A quarter-century of research on geographic variation in Medicare costs has failed to find any positive association between high spending and better health outcomes. We conducted this study using a 5 percent random sample of Medicare beneficiaries with diabetes or heart failure in 2006 and 2007 to see whether there was any correlation between geographic variation in Part D spending and good medication-taking behavior-and, if so, whether that correlation resulted in reduced Medicare Parts A and B spending on diabetes and heart failure treatments. We found that beneficiaries residing in areas characterized by higher adjusted drug spending had significantly more "therapy days"-days with recommended medications on hand-than did beneficiaries in lower-spending areas. However, we did not find that this factor translated into short-term savings in Medicare treatment costs for these two diseases. This result might not be surprising, since returns from medication adherence can take years to manifest. At the same time, discovering which regional factors are responsible for differences in drug spending and medication practices should be a high priority. If the observed differences are related to poor physician communication or lack of good care coordination, then appropriately designed policy tools-including accountable care organizations, medical homes, and provider quality reporting initiatives-might help address them.

  19. 20 CFR 10.415 - What must a beneficiary do if the number of beneficiaries decreases?

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... compensation. The terms “marriage” and “remarriage” include common-law marriage as recognized and defined by State law in the State where the beneficiary resides. If a beneficiary, or someone acting on his or...

  20. 20 CFR 10.415 - What must a beneficiary do if the number of beneficiaries decreases?

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... compensation. The terms “marriage” and “remarriage” include common-law marriage as recognized and defined by State law in the State where the beneficiary resides. If a beneficiary, or someone acting on his or...

  1. 20 CFR 10.415 - What must a beneficiary do if the number of beneficiaries decreases?

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... compensation. The terms “marriage” and “remarriage” include common-law marriage as recognized and defined by State law in the State where the beneficiary resides. If a beneficiary, or someone acting on his or...

  2. 20 CFR 10.415 - What must a beneficiary do if the number of beneficiaries decreases?

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... compensation. The terms “marriage” and “remarriage” include common-law marriage as recognized and defined by State law in the State where the beneficiary resides. If a beneficiary, or someone acting on his or...

  3. 20 CFR 10.415 - What must a beneficiary do if the number of beneficiaries decreases?

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... compensation. The terms “marriage” and “remarriage” include common-law marriage as recognized and defined by State law in the State where the beneficiary resides. If a beneficiary, or someone acting on his or...

  4. Urban-Rural Differences in the Effect of a Medicare Health Promotion and Disease Self-Management Program on Physical Function and Health Care Expenditures

    ERIC Educational Resources Information Center

    Meng, Hongdao; Wamsley, Brenda; Liebel, Diane; Dixon, Denise; Eggert, Gerald; Van Nostrand, Joan

    2009-01-01

    Purpose: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. Design and Methods: We analyzed data from a 22-month randomized controlled trial of a health…

  5. The National Market for Medicare Clinical Laboratory Testing: Implications for Payment Reform

    PubMed Central

    Gass Kandilov, Amy M.; Pope, Gregory C.; Kautter, John; Healy, Deborah

    2012-01-01

    Current Medicare payment policy for outpatient laboratory services is outdated. Future reforms, such as competitive bidding, should consider the characteristics of the laboratory market. To inform payment policy, we analyzed the structure of the national market for Medicare Part B clinical laboratory testing, using a 5-percent sample of 2006 Medicare claims data. The independent laboratory market is dominated by two firms—Quest Diagnostics and Laboratory Corporation of America. The hospital outreach market is not as concentrated as the independent laboratory market. Two subgroups of Medicare beneficiaries, those with end-stage renal disease and those residing in nursing homes, are each served in separate laboratory markets. Despite the concentrated independent laboratory market structure, national competitive bidding for non-patient laboratory tests could result in cost savings for Medicare. PMID:24800143

  6. How Successful Is Medicare Advantage?

    PubMed Central

    Newhouse, Joseph P; McGuire, Thomas G

    2014-01-01

    Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan

  7. Treatment patterns, overall survival, healthcare resource use and costs in elderly Medicare beneficiaries with chronic myeloid leukemia using second-generation tyrosine kinase inhibitors as second-line therapy.

    PubMed

    Smith, B Douglas; Liu, Jun; Latremouille-Viau, Dominick; Guerin, Annie; Fernandez, Daniel; Chen, Lei

    2016-05-01

    Objective Though the median age at diagnosis is 64 years, few studies focus on elderly (≥65 years) patients with chronic myeloid leukemia (CML). This study examines healthcare outcomes among elderly Medicare beneficiaries with CML who started nilotinib or dasatinib after imatinib. Research design and methods Patients were identified in the Medicare Research Identifiable Files (2006-2012) and had continuous Medicare Parts A, B, and D coverage. Main outcome measures Treatment patterns, overall survival (OS), monthly healthcare resource utilization and medical costs were measured from the second-line tyrosine kinase inhibitor (TKI) initiation (index date) to end of Medicare coverage. Results Despite similar adherence, dasatinib patients (N = 379) were more likely to start on the recommended dose (74% vs. 53%; p < 0.001), and to have dose reductions (21% vs. 11%, adjusted hazard ratio [HR] = 1.94; p = 0.002) or dose increases (9% vs. 7%; adjusted HR = 1.81; p = 0.048) than nilotinib patients (N = 280). Fewer nilotinib patients discontinued (59% vs. 67%; adjusted HR = 0.80; p = 0.026) or switched to another TKI (21% vs. 29%; adjusted HR = 0.72; p = 0.044) than dasatinib patients. Nilotinib patients had longer median OS (>4.9 years vs. 4.0 years; p = 0.032) and 37% lower mortality risk than dasatinib patients (adjusted HR = 0.63; p = 0.008). Nilotinib patients had 23% fewer inpatient admissions, 30% fewer emergency room visits, 13% fewer outpatient visits (all p < 0.05), and lower monthly medical costs (by $513, p = 0.024) than dasatinib patients. Limitations Lack of clinical assessment (disease phase and response to first-line therapy) and retrospective nature of study (unobservable potential confounding factors, non-randomized treatment choice). Conclusions In the current study of elderly CML patients, initiation of second-line TKIs frequently occurs at doses lower than the recommended starting doses and

  8. Clinical and economic value of performing dialysis vascular access procedures in a freestanding office-based center as compared with the hospital outpatient department among Medicare ESRD beneficiaries.

    PubMed

    Dobson, Al; El-Gamil, Audrey M; Shimer, Matthew T; DaVanzo, Joan E; Urbanes, Aris Q; Beathard, Gerald A; Litchfield, Terry Foust

    2013-01-01

    Dialysis vascular access (DVA) care is being increasingly provided in freestanding office-based centers (FOC). Small-scale studies have suggested that DVA care in a FOC results in favorable patient outcomes and lower costs. To further evaluate this issue, data were drawn from incident and prevalent ESRD patients within a 4-year sample (2006-2009) of Medicare claims (USRDS) on cases who receive at least 80% of their DVA care in a FOC or a hospital outpatient department (HOPD). Using propensity score matching techniques, cases with a similar clinical and demographic profile from these two sites of service were matched. Medicare utilization, payments, and patient outcomes were compared across the matched cohorts (n = 27,613). Patients treated in the FOC had significantly better outcomes (p < 0.001), including fewer related or unrelated hospitalizations (3.8 vs. 4.4), vascular access-related infections (0.18 vs. 0.29), and septicemia-related hospitalizations (0.15 vs. 0.18). Mortality rate was lower (47.9% vs. 53.5%) as were PMPM payments ($4,982 vs. $5,566). This study shows that DVA management provided in a FOC has multiple advantages over that provided in a HOPD.

  9. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Medicare secondary payer (MSP) procedures. 422.108 Section 422.108 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections §...

  10. 2015: Rural Medicare Advantage Enrollment Update.

    PubMed

    Finegan, Chance; Ullrich, Fred; Mueller, Keith

    2015-07-01

    Key Findings. (1) Rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by 6.8 percent between March 2014 and March 2015 to 2.1 million members, or 21.2 percent of all rural residents eligible for Medicare. This compares to a national enrollment in MA and other prepaid plans of 31.1 percent (16.7 million) of enrollees. (2) Rural enrollment in Health Maintenance Organization (HMO) plans (including point-of-service, or POS, plans), Preferred Provider Organization (PP0) plans, and other pre-paid plans (including Medicare Cost and Program of All-Inclusive Care for the Elderly Plans) all increased by 5-13 percent. (3) Enrollment in private fee-for-service (PFFS) plans continued to decline (decreasing nationally by 15.8 percent and 12.1 percent in rural counties over the period March 2014-2015). Only eight states showed an increase in PFFS plan enrollment. Five states experienced decreases of 50 percent or more. (4) The five states with the highest percentages of rural beneficiaries enrolled in a Medicare Advantage plan are Minnesota (51.8 percent), Hawaii (39.4 percent), Pennsylvania (36.2 percent), Wisconsin (35.5 percent), and New York (31.5 percent).

  11. 2015: Rural Medicare Advantage Enrollment Update.

    PubMed

    Finegan, Chance; Ullrich, Fred; Mueller, Keith

    2015-07-01

    Key Findings. (1) Rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by 6.8 percent between March 2014 and March 2015 to 2.1 million members, or 21.2 percent of all rural residents eligible for Medicare. This compares to a national enrollment in MA and other prepaid plans of 31.1 percent (16.7 million) of enrollees. (2) Rural enrollment in Health Maintenance Organization (HMO) plans (including point-of-service, or POS, plans), Preferred Provider Organization (PP0) plans, and other pre-paid plans (including Medicare Cost and Program of All-Inclusive Care for the Elderly Plans) all increased by 5-13 percent. (3) Enrollment in private fee-for-service (PFFS) plans continued to decline (decreasing nationally by 15.8 percent and 12.1 percent in rural counties over the period March 2014-2015). Only eight states showed an increase in PFFS plan enrollment. Five states experienced decreases of 50 percent or more. (4) The five states with the highest percentages of rural beneficiaries enrolled in a Medicare Advantage plan are Minnesota (51.8 percent), Hawaii (39.4 percent), Pennsylvania (36.2 percent), Wisconsin (35.5 percent), and New York (31.5 percent). PMID:26793818

  12. Trends in Medicare Health Maintenance Organization Enrollment: 1986-93

    PubMed Central

    McMillan, Alma

    1993-01-01

    This study examines Medicare health maintenance organization (HMO) enrollment under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (Public Law 97-248) from 1986 to 1993. It shows that there was moderate growth in the number of Medicare beneficiaries participating in the TEFRA risk program, reaching 1 in 20 beneficiaries in 1993. Medicare HMO enrollment is heavily concentrated in a few large plans, resulting in heavy concentrations geographically. California and Florida accounted for over one-third of Medicare HMO enrollees. One-half of the States have no Medicare HMO enrollment and one-fifth of the States have fewer than 15,000 Medicare HMO enrollees. PMID:10133705

  13. Variations in county-level costs between traditional medicare and medicare advantage have implications for premium support.

    PubMed

    Biles, Brian; Casillas, Giselle; Guterman, Stuart

    2015-01-01

    Concern about the future growth of Medicare spending has led some in Congress and elsewhere to promote converting Medicare to a "premium support" system. Under premium support, Medicare would provide a "defined contribution" to each Medicare beneficiary to purchase either a Medicare Advantage (MA)-type private health plan or the traditional Medicare public plan. To better understand the implications of such a shift, we compared the average costs per beneficiary of providing Medicare benefits at the county level for traditional Medicare and four types of MA plans. We found that the relative costs of Medicare Advantage and traditional Medicare varied greatly by MA plan type and by geographic location. The costs of health maintenance organization-type plans averaged 7 percent less than those of traditional Medicare, but the costs of the more loosely structured preferred provider organization and private fee-for-service plans averaged 12-18 percent more than those of traditional Medicare. In some counties MA plan costs averaged 28 percent less than costs in traditional Medicare, while in other counties MA plan costs averaged 26 percent more than traditional Medicare costs. Enactment of a Medicare premium-support proposal could trigger cost increases for beneficiaries participating in Medicare Advantage as well as those in traditional Medicare.

  14. Clinical and Economic Impact of a Digital, Remotely-Delivered Intensive Behavioral Counseling Program on Medicare Beneficiaries at Risk for Diabetes and Cardiovascular Disease

    PubMed Central

    Chen, Fang; Su, Wenqing; Becker, Shawn H.; Payne, Mike; Peters, Anne L.; Dall, Timothy M.

    2016-01-01

    Background Type 2 diabetes and cardiovascular disease impose substantial clinical and economic burdens for seniors (age 65 and above) and the Medicare program. Intensive Behavioral Counseling (IBC) interventions like the National Diabetes Prevention Program (NDPP), have demonstrated effectiveness in reducing excess body weight and lowering or delaying morbidity onset. This paper estimated the potential health implications and medical savings of a digital version of IBC modeled after the NDPP. Methods and Findings Participants in this digital IBC intervention, the Omada program, include 1,121 overweight or obese seniors with additional risk factors for diabetes or heart disease. Weight changes were objectively measured via participant use of a networked weight scale. Participants averaged 6.8% reduction in body weight within 26 weeks, and 89% of participants completed 9 or more of the 16 core phase lessons. We used a Markov-based microsimulation model to simulate the impact of weight loss on future health states and medical expenditures over 10 years. Cumulative per capita medical expenditure savings over 3, 5 and 10 years ranged from $1,720 to 1,770 (3 years), $3,840 to $4,240 (5 years) and $11,550 to $14,200 (10 years). The range reflects assumptions of weight re-gain similar to that seen in the DPP clinical trial (lower bound) or minimal weight re-gain aligned with age-adjusted national averages (upper bound). The estimated net economic benefit after IBC costs is $10,250 to $12,840 cumulative over 10 years. Simulation outcomes suggest reduced incidence of diabetes by 27–41% for participants with prediabetes, and stroke by approximately 15% over 5 years. Conclusions A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings. These findings affirm recommendations for IBC coverage by the

  15. 42 CFR 411.51 - Beneficiary's responsibility with respect to no-fault insurance.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...-fault insurance. 411.51 Section 411.51 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.51 Beneficiary's responsibility with respect to no-fault insurance. (a) The beneficiary...

  16. 42 CFR 411.51 - Beneficiary's responsibility with respect to no-fault insurance.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ...-fault insurance. 411.51 Section 411.51 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.51 Beneficiary's responsibility with respect to no-fault insurance. (a) The beneficiary...

  17. 42 CFR 411.51 - Beneficiary's responsibility with respect to no-fault insurance.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ...-fault insurance. 411.51 Section 411.51 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.51 Beneficiary's responsibility with respect to no-fault insurance. (a) The beneficiary...

  18. 42 CFR 411.51 - Beneficiary's responsibility with respect to no-fault insurance.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...-fault insurance. 411.51 Section 411.51 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.51 Beneficiary's responsibility with respect to no-fault insurance. (a) The beneficiary...

  19. 42 CFR 411.51 - Beneficiary's responsibility with respect to no-fault insurance.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...-fault insurance. 411.51 Section 411.51 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance § 411.51 Beneficiary's responsibility with respect to no-fault insurance. (a) The beneficiary...

  20. Accuracy of Medicare expenditures in the medical expenditure panel survey.

    PubMed

    Zuvekas, Samuel H; Olin, Gary L

    2009-01-01

    This paper examines underreporting and underrepresentation of high expenditure cases in the Medical Expenditure Panel Survey (MEPS) and their implications for analyses. Our data come from a sample of Medicare beneficiaries in the MEPS who were matched to their Medicare claims and enrollment files, with supplemental data from the Medicare Current Beneficiary Survey (MCBS). Underreporting of expenditures affected all groups of Medicare beneficiaries in the matched sample, but uniformly so that behavioral analyses were largely unaffected. Straightforward adjustments to the MEPS expenditure estimates could align them with aggregate sources, such as the National Health Expenditure Accounts, while preserving underlying relationships between expenditures and key correlates.

  1. Lessons Learned from the National Medicare & You Education Program

    PubMed Central

    Goldstein, Elizabeth; Teichman, Lori; Crawley, Barbara; Gaumer, Gary; Joseph, Catherine; Reardon, Leo

    2001-01-01

    In fall 1998 CMS implemented the National Medicare Education Program (NMEP) to educate beneficiaries about their Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS has been monitoring the implementation of the NMEP in six case study sites as well as monitoring each of the information channels for communicating with beneficiaries. This article describes select findings from the case studies, and highlights from assessment activities related to the Medicare & You handbook, the toll-free 1-800-MEDICARE Helpline, Internet, and Regional Education About Choices in Health (REACH). PMID:12500359

  2. Does Medicare Advantage Cost Less Than Traditional Medicare?

    PubMed

    Biles, Brian; Casillas, Giselle; Guterman, Stuart

    2016-01-01

    The costs of providing benefits to enrollees in private Medicare Advantage (MA) plans are slightly less, on average, than what traditional Medicare spends per beneficiary in the same county. However, MA plans that are able to keep their costs comparatively low are concen­trated in a fairly small number of U.S. counties. In the 25 counties where the cost differences between MA plans and traditional Medicare are largest, MA plans spent a total of $5.2 billion less than what traditional Medicare would have been expected to spend on the same benefi­ciaries, with health maintenance organizations (HMOs) accounting for all of that difference. In the rest of the country, MA plans spent $4.8 billion above the expected costs under tradi­tional Medicare. Broad determinations about the relative efficiency of MA plans and traditional Medicare can therefore be misleading, as they fail to take into account local conditions and individual plans' performance.

  3. Impact of Critical Access Hospital Conversion on Beneficiary Liability

    ERIC Educational Resources Information Center

    Gilman, Boyd H.

    2008-01-01

    Context: While the Medicare Critical Access Hospital (CAH) program has improved the financial viability of small rural hospitals and enhanced access to care in rural communities, the program puts beneficiaries at risk for paying a larger share of the cost of services covered under the Medicare part B benefit. Purpose: This paper examines the…

  4. Privacy Act of 1974; matching program--HCFA. Notice of a matching program--the Internal Revenue Service (IRS), the Social Security Administration (SSA), and HCFA--disclosure of IRS taxpayer identity and filing status information to be matched with SSA earned income information for Medicare beneficiaries and their spouses.

    PubMed

    1990-09-21

    As required by Section 6202 of the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989), Public Law 101-239, the Department of Health and Human Services is providing public notice that the IRS and the SSA will disclose certain information regarding the taxpayer identification and filing status and the earned income of Medicare beneficiaries and their spouses for HCFA's use in identifying Medicare secondary payer (MSP) situations. This will enable HCFA to seek recovery of identified mistaken payments that were the liability of another primary insurer or other type of payer. The matching report set forth below is in compliance with the Computer Matching and Privacy Protection Act of 1988 (Pub. L. No. 100-503). PMID:10107026

  5. 76 FR 13515 - Medicare Program; Revisions to the Reductions and Increases to Hospitals' FTE Resident Caps for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-14

    ... investment of time and audit resources. There are approximately 1,100 teaching hospitals and more than 300 of... Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that are... order to account for the higher indirect patient care costs of teaching hospitals relative...

  6. Medicare Care Choices Model Enables Concurrent Palliative and Curative Care.

    PubMed

    2015-01-01

    On July 20, 2015, the federal Centers for Medicare & Medicaid Services (CMS) announced hospices that have been selected to participate in the Medicare Care Choices Model. Fewer than half of the Medicare beneficiaries use hospice care for which they are eligible. Current Medicare regulations preclude concurrent palliative and curative care. Under the Medicare Choices Model, dually eligible Medicare beneficiaries may elect to receive supportive care services typically provided by hospice while continuing to receive curative services. This report describes how CMS has expanded the model from an originally anticipated 30 Medicare-certified hospices to over 140 Medicare-certified hospices and extended the duration of the model from 3 to 5 years. Medicare-certified hospice programs that will participate in the model are listed.

  7. 77 FR 38066 - Medicare Program; Announcement of a New Opportunity for Participation in the Advance Payment...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ..., Medicaid, and Children's Health Insurance Program beneficiaries. One potential mechanism for achieving... partnerships through complementary efforts, including the Medicare Shared Savings Program and initiatives... Register (76 FR 68012), we published a notice entitled ``Medicare Program; Advance Payment Model''...

  8. Demand for a Medicare prescription drug benefit: exploring consumer preferences under a managed competition framework.

    PubMed

    Cline, Richard R; Mott, David A

    2003-01-01

    Several proposals for adding a prescription drug benefit to the Medicare program rely on consumer choice and market forces to promote efficiency. However, little information exists regarding: 1) the extent of price sensitivity for such plans among Medicare beneficiaries, or 2) the extent to which drug-only insurance plans using various cost-control mechanisms might experience adverse selection. Using data from a survey of elderly Wisconsin residents regarding their likely choices from a menu of hypothetical drug plans, we show that respondents are likely to be price sensitive with respect to both premiums and out-of-pocket costs but that selection problems may arise in these markets. Outside intervention may be necessary to ensure the feasibility of a market-based approach to a Medicare drug benefit. PMID:13677564

  9. 42 CFR 424.86 - Prohibition of assignment of claims by beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Prohibition of assignment of claims by beneficiaries. 424.86 Section 424.86 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM CONDITIONS FOR MEDICARE PAYMENT Limitations...

  10. 42 CFR 423.6 - Cost-sharing in beneficiary education and enrollment-related costs.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... enrollment-related costs. 423.6 Section 423.6 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT General Provisions § 423.6 Cost-sharing in beneficiary education and enrollment-related costs....

  11. Eliminating cost-sharing requirements for colon cancer screening in Medicare.

    PubMed

    Howard, David H; Guy, Gery P; Ekwueme, Donatus U

    2014-12-15

    Medicare beneficiaries do not have to pay for screening colonoscopies but must pay coinsurance if a polyp is removed via polypectomy. Likewise, beneficiaries do not have to pay for fecal occult blood tests but are liable for cost-sharing for diagnostic colonoscopies after a positive test. Legislative and regulatory requirements related to colorectal cancer screening are described, and on the basis of Medicare claims, it is estimated that Medicare spending would increase by $48 million annually if Medicare were to waive cost-sharing requirements for these services. The economic impact on Medicare if beneficiaries were not responsible for any cost-sharing requirements related to colorectal cancer screening services is described.

  12. An Economic History of Medicare Part C

    PubMed Central

    Mcguire, Thomas G; Newhouse, Joseph P; Sinaiko, Anna D

    2011-01-01

    Context: Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period. Findings: Beneficiaries' access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high-quality care, and to save Medicare money. PMID:21676024

  13. Serving Older Adults with Complex Care Needs: A New Benefit Option for Medicare.

    PubMed

    Moon, Marilyn; Hollin, Ilene L; Nicholas, Lauren H; Schoen, Cathy; Davis, Karen

    2015-07-01

    Medicare was originally designed to protect beneficiaries from the financial burden of acute episodes of illness. As lifespans lengthen, Medicare must adapt to serve beneficiaries with substantial long-term physical or cognitive impairment who need personal care assistance. These beneficiaries often incur high out-of-pocket costs for Medicare-covered services as well as home and community care not covered by Medicare. This latter category of care is often key to continued independence. To improve Medicare's capacity to serve such beneficiaries, and to prevent unnecessary institutionalization, this issue brief, one in a series on Medicare's future challenges, proposes a complex care benefit option that would include home and community services, and describes how it might be structured to balance the goals of improving care for beneficiaries and ensuring affordability.

  14. Shaping the future of Medicare.

    PubMed Central

    Davis, K

    1999-01-01

    This article suggests that further major changes in Medicare at this time are unwarranted. The enactment of the Balanced Budget Act (BBA) has eliminated the need for quick action to assure solvency of the Part A Trust Fund, which is projected to be in balance for at least ten years. It will take time to implement and assess the effects of the BBA. The uncertainties of future trends in the health sector and Medicare suggest a go-slow approach. Future reforms to finance health care as the baby boom generation retires should be guided by the goals of continuing to assure health and economic security to elderly and disabled beneficiaries, with particular attention to the financial burdens on lower-income beneficiaries and those with serious illnesses or chronic conditions. Employers are cutting back on retiree health coverage, and the appropriate contribution of employers will need to be addressed. The BBA included major provisions to expand Medicare managed care choices. Special attention will need to be given to how well these innovations work, their cost impact on Medicare, the extent to which beneficiaries are able to make informed choices, and whether risk selection among plans and between traditional Medicare and plans can be adequately addressed. Most of the savings of BBA came from tighter payment rates to managed care plans and fee-for-service providers; it is unclear whether these will lead to rates well below the private sector or whether further savings can be achieved by extending these changes beyond 2002. PMID:10199676

  15. New York's Medicare Marketplace: examining new York's Medicare advantage plan landscape in light of payment reform.

    PubMed

    Goggin-Callahaan, Doug; Baker, Joe; Bennett, Rachel; Clerk, Michell; Hersey, Eric; Riccardi, Fred; Torbattejad, May; Xu, Denise

    2013-01-01

    The Patient Protection and Affordable Care Act (ACA) provided for cost savings in the Medicare program, in part to underwrite coverage expansion to Medicare beneficiaries, to finance new coverage for those not eligible for Medicare, and to strengthen Medicare's financial outlook. One cost-saving measure, a reformulation and reduction in payments to private health insurance plans that provide Medicare benefits through the Medicare Advantage (MA) program, had a sound policy basis but was criticized, particularly by opponents o fthe ACA, as a measure that would lead to increased costs, reductions in benefits, and diminished plan choices to Medicare beneficiaries enrolled in MA plans. Despite dire predictions to this effect, a review of a sample of MA plan offerings in New York State in 2012 shows that Medicare beneficiaries enrolled in such plans did not experience significant benefit reductions or increased costs. While the number of plan offerings decreased, the reduction was mostly caused by the elimination of duplicative plan choices in 2011. Although the MA plan executives we interviewed indicated that further reductions in plan reimbursement in future years-tempered by potential bonus payments for meeting quality and performance metrics-could impact plan costs and benefits, they believed plans will employ a number of strategies to remain in the market and maintain benefciary benefits and cost structures. However, government regulators and consumer advocates will need to examine MA plan offerings in the coming years to determine the efect ofplan reaction to the ACA payments on beneficiaries'costs for coverage and access

  16. Medicare Payment Reform: Aligning Incentives for Better Care.

    PubMed

    Anderson, Gerard F; Davis, Karen; Guterman, Stuart

    2015-06-01

    The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare's past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption. PMID:26151988

  17. Medicare Payment Reform: Aligning Incentives for Better Care.

    PubMed

    Anderson, Gerard F; Davis, Karen; Guterman, Stuart

    2015-06-01

    The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare's past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption.

  18. Capitation and the Medicare program: History, issues, and evidence

    PubMed Central

    Langwell, Kathryn M.; Hadley, James P.

    1986-01-01

    This article reviews the history of capitation in the Medicare program and examines issues and research findings related to Medicare capitation. Specific capitation issues and related research findings reviewed include: the feasibility and extent of health maintenance organization participation in Medicare; plan marketing; beneficiary choice behavior; quality of care; and the use and cost of services. In addition, areas requiring further study are noted, and the potential for extensions of capitation under Medicare are explored. PMID:10311935

  19. Health-related quality of life and quality of care in specialized medicare-managed care plans.

    PubMed

    Grace, Susan C; Elliott, Marc N; Giordano, Laura A; Burroughs, James N; Malinoff, Rochelle L

    2013-01-01

    Special needs plans (SNPs) were created under the Medicare Modernization Act of 2003 to focus on Medicare beneficiaries who required more coordination of care than most beneficiaries served through the Medicare Advantage program. This research indicates that beneficiaries in 3 types of SNPs show evidence of worse health-related quality of life. Special needs plans demonstrated worse plan performance on the HEDIS osteoporosis testing in older women measure compared with non-SNP Medicare Advantage beneficiaries, but better plan performance on the HEDIS fall risk management measure. Future research should consider broader measures of plan performance, quality of care, and cost.

  20. The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization

    PubMed Central

    Baicker, Katherine; Chernew, Michael; Robbins, Jacob

    2013-01-01

    More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial – offsetting more than 10% of increased payments to Medicare Advantage plans. PMID:24308880

  1. The spillover effects of Medicare managed care: Medicare Advantage and hospital utilization.

    PubMed

    Baicker, Katherine; Chernew, Michael E; Robbins, Jacob A

    2013-12-01

    More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial - offsetting more than 10% of increased payments to Medicare Advantage plans.

  2. Medicare Advantage update: benefits, enrollment, and payments after the ACA.

    PubMed

    Linehan, Kathryn

    2013-07-19

    In 2012, the Medicare program paid private health plans $136 billion to cover about 13 million beneficiaries who received Part A and B benefits through the Medicare Advantage (MA) program rather than traditional fee-for-service (FFS) Medicare. Private plans have been a part of the program since the 1970s. Debate about the policy goals--Should they cost less per beneficiary than FFS Medicare? Should they be available to all beneficiaries? Should they be able to offer additional benefits?--has long accompanied Medicare's private plan option.This debate is reflected in the history of Medicare payment policy,and policy decisions over the years have affected plans' willingness to participate and beneficiaries' enrollment at different periods of the program. Recently, evidence that the Medicare program was paying more per beneficiary in MA relative to what would have been spent under FFS Medicare prompted policymakers to reduce MA payments in the Patient Protection and Affordable Care Act of 2010 (ACA). So far, plans continue to participate in MA and enrollment continues to grow, but payment reductions in 2012 through 2014 have been partially offset by payments made to plans through the quality bonus payment demonstration.This brief contains recent data on plan enrollment, availability, and benefits and discusses MA plan payment policy, including changes to MA payment made in the ACA and their actual and projected effects.

  3. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... deductible obligation. (3) An ESRD beneficiary received 8 dialysis treatments for which a facility charged... met. The primary payer paid $1,024 for Medicare-covered services. The composite rate per...

  4. 42 CFR 411.33 - Amount of Medicare secondary payment.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... deductible obligation. (3) An ESRD beneficiary received 8 dialysis treatments for which a facility charged... met. The primary payer paid $1,024 for Medicare-covered services. The composite rate per...

  5. Medicare Advantage: options for standardizing benefits and information to improve consumer choice.

    PubMed

    O'Brien, Ellen; Hoadley, Jack

    2008-04-01

    The Medicare Advantage (MA) program offers beneficiaries a choice of private health plans as alternatives to the traditional fee-for-service Medicare program. MA plans potentially provide additional value, but as plan choices have proliferated, consumers contemplating their options have had difficulty understanding how they differ. Through "standardization" more consistent types of information and a limited number of dimensions along which plans vary--MA plans could reduce complexity and improve beneficiaries' ability to make informed choices. Such standardization steps would offer more meaningful variation in the health coverage options available to beneficiaries, Medicare officials and their community partners would find it far easier to educate beneficiaries about their health plan choices, and beneficiaries would better understand what they were buying. Standardization might also strengthen the ability of the market-based Medicare Advantage program to incorporate beneficiary preferences. PMID:18426037

  6. 26 CFR 509.121 - Beneficiaries of an estate or trust.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS SWITZERLAND General Income Tax § 509.121 Beneficiaries of an estate or trust... concerned, a nonresident alien who is a resident of Switzerland and who is a beneficiary of an estate...

  7. 26 CFR 509.121 - Beneficiaries of an estate or trust.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS SWITZERLAND General Income Tax § 509.121 Beneficiaries of an estate or trust... concerned, a nonresident alien who is a resident of Switzerland and who is a beneficiary of an estate...

  8. 26 CFR 509.121 - Beneficiaries of an estate or trust.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS SWITZERLAND General Income Tax § 509.121 Beneficiaries of an estate or trust... concerned, a nonresident alien who is a resident of Switzerland and who is a beneficiary of an estate...

  9. 26 CFR 509.121 - Beneficiaries of an estate or trust.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS SWITZERLAND General Income Tax § 509.121 Beneficiaries of an estate or trust... concerned, a nonresident alien who is a resident of Switzerland and who is a beneficiary of an estate...

  10. 26 CFR 509.121 - Beneficiaries of an estate or trust.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS SWITZERLAND General Income Tax § 509.121 Beneficiaries of an estate or trust... concerned, a nonresident alien who is a resident of Switzerland and who is a beneficiary of an estate...

  11. Medicare program; Medicare prescription drug benefit. Final rule.

    PubMed

    2005-01-28

    This final rule implements the provisions of the Social Security Act (the Act) establishing and regulating the Medicare Prescription Drug Benefit. The new voluntary prescription drug benefit program was enacted into law on December 8, 2003 in section 101 of Title I of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173). Although this final rule specifies most of the requirements for implementing the new prescription drug program, readers should note that we are also issuing a closely related rule that concerns Medicare Advantage organizations, which, if they offer coordinated care plans, must offer at least one plan that combines medical coverage under Parts A and B with prescription drug coverage. Readers should also note that separate CMS guidance on many operational details appears or will soon appear on the CMS website, such as materials on formulary review criteria, risk plan and fallback plan solicitations, bid instructions, solvency standards and pricing tools, plan benefit packages. The addition of a prescription drug benefit to Medicare represents a landmark change to the Medicare program that will significantly improve the health care coverage available to millions of Medicare beneficiaries. The MMA specifies that the prescription drug benefit program will become available to beneficiaries beginning on January 1, 2006. Generally, coverage for the prescription drug benefit will be provided under private prescription drug plans (PDPs), which will offer only prescription drug coverage, or through Medicare Advantage prescription drug plans (MA PDs), which will offer prescription drug coverage that is integrated with the health care coverage they provide to Medicare beneficiaries under Part C of Medicare. PDPs must offer a basic prescription drug benefit. MA-PDs must offer either a basic benefit or broader coverage for no additional cost. If this required level of coverage is offered, MA-PDs or PDPs, but not

  12. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for Medicare primary payments....

  13. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payments....

  14. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payments....

  15. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for Medicare primary payments....

  16. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for Medicare primary payments....

  17. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payments....

  18. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payments....

  19. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for Medicare primary payments....

  20. 42 CFR 411.165 - Basis for conditional Medicare payments.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... the plan denies the claim in whole or in part; or (2) The beneficiary, because of physical or mental... that failure is for any reason other than the physical or mental incapacity of the beneficiary. (2) The... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payments....

  1. 42 CFR 411.175 - Basis for Medicare primary payments.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... plan has denied the claim in whole or in part; or (2) The beneficiary, because of physical or mental... or mental incapacity of the beneficiary. (2) The group health plan fails to furnish information... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for Medicare primary payments....

  2. Evaluating Alternative Risk Adjusters for Medicare.

    PubMed

    Pope, Gregory C; Adamache, Killard W; Walsh, Edith G; Khandker, Rezaul K

    1998-01-01

    In this study the authors use 3 years of the Medicare Current Beneficiary Survey (MCBS) to evaluate alternative demographic, survey, and claims-based risk adjusters for Medicare capitation payment. The survey health-status models have three to four times the predictive power of the demographic models. The risk-adjustment model derived from claims diagnoses has 75-percent greater predictive power than a comprehensive survey model. No single model predicts average expenditures well for all beneficiary subgroups of interest, suggesting a combined model may be appropriate. More data are needed to obtain stable estimates of model parameters. Advantages and disadvantages of alternative risk adjusters are discussed.

  3. Cost of schizophrenia in the Medicare program.

    PubMed

    Feldman, Rachel; Bailey, Robert A; Muller, James; Le, Jennifer; Dirani, Riad

    2014-06-01

    Medicare beneficiaries diagnosed with non-schizoaffective schizophrenia (MBS) in a 5% national Medicare fee-for-service sample from 2003-2007 were followed for 1-6 years. Medicare population and cost estimates also were made from 2001-2009. Service utilization and Medicare (and beneficiary share) payments for all services except prescription drugs were analyzed. Although adults with schizophrenia make up approximately 1% of the US adult population, they represent about 1.5% of Medicare beneficiaries. MBSs are disproportionately male and minority compared to national data describing the overall schizophrenia population. They also are younger than the general Medicare population (GMB): males are 9 years younger than females on average, and most enter Medicare long before age 65 through eligibility for social security disability, remaining in the program until death. The cost of care for MBSs in 2009 was, on average, 80% higher than for the average GMB per patient year (2010 dollars), and more than 50% of these costs are attributable to a combination of psychiatric and medical hospitalizations, concentrated in about 30% of MBSs with 1 or more hospitalizations per year. From 2004-2009, total estimated Medicare fee-for-service payments for MBSs increased from $9.4 billion to $11.5 billion, excluding Part D prescription drugs and payments for services to MBSs in Medicare for less than 1 year. Study results characterize utilization and costs for other services and suggest opportunities for further study to inform policy to improve access and continuity of care and decrease costs to the Medicare program associated with this population.

  4. 42 CFR 489.42 - Payment of offset amounts to beneficiary or other person.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Payment of offset amounts to beneficiary or other person. 489.42 Section 489.42 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... APPROVAL Handling of Incorrect Collections § 489.42 Payment of offset amounts to beneficiary or...

  5. 42 CFR 489.42 - Payment of offset amounts to beneficiary or other person.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Payment of offset amounts to beneficiary or other person. 489.42 Section 489.42 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... APPROVAL Handling of Incorrect Collections § 489.42 Payment of offset amounts to beneficiary or...

  6. Medicare's fee schedule for hospital outpatient care.

    PubMed

    Grimaldi, Paul L

    2002-01-01

    Medicare's hospital outpatient prospective payment system (OPPS) went live on August 1, 2000, after a decade of developmental work. The new system introduced a fee schedule that replaced the cost-related methods that Medicare previously used to reimburse various hospital outpatient services. Hospitals are now paid predetermined rates or fees based on the Ambulatory Patient Classification (APC) groups assigned to the services that Medicare patients receive during outpatient encounters. The new system aims to simplify Medicare's intricate cost-based reimbursement policies, improve hospital efficiency, ensure that payments are sufficient to compensate hospitals for reasonable Medicare costs, and reduce Medicare coinsurance amounts for beneficiaries. Implementation of OPPS-related administrative and operational changes has been a major challenge for hospitals. PMID:12079149

  7. Voucherizing Medicare.

    PubMed

    Oberlander, Jonathan

    2014-04-01

    This article explores the evolving language of Medicare reform and recent conflicts over "voucherizing" Medicare. The Medicare reform debate is, in part, a contest over how to frame policy alternatives in order to enhance (or diminish) their political viability. "Voucherizing" has emerged as a powerful rhetorical weapon in that fight. Yet the accompanying debate is often misleading about both the current state of Medicare and the necessity of altering its programmatic structure to ensure future stability. PMID:24305847

  8. Educating Older Adults About Medicare: The Role of Cognitive Variables

    ERIC Educational Resources Information Center

    Bayen, Ute J.; McCormack, Lauren A.; Bann, Carla M.

    2005-01-01

    A survey was conducted on 3,738 beneficiaries about their knowledge of the Medicare program as well as their reading habits, reading comprehension ability, and metamemory. Factor analysis yielded a reading and a metamemory factor. These factors explained variance in knowledge about Medicare above and beyond the variance explained by formal…

  9. The Experience of Rural Independent Pharmacies with Medicare Part D: Reports from the Field

    ERIC Educational Resources Information Center

    Radford, Andrea; Slifkin, Rebecca; Fraser, Roslyn; Mason, Michelle; Mueller, Keith

    2007-01-01

    Context: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created prescription drug coverage for Medicare beneficiaries through a new Part D program, the single largest addition to Medicare since its creation in 1965. Prior to program implementation in January 2006, concerns had been voiced as to how independent…

  10. 42 CFR 405.455 - Application to Medicare+Choice contracts.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Application to Medicare+Choice contracts. 405.455... Application to Medicare+Choice contracts. An organization that has a contract with CMS to provide one or more Medicare+Choice (M+C) plans to beneficiaries (part 422 of this chapter): (a) Must acquire and...

  11. Purchasing Medicare prescription drug benefits: a new proposal.

    PubMed

    Etheredge, L

    1999-01-01

    Medicare policymakers are considering using private-sector firms to offer and manage a prescription drug benefit. In such arrangements Medicare and its potential contractors will need to consider four major areas of risk: selection risk, cost management risk, risks of government as a business partner, and risks that new Medicare benefits will change competitive advantages. This paper considers these risk factors and suggests a model for Medicare prescription drug coverage. By adapting private-sector purchasing practices and using competitive markets, Medicare could offer prescription drug benefits--at affordable premiums for beneficiaries--without resorting to national price controls for pharmaceutical products.

  12. 42 CFR 456.211 - Beneficiary information required for UR.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Beneficiary information required for UR. 456.211 Section 456.211 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental...

  13. 42 CFR 456.211 - Beneficiary information required for UR.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Beneficiary information required for UR. 456.211 Section 456.211 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental...

  14. 42 CFR 456.211 - Beneficiary information required for UR.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Beneficiary information required for UR. 456.211 Section 456.211 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental...

  15. 42 CFR 412.507 - Limitation on charges to beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... System for Long-Term Care Hospitals § 412.507 Limitation on charges to beneficiaries. (a) Prohibited charges. Except as provided in paragraph (b) of this section, a long-term care hospital may not charge a... days used to calculate the Medicare payment. (b) Permitted charges. (1) A long-term care hospital...

  16. 42 CFR 422.110 - Discrimination against beneficiaries prohibited.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... following: (1) Medical condition, including mental as well as physical illness. (2) Claims experience. (3... 42 Public Health 3 2010-10-01 2010-10-01 false Discrimination against beneficiaries prohibited. 422.110 Section 422.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF...

  17. 42 CFR 422.110 - Discrimination against beneficiaries prohibited.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... following: (1) Medical condition, including mental as well as physical illness. (2) Claims experience. (3... 42 Public Health 3 2012-10-01 2012-10-01 false Discrimination against beneficiaries prohibited. 422.110 Section 422.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF...

  18. 42 CFR 489.27 - Beneficiary notice of discharge rights.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Beneficiary notice of discharge rights. 489.27 Section 489.27 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION PROVIDER AGREEMENTS AND SUPPLIER APPROVAL Essentials...

  19. 42 CFR 431.808 - Protection of beneficiary rights.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Protection of beneficiary rights. 431.808 Section 431.808 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION...

  20. 42 CFR 431.808 - Protection of beneficiary rights.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Protection of beneficiary rights. 431.808 Section 431.808 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION...

  1. 42 CFR 431.808 - Protection of beneficiary rights.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Protection of beneficiary rights. 431.808 Section 431.808 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION...

  2. Individualizing Medicare.

    PubMed

    Chollet, D J

    1999-05-01

    Despite the enactment of significant changes to the Medicare program in 1997, Medicare's Hospital Insurance trust fund is projected to be exhausted just as the baby boom enters retirement. To address Medicare's financial difficulties, a number of reform proposals have been offered, including several to individualize Medicare financing and benefits. These proposals would attempt to increase Medicare revenues and reduce Medicare expenditures by having individuals bear risk--investment market risk before retirement and insurance market risk after retirement. Many fundamental aspects of these proposals have yet to be worked out, including how to guarantee a baseline level of saving for health insurance after retirement, how retirees might finance unanticipated health insurance price increases after retirement, the potential implications for Medicaid of inadequate individual saving, and whether the administrative cost of making the system fair and adequate ultimately would eliminate any rate-of-return advantages from allowing workers to invest their Medicare contributions in corporate stocks and bonds.

  3. Individualizing Medicare.

    PubMed

    Chollet, D J

    1999-05-01

    Despite the enactment of significant changes to the Medicare program in 1997, Medicare's Hospital Insurance trust fund is projected to be exhausted just as the baby boom enters retirement. To address Medicare's financial difficulties, a number of reform proposals have been offered, including several to individualize Medicare financing and benefits. These proposals would attempt to increase Medicare revenues and reduce Medicare expenditures by having individuals bear risk--investment market risk before retirement and insurance market risk after retirement. Many fundamental aspects of these proposals have yet to be worked out, including how to guarantee a baseline level of saving for health insurance after retirement, how retirees might finance unanticipated health insurance price increases after retirement, the potential implications for Medicaid of inadequate individual saving, and whether the administrative cost of making the system fair and adequate ultimately would eliminate any rate-of-return advantages from allowing workers to invest their Medicare contributions in corporate stocks and bonds. PMID:10915458

  4. 42 CFR 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Disenrollment of beneficiaries by an HMO or CMP. 417.460 Section 417.460 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE...

  5. Potential Consequences of Reforming Medicare into a Competitive Bidding System

    PubMed Central

    Song, Zirui; Cutler, David M.; Chernew, Michael E.

    2012-01-01

    The idea of a premium support (or voucher) system for Medicare has generated substantial debate. Under premium support, Medicare beneficiaries choose among health plans that compete in a market-based bidding system. In some models, the Traditional Medicare (TM) program is abandoned entirely in favor of private health plans. In other models, such as the Ryan-Wyden plan, TM becomes one option among many. PMID:22851110

  6. Does Medicare Advantage Cost Less Than Traditional Medicare?

    PubMed

    Biles, Brian; Casillas, Giselle; Guterman, Stuart

    2016-01-01

    The costs of providing benefits to enrollees in private Medicare Advantage (MA) plans are slightly less, on average, than what traditional Medicare spends per beneficiary in the same county. However, MA plans that are able to keep their costs comparatively low are concen­trated in a fairly small number of U.S. counties. In the 25 counties where the cost differences between MA plans and traditional Medicare are largest, MA plans spent a total of $5.2 billion less than what traditional Medicare would have been expected to spend on the same benefi­ciaries, with health maintenance organizations (HMOs) accounting for all of that difference. In the rest of the country, MA plans spent $4.8 billion above the expected costs under tradi­tional Medicare. Broad determinations about the relative efficiency of MA plans and traditional Medicare can therefore be misleading, as they fail to take into account local conditions and individual plans' performance. PMID:26934756

  7. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... services of physicians furnished to beneficiaries and supervision of interns and residents furnishing care... services furnished to beneficiaries and supervision of interns and residents furnishing care to... section. (b) Reasonable cost of physician services and supervision of interns and residents. (1)...

  8. Obesity utilization and health-related quality of life in Medicare enrollees.

    PubMed

    Malinoff, Rochelle L; Elliott, Marc N; Giordano, Laura A; Grace, Susan C; Burroughs, James N

    2013-01-01

    The obese, with disproportionate chronic disease incidence, consume a large share of health care resources and drive up per capita Medicare spending. This study examined the prevalence of obesity and its association with health status, health-related quality of life (HRQOL), function, and outpatient utilization among Medicare Advantage seniors. Results indicate that obese beneficiaries, much more than overweight beneficiaries, have poorer health, functions, and HRQOL than normal weight beneficiaries and have substantially higher outpatient utilization. While weight loss is beneficial to both the overweight and obese, the markedly worse health status and high utilization of obese beneficiaries may merit particular attention.

  9. Paradigm shifts in Medicare reform.

    PubMed

    Jones, S B; Etheredge, L

    1996-04-01

    Reforms passed by Congress and vetoed by the president during the past year would have accelerated initiatives already transforming Medicare. Operating in a rapidly changing insurance marketplace, Medicare is shifting from a social insurance model toward a private individual insurance model-expanding the number and type of alternative health plans it offers-and growing numbers of beneficiaries are enrolling in these plans. Such reforms, especially if bolstered by legislative reforms that are likely to resurface after the November elections, will rewrite the social contract enacted more than 30 years ago. They require fundamental shifts in ways of thinking about the federal government's responsibilities; the Medicare program's management; relations between the Medicare program and doctors, hospitals, and other health care providers; and the role of beneficiaries in the Medicare program. The likely deferral of further legislative attempts to reform Medicare affords an opportunity to step back and consider these ongoing changes. It is not easy to describe paradigm shifts accurately, but there are advantages to trying. First, conceptual comparisons can allow public discussion to go beyond budget scorekeeping and media soundbites to consider how different the Medicare program will be if it evolves in the new ways being proposed. Second, a conceptual framework can assist health policy analysts to target what to watch for in tracking changes, to assess the tradeoffs involved, and to advise about the needs for refining legislation. This paper includes examples of what to watch for in tracking the implemented changes. The paradigm shifts are summarized below, then described individually in terms of directions of change along a number of continuums. Note that complete paradigm shifts, from one end of a continuum to the other, are seldom completely realized nor even far advanced. But Medicare's ongoing reforms, accelerated by legislative proposals, seem likely predecessors of

  10. MIPPA: First Broad Changes to Medicare Part D Plan Operations

    PubMed Central

    LeMasurier, Jean D.; Edgar, Babette

    2009-01-01

    In July 2008, as part of broad Medicare reform, Congress passed the first major legislative changes to Medicare Part D since its enactment in 2003—the Medicare Improvements for Patients and Providers Act. This new legislation has significant implications for how Part D plans can market and enroll Medicare beneficiaries. The new legislation also strengthened beneficiary protections, expanded the low-income subsidy provisions originally included in Part D, and expanded Part D coverage. These changes have significant implications for the operation of Part D plans and can affect those involved in benefit design, including specialty pharmacy coverage. This article discusses the major changes that took effect on January 1, 2009, and have immediate implications for Part D plan sponsors, including Medicare Advantage plans and stand-alone prescription drug plans. PMID:25126279

  11. Open-ended options in Medicare risk contracts with HMOs.

    PubMed

    Christianson, J B; Dowd, B; Feldman, R

    1995-01-01

    The open-ended option has achieved broad acceptance in the health maintenance organization (HMO) industry. Permitting HMOs that enter into risk contracts with Medicare to offer open-ended products would expand the number of managed care options available to Medicare beneficiaries. The attractiveness of this option to HMOs depends in part on how issues are addressed relating to tracking and managing of out-of-plan use, education of Medicare beneficiaries, interface with peer review organizations (PROs), payment of nonnetwork providers, and use of medical screening. Perhaps most importantly, changes in the Medicare supplementary insurance market probably would be necessary before an open-ended product would be offered by HMOs under Medicare risk contracts. PMID:10140988

  12. Monitoring access following Medicare price changes: physician perspective.

    PubMed

    McCall, N T

    1993-01-01

    In this article, the author examines changes in Medicare beneficiaries' access to services following the Omnibus Budget Reconciliation Act of 1987 "overpriced" procedure price reductions from the physician perspective. Three measures of physician availability remained essentially constant: number of physicians treating beneficiaries or performing overpriced procedures; average Medicare caseload; and average share of a physician's Medicare practice comprised of those who are poor and not white. Physician practice characteristics were examined and provided evidence of continuing participation in Medicare: Average Medicare revenue increased 10 percent, and average volume of all services increased. However, physicians with the largest fee reductions or who were the most financially dependent on the procedures did not change overpriced procedure volume. PMID:10130586

  13. Medicare Rights and Protections

    MedlinePlus

    CENTERS for MEDICARE & MEDICAID SERVICES Medicare Rights & Protections This official government booklet has important information about: Your rights & protections in: ■ ■ Original Medicare ■ ■ Medicare Advantage Plan or other Medicare health ...

  14. Variations in Medicare Access and Satisfaction by Health Status: 1991-93

    PubMed Central

    Rosenbach, Margo L.; Adamache, Killard W.; Khandker, Rezaul K.

    1995-01-01

    This article examines Medicare access, use, and satisfaction before and after implementation of the Medicare Fee Schedule (MFS), based on 3 years of data from the Medicare Current Beneficiary Survey (MCBS). Descriptive and multivariate analysis revealed that access has not deteriorated from 1991 to 1993; Medicare beneficiaries are reporting increased satisfaction—especially with the costs of care—as well as reporting fewer barriers to care. Moreover, the gaps in levels of satisfaction and frequency of perceived barriers have narrowed among those in better and poorer health, suggesting that the program has become more equitable over time. PMID:10157378

  15. Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.

    PubMed

    Landon, Bruce E; Zaslavsky, Alan M; Saunders, Robert C; Pawlson, L Gregory; Newhouse, Joseph P; Ayanian, John Z

    2012-12-01

    Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, which can be a hallmark of more integrated care. We found that utilization rates in some major categories, including emergency departments and ambulatory surgery or procedures, generally were 20-30 percent lower in Medicare Advantage HMOs in all years. Medicare Advantage HMO enrollees initially had lower rates of ambulatory visits and hospitalizations, although these rates converged by 2008; they also received about 10 percent fewer hip or knee replacements. In contrast, HMO enrollees underwent more coronary bypass surgery than patients in traditional Medicare. These findings suggest that overall, Medicare Advantage HMO enrollees might use fewer services and be experiencing more appropriate use of services than enrollees in traditional Medicare.

  16. Medicare program; FY 2015 hospice wage index and payment rate update; hospice quality reporting requirements and process and appeals for Part D payment for drugs for beneficiaries enrolled in hospice. Final rule.

    PubMed

    2014-08-22

    This final rule will update the hospice payment rates and the wage index for fiscal year (FY) 2015 and continue the phase-out of the wage index budget neutrality adjustment factor (BNAF). This rule provides an update on hospice payment reform analyses, potential definitions of "terminal illness'' and "related conditions,'' and information on potential processes and appeals for Part D payment for drugs while beneficiaries are under a hospice election. This rule will specify timeframes for filing the notice of election and the notice of termination/revocation; add the attending physician to the hospice election form, and require hospices to document changes to the attending physician; require hospices to complete their hospice aggregate cap determinations within 5 months after the cap year ends, and remit any overpayments; and update the hospice quality reporting program. In addition, this rule will provide guidance on determining hospice eligibility; information on the delay in the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM); and will further clarify how hospices are to report diagnoses on hospice claims. Finally, the rule will make a technical regulations text change. PMID:25167592

  17. Recent proposals to limit Medigap coverage and modify Medicare cost sharing.

    PubMed

    Linehan, Kathryn

    2012-02-24

    As policymakers look for savings from the Medicare program, some have proposed eliminating or discouraging "first-dollar coverage" available through privately purchased Medigap policies. Medigap coverage, which beneficiaries obtain to protect themselves from Medicare's cost-sharing requirements and its lack of a cap on out-of-pocket spending, may discourage the judicious use of medical services by reducing or eliminating beneficiary cost sharing. It is estimated that eliminating such coverage, which has been shown to be associated with higher Medicare spending, and requiring some cost sharing would encourage beneficiaries to reduce their service use and thus reduce pro­gram spending. However, eliminating first-dollar coverage could cause some beneficiaries to incur higher spending or forego necessary services. Some policy proposals to eliminate first-dollar coverage would also modify Medicare's cost sharing and add an out-of-pocket spending cap for fee-for-service Medicare. This paper discusses Medicare's current cost-sharing requirements, Medigap insurance, and proposals to modify Medicare's cost sharing and eliminate first-dollar coverage in Medigap plans. It reviews the evidence on the effects of first-dollar coverage on spending, some objections to eliminating first-dollar coverage, and results of research that has modeled the impact of eliminating first-dollar coverage, modifying Medicare's cost-sharing requirements, and adding an out-of-pocket limit on beneficiaries' spending.

  18. Medicare Part D: Things People with Cancer May Want to Know

    MedlinePlus

    ... of Part D plan formularies’ tiered cost-sharing requirements in different plans Prescription Drug Plan Tier 1 ( ... plan to make an exception to its formulary requirements. If the plan turns the Medicare beneficiary down, ...

  19. More accurate racial and ethnic codes for Medicare administrative data.

    PubMed

    Eicheldinger, Celia; Bonito, Arthur

    2008-01-01

    Analyses of health care disparities in Medicare using administrative race and ethnicity data have typically been limited to Black and White beneficiaries. This is in part due to the small size of the other categories, inaccuracies in the race and ethnicity codes, and caveats that more extensive analyses would produce biased results. While previous Medicare efforts certainly improved the accuracy of race and ethnicity coding, we have developed an imputation algorithm that dramatically improves the accuracy of coding for Hispanic and Asian or Pacific Islander beneficiaries. When compared with self-reported race and ethnicity, sensitivity increased from 29.5 to 76.6 percent for Hispanic and from 54.7 to 79.2 percent for Asian and Pacific Islander beneficiaries, with no loss of specificity, and Kappa coefficients reaching 0.80. As a result, 2,245,792 beneficiaries were recoded to Hispanic and 336,363 to Asian or Pacific Islander.

  20. Competitive Bidding in Medicare: Who Benefits From Competition?

    PubMed Central

    Song, Zirui; Landrum, Mary Beth; Chernew, Michael E.

    2012-01-01

    Objectives To conduct the first empirical study of competitive bidding in Medicare. Study Design and Methods We analyzed 2006–2010 Medicare Advantage data from the Centers for Medicare & Medicaid Services using longitudinal models adjusted for market and plan characteristics. Results A $1 increase in Medicare's payment to health maintenance organization (HMO) plans led to a $0.49 (P <.001) increase in plan bids, with $0.34 (P <.001) going to beneficiaries in the form of extra benefits or lower cost sharing. With preferred provider organization and private fee-for-service plans included, higher Medicare payments increased bids less ($0.33 per dollar), suggesting more competition among these latter plans. Conclusions As a market-based alternative to cost control through administrative pricing, competitive bidding relies on private insurance plans proposing prices they are willing to accept for insuring a beneficiary. However, competition is imperfect in the Medicare bidding market. As much as half of every dollar in increased plan payment went to higher bids rather than to beneficiaries. While having more insurers in a market lowered bids, the design of any bidding system for Medicare should recognize this shortcoming of competition. PMID:23009305

  1. An outlier pool for Medicare HMO payments

    PubMed Central

    Beebe, James C.

    1992-01-01

    Medicare pays “at-risk” health maintenance organizations a prospective capitation amount that is established by the adjusted average per capita cost (AAPCC) formula for estimating the amount enrollees would have cost had they remained in the fee-for-service sector. Because the AAPCC accounts for a very small percentage of the variation in beneficiary costs, considerable research has been devoted to improving the formula. A way to improve the explained variance is to remove the most expensive beneficiaries from the AAPCC payment system and pay for them separately. This article examines one approach to a payment system that combines the AAPCC with an outlier payment mechanism. PMID:10124439

  2. 42 CFR 413.35 - Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services. 413.35 Section 413.35 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR...

  3. Medicare: Physician Compare

    MedlinePlus

    ... by the Centers for Medicare & Medicaid Services 7500 Security Boulevard, Baltimore, MD 21244 Sign Up / Change Plans Your Medicare Costs What Medicare Covers Drug Coverage (Part D) Supplements & ...

  4. Potential effects of raising Medicare's eligibility age.

    PubMed

    Waidmann, T A

    1998-01-01

    Recent fiscal pressures on Medicare and an already enacted increase in Social Security's normal retirement age have generated discussion of raising Medicare's age of entitlement. This DataWatch examines potential impacts of raising Medicare's eligibility age to sixty-seven on public-sector health spending and individual insurance coverage. The proposed increase would affect a substantial fraction of beneficiaries without having a commensurate effect on expenditures, even in the long run. It is estimated that if the eligibility age were sixty-seven, upwards of 500,000 persons ages sixty-five and sixty-six would be left without any insurance, and even more would not be able to afford coverage with benefits similar to those of Medicare. PMID:9558794

  5. The Star Rating System and Medicare Advantage Plans.

    PubMed

    Sprague, Lisa

    2015-05-01

    With nearly 30 percent of Medicare beneficiaries opting to enroll in Medicare Advantage (MA) plans instead of fee-for-service Medicare, it's safe to say the MA program is quite popular. The Centers for Medicare & Medicaid Services (CMS) administers a Star Ratings program for MA plans, which offers measures of quality and service among the plans that are used not only to help beneficiaries choose plans but also to award additional payments to plans that meet high standards. These additional payments, in turn, are used by plans to provide additional benefits to beneficiaries or to reduce cost sharing--added features that are likely to factor into beneficiaries' choice of MA plans. The Star Ratings program is also meant to drive improvements in the quality of plans, and this secondary effort seems to have been successful. Despite this success, issues with the Star Ratings system remain, including: how performance metrics are developed, chosen, and maintained; how differences among beneficiary populations (particularly with regard to the dually eligible and those receiving low-income subsidies) should be recognized; and the extent to which health plans can control the variables on which they are being measured. Because the Star Ratings approach has been extended to providers of health care as well--hospitals, nursing homes, and dialysis facilities--these issues are worth exploring as CMS fine-tunes its methods of measurement. PMID:26072530

  6. The Star Rating System and Medicare Advantage Plans.

    PubMed

    Sprague, Lisa

    2015-05-01

    With nearly 30 percent of Medicare beneficiaries opting to enroll in Medicare Advantage (MA) plans instead of fee-for-service Medicare, it's safe to say the MA program is quite popular. The Centers for Medicare & Medicaid Services (CMS) administers a Star Ratings program for MA plans, which offers measures of quality and service among the plans that are used not only to help beneficiaries choose plans but also to award additional payments to plans that meet high standards. These additional payments, in turn, are used by plans to provide additional benefits to beneficiaries or to reduce cost sharing--added features that are likely to factor into beneficiaries' choice of MA plans. The Star Ratings program is also meant to drive improvements in the quality of plans, and this secondary effort seems to have been successful. Despite this success, issues with the Star Ratings system remain, including: how performance metrics are developed, chosen, and maintained; how differences among beneficiary populations (particularly with regard to the dually eligible and those receiving low-income subsidies) should be recognized; and the extent to which health plans can control the variables on which they are being measured. Because the Star Ratings approach has been extended to providers of health care as well--hospitals, nursing homes, and dialysis facilities--these issues are worth exploring as CMS fine-tunes its methods of measurement.

  7. Older adults navigating medicare: when benefits are denied.

    PubMed

    Aranha, Karen M; Bell, Nancy J; Dunham, Charlotte

    2013-01-01

    Guided by Bourdieu's theory of practice and symbolic violence, this qualitative study explored experiences and perceptions of elderly beneficiaries who had been denied rehabilitation services by Medicare. In semistructured interviews, 12 beneficiaries or family members told of the physical, psychological, and financial consequences of service denial/termination. The resulting perception of Medicare was as a cumbersome, difficult to negotiate system. Findings have implications for future research on service denial and indicate the need for better communication with, and support of, consumers by health care professionals when this occurs.

  8. Prevalence of multiple chronic conditions in the United States' Medicare population.

    PubMed

    Schneider, Kathleen M; O'Donnell, Brian E; Dean, Debbie

    2009-01-01

    In 2006, the Centers for Medicare & Medicaid Services, which administers the Medicare program in the United States, launched the Chronic Condition Data Warehouse (CCW). The CCW contains all Medicare fee-for-service (FFS) institutional and non-institutional claims, nursing home and home health assessment data, and enrollment/eligibility information from January 1, 1999 forward for a random 5% sample of Medicare beneficiaries (and 100% of the Medicare population from 2000 forward). Twenty-one predefined chronic condition indicator variables are coded within the CCW, to facilitate research on chronic conditions. The current article describes this new data source, and the authors demonstrate the utility of the CCW in describing the extent of chronic disease among Medicare beneficiaries. Medicare claims were analyzed to determine the prevalence, utilization, and Medicare program costs for some common and high cost chronic conditions in the Medicare FFS population in 2005. Chronic conditions explored include diabetes, chronic obstructive pulmonary disease (COPD), heart failure, cancer, chronic kidney disease (CKD), and depression. Fifty percent of Medicare FFS beneficiaries were receiving care for one or more of these chronic conditions. The highest prevalence is observed for diabetes, with nearly one-fourth of the Medicare FFS study cohort receiving treatment for this condition (24.3 percent). The annual number of inpatient days during 2005 is highest for CKD (9.51 days) and COPD (8.18 days). As the number of chronic conditions increases, the average per beneficiary Medicare payment amount increases dramatically. The annual Medicare payment amounts for a beneficiary with only one of the chronic conditions is $7,172. For those with two conditions, payment jumps to $14,931, and for those with three or more conditions, the annual Medicare payments per beneficiary is $32,498. The CCW data files have tremendous value for health services research. The longitudinal data and

  9. Pharmacy utilization and the Medicare Modernization Act.

    PubMed

    Maio, Vittorio; Pizzi, Laura; Roumm, Adam R; Clarke, Janice; Goldfarb, Neil I; Nash, David B; Chess, David

    2005-01-01

    To control expenditures and use medications appropriately, the Medicare drug coverage program has established pharmacy utilization management (PUM) measures. This article assesses the effects of these strategies on the care of seniors. The literature suggests that although caps on drug benefits lower pharmaceutical costs, they may also increase the use of other health care services and hurt health outcomes. Our review raises concerns regarding the potential unintended effects of the Medicare drug program's PUM policies for beneficiaries. Therefore, the economic and clinical impact of PUM measures on seniors should be studied further to help policymakers design better drug benefit plans. PMID:15787955

  10. Medicare drug coverage and moral hazard.

    PubMed

    Pauly, Mark V

    2004-01-01

    This paper explores the effect of more extensive drug coverage in Medicare on the use of and spending for prescription drugs and considers whether any additional use is likely to represent satisfaction of previously unmet needs or whether it represents yet more overuse. Reasonable estimates of the effect on spending strongly suggest that the spending increase will be small and that some of it will go to beneficiaries who do not face high financial barriers at present. Thus, from the viewpoint of improvements in health, national spending on drugs, or pharmaceutical firm revenues, effects are small. The effects of such programs on Medicare's fiscal future are much more important. PMID:15002634

  11. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2012-10-01 2012-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  12. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2011-10-01 2011-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  13. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2010-10-01 2010-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  14. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2013-10-01 2013-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  15. 42 CFR 411.45 - Basis for conditional Medicare payment in workers' compensation cases.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...) The beneficiary, because of physical or mental incapacity, failed to file a proper claim. (b) Any... 42 Public Health 2 2014-10-01 2014-10-01 false Basis for conditional Medicare payment in workers' compensation cases. 411.45 Section 411.45 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT...

  16. Reforming Medicare through 'version 2.0' of accountable care.

    PubMed

    Lieberman, Steven M

    2013-07-01

    Medicare needs fundamental reform to achieve fiscal sustainability, improve value and quality, and preserve beneficiaries' access to physicians. Physician fees will fall by one-quarter in 2014 under current law, and the dire federal budget outlook virtually precludes increasing Medicare spending. There is a growing consensus among policy makers that reforming fee-for-service payment, which has long served as the backbone of Medicare, is unavoidable. Accountable care organizations (ACOs) provide a new payment alternative but currently have limited tools to control cost growth or engage and reward beneficiaries and providers. To fundamentally reform Medicare, this article proposes an enhanced version of ACOs that would eliminate the scheduled physician fee cuts, allow fees to increase with inflation, and enhance ACOs' ability to manage care. In exchange, the proposal would require modest reductions in overall Medicare spending and require ACOs to accept increased accountability and financial risk. It would cause per beneficiary Medicare spending by 2023 to fall 4.2 percent below current Congressional Budget Office projections and help the program achieve fiscal sustainability. PMID:23836742

  17. Fixing flaws in Medicare drug coverage that prompt insurers to avoid low-income patients.

    PubMed

    Hsu, John; Fung, Vicki; Huang, Jie; Price, Mary; Brand, Richard; Hui, Rita; Fireman, Bruce; Dow, William H; Bertko, John; Newhouse, Joseph P

    2010-12-01

    Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives.

  18. MCBS Highlights: Ownership and Average Premiums for Medicare Supplementary Insurance Policies

    PubMed Central

    Chulis, George S.; Eppig, Franklin J.; Poisal, John A.

    1995-01-01

    This article describes private supplementary health insurance holdings and average premiums paid by Medicare enrollees. Data were collected as part of the 1992 Medicare Current Beneficiary Survey (MCBS). Data show the number of persons with insurance and average premiums paid by type of insurance held—individually purchased policies, employer-sponsored policies, or both. Distributions are shown for a variety of demographic, socioeconomic, and health status variables. Primary findings include: Seventy-eight percent of Medicare beneficiaries have private supplementary insurance; 25 percent of those with private insurance hold more than one policy. The average premium paid for private insurance in 1992 was $914. PMID:10153473

  19. The economic impact of Medicare Part D on congestive heart failure.

    PubMed

    Dall, Timothy M; Blanchard, Tericke D; Gallo, Paul D; Semilla, April P

    2013-05-01

    Medicare Part D has had important implications for patient outcomes and treatment costs among beneficiaries with congestive heart failure (CHF). This study finds that improved medication adherence associated with expansion of drug coverage under Part D led to nearly $2.6 billion in reductions in medical expenditures annually among beneficiaries diagnosed with CHF and without prior comprehensive drug coverage, of which over $2.3 billion was savings to Medicare. Further improvements in adherence could potentially save Medicare another $1.9 billion annually, generating upwards of $22.4 billion in federal savings over 10 years. PMID:23725537

  20. Patient health causes substantial portion of geographic variation in Medicare costs.

    PubMed

    Collado, Megan

    2013-10-01

    Key findings. (1) Substantial geographic variation exists in Medicare costs, but to determine the source and extent of this variation requires proper accounting for population health differences. (2) While physician practice patterns likely affect Medicare geographic cost variations, population health explains at least 75 to 85 percent of the variations—more than previously estimated. (3) Policy strategies should consider the magnitude of the impact of beneficiary health status on Medicare costs in order to address geographic variation.

  1. How Medicare Prescription Drug Coverage Works with a Medicare Advantage Plan or Medicare Cost Plan

    MedlinePlus

    ... Works with a Medicare Advantage Plan or Medicare Cost Plan Medicare offers prescription drug coverage for everyone ... t offer Medicare prescription drug coverage. • A Medicare Cost Plan if it doesn’t offer Medicare prescription ...

  2. Medicare on life support: will it survive?

    PubMed

    Fronstin, P; Copeland, C

    1997-09-01

    increase in costs, because older workers are the most costly to cover. Some employers might respond to an increase in the Medicare eligibility age by dropping coverage altogether. The message for future beneficiaries is becoming very clear: expect less from Medicare at later ages and higher premiums. As was true prior to the enactment of Medicare in 1965, workers will increasingly need to include retiree health insurance as an expected expense as they plan and save for retirement.

  3. Medicare, managed care, and vision services to the elderly.

    PubMed

    Soroka, M

    1995-06-01

    Proportionately, fewer Medicare patients are enrolled in HMOs than in fee-for-service programs. Despite the advantages of selecting the HMO option, only 2.9 million beneficiaries are enrolled. Integrating Medicare into health care reform will be a major challenge to this administration. There is general recognition that it will be difficult to control health costs if people at least 65 years of age remain outside the system. With renewed marketing programs directed toward the elderly, we can expect further increases in Medicare HMO enrollment.

  4. Medicare advantage plans at a crossroads--yet again.

    PubMed

    Berenson, Robert A; Dowd, Bryan E

    2009-01-01

    Since risk-taking, private health insurance plans were introduced into Medicare twenty-five years ago, policymakers have disagreed on these plans' fundamental purposes. Articulated objectives, which include improving quality, reducing government spending, providing additional benefits (without expanding the entitlement), increasing choices for beneficiaries, and providing benchmark competition for traditional Medicare, are plausible but sometimes conflicting. The program's history demonstrates continuous shifts in emphasis on these objectives. We enumerate the differing advantages of public and private plans in Medicare and argue that policymakers should focus their efforts on leveling the public-private playing field, thereby dealing forthrightly with the reality of growing fiscal problems.

  5. 76 FR 79193 - Medicare Program; Independence at Home Demonstration Program

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... beneficiaries are defined as Medicare fee-for-service (FFS) patients, who have at least 2 chronic illnesses... practitioners and must have experience providing home-based primary care to patients with multiple chronic illnesses. These practices will also be organized, at least in part, for the purpose of providing...

  6. Steps to reduce favorable risk selection in medicare advantage largely succeeded, boding well for health insurance exchanges.

    PubMed

    Newhouse, Joseph P; Price, Mary; Huang, Jie; McWilliams, J Michael; Hsu, John

    2012-12-01

    Within Medicare, the Medicare Advantage program has historically attracted better risks-healthier, lower-cost patients-than has traditional Medicare. The disproportionate enrollment of lower-cost patients and avoidance of higher-cost ones during the 1990s-known as favorable selection-resulted in Medicare's spending more per beneficiary who enrolled in Medicare Advantage than if the enrollee had remained in traditional Medicare. We looked at two measures that can indicate whether favorable selection is taking place-predicted spending on beneficiaries and mortality-and studied whether policies that Medicare implemented in the past decade succeeded in reducing favorable selection in Medicare Advantage. We found that these policies-an improved risk adjustment formula and a prohibition on monthly disenrollment by beneficiaries-largely succeeded. Differences in predicted spending between those switching from traditional Medicare to Medicare Advantage relative to those who remained in traditional Medicare markedly narrowed, as did adjusted mortality rates. Because insurance exchanges set up under the Affordable Care Act will employ similar policies to combat risk selection, our results give reason for optimism about managing competition among health plans.

  7. Use of intelligent assignment to Medicare Part D plans for people with schizophrenia could produce substantial savings.

    PubMed

    Zhang, Yuting; Baik, Seo Hyon; Newhouse, Joseph P

    2015-03-01

    Medicare insures about half of the people in the United States diagnosed with schizophrenia. More than 90 percent of these beneficiaries are eligible for a low-income subsidy for their Part D prescription drug benefit, and the great majority of them are randomly assigned to a stand-alone drug plan. We simulated savings from replacing random assignment with an "intelligent assignment" algorithm that would assign beneficiaries to the least expensive plan in 2010 based on their drug usage in the previous year. Doing so generated projected annual drug savings of $379 per dual-eligible (those enrolled in both Medicaid and Medicare) beneficiary with a low-income subsidy; $404 per non-dual eligible with the subsidy; and $604 per beneficiary for those without the subsidy who chose their own plans. This translates into savings of $466 per beneficiary with schizophrenia. Intelligent assignment could have saved about $150 million for Medicare and beneficiaries with schizophrenia combined in 2010. We recommend that Medicare use intelligent assignment as the default approach for all beneficiaries with schizophrenia who receive a low-income subsidy, and consider it as an option for all Part D beneficiaries, regardless of their income.

  8. Medicare: Comparison of Catastrophic Health Insurance Proposals. Briefing Report to the Chairman, Select Committee on Aging, House of Representatives.

    ERIC Educational Resources Information Center

    General Accounting Office, Washington, DC. Div. of Human Resources.

    In response to a request from the chairman of the Congressional Select Committee on Aging, the General Accounting Office (GAO) investigated the potential effects of legislative proposals to provide catastrophic coverage to Medicare beneficiaries on beneficiaries' out-of-pocket health care expenses. The GAO reviewed GAO and other reports to…

  9. Making Medicare advantage a middle-class program.

    PubMed

    Glazer, Jacob; McGuire, Thomas G

    2013-03-01

    This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the "middle class." Current Medicare policy of a "single premium" for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare.

  10. Making Medicare Advantage a Middle-Class Program

    PubMed Central

    Glazer, Jacob; McGuire, Thomas

    2013-01-01

    This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare Advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the “middle class.” Current Medicare policy of a “single premium” for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare. PMID:23454916

  11. Medical costs of CKD in the Medicare population.

    PubMed

    Honeycutt, Amanda A; Segel, Joel E; Zhuo, Xiaohui; Hoerger, Thomas J; Imai, Kumiko; Williams, Desmond

    2013-09-01

    Estimates of the medical costs associated with different stages of CKD are needed to assess the economic benefits of interventions that slow the progression of kidney disease. We combined laboratory data from the National Health and Nutrition Examination Survey with expenditure data from Medicare claims to estimate the Medicare program's annual costs that were attributable to CKD stage 1-4. The Medicare costs for persons who have stage 1 kidney disease were not significantly different from zero. Per person annual Medicare expenses attributable to CKD were $1700 for stage 2, $3500 for stage 3, and $12,700 for stage 4, adjusted to 2010 dollars. Our findings suggest that the medical costs attributable to CKD are substantial among Medicare beneficiaries, even during the early stages; moreover, costs increase as disease severity worsens. These cost estimates may facilitate the assessment of the net economic benefits of interventions that prevent or slow the progression of CKD.

  12. 42 CFR 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    .... (iii) HMOs and CMPs that choose to exercise this exception must make the option available to all... 42 Public Health 3 2013-10-01 2013-10-01 false Disenrollment of beneficiaries by an HMO or CMP. 417.460 Section 417.460 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF...

  13. 42 CFR 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... scope of services described in § 417.440. (iii) HMOs and CMPs that choose to exercise this exception... 42 Public Health 3 2014-10-01 2014-10-01 false Disenrollment of beneficiaries by an HMO or CMP. 417.460 Section 417.460 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF...

  14. 42 CFR 456.608 - Personal contact with and observation of beneficiaries and review of records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Personal contact with and observation of beneficiaries and review of records. 456.608 Section 456.608 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS...

  15. 42 CFR 441.102 - Plan of care for institutionalized beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Plan of care for institutionalized beneficiaries. 441.102 Section 441.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH... APPLICABLE TO SPECIFIC SERVICES Medicaid for Individuals Age 65 or Over in Institutions for Mental...

  16. 42 CFR 456.604 - Physician team member inspecting care of beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Physician team member inspecting care of beneficiaries. 456.604 Section 456.604 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Inspections of...

  17. Trends in the Health Status of Medicare Risk Contract Enrollees

    PubMed Central

    Riley, Gerald; Zarabozo, Carlos

    2006-01-01

    Previous research has found Medicare risk contract enrollees to be healthier than beneficiaries in fee-for-service (FFS). Medicare Current Beneficiary Survey (MCBS) data were used to examine trends in health and functional status measures among risk contract and FFS enrollees from 1991 to 2004. Risk contract enrollees reported better health and functioning, but the differences tended to narrow over time. Most of the differences in trends were observed for functional status measures and institutionalization; differences in trends for perceived health status and prevalence rates of chronic conditions tended to be small or non-existent. The narrowing of functional and health status differences between the risk contract and FFS populations may have implications for payment policy, as well as implications for the role of private health plans in Medicare. PMID:17427847

  18. Claims and Appeals (Medicare)

    MedlinePlus

    ... Change Plans Getting started with Medicare Your Medicare coverage choices When & how to sign up for Part ... Apply for Medicare online How to get drug coverage When can I join a health or drug ...

  19. What Medicare Covers

    MedlinePlus

    ... Change Plans Getting started with Medicare Your Medicare coverage choices When & how to sign up for Part ... Apply for Medicare online How to get drug coverage When can I join a health or drug ...

  20. Medical cost offsets from prescription drug utilization among Medicare beneficiaries.

    PubMed

    Roebuck, M Christopher

    2014-10-01

    This brief commentary extends earlier work on the value of adherence to derive medical cost offset estimates from prescription drug utilization. Among seniors with chronic vascular disease, 1% increases in condition-specific medication use were associated with significant (P  less than  0.001) reductions in gross nonpharmacy medical costs in the amounts of 0.63% for dyslipidemia, 0.77% for congestive heart failure, 0.83% for diabetes, and 1.17% for hypertension. PMID:25278321

  1. Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014

    THOMAS, 113th Congress

    Sen. Wyden, Ron [D-OR

    2014-03-11

    03/12/2014 Read the second time. Placed on Senate Legislative Calendar under General Orders. Calendar No. 327. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  2. SGR Repeal and Medicare Beneficiary Access Act of 2013

    THOMAS, 113th Congress

    Sen. Baucus, Max [D-MT

    2013-12-19

    01/16/2014 By Senator Baucus from Committee on Finance filed written report. Report No. 113-135. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  3. Medicare Special Needs Plan (SNP)

    MedlinePlus

    ... up/change plans About Medicare health plans Medicare Advantage Plans + Share widget - Select to show Subcategories Getting ... plan? About Medicare health plans , current subcategory Medicare Advantage Plans , current page Medicare Medical Savings Account (MSA) ...

  4. HOW MUCH FAVORABLE SELECTION IS LEFT IN MEDICARE ADVANTAGE?

    PubMed Central

    PRICE, MARY; MCWILLIAMS, J. MICHAEL; HSU, JOHN; MCGUIRE, THOMAS G.

    2015-01-01

    The health economics literature contains two models of selection, one with endogenous plan characteristics to attract good risks and one with fixed plan characteristics; neither model contains a regulator. Medicare Advantage, a principal example of selection in the literature, is, however, subject to anti-selection regulations. Because selection causes economic inefficiency and because the historically favorable selection into Medicare Advantage plans increased government cost, the effectiveness of the anti-selection regulations is an important policy question, especially since the Medicare Advantage program has grown to comprise 30 percent of Medicare beneficiaries. Moreover, similar anti-selection regulations are being used in health insurance exchanges for those under 65. Contrary to earlier work, we show that the strengthened anti-selection regulations that Medicare introduced starting in 2004 markedly reduced government overpayment attributable to favorable selection in Medicare Advantage. At least some of the remaining selection is plausibly related to fixed plan characteristics of Traditional Medicare versus Medicare Advantage rather than changed selection strategies by Medicare Advantage plans. PMID:26389127

  5. Enrollee health status under Medicare risk contracts: an analysis of mortality rates.

    PubMed Central

    Riley, G; Lubitz, J; Rabey, E

    1991-01-01

    Previous studies comparing the health status of Medicare beneficiaries enrolled under HMO risk contracts to that of Medicare beneficiaries in fee-for-service (FFS) have generally focused on demonstration projects conducted before 1985. This study examines mortality rates in 1987 for approximately 1 million aged Medicare beneficiaries enrolled in 108 HMOs. We estimated adjusted mortality ratios (AMR) for each HMO and across all HMOs, by dividing the actual number of deaths among HMO enrollees by the "expected" number of deaths. The expected number of deaths was based on death rates among local FFS populations, adjusting for age, sex, Medicaid buy-in status, and institutional status. The AMR for all HMO enrollees pooled together was 0.80. For persons newly enrolled in 1987, the AMR was 0.69; in general, AMRs were higher for beneficiaries who had been enrolled for longer periods of time. Among individual HMOs, none exhibited an AMR substantially above 1.00. Regression analysis indicated lower AMRs for staff model HMOs than for either IPA or group models. Low mortality among Medicare HMO enrollees is consistent with favorable selection or with improvements in the health status of enrollees due to better access or quality of care in HMOs. In either case, health status differences between HMO enrollees and FFS beneficiaries have implications for the appropriateness of Medicare's Adjusted Average Per Capita Cost (AAPCC) payment formula for HMOs. PMID:2061054

  6. 26 CFR 514.7 - Beneficiaries of a domestic estate or trust.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS FRANCE Withholding of Tax § 514.7 Beneficiaries of a domestic estate or... respective articles concerned, a nonresident alien individual who is a resident of France and who is...

  7. 26 CFR 514.7 - Beneficiaries of a domestic estate or trust.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS FRANCE Withholding of Tax § 514.7 Beneficiaries of a domestic estate or... respective articles concerned, a nonresident alien individual who is a resident of France and who is...

  8. 26 CFR 514.7 - Beneficiaries of a domestic estate or trust.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS FRANCE Withholding of Tax § 514.7 Beneficiaries of a domestic estate or... respective articles concerned, a nonresident alien individual who is a resident of France and who is...

  9. 26 CFR 514.7 - Beneficiaries of a domestic estate or trust.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS FRANCE Withholding of Tax § 514.7 Beneficiaries of a domestic estate or... respective articles concerned, a nonresident alien individual who is a resident of France and who is...

  10. 26 CFR 514.7 - Beneficiaries of a domestic estate or trust.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...) REGULATIONS UNDER TAX CONVENTIONS FRANCE Withholding of Tax § 514.7 Beneficiaries of a domestic estate or... respective articles concerned, a nonresident alien individual who is a resident of France and who is...

  11. Who are the beneficiaries?

    PubMed

    Tännsjö, Torbjörn

    1992-10-01

    Is it defensible that society spends money on medical or research projects intended to help people solve their fertility problems? Suppose that we want to answer this question from the point of view of a utilitarian cost-benefit analysis. The answer to the question then depends, of course, on how expensive these projects turn out to be, relative to the costs of other possible projects. But it depends also on how we assess the benefits of these projects. To whom do they accrue? Who are the beneficiaries of these projects?

  12. Rural Medicare Advantage Plan Payment in 2015.

    PubMed

    Kemper, Leah; Barker, Abigail R; McBride, Timothy D; Mueller, Keith

    2015-12-01

    Payment to Medicare Advantage (MA) plans was fundamentally altered in the Patient Protection and Affordable Care Act of 2010 (ACA). MA plans now operate under a new formula for county-level payment area benchmarks, and in 2012 began receiving quality-based bonus payments. The Medicare Advantage Quality Bonus Payment Demonstration expanded the bonus payments to most MA plans through 2014; however, with the end of the demonstration bonus payments has been reduced for intermediate quality MA plans. This brief examines the impact that these changes in MA baseline payment are having on MA plans and beneficiaries in rural and urban areas. Key Data Findings. (1) Payments to plans in rural areas were 3.9 percent smaller under ACA payment policies in 2015 than they would have been in the absence of the ACA. For plans in urban areas, the payments were 8.8 percent smaller than they would have been. These figures were determined using hypothetical pre-ACA and actual ACA-mandated benchmarks for 2015. (2) MA plans in rural areas received an average annual bonus payment of $326.77 per enrollee in 2014, but only $63.76 per enrollee in 2015, with the conclusion of the demonstration. (3) In 2014, 92 percent of rural MA beneficiaries were in a plan that received quality-based bonus payments under the demonstration, while in March 2015, 56 percent of rural MA beneficiaries were in a plan that was eligible for quality-based bonus payments.

  13. Modeling the Impact of Medicare Advantage Payment Cuts on Ambulatory Care Sensitive and Elective Hospitalizations

    PubMed Central

    Nicholas, Lauren Hersch

    2011-01-01

    Objective To assess relationships between changes in Medicare Advantage (MA) payment rates and Medicare beneficiary hospitalizations and to simulate the effects of scheduled payment cuts on ambulatory care sensitive (ACS) and elective hospitalization rates. Data State Inpatient Database discharge abstracts from Arizona, Florida, and New York merged with administrative Medicare enrollment and MA payment data. Study Design Retrospective, fixed effect regression analysis of the relationship between MA payment rates and rates of ACS and elective hospitalizations among Medicare beneficiaries in counties with at least 10,000 Medicare beneficiaries and 3 percent MA penetration from 1999 to 2005. Principal Findings MA payment rates were negatively related to rates of ACS admissions. Simulations suggest that payment cuts could be associated with higher rates of ACS admissions. No relationship between MA payments and rates of elective hospitalizations was found. Conclusions Reductions in MA payment rates may result in a small increase in ACS admissions. Trends in ACS admissions among chronically ill Medicare beneficiaries should be tracked following MA payment cuts. PMID:21609330

  14. State unemployment in recessions during 1991-2009 was linked to faster growth in Medicare spending.

    PubMed

    McInerney, Melissa Powell; Mellor, Jennifer M

    2012-11-01

    During the US recession of 2007-09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991-2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population.

  15. State unemployment in recessions during 1991-2009 was linked to faster growth in Medicare spending.

    PubMed

    McInerney, Melissa Powell; Mellor, Jennifer M

    2012-11-01

    During the US recession of 2007-09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991-2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population. PMID:23129677

  16. Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal. Final rule.

    PubMed

    2016-05-17

    This final rule specifies the process and timeline for expanding CMS' existing Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act). The final rule specifies a timeline for developing a multifactor authentication solution to securely permit authorized users other than the beneficiary to access CMS' MSP conditional payment amounts and claims detail information via the MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that permits users to: Notify us that the specified case is approaching settlement; obtain time and date stamped final conditional payment summary statements and amounts before reaching settlement; and ensure that relatedness disputes and any other discrepancies are addressed within 11 business days of receipt of dispute documentation.

  17. Population-based disease management under fee-for-service Medicare.

    PubMed

    Foote, Sandra M

    2003-01-01

    Medicare policymakers are considering testing population-based disease management (PDM) programs under fee-for-service (FFS) Medicare as a way to improve health and cost outcomes for selected subgroups of chronically ill beneficiaries. This paper provides a brief overview of how PDM programs are evolving in the private sector and describes how they differ from other approaches already being tested in Medicare disease management demonstrations. It also discusses some key opportunities and issues to be considered in adapting PDM programs for testing in the FFS Medicare context.

  18. Trends in Medicare Part D Medication Therapy Management Eligibility Criteria

    PubMed Central

    Wang, Junling; Shih, Ya-Chen Tina; Qin, Yolanda; Young, Theo; Thomas, Zachary; Spivey, Christina A.; Solomon, David K.; Chisholm-Burns, Marie

    2015-01-01

    Background To increase the enrollment rate of medication therapy management (MTM) programs in Medicare Part D plans, the US Centers for Medicare & Medicaid Services (CMS) lowered the allowable eligibility thresholds based on the number of chronic diseases and Part D drugs for Medicare Part D plans for 2010 and after. However, an increase in MTM enrollment rates has not been realized. Objectives To describe trends in MTM eligibility thresholds used by Medicare Part D plans and to identify patterns that may hinder enrollment in MTM programs. Methods This study analyzed data extracted from the Medicare Part D MTM Programs Fact Sheets (2008–2014). The annual percentages of utilizing each threshold value of the number of chronic diseases and Part D drugs, as well as other aspects of MTM enrollment practices, were analyzed among Medicare MTM programs that were established by Medicare Part D plans. Results For 2010 and after, increased proportions of Medicare Part D plans set their eligibility thresholds at the maximum numbers allowable. For example, in 2008, 48.7% of Medicare Part D plans (N = 347:712) opened MTM enrollment to Medicare beneficiaries with only 2 chronic disease states (specific diseases varied between plans), whereas the other half restricted enrollment to patients with a minimum of 3 to 5 chronic disease states. After 2010, only approximately 20% of plans opened their MTM enrollment to patients with 2 chronic disease states, with the remaining 80% restricting enrollment to patients with 3 or more chronic diseases. Conclusion The policy change by CMS for 2010 and after is associated with increased proportions of plans setting their MTM eligibility thresholds at the maximum numbers allowable. Changes to the eligibility thresholds by Medicare Part D plans might have acted as a barrier for increased MTM enrollment. Thus, CMS may need to identify alternative strategies to increase MTM enrollment in Medicare plans. PMID:26380030

  19. Preparing PharmD Students to Participate in Medicare Part D Education and Enrollment

    PubMed Central

    Zagar, Michelle

    2007-01-01

    Objective To create and implement a teaching module that prepares students to assist Medicare beneficiaries in evaluating and enrolling in Medicare Part D plans. Design A 6-hour module entitled “Medicare 2006: This Year, It's Different!”1 was developed and first presented to students in February 2006. Material describing provisions of Medicare Part D was included as well as instructions on using the plan selection tools available on the Medicare web site. Learning activities developed included listing the top 10 things a Medicare beneficiary should know about Medicare Part D, participating in a mock patient counseling activity, selecting an appropriate Medicare prescription drug plan for a given list of drugs, and writing a paper explaining features of the plan they selected and justifying their selection. Assessment Assessment of the 64 students who completed the module was based on completion of individual Top 10 lists, participation in mock counseling sessions, and appropriate drug plan recommendations in plan selection assignments. Overall student response to the series was overwhelmingly positive. Conclusion Given opportunities to apply Medicare Part D knowledge in the classroom setting, PharmD students were able to empathize with the plight of elderly patients and took the initiative to participate in Part D education and enrollment efforts in their communities. PMID:17786265

  20. Improving the design of competitive bidding in Medicare Advantage.

    PubMed

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders.

  1. Improving the design of competitive bidding in Medicare Advantage.

    PubMed

    Cawley, John H; Whitford, Andrew B

    2007-04-01

    In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which required that in 2006 the Centers for Medicare and Medicaid Services (CMS) implement a system of competitive bids to set payments for the Medicare Advantage program. Managed care plans now bid for the right to enroll Medicare beneficiaries. Data from the first year of bidding suggest that imperfect competition is limiting the success of the bidding system. This article offers suggestions to improve this system based on findings from auction theory and previous government-run auctions. In particular, CMS can benefit by adjusting its system of competitive bids in four ways: credibly committing to regulations governing bidding; limiting the scope for collusion, entry deterrence, and predatory behavior among bidders; adjusting how benchmark reimbursement rates are set; and accounting for asymmetric information among bidders. PMID:17463410

  2. The cost of cancer-related physician services to Medicare.

    PubMed

    Maroongroge, Sean; Kim, Simon P; Mougalian, Sarah; Johung, Kimberly; Decker, Roy H; Soulos, Pamela R; Long, Jessica B; Gross, Cary P; Yu, James B

    2015-06-01

    Although physician services represent a substantial portion of cancer care costs, little is known about trends in the costs of physician cancer services in the fee-for-service Medicare program. We analyzed aggregated data from all Part B Medicare claims for physician and supplier services attributed to cancer patients from 1999 to 2012 to characterize how billing and payments have changed over time for the most common cancer types. Billing and expenditure data are from the Medicare Statistical Supplement, and age-adjusted incidence data are from SEER. Physician services for cancer patients grew from $7.6 billion in 1999 to $12.3 billion in 2012 (60 percent increase). Reimbursements for physician and supplier services for cancer treatment in Medicare Part B beneficiaries steadily grew from 1999 to 2005 and then plateaued through 2012, led by a decrease in reimbursements for prostate cancer care. These trends may reflect shifts toward hospital-based care or changes in aggressiveness of care.

  3. Predicting risk selection following major changes in Medicare.

    PubMed

    Pizer, Steven D; Frakt, Austin B; Feldman, Roger

    2008-04-01

    The Medicare Modernization Act of 2003 created several new types of private insurance plans within Medicare, starting in 2006. Some of these plan types previously did not exist in the commercial market and there was great uncertainty about their prospects. In this paper, we show that statistical models and historical data from the Medicare Current Beneficiary Survey can be used to predict the experience of new plan types with reasonable accuracy. This lays the foundation for the analysis of program modifications currently under consideration. We predict market share, risk selection, and stability for the most prominent new plan type, the stand-alone Medicare prescription drug plan (PDP). First, we estimate a model of consumer choice across Medicare insurance plans available in the data. Next, we modify the data to include PDPs and use the model to predict the probability of enrollment for each beneficiary in each plan type. Finally, we calculate mean-adjusted actual spending by plan type. We predict that adverse selection into PDPs will be substantial, but that enrollment and premiums will be stable. Our predictions correspond well to actual experience in 2006. PMID:17557273

  4. Kaiser-Permanente's Medicare Plus Project: A Successful Medicare Prospective Payment Demonstration

    PubMed Central

    Greenlick, Merwyn R.; Lamb, Sara J.; Carpenter, Theodore M.; Fischer, Thomas S.; Marks, Sylvia D.; Cooper, William J.

    1983-01-01

    The Medicare Plus project of the Oregon Region Kaiser-Permanente Medical Care Program was designed as a model for prospective payment to Increase Health Maintenance Organization (HMO) participation in the Medicare program. The project demonstrated that it is possible to design a prospective payment system that costs the Medicare program less than services purchased in the community from fee-for-service providers; would provide appropriate payment to the HMO; and in addition, creates a “savings” to return to beneficiaries in the form of comprehensive benefits to motivate them to enroll in the HMO. Medicare Plus was highly successful in recruiting 5,500 new and 1,800 conversion members into the demonstration, through use of a media campaign, a recruitment brochure, and a telephone information center. Members recruited were a representative age and geographic cross section of the senior citizen population in the Portland, Oregon metropolitan area. Utilization of inpatient services by Medicare Plus members in the first full year (1981) was 1679 days per thousand members and decreased to 1607 in the second full year (1982). New members made an average of eight visits per year to ambulatory care facilities. PMID:10310002

  5. Medicare program: changes to the Medicare claims appeal procedures. Final rule.

    PubMed

    2009-12-01

    Under the procedures in this final rule, Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B pursuant to sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. After publication of a proposed rule implementing the section 521 changes, additional new statutory requirements for the appeals process were enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In March 2005, we published an interim final rule with comment period to implement these statutory changes. This final rule responds to comments on the interim final rule regarding changes to these appeal procedures, makes revisions where warranted, establishes the final implementing regulations, and explains how the new procedures will be put into practice.

  6. The Relationship between Commercial Health Care Prices and Medicare Spending and Utilization

    PubMed Central

    Romley, John A; Axeen, Sarah; Lakdawalla, Darius N; Chernew, Michael E; Bhattacharya, Jay; Goldman, Dana P

    2015-01-01

    Objective To explore the relationship between commercial health care prices and Medicare spending/utilization across U.S. regions. Data Sources Claims from large employers and Medicare Parts A/B/D over 2007–2009. Study Design We compared prices paid by commercial health plans to Medicare spending and utilization, adjusted for beneficiary health and the cost of care, across 301 hospital referral regions. Principal Findings A 10 percent lower commercial price (around the average level) is associated with 3.0 percent higher Medicare spending per member per year, and 4.3 percent more specialist visits (p < .01). Conclusions Commercial health care prices are negatively associated with Medicare spending across regions. Providers may respond to low commercial prices by shifting service volume into Medicare. Further investigation is needed to establish causality. PMID:25429755

  7. What Is Medicare?

    MedlinePlus

    ... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... health plan offered by a private company that contracts with Medicare to provide you with all your ...

  8. Medicare Advantage Plans

    MedlinePlus

    ... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... health plan offered by a private company that contracts with Medicare to provide you with all your ...

  9. TMA Uncovers Medicare Mistakes.

    PubMed

    Sorrel, Amy Lynn

    2015-07-01

    The Texas Medical Association recently uncovered some major Medicare mistakes that show just why some physicians talk about leaving the federal program. Investigations and advocacy by TMA staff put Medicare on the path to a fix. PMID:26201065

  10. TMA Uncovers Medicare Mistakes.

    PubMed

    Sorrel, Amy Lynn

    2015-07-01

    The Texas Medical Association recently uncovered some major Medicare mistakes that show just why some physicians talk about leaving the federal program. Investigations and advocacy by TMA staff put Medicare on the path to a fix.

  11. Medicare program; appeals of CMS or CMS contractor determinations when a provider or supplier fails to meet the requirements for Medicare billing privileges. Final rule.

    PubMed

    2008-06-27

    This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. In addition, this final rule allows Medicare FFS contractors to revoke Medicare billing privileges when a provider or supplier submits a claim or claims for services that could not have been furnished to a beneficiary. This final rule also specifies that a Medicare contractor may establish a Medicare enrollment bar for any provider or supplier whose billing privileges have been revoked. Lastly, the final rule requires that all providers and suppliers receive Medicare payments by electronic funds transfer (EFT) if the provider or supplier, is submitting an initial enrollment application to Medicare, changing their enrollment information, revalidating or re-enrolling in the Medicare program. PMID:18677828

  12. Temporal variation in patterns of comorbidities in the medicare population.

    PubMed

    Sorace, James; Millman, Michael; Bounds, Mallory; Collier, Michael; Wong, Hui-Hsing; Worrall, Chris; Kelman, Jeffrey; MaCurdy, Thomas

    2013-04-01

    It is widely accepted that Medicare beneficiaries with multiple comorbidities (ie, patients with combinations of more than 1 disease) account for a disproportionate amount of mortality and expenditures. The authors previously studied this phenomenon by analyzing Medicare claims data from 2008 to determine the pattern of disease combinations (DCs) for 32,220,634 beneficiaries. Their findings indicated that 22% of these individuals mapped to a long-tailed distribution of approximately 1 million DCs. The presence of so many DCs, each populated by a small number of individuals, raises the possibility that the DC distribution varies over time. Measuring this variability is important because it indicates the rate at which the health care system must adapt to the needs of new patients. This article analyzes Medicare claims data for 3 consecutive calendar years, using 2 algorithms based on the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Conditions Categories (HCC) claims model. These algorithms make different assumptions regarding the degree to which the CMS-HCC model could be disaggregated into its underlying International Classification of Diseases, Ninth Revision, Clinical Modification codes. The authors find that, although a large number of beneficiaries belong to a set of DCs that are nationally stable across the 3 study years, the number of DCs in this set is large (in the range of several hundred thousand). Furthermore, the small number of beneficiaries associated with the larger number of variable DCs (ie, DCs that were not constantly populated in all 3 study years) represents a disproportionally high level of expenditures and death.

  13. Medicare Part D and Its Effect on the Use of Prescription Drugs and Use of Other Health Care Services of the Elderly

    ERIC Educational Resources Information Center

    Kaestner, Robert; Nasreen Khan,

    2012-01-01

    We examine the effect of gaining prescription drug insurance, as a result of Medicare Part D, on use of prescription drugs and other medical services for a nationally representative sample of Medicare beneficiaries. Given the heightened importance of prescription drugs for those with chronic illness, we provide separate estimates for elderly in…

  14. 26 CFR 1.679-2 - Trusts treated as having a U.S. beneficiary.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...-2 Trusts treated as having a U.S. beneficiary. (a) Existence of U.S. beneficiary—(1) In general. The... illustrate the rules of paragraphs (a)(1) and (2) of this section. In these examples, A is a resident alien, B is A's son, who is a resident alien, C is A's daughter, who is a nonresident alien, and FT is...

  15. 26 CFR 1.679-2 - Trusts treated as having a U.S. beneficiary.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...-2 Trusts treated as having a U.S. beneficiary. (a) Existence of U.S. beneficiary—(1) In general. The... illustrate the rules of paragraphs (a)(1) and (2) of this section. In these examples, A is a resident alien, B is A's son, who is a resident alien, C is A's daughter, who is a nonresident alien, and FT is...

  16. 26 CFR 1.679-2 - Trusts treated as having a U.S. beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... treated as having a U.S. beneficiary. (a) Existence of U.S. beneficiary—(1) In general. The determination... illustrate the rules of paragraphs (a)(1) and (2) of this section. In these examples, A is a resident alien, B is A's son, who is a resident alien, C is A's daughter, who is a nonresident alien, and FT is...

  17. 26 CFR 1.679-2 - Trusts treated as having a U.S. beneficiary.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...-2 Trusts treated as having a U.S. beneficiary. (a) Existence of U.S. beneficiary—(1) In general. The... illustrate the rules of paragraphs (a)(1) and (2) of this section. In these examples, A is a resident alien, B is A's son, who is a resident alien, C is A's daughter, who is a nonresident alien, and FT is...

  18. 26 CFR 1.679-2 - Trusts treated as having a U.S. beneficiary.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ...-2 Trusts treated as having a U.S. beneficiary. (a) Existence of U.S. beneficiary—(1) In general. The... illustrate the rules of paragraphs (a)(1) and (2) of this section. In these examples, A is a resident alien, B is A's son, who is a resident alien, C is A's daughter, who is a nonresident alien, and FT is...

  19. Medicare Part D Research and Policy Highlights, 2012: Impact and Insights

    PubMed Central

    Lau, Denys T.; Stubbings, JoAnn

    2012-01-01

    Background In the 6 years since the implementation of Medicare Part D in the United States, the program has been reported to improve quality, offer better beneficiary protections, and lower drug costs. Objective The purpose of this article was to highlight the latest key peer-reviewed research findings on Medicare Part D and major public policy initiatives for Part D for 2012. Methods PubMed was searched for studies on Medicare Part D published in 2011 in biomedical/scientific, peer-reviewed, English-language journals. For the policy update, sources included the Federal Register, the Medicare Prescription Drug Benefit Manual, the 2012 Final Call Letter, and guidance from the Centers for Medicare and Medicaid Services. Results Medicare Part D has been associated with increased medication utilization, reduced out-of-pocket expenditures, and an overall decrease in cost-related non-adherence and nonpersistence. Its impact on reduction in non-drug utilization of health services has been more apparent after the transition year in 2006 and among subsets of Medicare beneficiaries. Recent policy changes promise to make Part D more user-friendly, simplify choice, and offer greater protection to beneficiaries. The coverage gap will phase out by 2020. Both the quality rating system for prescription drug plans and medication therapy management programs were enhanced. Conclusions Although Part D was designed to improve drug benefits, improvements may be needed in plan selection and simplification, quality assessment (especially with regard to long-term impact and health outcomes), evidence-based improvements in medication therapy management, and disparities among priority subpopulations. Medicare Parts A, B, and D could be coordinated to offset costs by increasing medication expenses and decreasing expenses for nonprescription medical services, thereby improving the overall cost-effectiveness of the Medicare program. PMID:22417714

  20. Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients

    PubMed Central

    Holden, Timothy R.; Smith, Maureen A.; Bartels, Christie M.; Campbell, Toby C.; Yu, Menggang

    2015-01-01

    Abstract Background: Rehospitalizations are prevalent and associated with decreased quality of life. Although hospice has been advocated to reduce rehospitalizations, it is not known how area-level hospice utilization patterns affect rehospitalization risk. Objectives: The study objective was to examine the association between hospice enrollment, local hospice utilization patterns, and 30-day rehospitalization in Medicare patients. Methods: With a retrospective cohort design, 1,997,506 hospitalizations were assessed between 2005 and 2009 from a 5% national sample of Medicare beneficiaries. Local hospice utilization was defined using tertiles representing the percentage of all deaths occurring in hospice within each Hospital Service Area (HSA). Cox proportional hazard models were used to assess the relationship between 30-day rehospitalization, hospice enrollment, and local hospice utilization, adjusting for patient sociodemographics, medical history, and hospital characteristics. Results: Rates of patients dying in hospice were 27% in the lowest hospice utilization tertile, 41% in the middle tertile, and 53% in the highest tertile. Patients enrolled in hospice had lower rates of 30-day rehospitalization than those not enrolled (2.2% versus 18.8%; adjusted hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.118–0.131). Patients residing in areas of low hospice utilization were at greater rehospitalization risk than those residing in areas of high utilization (19.1% versus 17.5%; HR, 1.05; 95% CI, 1.04–1.06), which persisted beyond that accounted for by individual hospice enrollment. Conclusions: Area-level hospice utilization is inversely proportional to rehospitalization rates. This relationship is not fully explained by direct hospice enrollment, and may reflect a spillover effect of the benefits of hospice extending to nonenrollees. PMID:25879990

  1. Fee-for-service joins the Medicare+Choice product line.

    PubMed

    Ahl, D; Wergin, K

    2000-10-01

    Despite hopes that providers would benefit from being able to participate in Medicare + Choice plans such as provider service organizations (PSOs) and coordinated care plans, providers have not realized many of these benefits. Private fee-for-service (FFS) Medicare + Choice plans, the first of which was approved by HCFA in May, allow Medicare beneficiaries to choose their hospitals and physicians and allow providers to be reimbursed on a FFS basis. The FFS option is particularly appealing for providers in rural markets. Financial managers for providers should identify the model that best meets the financial and operational needs of their marketplace. PMID:11183543

  2. MEDICARE PAYMENTS AND SYSTEM-LEVEL HEALTH-CARE USE

    PubMed Central

    ROBBINS, JACOB A.

    2015-01-01

    The rapid growth of Medicare managed care over the past decade has the potential to increase the efficiency of health-care delivery. Improvements in care management for some may improve efficiency system-wide, with implications for optimal payment policy in public insurance programs. These system-level effects may depend on local health-care market structure and vary based on patient characteristics. We use exogenous variation in the Medicare payment schedule to isolate the effects of market-level managed care enrollment on the quantity and quality of care delivered. We find that in areas with greater enrollment of Medicare beneficiaries in managed care, the non–managed care beneficiaries have fewer days in the hospital but more outpatient visits, consistent with a substitution of less expensive outpatient care for more expensive inpatient care, particularly at high levels of managed care. We find no evidence that care is of lower quality. Optimal payment policies for Medicare managed care enrollees that account for system-level spillovers may thus be higher than those that do not. PMID:27042687

  3. 78 FR 8535 - Medicare Program: Comprehensive End-Stage Renal Disease Care Model Announcement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-06

    ... Disease Care Model Announcement AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION... the testing of the Comprehensive End- Stage Renal Disease (ESRD) Care Model, a new initiative from the... populations. One population is beneficiaries with end- stage renal disease (ESRD). This population has...

  4. 78 FR 42778 - Medicare Program; Comprehensive ESRD Care Initiative; Extension of the Submission Deadlines for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-17

    ... beneficiaries with ESRD regarding the functional status, quality of life, and overall well-being, as well as... quality of care for this population, while lowering total per-capita expenditures under the Medicare... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH...

  5. Rural Implications of Medicare's Post-Acute-Care Transfer Payment Policy

    ERIC Educational Resources Information Center

    Schoenman, Julie A.; Mueller, Curt D.

    2005-01-01

    Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the…

  6. Medicare and Medicaid: Conflicting Incentives for Long-Term Care

    PubMed Central

    Grabowski, David C

    2007-01-01

    The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives—capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government—may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades. PMID:18070331

  7. Medicare Payments: How Much Do Chronic Conditions Matter?

    PubMed Central

    Erdem, Erkan; Prada, Sergio I.; Haffer, Samuel C.

    2013-01-01

    Objective Analyze differences in Medicare Fee-for-Service utilization (i.e., program payments) by beneficiary characteristics, such as gender, age, and prevalence of chronic conditions. Methods Using the 2008 and 2010 Chronic Conditions Public Use Files, we conduct a descriptive analysis of enrollment and program payments by gender, age categories, and eleven chronic conditions. Results We find that the effect of chronic conditions on Medicare payments is dramatic. Average Medicare payments increase significantly with the number of chronic conditions. Finally, we quantify the effect of individual conditions and find that “Stroke / Transient Ischemic Attack” and “Chronic Kidney Disease” are the costliest chronic conditions for Part A, and “Cancer” and “Chronic Kidney Disease” are the costliest for Part B. PMID:24753967

  8. A Political History of Medicare and Prescription Drug Coverage

    PubMed Central

    Oliver, Thomas R; Lee, Philip R; Lipton, Helene L

    2004-01-01

    This article examines the history of efforts to add prescription drug coverage to the Medicare program. It identifies several important patterns in policymaking over four decades. First, prescription drug coverage has usually been tied to the fate of broader proposals for Medicare reform. Second, action has been hampered by divided government, federal budget deficits, and ideological conflict between those seeking to expand the traditional Medicare program and those preferring a greater role for private health care companies. Third, the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 reflect earlier missed opportunities. Policymakers concluded from past episodes that participation in the new program should be voluntary, with Medicare beneficiaries and taxpayers sharing the costs. They ignored lessons from past episodes, however, about the need to match expanded benefits with adequate mechanisms for cost containment. Based on several new circumstances in 2003, the article demonstrates why there was a historic opportunity to add a Medicare prescription drug benefit and identify challenges to implementing an effective policy. PMID:15225331

  9. 42 CFR 422.262 - Beneficiary premiums.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... and Plan Approval § 422.262 Beneficiary premiums. (a) Determination of MA monthly basic beneficiary premium. (1) For an MA plan with an unadjusted statutory non-drug bid amount that is less than the relevant unadjusted non-drug benchmark amount, the basic beneficiary premium is zero. (2) For an MA...

  10. 42 CFR 422.262 - Beneficiary premiums.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... and Plan Approval § 422.262 Beneficiary premiums. (a) Determination of MA monthly basic beneficiary premium. (1) For an MA plan with an unadjusted statutory non-drug bid amount that is less than the relevant unadjusted non-drug benchmark amount, the basic beneficiary premium is zero. (2) For an MA...

  11. 78 FR 57807 - Aged Beneficiary Designation Forms

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ... record- keeper in regulations on June 13, 1997 (62 FR 32426). All beneficiary designation forms in an...; ] FEDERAL RETIREMENT THRIFT INVESTMENT BOARD 5 CFR Part 1651 Aged Beneficiary Designation Forms AGENCY... beneficiary designation form is valid only if it is received by the TSP record- keeper not more than one...

  12. Boutique to Booming: Medicare Managed Care and the Private Path to Policy Change.

    PubMed

    Kelly, Andrew S

    2016-06-01

    In 2014, Medicare Advantage (MA) enrollment surpassed 30 percent of eligible beneficiaries. Twenty-five years earlier, enrollment hovered at just 3 percent. The expansion of private Medicare plans presents a puzzling instance of policy change within Medicare-a program long held to be a quintessential case of policy stasis. This article investigates the policy features that made Medicare susceptible to this dramatic policy shift, as well as the processes by which the initial policy change remade the politics of Medicare and solidified the MA program. The first enrollment surge occurred in the absence of a proximate legislative or administrative change. Instead, increased spending and expanded benefits were the result of the interaction of new market dynamics with an existing legislative framework-demonstrating an expansionary form of policy drift. The 1982 Tax Equity and Fiscal Responsibility Act created a policy space that gave the new and lightly controlled managed care industry considerable operational discretion. As the interests of the government's private partners changed in response to new market dynamics, a change occurred in the output and performance of the Medicare managed care program. As enrollment and spending increased, Medicare's politics were remade by the political empowerment of the managed care industry and the creation of a new subconstituency of beneficiaries. PMID:26921379

  13. Boutique to Booming: Medicare Managed Care and the Private Path to Policy Change.

    PubMed

    Kelly, Andrew S

    2016-06-01

    In 2014, Medicare Advantage (MA) enrollment surpassed 30 percent of eligible beneficiaries. Twenty-five years earlier, enrollment hovered at just 3 percent. The expansion of private Medicare plans presents a puzzling instance of policy change within Medicare-a program long held to be a quintessential case of policy stasis. This article investigates the policy features that made Medicare susceptible to this dramatic policy shift, as well as the processes by which the initial policy change remade the politics of Medicare and solidified the MA program. The first enrollment surge occurred in the absence of a proximate legislative or administrative change. Instead, increased spending and expanded benefits were the result of the interaction of new market dynamics with an existing legislative framework-demonstrating an expansionary form of policy drift. The 1982 Tax Equity and Fiscal Responsibility Act created a policy space that gave the new and lightly controlled managed care industry considerable operational discretion. As the interests of the government's private partners changed in response to new market dynamics, a change occurred in the output and performance of the Medicare managed care program. As enrollment and spending increased, Medicare's politics were remade by the political empowerment of the managed care industry and the creation of a new subconstituency of beneficiaries.

  14. Medicare immunosuppressant coverage and access to kidney transplantation: a retrospective national cohort study

    PubMed Central

    2012-01-01

    Background In December 2000, Medicare eliminated time limitations in immunosuppressant coverage after kidney transplant for beneficiaries age ≥65 and those who were disabled. This change did not apply to younger non-disabled beneficiaries who qualified for Medicare only because of their end-stage renal disease (ESRD). We sought to examine access to waitlisting for kidney transplantation in a cohort spanning this policy change. Methods This was a retrospective cohort analysis of 241,150 Medicare beneficiaries in the United States Renal Data System who initiated chronic dialysis between 1/1/96 and 11/30/03. We fit interrupted time series Cox proportional hazard models to compare access to kidney transplant waitlist within 12 months of initiating chronic dialysis by age/disability status, accounting for secular trends. Results Beneficiaries age <65 who were not disabled were less likely to be waitlisted after the policy change (hazard ratio (HR) for the later vs. earlier period, 0.93, p = 0.002), after adjusting for sociodemographic factors, co-morbid conditions, income, and ESRD network. There was no evidence of secular trend in this group (HR per year, 1.00, p = 0.989). Likelihood of being waitlisted among those age ≥65 or disabled increased steadily throughout the study period (HR per year, 1.04, p < 0.001), but was not clearly affected by the policy change (HR for the immediate effect of policy change, 0.93, p = 0.135). Conclusions The most recent extension in Medicare immunosuppressant coverage appears to have had little impact on the already increasing access to waitlisting among ≥65/ disabled beneficiaries eligible for the benefit but may have decreased access for younger, non-disabled beneficiaries who were not. The potential ramifications of policies on candidacy appeal for access to kidney transplantation should be considered. PMID:22894737

  15. The entry of HMOs into the Medicare market: implications for TEFRA's mandate.

    PubMed

    Adamache, K W; Rossiter, L F

    1986-01-01

    The Tax Equity and Fiscal Responsibility Act of 1982, under rules implemented in April 1985, creates incentives for HMOs and other competitive medical plans to significantly expand their participation in Medicare on an at-risk basis. In an attempt to gauge the likely response of HMOs to the new incentives, we examined data on a census of HMOs operating in 1982 to look for differences between HMOs that entered the Medicare program at risk under the earlier National Medicare Competition demonstration and those that did not. The most consistent difference we found was that HMOs in areas with a high adjusted average per capita cost were more likely to enter the Medicare market. HMOs with prior experience serving Medicare beneficiaries were also more likely to join the demonstration, as were HMOs that were federally qualified. No other HMO characteristics appeared to significantly affect the likelihood of entry. PMID:2947856

  16. Raising Awareness of Medicare Member Rights Among Seniors and Caregivers in California

    PubMed Central

    Grossman, Ruth M.; Fu, Patricia L.; Sabogal, Fabio

    2010-01-01

    Many Medicare recipients do not understand their health care rights. Lumetra, formerly California's Medicare quality improvement organization, developed a multifaceted outreach program to increase beneficiary awareness of its services and of the right to file quality-of-care complaints and discharge appeals. Layered outreach activities to Medicare members and their caregivers in 2 targeted counties consisted of paid media, direct mailings, community outreach, and online marketing. Calls to Lumetra's helpline and visits to its Web site—measures of beneficiary awareness of case review services—increased by 106% and 1214%, respectively, in the targeted counties during the 4-month outreach period. Only small increases occurred in nontargeted counties. Increases in quality-of-care complaints and discharge appeal rates were detected during a longer follow-up period. PMID:19965568

  17. Centers for Medicare & Medicaid Services

    MedlinePlus

    ... Websites Visit other Centers for Medicare and Medicaid Services & Health and Human Services Websites section Expand Medicare.gov Link to the ... helpful links for all Centers for Medicare & Medicaid Services websites section Expand Web Policies & Important Links Privacy ...

  18. Medicare program; changes to the requirements for Part D prescribers. Interim final rule with comment period.

    PubMed

    2015-05-01

    This interim final rule with comment period revises requirements related to beneficiary access to covered Part D drugs. Under these revised requirements, pharmacy claims and beneficiary requests for reimbursement for Medicare Part D prescriptions, written by prescribers other than physicians and eligible professionals who are permitted by state or other applicable law to prescribe medications, will not be rejected at the point of sale or denied by the plan if all other requirements are met. In addition, a plan sponsor will not reject a claim or deny a beneficiary request for reimbursement for a drug when prescribed by a prescriber who does not meet the applicable enrollment or opt-out requirement without first providing provisional coverage of the drug and individualized written notice to the beneficiary. This interim final rule with comment period also revises certain terminology to be consistent with existing policy and to improve clarity. PMID:25985480

  19. Pharmaceuticals: Medicare Modernization Act--2005. End of Year Issue Brief.

    PubMed

    Seay, Melicia

    2005-12-31

    The enactment of the landmark Medicare Modernization Act of 2003 (MMA) marked the first structural change to Medicare since its inception in 1965. The MMA established the Medicare prescription drug benefit with an intermediate Medicare-approved drug discount card program to be implemented six months after enactment and full implementation in January 2006. The MMA marks the first time the federal government would be providing access to prescription drugs for seniors. Though the merits and cost of the MMA continue to be debated, the impending change to how seniors and the low-income access prescription drugs is on the horizon. Historically, state lawmakers believed it was appropriate to provide assistance to the elderly and, in some states, the disabled and indigent, for the purchase of much needed prescription drugs. Since 1975, states have been creating, terminating and redesigning state pharmaceutical assistance programs (SPAPs) that either provides a prescription drug subsidy, discount card program or full benefit design. Currently, 33 states operate pharmaceutical assistance programs that provide coverage for seniors. Now, due to the MMA, the states' role as provider of prescription drug benefits to seniors is being re-evaluated. The MMA is intended to save costs for the states. Medicare beneficiaries, the bulk of enrollees in state pharmaceutical assistance programs, will now access prescription drugs through the new Medicare prescription drug benefit. The MMA mandates a state to federal government cost shift when the financial burden of those who are eligible for both Medicaid and Medicare (dual eligibles) switch to receiving prescription drug coverage through Medicare, with Medicaid only being an option for drugs not covered by Medicare. Employers, many of which have been cutting prescription drug benefits to retirees because of rising health care costs, will now receive subsidies from the federal government to continue providing prescription drug benefits to

  20. Did Medicare Part D Reduce Disparities?

    PubMed Central

    Zissimopoulos, Julie; Joyce, Geoffrey F.; Scarpati, Lauren M.; Goldman, Dana P.

    2015-01-01

    Objective We assessed whether Medicare Part D reduced disparities in access to medication. Study Design Secondary data analysis of a twenty percent sample of Medicare beneficiaries, using Parts A and B medical claims from 2002–2008 and Part D drug claims from 2006–2008. Methods We analyzed medication use of Hispanics, blacks and whites beneficiaries with diabetes before and after reaching the Part D coverage gap, and compared it to race-specific reference groups not exposed to the loss in coverage. Unadjusted difference-indifference results were validated with multivariate regression models adjusted for demographics, comorbidities, and ZIP code-level household income used as a proxy for socioeconomic status. Results The rate at which Hispanics reduced use of diabetes-related medications in the coverage gap was twice as high as whites, while blacks decreased use of diabetes-related medications by thirty-three percent more than whites. The reduction in medication use was correlated with drug price. Hispanics and blacks were more likely than whites to discontinue a therapy after reaching the coverage gap but more likely to resume once coverage restarted. Hispanics without subsidies and living in low income areas reduced medication use more than similar blacks and whites in the coverage gap. Conclusions We find that the Part D coverage gap is particularly disruptive to minorities and those living in low-income areas. The implications of this work suggest that protecting the health of vulnerable groups requires more than premium subsidies. Patient education may be a first step, but more substantive improvements in adherence may require changes in health care delivery. PMID:25880361

  1. Medicare and Rural Health

    MedlinePlus

    ... Health Gateway Evidence-based Toolkits Rural Health Models & Innovations Supporting Rural Community Health Tools for Success Am ... in rural areas. Center for Medicare and Medicaid Innovation (CMMI) – CMMI, also known as the CMS Innovation ...

  2. The Impact of Hospital Pay-for-Performance on Hospital and Medicare Costs

    PubMed Central

    Kruse, Gregory B; Polsky, Daniel; Stuart, Elizabeth A; Werner, Rachel M

    2012-01-01

    Objective To evaluate the effects of Medicare's hospital pay-for-performance demonstration project on hospital revenues, costs, and margins and on Medicare costs. Data Sources/Study Setting All health care utilization for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI; ICD-9-CM code 410.x1) in fiscal years 2002–2005 from Medicare claims, containing 420,211 admissions with AMI. Study Design We test for changes in hospital costs and revenues and Medicare payments among 260 hospitals participating in the Medicare hospital pay-for-performance demonstration project and a group of 780 propensity-score-matched comparison hospitals. Effects were estimated using a difference-in-difference model with hospital fixed effects, testing for changes in costs among pay-for-performance hospitals above and beyond changes in comparison hospitals. Principal Findings We found no significant effect of pay-for-performance on hospital financials (revenues, costs, and margins) or Medicare payments (index hospitalization and 1 year after admission) for AMI patients. Conclusions Pay-for-performance in the CMS hospital demonstration project had minimal impact on hospital financials and Medicare payments to providers. As P4P extends to all hospitals under the Affordable Care Act, these results provide some estimates of the impact of P4P and emphasize our need for a better understanding of the financial implications of P4P on providers and payers if we want to create sustainable and effective programs to improve health care value. PMID:23088391

  3. Policy Changes in Medicare Home Health Care: Challenges to Providing Family-Centered, Community-Based Care for Older Adults

    ERIC Educational Resources Information Center

    Davitt, Joan K.

    2009-01-01

    The Balanced Budget Act of 1997 (BBA) established new reimbursement systems in the Medicare home health fee-for-service benefit. Reimbursements were reduced to 1993 levels and per-beneficiary capitated limits were introduced for the first time. This article analyzes the impact of these changes on chronically ill older adults and their families.…

  4. 38 CFR 8.27 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... of National Service life insurance only if such beneficiary shall survive him for such period (not... beneficiary during that period. In the event such beneficiary fails to survive the specified period,...

  5. 20 CFR 234.43 - Payment to designated beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... beneficiaries. If a designated beneficiary dies before the date on which the RLS becomes payable, his or her... beneficiary dies before negotiating the RLS check, that share is payable to his or her estate. (b)...

  6. 20 CFR 234.43 - Payment to designated beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... beneficiaries. If a designated beneficiary dies before the date on which the RLS becomes payable, his or her... beneficiary dies before negotiating the RLS check, that share is payable to his or her estate. (b)...

  7. 20 CFR 234.43 - Payment to designated beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... beneficiaries. If a designated beneficiary dies before the date on which the RLS becomes payable, his or her... beneficiary dies before negotiating the RLS check, that share is payable to his or her estate. (b)...

  8. 20 CFR 234.43 - Payment to designated beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... beneficiaries. If a designated beneficiary dies before the date on which the RLS becomes payable, his or her... beneficiary dies before negotiating the RLS check, that share is payable to his or her estate. (b)...

  9. 20 CFR 234.43 - Payment to designated beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... beneficiaries. If a designated beneficiary dies before the date on which the RLS becomes payable, his or her... beneficiary dies before negotiating the RLS check, that share is payable to his or her estate. (b)...

  10. Predictable Unpredictability: the Problem with Basing Medicare Policy on Long-Term Financial Forecasting.

    PubMed

    Glied, Sherry; Zaylor, Abigail

    2015-07-01

    The authors assess how Medicare financing and projections of future costs have changed since 2000. They also assess the impact of legislative reforms on the sources and levels of financing and compare cost forecasts made at different times. Although the aging U.S. population and rising health care costs are expected to increase the share of gross domestic product devoted to Medicare, changes made in the program over the past decade have helped stabilize Medicare's financial outlook--even as benefits have been expanded. Long-term forecasting uncertainty should make policymakers and beneficiaries wary of dramatic changes to the program in the near term that are intended to alter its long-term forecast: the range of error associated with cost forecasts rises as the forecast window lengthens. Instead, policymakers should focus on the immediate policy window, taking steps to reduce the current burden of Medicare costs by containing spending today. PMID:26219117

  11. Another view of Medicare HMOs: not always what the doctor ordered. Interview by Meg Matheny.

    PubMed

    Wilson, S A

    1995-06-01

    Sally Hart Wilson is one of several lawyers who, on behalf of the Center for Medicare Advocacy, have filed a class-action suit seeking better protections for Medicare beneficiaries in HMOs. The experience of the lead plaintiff (one of 15) in Grijalva v. Shalala illustrates the down side of Medicare HMOs, says Ms. Wilson. Grigoria Grijalva, 71, an enrollee with diabetes, hypertension, congestive heart failure, anemia, and a uremic bladder, complained to her physician about pain in her foot. But the physician's treatment was inadequate, the complaint alleges, and as a result her right leg was amputated. In subsequent years, the lawsuit says, the HMO denied necessary skilled nursing home days and skilled home health services and never sent a notice of denial or a description of her appeal rights, as Medicare requires.

  12. The transition to Medicare Part D and the new senior care landscape.

    PubMed

    Gorman, John

    2006-07-01

    The landscape of coverage for prescription drugs for Medicare beneficiaries has dramatically changed as a result of Medicare Part D. As regulations were drafted to govern this program, the federal government's fear was that because pharmacy benefit managers had never gone at risk for the management of medications, plans would be reluctant to enter the new arena of Medicare drug coverage. Of course, that has not happened as hundreds of various plans have entered this market, including a new form of managed care plan referred to as a "special needs plan". The landscape of health care has changed and will continue to change as Medicare Part D changes, both as the result of competitive market forces and regulatory actions. PMID:16898053

  13. Predictable Unpredictability: the Problem with Basing Medicare Policy on Long-Term Financial Forecasting.

    PubMed

    Glied, Sherry; Zaylor, Abigail

    2015-07-01

    The authors assess how Medicare financing and projections of future costs have changed since 2000. They also assess the impact of legislative reforms on the sources and levels of financing and compare cost forecasts made at different times. Although the aging U.S. population and rising health care costs are expected to increase the share of gross domestic product devoted to Medicare, changes made in the program over the past decade have helped stabilize Medicare's financial outlook--even as benefits have been expanded. Long-term forecasting uncertainty should make policymakers and beneficiaries wary of dramatic changes to the program in the near term that are intended to alter its long-term forecast: the range of error associated with cost forecasts rises as the forecast window lengthens. Instead, policymakers should focus on the immediate policy window, taking steps to reduce the current burden of Medicare costs by containing spending today.

  14. Medicare Reimbursement Attributable to Periprosthetic Joint Infection Following Primary Hip and Knee Arthroplasty.

    PubMed

    Yi, Sarah H; Baggs, James; Culler, Steven D; Berríos-Torres, Sandra I; Jernigan, John A

    2015-06-01

    This study estimated Medicare reimbursement attributable to periprosthetic joint infection (PJI) across the continuum of covered services four years following hip or knee arthroplasty. Using 2001-2008 Medicare claims data, total and annual attributable reimbursements were assessed using generalized linear regression, adjusting for potential confounders. Within one year following arthroplasty, 109 (1.04%) of 10,418 beneficiaries were diagnosed with PJI. Cumulative Medicare reimbursement in the PJI arm was 2.2-fold (1.9-2.6, P<.0001) or $53,470 ($39,575-$68,221) higher than that of the non-PJI arm. The largest difference in reimbursement occurred the first year (3.2-fold); differences persisted the second (2.3-fold) and third (1.9-fold) follow up years. PJI following hip or knee arthroplasty appears costly to Medicare, with cost traversing several years and health care service areas.

  15. Fostering accountable health care: moving forward in medicare.

    PubMed

    Fisher, Elliott S; McClellan, Mark B; Bertko, John; Lieberman, Steven M; Lee, Julie J; Lewis, Julie L; Skinner, Jonathan S

    2009-01-01

    To succeed, health care reform must slow spending growth while improving quality. We propose a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and "shared savings" payment reform. The approach is practical and feasible: it is voluntary for providers, builds on current referral patterns, requires no change in benefits or lock-in for beneficiaries, and offers the possibility of sustained provider incomes even as total costs are constrained. We simulate the potential expenditure impact and show that significant Medicare savings are possible. PMID:19174383

  16. Alternative geographic adjustments in Medicare payment to health maintenance organizations

    PubMed Central

    Welch, W. Pete

    1992-01-01

    The payment received by a health maintenance organization (HMO) for its Medicare enrollees is proportionate to the average cost of Medicare beneficiaries in that county. However, HMO market share in an area appears to decrease costs in the fee-for-service sector, so that HMOs are paid less. For this and other reasons, alternative payment formulas may be desirable and several are developed in this article. The conceptually simplest location factor would be an input price index. An alternative strategy would also recognize systematic variation in utilization. Utilization rate is regressed on variables such as county population density and physicians per 1,000 persons. The predicted utilization rate times an input price index could serve as a location factor. The value of alternative location factors are presented for specific counties. PMID:10120186

  17. Medicare clarified support surface policies and coverage requirements.

    PubMed

    Schaum, Kathleen D

    2010-07-01

    Before providers order pressure-reducing support surfaces for Medicare beneficiaries, they should obtain and read (1) the LCD and attached articles that pertain to their DME MAC jurisdiction and (2) the Special Edition SE1014 educational article released by the Medicare Learning Network of CMS. Providers should be sure that the patient's medical record contains the required order (including the dated and signed physician order) and documentation that proves medical necessity for the support surface ordered. The OIG report has identified that a large percentage of medical records are deficient in this area. Now CMS has provided special education about their order, coverage, and documentation requirements. The OIG report and the CMS educational article should serve as a warning that audits on this topic are likely. Providers should take time to review the pressure-reducing support documents and immediately refine their support surface ordering and documentation.

  18. Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

    PubMed

    Baker, Laurence C; Bundorf, M Kate; Devlin, Aileen M; Kessler, Daniel P

    2016-08-01

    There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.

  19. Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.

    PubMed

    Baker, Laurence C; Bundorf, M Kate; Devlin, Aileen M; Kessler, Daniel P

    2016-08-01

    There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines. PMID:27503970

  20. Unintended consequences of eliminating Medicare payments for consultations1

    PubMed Central

    Song, Zirui; Ayanian, John Z.; Wallace, Jacob; He, Yulei; Gibson, Teresa B.; Chernew, Michael E.

    2013-01-01

    Background Prior to 2010, Medicare payments for consultations (commonly billed by specialists) were substantially higher than for office visits of similar complexity (commonly billed by primary care physicians). In January 2010, Medicare eliminated consultation payments from the Part B Physician Fee Schedule and increased fees for office visits. This change was intended to be budget neutral and to decrease payments to specialists while increasing payments to primary care physicians. We assessed the impact of this policy on spending, volume, and complexity for outpatient office encounters in 2010. Methods We examined 2007–2010 outpatient claims for 2,247,810 Medicare beneficiaries with Medicare Supplemental (Medigap) coverage through large employers in the Thomson Reuters MarketScan Database. We used segmented regression analysis to study changes in spending, volume, and complexity of office encounters adjusted for age, sex, health status, secular trends, seasonality, and hospital referral region. Results “New” office visits largely replaced consultations in 2010. An average of $10.20 (6.5 percent) more was spent per beneficiary per quarter on physician encounters after the policy. The total volume of physician encounters did not change significantly. The increase in spending was largely explained by higher office visit fees from the policy and a shift toward higher complexity visits to both specialists and primary care physicians. Conclusions The elimination of consultations led to a net increase in spending on visits to both primary care physicians and specialists. Higher prices, partially due to the subjectivity of codes in the physician fee schedule, explained the spending increase, rather than higher volumes. PMID:23336095

  1. Medicare Cost Differences between Nursing Home Patients Admitted with and without Dementia

    ERIC Educational Resources Information Center

    Stuart, Bruce; Gruber-Baldini, Ann L.; Fahlman, Cheryl; Quinn, Charlene C.; Burton, Lynda; Zuckerman, Illene H.; Hebel, J. Rich; Zimmerman, Sheryl; Singhal, Puneet K.; Magaziner, Jay

    2005-01-01

    Purpose: Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings. Design and Methods: An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures…

  2. Bringing Managed Care Incentives to Medicare's Fee-for-Service Sector

    PubMed Central

    Tompkins, Christopher P.; Wallack, Stanley S.; Bhalotra, Sarita; Chilingerian, Jon A.; Glavin, Mitchell P.V.; Ritter, Grant A.; Hodgkin, Dominic

    1996-01-01

    The Health Care Financing Administration (HCFA) could work with eligible physician organizations to generate savings in total reimbursements for their Medicare patients. Medicare would continue to reimburse all providers according to standard payment policies and mechanisms, and beneficiaries would retain the freedom to choose providers. However, implementation of new financial incentives, based on meeting targets called Group-Specific Volume Performance Standards (GVPS), would encourage cost-effective service delivery patterns. HCFA could use new and existing data systems to monitor access, utilization patterns, cost outcomes and quality of care. In short, HCFA could manage providers, who, in turn, would manage their patients' care. PMID:10165712

  3. Insurers’ Negotiating Leverage and the External Effects of Medicare Part D*

    PubMed Central

    Lakdawalla, Darius; Yin, Wesley

    2014-01-01

    By influencing the size and bargaining power of private insurers, public subsidization of private health insurance may project effects beyond the subsidized population. We test for such spillovers by analyzing how increases in insurer size resulting from the implementation of Medicare Part D affected drug prices negotiated in the non-Medicare commercial market. On average, Part D lowered prices for commercial enrollees by 3.7%. The external commercial market savings amount to $1.5 billion per year, which, if passed to consumers, approximates the internal cost-savings of newly-insured subsidized beneficiaries. If retained by insurers, it corresponds to a 5% average increase in profitability. PMID:25937676

  4. The emergence of Medicare hospice care in US nursing homes.

    PubMed

    Miller, S C; Mor, V

    2001-11-01

    Although Medicare-financed hospice care has been provided in nursing homes in the USA for over 10 years, very little is known regarding the use of this government health care benefit in nursing homes. Using resident assessment data and hospice and inpatient Medicare claim data from five US states, we were able to identify and describe nursing home residents receiving hospice care between 1992 and 1996, and their hospice utilization patterns. Six per cent of all dying nursing home residents received hospice care at some point in time and, in 1996, an estimated 24% of all Medicare hospice patients in the five study states received hospice while in a nursing home. Of those residents beginning hospice care after nursing home admission, 48% were 85 years or older, 70% were female, 94% were white, 76% were unmarried and 62% had a non-cancer principal diagnosis. The average length of stay in the hospice programme for residents receiving hospice care while in the nursing home was 90.6 days, the median 35 and the mode 2. Hospice care in US nursing homes is a prevalent model of care that appears further to extend the Medicare hospice benefit to older adults who are female and to those with non-cancer diagnoses. Lengths of stay in the programme are similar to those observed in the community and the average length of stay is substantially shorter than previously estimated by an influential government study.

  5. The Cost of Cancer-Related Physician Services to Medicare

    PubMed Central

    Maroongroge, Sean; Kim, Simon P.; Mougalian, Sarah; Johung, Kimberly; Decker, Roy H.; Soulos, Pamela R.; Long, Jessica B.; Gross, Cary P.; Yu, James B.

    2015-01-01

    Although physician services represent a substantial portion of cancer care costs, little is known about trends in the costs of physician cancer services in the fee-for-service Medicare program. We analyzed aggregated data from all Part B Medicare claims for physician and supplier services attributed to cancer patients from 1999 to 2012 to characterize how billing and payments have changed over time for the most common cancer types. Billing and expenditure data are from the Medicare Statistical Supplement, and age-adjusted incidence data are from SEER. Physician services for cancer patients grew from $7.6 billion in 1999 to $12.3 billion in 2012 (60 percent increase). Reimbursements for physician and supplier services for cancer treatment in Medicare Part B beneficiaries steadily grew from 1999 to 2005 and then plateaued through 2012, led by a decrease in reimbursements for prostate cancer care. These trends may reflect shifts toward hospital-based care or changes in aggressiveness of care. PMID:26029009

  6. Medicare Preventive and Screening Services

    MedlinePlus

    ... covered? Search Medicare.gov for covered items Preventive & screening services How often is it covered? Medicare Part B (Medical Insurance) covers: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone ...

  7. Do Medicare Advantage plans select enrollees in higher margin clinical categories?

    PubMed

    Newhouse, Joseph P; McWilliams, J Michael; Price, Mary; Huang, Jie; Fireman, Bruce; Hsu, John

    2013-12-01

    The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or average revenue/average cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans' margins for these 48 conditions are correlated (r=0.39, p<0.01). Both plans have margins that are more positive for persons with conditions that are managed by primary care physicians and where medical management can be effective. Conversely they have lower margins for persons with conditions that tend to be treated by specialists with greater market power than primary care physicians and for acute conditions where little medical management is possible. The two plan's margins among beneficiaries with different observable characteristics vary over a range of 160 and 98 percentage points, respectively, and thus would appear to offer substantial incentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC's in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation of high

  8. Do Medicare Advantage Plans Select Enrollees in Higher Margin Clinical Categories?

    PubMed Central

    Newhouse, Joseph P.; McWilliams, J. Michael; Price, Mary; Huang, Jie; Fireman, Bruce; Hsu, John

    2013-01-01

    The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or Average Revenue/Average Cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans’ margins for these 48 conditions are correlated (r=0.39, p<0.01). Both plans have margins that are more positive for persons with conditions that are managed by primary care physicians and where medical management can be effective. Conversely they have lower margins for persons with conditions that tend to be treated by specialists with greater market power than primary care physicians and for acute conditions where little medical management is possible. The two plan’s margins among beneficiaries with different observable characteristics vary over a range of 160 and 98 percentage points, respectively, and thus would appear to offer substantial incentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC’s in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation

  9. Do Medicare Advantage plans select enrollees in higher margin clinical categories?

    PubMed

    Newhouse, Joseph P; McWilliams, J Michael; Price, Mary; Huang, Jie; Fireman, Bruce; Hsu, John

    2013-12-01

    The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or average revenue/average cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans' margins for these 48 conditions are correlated (r=0.39, p<0.01). Both plans have margins that are more positive for persons with conditions that are managed by primary care physicians and where medical management can be effective. Conversely they have lower margins for persons with conditions that tend to be treated by specialists with greater market power than primary care physicians and for acute conditions where little medical management is possible. The two plan's margins among beneficiaries with different observable characteristics vary over a range of 160 and 98 percentage points, respectively, and thus would appear to offer substantial incentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC's in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation of high

  10. Medicare essential: an option to promote better care and curb spending growth.

    PubMed

    Davis, Karen; Schoen, Cathy; Guterman, Stuart

    2013-05-01

    Medicare's core benefit design reflects private insurance as of 1965, with separate coverage for hospital and physician services (and now prescription drugs) and no protection against catastrophic costs. Modernizing Medicare's benefit design to offer comprehensive benefits, financial protection, and incentives to choose high-value care could improve coverage and lower beneficiary costs. We describe a new option we call Medicare Essential, which would combine Medicare's hospital, physician, and prescription drug coverage into an integrated benefit with an annual limit on out-of-pocket expenses for covered benefits. Cost sharing would be reduced for enrollees who seek care from high-quality low-cost providers. Out-of-pocket savings from lower premiums and health care costs for a Medicare Essential enrollee could be $173 per month, compared to what an enrollee would pay with traditional Medicare, prescription drug and private supplemental coverage. Financed by a budget-neutral premium, we estimate that this new plan choice could reduce total health spending relative to current projections by $180 billion and reduce employer retiree spending by $90 billion during 2014-23. Given its potential, such an alternative should be a part of the debate over the future of Medicare.

  11. Effects of Medicare Part D on Disparity Implications of Medication Therapy Management Eligibility Criteria

    PubMed Central

    Wang, Junling; Qiao, Yanru; Shih, Ya-Chen Tina; Jamison, JoEllen Jarrett; Spivey, Christina A.; Li, Liyuan; Wan, Jim Y.; White-Means, Shelley I.; Dagogo-Jack, Samuel; Cushman, William C.; Chisholm-Burns, Marie

    2014-01-01

    Background Previous studies have shown that there were greater racial and ethnic disparities among individuals who were ineligible for medication therapy management (MTM) services than among MTM-eligible individuals before the implementation of Medicare Part D in 2006. Objective To determine whether the implementation of Medicare Part D in 2006 correlates to changes in racial and ethnic disparities among MTM-ineligible and MTM-eligible beneficiaries. Methods Data from the Medicare Current Beneficiary Survey were analyzed in this retrospective observational analysis. To examine potential racial and ethnic disparities, non-Hispanic whites were compared with non-Hispanic blacks and Hispanics. Three aspects of disparities were analyzed, including health status, health services utilization and costs, and medication utilization patterns. A generalized difference-in-differences analysis was used to examine the changes in difference in disparities between MTM-ineligible and MTM-eligible individuals from 2004–2005 to 2007–2008 relative to changes from 2001–2002 and 2004–2005. Various multivariate regressions were used based on the types of dependent variables. A main analysis and several sensitivity analyses were conducted to represent the ranges of MTM eligibility thresholds used by Medicare Part D plans in 2010. Results The main analysis showed that Part D implementation was not associated with reductions in greater racial and ethnic disparities among MTM-ineligible than MTM-eligible Medicare beneficiaries. The main analysis suggests that after Part D implementation, Medicare MTM eligibility criteria may not consistently improve the existing racial and ethnic disparities in health status, health services utilization and costs, and medication utilization. By contrast, several sensitivity analyses showed that Part D implementation did correlate with a significant reduction in greater racial disparities among the MTM-ineligible group than the MTM-eligible group in

  12. Diagnosis and Treatment of Depression in the Elderly Medicare Population: Predictors, Disparities, and Trends

    PubMed Central

    Crystal, Stephen; Sambamoorthi, Usha; Walkup, James T.; Akincigil, Ayşe

    2008-01-01

    Objectives To develop nationally representative estimates of rates of diagnosis of depression; to determine rates and type of treatment received by those diagnosed with depression; and to ascertain socioeconomic differences and trends in treatment rates of depression, including the effect of supplemental insurance coverage, for elderly Medicare fee-for-service beneficiaries. Design Analysis of merged interview and Medicare claims data for multiple years from merged Medicare claims and interview data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare participants. Setting Community dwellers. Participants Twenty thousand nine hundred sixty-six community-dwelling respondents aged 65 and older in the MCBS cost and use files for 1992 through 1998. Measurements Diagnoses recorded in Medicare claims were used to identify individuals who received a diagnosis of depression from a healthcare provider; pharmacy and claims data were used to identify receipt of antidepressants and psychotherapy by those diagnosed. Results The rate of depression diagnosis more than doubled, reaching 5.8% in 1998. Overall, about two-thirds of those diagnosed received treatment in each year; but those aged 75 and older, those of “Hispanic or other” ethnicity, and those without additional coverage to supplement Medicare were significantly less likely to receive treatment, controlling for other characteristics. If treated, members of these disadvantaged subgroups were less likely to receive psychotherapy. Conclusion Although depression has been thought until recent years to be underrecognized in the elderly, rates of diagnosis increased dramatically in the 1990s, with concomitant increases in treatment. Nevertheless, significant disparities by age, ethnicity, and supplemental insurance coverage persist in treatment of those diagnosed. Because depression is a major source of potentially treatable morbidity in older people, increased efforts are

  13. Medicare Prescription Drug Coverage

    MedlinePlus

    ... people also have to pay an additional monthly cost. Private companies provide Medicare prescription drug coverage. You choose the drug plan you like best. Whether or not you should sign up depends on how good your current coverage is. You need to sign up as ...

  14. Medicare Part D and the Nursing Home Setting

    ERIC Educational Resources Information Center

    Stevenson, David G.; Huskamp, Haiden A.; Newhouse, Joseph P.

    2008-01-01

    Purpose: The purpose of this article is to explore how the introduction of Medicare Part D is changing the operations of long-term-care pharmacies (LTCPs) and nursing homes, as well as implications of those changes for nursing home residents. Design and Methods: We reviewed existing sources of information and interviewed stakeholders across…

  15. Mispricing in the medicare advantage risk adjustment model.

    PubMed

    Chen, Jing; Ellis, Randall P; Toro, Katherine H; Ash, Arlene S

    2015-01-01

    The Centers for Medicare and Medicaid Services (CMS) implemented hierarchical condition category (HCC) models in 2004 to adjust payments to Medicare Advantage (MA) plans to reflect enrollees' expected health care costs. We use Verisk Health's diagnostic cost group (DxCG) Medicare models, refined "descendants" of the same HCC framework with 189 comprehensive clinical categories available to CMS in 2004, to reveal 2 mispricing errors resulting from CMS' implementation. One comes from ignoring all diagnostic information for "new enrollees" (those with less than 12 months of prior claims). Another comes from continuing to use the simplified models that were originally adopted in response to assertions from some capitated health plans that submitting the claims-like data that facilitate richer models was too burdensome. Even the main CMS model being used in 2014 recognizes only 79 condition categories, excluding many diagnoses and merging conditions with somewhat heterogeneous costs. Omitted conditions are typically lower cost or "vague" and not easily audited from simplified data submissions. In contrast, DxCG Medicare models use a comprehensive, 394-HCC classification system. Applying both models to Medicare's 2010-2011 fee-for-service 5% sample, we find mispricing and lower predictive accuracy for the CMS implementation. For example, in 2010, 13% of beneficiaries had at least 1 higher cost DxCG-recognized condition but no CMS-recognized condition; their 2011 actual costs averaged US$6628, almost one-third more than the CMS model prediction. As MA plans must now supply encounter data, CMS should consider using more refined and comprehensive (DxCG-like) models.

  16. Stage of Change for Making an Informed Decision about Medicare Health Plans

    PubMed Central

    Levesque, Deborah A; Cummins, Carol O; Prochaska, Janice M; Prochaska, James O

    2006-01-01

    Objective To assess the applicability of the transtheoretical model of change (TTM) to informed choice in the Medicare population. Data Sources/Study Setting Two hundred and thirty-nine new Medicare enrollees randomly selected from the Center for Medicare and Medicaid Services' October 2001 Initial Enrollee File, a repository of data for persons who are going to turn 65 and become entitled to enroll in Medicare in the next 3 months. Study Design Study participants completed TTM measures of stage of change, decisional balance, and self-efficacy for informed choice, as well as measures of Medicare knowledge, perceived knowledge, and information seeking. Model testing was conducted to determine whether well-established relationships between stage of change, decisional balance, and self-efficacy replicate for informed choice in the Medicare population, and whether Medicare knowledge and information-seeking increase across the stages. Data Collection/Extraction Methods Survey data were collected using mail surveys with telephone follow-up for nonresponders. Principal Findings Predicted relationships were established between stage of change for informed choice and decisional balance, self-efficacy, Medicare knowledge, and information seeking. The amount of variance accounted for by stage of change for informed choice was larger than that found for smoking cessation, where the TTM has had its greatest successes. Conclusions The methods and findings lay the groundwork for development of TTM-based interventions for Medicare beneficiaries, and provide a prototype for the application of the TTM to informed decision making among other types of consumers who are being asked to take more responsibility for their health care. PMID:16899013

  17. DOES MEDICARE SAVE LIVES?*

    PubMed Central

    Card, David; Dobkin, Carlos; Maestas, Nicole

    2009-01-01

    Health insurance characteristics shift at age 65 as most people become eligible for Medicare. We measure the impacts of these changes on patients who are admitted to hospitals through emergency departments for conditions with similar admission rates on weekdays and weekends. The age profiles of admissions and comorbidities for these patients are smooth at age 65, suggesting that the severity of illness is similar on either side of the Medicare threshold. In contrast, the number of procedures performed in hospitals and total list charges exhibit small but statistically significant discontinuities, implying that patients over 65 receive more services. We estimate a nearly 1-percentage-point drop in 7-day mortality for patients at age 65, equivalent to a 20% reduction in deaths for this severely ill patient group. The mortality gap persists for at least 9 months after admission. PMID:19920880

  18. Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers.

    PubMed

    Sacarny, Adam; Yokum, David; Finkelstein, Amy; Agrawal, Shantanu

    2016-03-01

    Inappropriate prescribing is a rising threat to the health of Medicare beneficiaries and a drain on Medicare's finances. In this study we used a randomized controlled trial approach to evaluate a low-cost, light-touch intervention aimed at reducing the inappropriate provision of Schedule II controlled substances in the Medicare Part D program. Potential overprescribers were sent a letter explaining that their practice patterns were highly unlike those of their peers. Using rich administrative data, we were unable to detect an effect of these letters on prescribing. We describe ongoing efforts to build on this null result with alternative interventions. Learning about the potential of light-touch interventions, both effective and ineffective, will help produce a better toolkit for policy makers to improve the value and safety of health care. PMID:26953302

  19. Socioeconomic characteristics of enrollees appear to influence performance scores for medicare part D contractors.

    PubMed

    Young, Gary J; Rickles, Nathaniel M; Chou, Chia-Hung; Raver, Eli

    2014-01-01

    More than 150 private companies contract with the federal government to provide Part D prescription drug benefits to Medicare beneficiaries, either through stand-alone drug plans or as part of Medicare Advantage plans. The Centers for Medicare and Medicaid Services (CMS) evaluates these companies on a set of performance measures, including plan enrollees' medication adherence. We used 2012 data from CMS and data from the US Census Bureau to investigate whether these performance ratings are influenced by the socioeconomic characteristics of enrollee populations. We found that some companies have a substantial advantage over others because of their enrollees' socioeconomic characteristics, with more than a third of the variation in adherence scores tied to these characteristics. CMS should seriously consider adjusting adherence scores to account for differences in the socioeconomic characteristics of enrollee populations. PMID:24395946

  20. New risk-adjustment system was associated with reduced favorable selection in medicare advantage.

    PubMed

    McWilliams, J Michael; Hsu, John; Newhouse, Joseph P

    2012-12-01

    Health plans participating in the Medicare managed care program, called Medicare Advantage since 2003, have historically attracted healthier enrollees than has the traditional fee-for-service program. Medicare Advantage plans have gained financially from this favorable risk selection since their payments have traditionally been adjusted only minimally for clinical characteristics of enrollees, causing overpayment for healthier enrollees and underpayment for sicker ones. As a result, a new risk-adjustment system was phased in from 2004 to 2007, and a lock-in provision instituted to limit midyear disenrollment by enrollees experiencing health declines whose exodus could benefit plans financially. To determine whether these reforms were associated with intended reductions in risk selection, we compared differences in self-reported health care use and health between Medicare Advantage and traditional Medicare beneficiaries before versus after these reforms were implemented. We similarly compared differences between those who switched into or out of Medicare Advantage and nonswitchers. Most differences in 2001-03 were substantially narrowed by 2006-07, suggesting reduced selection. Similar risk-adjustment methods may help reduce incentives for plans competing in health insurance exchanges and accountable care organizations to select patients with favorable clinical risks.

  1. Medicare home health payment reform may jeopardize access for clinically complex and socially vulnerable patients.

    PubMed

    Rosati, Robert J; Russell, David; Peng, Timothy; Brickner, Carlin; Kurowski, Daniel; Christopher, Mary Ann; Sheehan, Kathleen M

    2014-06-01

    The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system.

  2. Telehealth and Medicare: Payment Policy, Current Use, and Prospects for Growth

    PubMed Central

    Gilman, Matlin; Stensland, Jeff

    2013-01-01

    Objective Evaluate the growth in various types of Medicare-paid telehealth services. Background There has been a long-standing hope that telehealth could be used to reduce rural patients’ travel times to specialty physicians. Medicare covers telehealth services provided through live, interactive videoconferencing between a beneficiary located at a certified rural site and a distant practitioner. Methods We analyzed 100% of telehealth Medicare claims for 2009 matched to individual patient ZIP codes and individual provider characteristics. Results Despite increases in Medicare payment rates for telehealth services, expansions of covered services, reductions in provider requirements, and provisions of federal grants to encourage telehealth, growth in adoption of telehealth among providers has been modest. Medicare claims indicate that only 369 providers had 10 or more Medicare telehealth consultations in 2009. Roughly half of the 369 were mental health professionals, and about one-in-five of the 369 were non-physician professionals (e.g., physician assistants and nurse practitioners). On balance, the strong areas of telehealth are mental health and, surprisingly, nonphysician professionals. The comparative advantage of mental health could be the verbal (rather than physical contact) nature of mental health care, and the comparative advantage of non-physician professionals could be their lower labor costs. PMID:24834368

  3. Medicare Part B income-related monthly adjustment amount. Final rules.

    PubMed

    2006-10-27

    We are adding to our regulations a new subpart, Medicare Part B Income-Related Monthly Adjustment Amount, to contain the rules we will follow for Medicare Part B income-related monthly adjustment amount determinations. The monthly adjustment amount represents the amount of decrease in the Medicare Part B premium subsidy, i.e. the amount of the Federal Government's contribution to the Federal Supplementary Medical Insurance (SMI) Trust Fund. This new subpart implements section 811 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (the Medicare Modernization Act or MMA) and contains the rules for determining when, based on income, a monthly adjustment amount will be added to a Medicare Part B beneficiary's standard monthly premium. These final rules describe: What the new subpart is about; what information we will use to determine whether you will pay an income-related monthly adjustment amount and the amount of the adjustment when applicable; when we will consider a major life-changing event that results in a significant reduction in your modified adjusted gross income; and how you can appeal our determination about your income-related monthly adjustment amount.

  4. Obesity and medicare expenditure: accounting for age-related height loss.

    PubMed

    Onwudiwe, Nneka C; Stuart, Bruce; Zuckerman, Ilene H; Sorkin, John D

    2011-01-01

    To determine the relationship between BMI and Medicare expenditure for adults 65-years and older and determine whether this relationship changes after accounting for misclassification due to age-related height loss. Using a cross sectional study design, the relationship between BMI and fee-for-service Medicare expenditure was examined among beneficiaries who completed the Medicare Current Beneficiary Survey (MCBS) in 2002, were not enrolled in Medicare Health Maintenance Organization, had a self-reported height and weight, and were 65 and older (n = 7,706). Subjects were classified as underweight, normal weight, overweight, obese (obese I), and severely obese (obese II/III). To adjust BMI for the artifactual increase associated with age-related height loss, the reported height was transformed by adding the sex-specific age-associated height loss to the reported height in MCBS. The main outcome variable was total Medicare expenditure. There was a significant U-shaped pattern between unadjusted BMI and Medicare expenditure: underweight $4,581 (P < 0.0003), normal weight $3,744 (P < 0.0000), overweight $3,115 (reference), obese I $3,686 (P < 0.0039), and obese II/III $4,386 (P < 0.0000). This pattern persisted after accounting for height loss: underweight $4,640 (P < 0.0000), normal weight $3,451 (P < 0.0507), overweight $3,165 (reference), obese I $3,915 (P < 0.0010), and obese II/III $4,385 (P < 0.0004) compared to overweight. In older adults, minimal cost is not found at "normal" BMI, but rather in overweight subjects with higher spending in the obese and underweight categories. Adjusting for loss-of-height with aging had little affect on cost estimates.

  5. 76 FR 59138 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-23

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  6. 77 FR 59618 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-28

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  7. 78 FR 59702 - Medicare Program; Medicare Appeals: Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-27

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals: Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription...

  8. TRICARE; constructive eligibility for TRICARE benefits of certain persons otherwise ineligible under retroactive determination of entitlement to Medicare Part A hospital insurance benefits. Final rule.

    PubMed

    2012-06-27

    The Department is publishing this final rule to implement section 706 of the National Defense Authorization Act (NDAA) for Fiscal Year 2010, Public Law 111-84. Specifically, section 706 exempts TRICARE beneficiaries under the age of 65 who become disabled from the requirement to enroll in Medicare Part B for the retroactive months of entitlement to Medicare Part A in order to maintain TRICARE coverage. This statutory amendment and final rule only impact eligibility for the period in which the beneficiary's disability determination is pending before the Social Security Administration. Eligible beneficiaries are still required to enroll in Medicare Part B in order to maintain their TRICARE coverage for future months, but are considered to have coverage under the TRICARE program for the retroactive months of their entitlement to Medicare Part A. This final rule also amends the eligibility section of the TRICARE regulation to more clearly address reinstatement of TRICARE eligibility following a gap in coverage due to lack of enrollment in Medicare Part B. PMID:22737761

  9. TRICARE; constructive eligibility for TRICARE benefits of certain persons otherwise ineligible under retroactive determination of entitlement to Medicare Part A hospital insurance benefits. Final rule.

    PubMed

    2012-06-27

    The Department is publishing this final rule to implement section 706 of the National Defense Authorization Act (NDAA) for Fiscal Year 2010, Public Law 111-84. Specifically, section 706 exempts TRICARE beneficiaries under the age of 65 who become disabled from the requirement to enroll in Medicare Part B for the retroactive months of entitlement to Medicare Part A in order to maintain TRICARE coverage. This statutory amendment and final rule only impact eligibility for the period in which the beneficiary's disability determination is pending before the Social Security Administration. Eligible beneficiaries are still required to enroll in Medicare Part B in order to maintain their TRICARE coverage for future months, but are considered to have coverage under the TRICARE program for the retroactive months of their entitlement to Medicare Part A. This final rule also amends the eligibility section of the TRICARE regulation to more clearly address reinstatement of TRICARE eligibility following a gap in coverage due to lack of enrollment in Medicare Part B.

  10. Using north carolina medicare data to assess excess prostate cancer mortality among african americans.

    PubMed

    Schenck; Stroud; Godley; Manning; Schoenbach; Symon

    2000-10-01

    PURPOSE: To investigate the basis for the higher prostate cancer mortality rate for African American (AA) men, which is twice the rate for White men.METHODS: 221 AA and 979 White men with a primary diagnosis code of prostate cancer ("patients") in the North Carolina Medicare Hospitalization claims from 1997 were compared with 1,326 AA and 5,874 White men of the same age with no cancer hospitalizations ("beneficiaries") selected from the NC Medicare Enrollment files. Mortality rates were calculated as the cumulative percent of deaths using the hospital discharge date as day 1. AA and White age distributions were similar.RESULTS: Cumulative mortality percentages at 6, 12, and 18 months were, respectively, 4.5, 7.7, 10.9 for AA patients; 2.8, 6.5, 9.2 for White patients; 2.3, 3.8, 7.4 for AA beneficiaries; and 1.8, 3.1, 6.1 for White beneficiaries.CONCLUSIONS: AA prostate cancer patients had higher overall mortality than did White prostate cancer patients during the first year, but by 12-months the White-Black survival advantage for prostate cancer patients was similar in magnitude to the White-Black survival advantage among the non-cancer Medicare beneficiaries. AAs' higher prostate cancer mortality may derive from higher short-term case fatality rates, which may reflect differences in treatment and access to quality medical care, co-morbidities, and tumor characteristics such as stage and grade at diagnosis, and in part from the survival disadvantage for AA in the general population.

  11. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Final rule.

    PubMed

    2016-09-16

    This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.

  12. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Final rule.

    PubMed

    2016-09-16

    This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters. PMID:27658313

  13. Medicare and Caregivers: Illness and Hospitilization

    MedlinePlus

    ... version of this page please turn Javascript on. Medicare and Caregivers Illness and Hospitalization Facing a chronic ... and give you Medicare-covered services. When Does Medicare Cover Hospital Care? If a person needs to ...

  14. Financial and Quality Impacts of the Medicare Physician Group Practice Demonstration

    PubMed Central

    Pope, Gregory; Kautter, John; Leung, Musetta; Trisolini, Michael; Adamache, Walter; Smith, Kevin

    2014-01-01

    Objective To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes. Data Source Secondary data analysis of 2001–2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups. Study Design We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01–12/04) and five demonstration years (4/05–3/10). We employed a propensity-weighted difference-in-differences regression model to estimate demonstration effects, adjusting for demographics, health status, geographic area, and secular trends. Principal Findings The ten demonstration sites combined saved $171 (2.0%) per assigned beneficiary person year (p<0.001) during the five-year demonstration period. Medicare paid performance bonuses to the participating PGPs that averaged $102 per person year. The net savings to the Medicare program were $69 (0.8%) per person year. Demonstration savings were achieved primarily from the inpatient setting. The demonstration improved quality of care as measured by six of seven claims-based process quality indicators. Conclusions The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program. PMID:25161812

  15. Enrollees Choose Priorities for Medicare

    ERIC Educational Resources Information Center

    Danis, Marion; Biddle, Andrea K.; Goold, Susan Dorr

    2004-01-01

    Purpose: The purpose of this study was to demonstrate the feasibility and results of ascertaining Medicare enrollees' priorities for insured medical benefits. Design and Methods: Structured group exercises were conducted with Medicare enrollees from clinical and community settings in central North Carolina. By participating in a decision exercise,…

  16. 5 CFR 1651.10 - Deceased and non-existent beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... BENEFITS § 1651.10 Deceased and non-existent beneficiaries. (a) Designated beneficiary dies before... the trust were a beneficiary that predeceased the participant. (c) Non-designated beneficiary dies... beneficiary form dies before the participant, the beneficiary's share will be paid equally to other...

  17. 5 CFR 1651.10 - Deceased and non-existent beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... BENEFITS § 1651.10 Deceased and non-existent beneficiaries. (a) Designated beneficiary dies before... the trust were a beneficiary that predeceased the participant. (c) Non-designated beneficiary dies... beneficiary form dies before the participant, the beneficiary's share will be paid equally to other...

  18. 5 CFR 1651.10 - Deceased and non-existent beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... BENEFITS § 1651.10 Deceased and non-existent beneficiaries. (a) Designated beneficiary dies before... the trust were a beneficiary that predeceased the participant. (c) Non-designated beneficiary dies... beneficiary form dies before the participant, the beneficiary's share will be paid equally to other...

  19. 5 CFR 1651.10 - Deceased and non-existent beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... BENEFITS § 1651.10 Deceased and non-existent beneficiaries. (a) Designated beneficiary dies before... the trust were a beneficiary that predeceased the participant. (c) Non-designated beneficiary dies... beneficiary form dies before the participant, the beneficiary's share will be paid equally to other...

  20. 5 CFR 1651.10 - Deceased and non-existent beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... BENEFITS § 1651.10 Deceased and non-existent beneficiaries. (a) Designated beneficiary dies before... the trust were a beneficiary that predeceased the participant. (c) Non-designated beneficiary dies... beneficiary form dies before the participant, the beneficiary's share will be paid equally to other...

  1. 38 CFR 8.19 - Beneficiary and optional settlement changes.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 false Beneficiary and optional settlement changes. 8.19 Section 8.19 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS NATIONAL SERVICE LIFE INSURANCE Beneficiaries § 8.19 Beneficiary and optional settlement changes....

  2. 5 CFR 870.802 - Designation of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 2 2010-01-01 2010-01-01 false Designation of beneficiary. 870.802 Section 870.802 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE... change his/her beneficiary at any time without the knowledge or consent of the previous beneficiary....

  3. 25 CFR 17.13 - Government employees as beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 25 Indians 1 2014-04-01 2014-04-01 false Government employees as beneficiaries. 17.13 Section 17... INDIANS § 17.13 Government employees as beneficiaries. In considering the will of a deceased Osage Indian the superintendent may disapprove any will which names as a beneficiary thereunder a...

  4. 42 CFR 423.293 - Collection of monthly beneficiary premium.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Collection of monthly beneficiary premium. 423.293... Monthly Beneficiary Premiums; Plan Approval § 423.293 Collection of monthly beneficiary premium. (a) General rules. Part D sponsors must— (1) Charge enrollees a consolidated monthly Part D premium equal...

  5. 5 CFR 1651.16 - Missing and unknown beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 3 2013-01-01 2013-01-01 false Missing and unknown beneficiaries. 1651.16 Section 1651.16 Administrative Personnel FEDERAL RETIREMENT THRIFT INVESTMENT BOARD DEATH BENEFITS § 1651.16 Missing and unknown beneficiaries. (a) Locate and identify beneficiaries. (1) The TSP...

  6. 5 CFR 1651.16 - Missing and unknown beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 3 2012-01-01 2012-01-01 false Missing and unknown beneficiaries. 1651.16 Section 1651.16 Administrative Personnel FEDERAL RETIREMENT THRIFT INVESTMENT BOARD DEATH BENEFITS § 1651.16 Missing and unknown beneficiaries. (a) Locate and identify beneficiaries. (1) The TSP...

  7. 5 CFR 1651.16 - Missing and unknown beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 3 2014-01-01 2014-01-01 false Missing and unknown beneficiaries. 1651.16 Section 1651.16 Administrative Personnel FEDERAL RETIREMENT THRIFT INVESTMENT BOARD DEATH BENEFITS § 1651.16 Missing and unknown beneficiaries. (a) Locate and identify beneficiaries. (1) The TSP...

  8. 5 CFR 1651.16 - Missing and unknown beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Missing and unknown beneficiaries. 1651.16 Section 1651.16 Administrative Personnel FEDERAL RETIREMENT THRIFT INVESTMENT BOARD DEATH BENEFITS § 1651.16 Missing and unknown beneficiaries. (a) Locate and identify beneficiaries. (1) The TSP...

  9. 32 CFR 728.55 - Department of Justice beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 5 2012-07-01 2012-07-01 false Department of Justice beneficiaries. 728.55... Federal Agencies § 728.55 Department of Justice beneficiaries. Upon presentation of a letter of... beneficiaries of the Department of Justice. See subpart J on completing and submitting forms for...

  10. 32 CFR 728.55 - Department of Justice beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 5 2010-07-01 2010-07-01 false Department of Justice beneficiaries. 728.55... Federal Agencies § 728.55 Department of Justice beneficiaries. Upon presentation of a letter of... beneficiaries of the Department of Justice. See subpart J on completing and submitting forms for...

  11. 32 CFR 728.55 - Department of Justice beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 5 2011-07-01 2011-07-01 false Department of Justice beneficiaries. 728.55... Federal Agencies § 728.55 Department of Justice beneficiaries. Upon presentation of a letter of... beneficiaries of the Department of Justice. See subpart J on completing and submitting forms for...

  12. 32 CFR 728.55 - Department of Justice beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 5 2013-07-01 2013-07-01 false Department of Justice beneficiaries. 728.55... Federal Agencies § 728.55 Department of Justice beneficiaries. Upon presentation of a letter of... beneficiaries of the Department of Justice. See subpart J on completing and submitting forms for...

  13. 32 CFR 728.55 - Department of Justice beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 5 2014-07-01 2014-07-01 false Department of Justice beneficiaries. 728.55... Federal Agencies § 728.55 Department of Justice beneficiaries. Upon presentation of a letter of... beneficiaries of the Department of Justice. See subpart J on completing and submitting forms for...

  14. 5 CFR 870.909 - Designations and changes of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES' GROUP LIFE INSURANCE PROGRAM Assignments of Life Insurance § 870.909 Designations and changes of beneficiary. (a)(1) An assignment automatically cancels an... may designate a beneficiary or beneficiaries to receive insurance benefits upon the death of...

  15. 25 CFR 17.13 - Government employees as beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 25 Indians 1 2013-04-01 2013-04-01 false Government employees as beneficiaries. 17.13 Section 17... INDIANS § 17.13 Government employees as beneficiaries. In considering the will of a deceased Osage Indian the superintendent may disapprove any will which names as a beneficiary thereunder a...

  16. 32 CFR 728.58 - Federal Aviation Agency (FAA) beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 5 2011-07-01 2011-07-01 false Federal Aviation Agency (FAA) beneficiaries. 728.58 Section 728.58 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL... Federal Agencies § 728.58 Federal Aviation Agency (FAA) beneficiaries. (a) Beneficiaries. Air...

  17. 32 CFR 728.58 - Federal Aviation Agency (FAA) beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 5 2013-07-01 2013-07-01 false Federal Aviation Agency (FAA) beneficiaries. 728.58 Section 728.58 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL... Federal Agencies § 728.58 Federal Aviation Agency (FAA) beneficiaries. (a) Beneficiaries. Air...

  18. 32 CFR 728.58 - Federal Aviation Agency (FAA) beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 5 2012-07-01 2012-07-01 false Federal Aviation Agency (FAA) beneficiaries. 728.58 Section 728.58 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL... Federal Agencies § 728.58 Federal Aviation Agency (FAA) beneficiaries. (a) Beneficiaries. Air...

  19. 32 CFR 728.58 - Federal Aviation Agency (FAA) beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 5 2014-07-01 2014-07-01 false Federal Aviation Agency (FAA) beneficiaries. 728.58 Section 728.58 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL... Federal Agencies § 728.58 Federal Aviation Agency (FAA) beneficiaries. (a) Beneficiaries. Air...

  20. 32 CFR 728.58 - Federal Aviation Agency (FAA) beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 5 2010-07-01 2010-07-01 false Federal Aviation Agency (FAA) beneficiaries. 728.58 Section 728.58 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL... Federal Agencies § 728.58 Federal Aviation Agency (FAA) beneficiaries. (a) Beneficiaries. Air...

  1. 25 CFR 17.13 - Government employees as beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 25 Indians 1 2010-04-01 2010-04-01 false Government employees as beneficiaries. 17.13 Section 17... INDIANS § 17.13 Government employees as beneficiaries. In considering the will of a deceased Osage Indian the superintendent may disapprove any will which names as a beneficiary thereunder a...

  2. 25 CFR 17.13 - Government employees as beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 25 Indians 1 2012-04-01 2011-04-01 true Government employees as beneficiaries. 17.13 Section 17.13....13 Government employees as beneficiaries. In considering the will of a deceased Osage Indian the superintendent may disapprove any will which names as a beneficiary thereunder a government employee who is...

  3. 25 CFR 17.13 - Government employees as beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 25 Indians 1 2011-04-01 2011-04-01 false Government employees as beneficiaries. 17.13 Section 17... INDIANS § 17.13 Government employees as beneficiaries. In considering the will of a deceased Osage Indian the superintendent may disapprove any will which names as a beneficiary thereunder a...

  4. 5 CFR 1651.19 - Beneficiary participant accounts.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... balance and the beneficiary participant's age, using the IRS Single Life Table, 26 CFR 1.401(a)(9)-9, Q&A-1. (3) The TSP will disburse minimum distributions pro rata from the beneficiary participant's... distributed pro rata from the tax-deferred balance and the tax-exempt balance; (4) A beneficiary...

  5. The Beneficiary Perspective - Benefits and Beyond

    EPA Science Inventory

    In this chapter of the Handbook on Ecosystem Services, we first explore distinctions between nature’s benefits and human beneficiaries of nature, and how seemingly slight differences in the definition of ecosystem services can lead to vastly different outcomes. We adopt a ...

  6. Choice Set Size and Decision-Making: The Case of Medicare Part D Prescription Drug Plans

    PubMed Central

    Bundorf, M. Kate; Szrek, Helena

    2013-01-01

    Background The impact of choice on consumer decision-making is controversial in U.S. health policy. Objective Our objective was to determine how choice set size influences decision-making among Medicare beneficiaries choosing prescription drug plans. Methods We randomly assigned members of an internet-enabled panel age 65 and over to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. We used ordered probit models to estimate the effect of choice set size on the study outcomes. Results Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision-making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan. Conclusions Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries. PMID:20228281

  7. 76 FR 21431 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-15

    ....564, 422.624, and 422.626 published April 4, 2003 at 68 FR 16652 are effective June 6, 2011... (70 FR 4588 through 4741 and 70 FR 4194 through 4585, respectively). As we have gained experience with... involving Medicare Advantage (MA) organizations and Medicare Part D prescription drug plan sponsors (72...

  8. 75 FR 32858 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-10

    ...; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Prescription Drug Benefit Programs'' which appeared in the April 15, 2010 Federal Register (FR Doc. 2010-7966... all covered Part D drugs must be included in Part D formularies (75 FR 19767), we indicated that...

  9. Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration

    PubMed Central

    Stason, William B.; Ritter, Grant A; Prottas, Jeffrey; Tompkins, Christopher; Shepard, Donald S.

    2016-01-01

    Background Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head. Methods The demonstration was conducted in 2005–2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework. Results Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa. Conclusion The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased. PMID:26928221

  10. Racial and ethnic group variations in service use in a national sample of Medicare home health care patients with type 2 diabetes mellitus.

    PubMed

    Yeboah-Korang, Amoah; Kleppinger, Alison; Fortinsky, Richard H

    2011-06-01

    Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention.

  11. What does Medicare pay for? Disentangling the flow of funds to health care providers.

    PubMed

    Welch, W P

    1998-01-01

    Many Medicare policies pertain to only part of an expenditure category for which there are publicly available data. Integrating three types of data sources, this DataWatch disaggregates Medicare spending by type of provider. It also disaggregates payments to hospital outpatient departments by type of service. The results reveal a number of patterns obscured by more aggregate figures. For instance, although Medicare pays for most skilled nursing facility (SNF) services through Part A, Part B paid SNFs almost a billion dollars for rehabilitation services in fiscal year 1996. The recipients were not eligible for Part A SNF benefits but were residents of nursing homes.

  12. 75 FR 58407 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-24

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Medicare Appeals; Adjustment... review under the Medicare appeals process. The adjustment to the AIC threshold amounts will be effective... and judicial review at $100 and $1,000, respectively, for Medicare Part A and Part B appeals....

  13. Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change

    PubMed Central

    LEPORE, MICHAEL J.; SHIELD, RENÉE R.; LOOZE, JESSICA; TYLER, DENISE; MOR, VINCENT; MILLER, SUSAN C.

    2016-01-01

    Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices. PMID:25941947

  14. Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change.

    PubMed

    Lepore, Michael J; Shield, Renée R; Looze, Jessica; Tyler, Denise; Mor, Vincent; Miller, Susan C

    2015-01-01

    Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and "culture change" NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH's payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices. PMID:25941947

  15. Rolling Back Medicare Home Health

    PubMed Central

    Komisar, Harriet L.

    2002-01-01

    The Balanced Budget Act (BBA) of 1997 included major changes to Medicare's home health benefit designed to control spending and promote efficient delivery of services. Using national data from Medicare home health claims, this study finds the initial effect of the BBA was to steeply reduce use of the home health benefit and intensify its focus on post-acute skilled nursing and therapy services. The striking responsiveness of home health agencies (HHAs) to altered financial incentives suggests that we may again see large shifts in patterns of care under the new incentives of Medicare's prospective payment system (PPS) for home health. PMID:12690694

  16. Performance of rural health clinics: an examination of efficiency and Medicare beneficiary outcomes

    PubMed Central

    Ortiz, J; Wan, TH

    2012-01-01

    Introduction In 2011, some 3800 Rural Health Clinics (RHCs) delivered primary care in underserved rural areas throughout the USA. To date, little research has been conducted to identify the variability in RHC performance. In an effort to address the knowledge gaps, a national, longitudinal study was conducted of a panel of 3565 RHCs. The goals of the study were to determine: (1) the relationship between two aspects of performance: efficiency and effectiveness; and (2) the factors that influence variation in RHC performance. Methods A non-experimental study of RHC performance was conducted using 2 years of secondary data from multiple sources. A study panel of RHCs was formed. This panel was composed of all RHCs continuously in operation during the period 2006–2007. The study panel was divided into two subsets - one for the provider-based clinics; another for the independent clinics. The individual RHC was the unit of analysis throughout the study. Descriptive statistics were calculated for each subset. Bivariate analyses was conducted of the relationships between the clinic characteristics and the performance outcome measures, as well as the interrelationships between various clinic characteristics using χ2, t-tests, Cramer's V, Pearson correlation, and Spearman correlation statistics. Next, using covariance structure analysis, the interrelationships were examined among the context (community or demographic factors), design (organizational structure and other mediating factors), and performance (efficiency and effectiveness) of RHCs. Three hypotheses were tested: (1) the effectiveness of RHCs is positively influenced by efficiency; (2) there is a reciprocal relationship between RHC efficiency and effectiveness; and (3) large RHCs are more efficient than small RHCs. Results To test the hypotheses that effectiveness of RHCs is positively influenced by efficiency and that there is a reciprocal relationship between efficiency and effectiveness, two covariance structure models were developed and revised: one for independent and one for provider-based RHCs. However, the revised models were not supported by the data. To test the hypothesis that large RHCs are more efficient than small ones, two additional efficiency-based structural equation models were constructed (one for independent RHCs and another for provider-based RHCs). Both of these models were supported by the data (independent model: χ2 = 13.8, df = 8, p = 0.088, relative χ2 = 1.723, adjusted goodness of fit index [AGFI] = .981, root mean square error of approximation [RMSEA] = .034 ; provider-based model: χ2 = 19.011, df = 8, p = 0.015, relative χ2 = 2.376, AGFI = .978, RMSEA = .043). Conclusion This study examined the relationship between efficiency and effectiveness of RHCs. In addition, it identified several factors that influence the variation in RHC performance. The study has implications for optimizing RHC performance, providing quality services to rural populations, and enhancing the value of RHC data. The present is a critical time in the history of RHCs as they transition to meet the goals and expectations of the US health system reform. Additional research is needed to quantify and trend RHCs’ contribution to the rural health delivery system in order to optimize their service to rural populations. PMID:22309096

  17. 42 CFR 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... medical institution); and any individuals deemed to be members of the groups identified in this sentence..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS ELIGIBILITY IN THE STATES... restrictions listed in paragraphs (b) and (e) of this section do not apply to expenditures for...

  18. 42 CFR 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... medical institution); and any individuals deemed to be members of the groups identified in this sentence..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS ELIGIBILITY IN THE STATES... restrictions listed in paragraphs (b) and (e) of this section do not apply to expenditures for...

  19. 42 CFR 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... medical institution); and any individuals deemed to be members of the groups identified in this sentence..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS ELIGIBILITY IN THE STATES... restrictions listed in paragraphs (b) and (e) of this section do not apply to expenditures for...

  20. 42 CFR 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... medical institution); and any individuals deemed to be members of the groups identified in this sentence..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS ELIGIBILITY IN THE STATES... restrictions listed in paragraphs (b) and (e) of this section do not apply to expenditures for...

  1. Responsible Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014

    THOMAS, 113th Congress

    Sen. Hatch, Orrin G. [R-UT

    2014-03-12

    03/13/2014 Read the second time. Placed on Senate Legislative Calendar under General Orders. Calendar No. 330. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  2. Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014

    THOMAS, 113th Congress

    Sen. Wyden, Ron [D-OR

    2014-03-25

    03/26/2014 Read the second time. Placed on Senate Legislative Calendar under General Orders. Calendar No. 336. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  3. 77 FR 43496 - Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-25

    ... comments we published in the Federal Register on December 7, 2010, at 75 FR 75884. The interim final rule... to the Social Security Act (Act) by the Affordable Care Act. The interim final rule allowed us to...: The interim final rule with request for comments published on December 7, 2010 (75 FR 75884)...

  4. Medicare claims data as public use files: a new tool for public health surveillance.

    PubMed

    Erdem, Erkan; Korda, Holly; Haffer, Samuel Chris; Sennett, Cary

    2014-01-01

    Claims data are an important source of data for public health surveillance but have not been widely used in the United States because of concern with personally identifiable health information and other issues. We describe the development and availability of a new set of public use files created using de-identified health care claims for fee-for-service Medicare beneficiaries, including individuals 65 years and older and individuals with disabilities younger than 65 years, and their application as tools for public health surveillance. We provide an overview of these files and their attributes; a review of beneficiary de-identification procedures and implications for analysis; a summary of advantages and limitations for use of the public use files for surveillance, alone and in combination with other data sources; and discussion and examples of their application for public health surveillance using examples that address chronic conditions monitoring, hospital readmissions, and prevalence and expenditures in diabetes care.

  5. Twenty years of Medicare and Medicaid: Covered populations, use of benefits, and program expenditures

    PubMed Central

    Gornick, Marian; Greenberg, Jay N.; Eggers, Paul W.; Dobson, Allen

    1985-01-01

    Marian Gornick is Director, Division of Beneficiary Studies, in the Office of Research, Health Care Financing Administration. She has been involved in research studies relating to Medicare and Medicaid since the programs were first implemented. Jay N. Greenberg is on the faculty of the Heller Graduate School, Brandeis University. Dr. Greenberg serves as the Associate Director for Research of the school's Health Policy Center. Paul W. Eggers is Chief, Program Evaluation Branch, in the Office of Research, Health Care Financing Administration (HCFA). Dr. Eggers’ research activities involve the evaluation of the impact of HCFA programs on the beneficiaries. Allen Dobson is Director, Office of Research, Health Care Financing Administration. Dr. Dobson is responsible for directing the planning and development of the Agency's research agenda. PMID:10311371

  6. Extending Medicare immunosuppressive medication coverage.

    PubMed

    Beaubrun, Anne Christine

    2012-02-01

    African Americans and the poor are at a high risk of suffering from kidney disease and are at an extreme disadvantage when it comes to obtaining the resources needed to maintain a functioning kidney post-transplant. Medicare currently covers 80% of the cost of immunosuppressive therapy for up to three years following a Medicare-covered transplant for patients whose Medicare entitlement was based solely on their end-stage renal disease diagnosis. Adequate insurance coverage has the potential to prevent graft failure and retransplantation resulting from cost-related immunosuppressive medication nonadherence. Given the multifactorial nature of medication nonadherence, extending insurance coverage in an attempt to reduce graft failures should be coupled with intensive interventions to prevent the socioeconomic and various other factors associated with medication nonadherence. Lifetime Medicare coverage for all kidney-transplant recipients, coupled with medication adherence promotion, has the potential to minimize poor outcomes associated with graft failure, especially among minorities and the impoverished.

  7. Staying Healthy: Medicare's Preventive Services

    MedlinePlus

    ... your doctor to test your cholesterol, lipid, and triglyceride levels to help determine if you’re at ... condititions. Medicare covers tests for cholesterol, lipid, and triglyceride levels every 5 years. Colorectal Cancer Screenings These ...

  8. 75 FR 76471 - Medicare Program; Renewal of the Medicare Evidence Development & Coverage Advisory Committee...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-08

    ... FR 68780) announcing the establishment of the Medicare Coverage Advisory Committee (MCAC). The... Evidence Development & Coverage Advisory Committee (MEDCAC) AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. SUMMARY: This notice announces the renewal of the Medicare...

  9. Service-level selection by HMOs in Medicare.

    PubMed

    Cao, Zhun; McGuire, Thomas G

    2003-11-01

    In the federal Medicare program, contracting health maintenance organizations (HMOs) are paid on a capitated basis. There has long been concern that an "adverse selection" of risks remain in the traditional fee-for-service (FFS) sector, since beneficiaries with low costs may leave the FFS sector and join the HMOs. The distortion associated with this form of selection is that health plans may design their mix of health care services in order to effectuate favorable selection. This paper scrutinizes patterns of HMO membership and costs by service in the FFS sector for evidence consistent with the hypothesis that HMOs engage in service-level product distortion. We develop a multi-service model of choice between FFS and HMOs and show that if the HMO sector is underproviding (overproviding) a service relative to the FFS sector, we should observe a positive (negative) correlation between the HMO market share and average costs of those remaining in the FFS sector. We estimate the correlation between the HMO market share and the average FFS costs for different health care services using Medicare data for 1996. We find evidence indicating that there exists significant service-level selection by HMOs.

  10. Access of Rural AFDC Medicaid Beneficiaries to Mental Health Services

    PubMed Central

    Lambert, David; Agger, Marc S.

    1995-01-01

    This article examines geographic differences in the use of mental health services among Aid to Families with Dependent Children (AFDC)-eligible Medicaid beneficiaries in Maine. Findings indicate that rural AFDC beneficiaries have significantly lower utilization of mental health services than urban beneficiaries. Specialty mental health providers account for the majority of ambulatory visits for both rural and urban beneficiaries. However, rural beneficiaries rely more on primary-care providers than do urban beneficiaries. Differences in use are largely explained by variations in the supply of specialty mental health providers. This finding supports the long-held assumption that lower supply is a barrier to access to mental health services in rural areas. PMID:10153467

  11. Medicare and Medicaid; corrections and conforming changes--HCFA. Final rules and corrections.

    PubMed

    1985-08-16

    This document--1. Removes unnecessary rules from the Social Security regulations. 2. Removes reporting requirements that never went into effect because they were not approved by the Office of Management and Budget. 3. Corrects errors and omissions in final rules published in December 1982 and March 1983. 4. Makes technical corrections and conforming changes in other Medicare and Medicaid regulations that deal with payment of benefits, exclusions from Medicare, beneficiary appeals, and physician certification. These changes are needed primarily to conform certain rules to changes made in other regulations since the rules were last published. 5. Redesignates Parts 481 and 488 to make possible a more logical organization of Subchapter E--Standards and Certification.

  12. 26 CFR 1.652(c)-2 - Death of individual beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 26 Internal Revenue 8 2012-04-01 2012-04-01 false Death of individual beneficiaries. 1.652(c)-2... Death of individual beneficiaries. If income is required to be distributed currently to a beneficiary... beneficiary (because of the beneficiary's death), the extent to which the income is included in the...

  13. 26 CFR 1.652(c)-2 - Death of individual beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 26 Internal Revenue 8 2013-04-01 2013-04-01 false Death of individual beneficiaries. 1.652(c)-2... Death of individual beneficiaries. If income is required to be distributed currently to a beneficiary... beneficiary (because of the beneficiary's death), the extent to which the income is included in the...

  14. 26 CFR 1.652(c)-2 - Death of individual beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 26 Internal Revenue 8 2014-04-01 2014-04-01 false Death of individual beneficiaries. 1.652(c)-2... Death of individual beneficiaries. If income is required to be distributed currently to a beneficiary... beneficiary (because of the beneficiary's death), the extent to which the income is included in the...

  15. 26 CFR 1.652(c)-2 - Death of individual beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 26 Internal Revenue 8 2011-04-01 2011-04-01 false Death of individual beneficiaries. 1.652(c)-2... Death of individual beneficiaries. If income is required to be distributed currently to a beneficiary... beneficiary (because of the beneficiary's death), the extent to which the income is included in the...

  16. What Influences the Awareness of Physician Quality Information? Implications for Medicare

    PubMed Central

    Christianson, Jon; Maeng, Daniel; Abraham, Jean; Scanlon, Dennis P; Alexander, Jeffrey; Mittler, Jessica; Finch, Michael

    2014-01-01

    Objective Examine the factors that are associated with awareness of physician quality information (PQI) among older people with one or more chronic illnesses and the implications for Medicare. Data Sources/Study Setting Random digit-dial survey of adults with one or more chronic illnesses. Research Design Structural equation modeling to examine factors related to awareness of PQI. Results Awareness of PQI is low (13 percent), but comparable to findings in general population surveys. Age, race, education, and self-reported health status are associated with PQI awareness. Trust in the Internet as a source of health care information and not trusting one’s physician as a source of information both are associated with a greater likelihood of being aware of PQI. Patients with high levels of activation have greater trust in physicians as information sources, but this is not associated with awareness, nor is degree of satisfaction with their care experience. Conclusions Awareness of PQI among older persons with chronic illnesses is relatively low across all socio-economic and demographic subgroups. Changes in population characteristics over time are unlikely to improve awareness in this population, nor are changes in patient activation or satisfaction with care. Medicare would need a broad-based effort if it wishes to raise PQI awareness among Medicare beneficiaries in the near term. Before undertaking resource-intensive efforts to increase awareness, Medicare may want to consider what level of awareness actually is needed to accomplish the overall objective for PQI transparency, which is raising the quality of care received by beneficiaries. It may be that relatively low levels of awareness are sufficient. PMID:24949225

  17. Medicare Prospective Payment and the Volume and Intensity of Skilled Nursing Facility Services

    PubMed Central

    Grabowski, David C.; Afendulis, Christopher C.; McGuire, Thomas G.

    2011-01-01

    In 1998, Medicare adopted a per diem Prospective Payment System (PPS) for skilled nursing facility care, which was intended to deter the use of high-cost rehabilitative services. The average per diem decreased under the PPS, but because per diems increased for greater therapy minutes, the ability of the PPS to deter the use of high-intensity services was questionable. In this study, we assess how the PPS affected the volume and intensity of Medicare services. By volume we mean the product of the number of Medicare residents in a facility and the average length-of-stay, by intensity we mean the time per week devoted to rehabilitation therapy. Our results indicate that the number of Medicare residents decreased under PPS, but rehabilitative services and therapy minutes increased while length-of-stay remained relatively constant. Not surprisingly, when subsequent Medicare policy changes increased payment rates, Medicare volume far surpassed the levels seen in the pre-PPS period. PMID:21705100

  18. Amendments for regulations regarding major life-changing events affecting income-related monthly adjustment amounts to Medicare Part B premiums. Interim rule with request for comments.

    PubMed

    2010-07-15

    We are modifying our regulations to clarify and revise what we consider major life-changing events for the Medicare Part B income-related monthly adjustment amount (IRMAA) and what evidence we require to support a claim of a major life-changing event. Recent changes in the economy and other unforeseen events have had a significant effect on many Medicare Part B beneficiaries. The changes we are making in this interim final rule will allow us to respond appropriately to circumstances brought about by the current economic climate and other unforeseen events, as described below.

  19. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    PubMed

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures. PMID:26606762

  20. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule.

    PubMed

    2015-11-24

    This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.

  1. Medicare program; medical loss ratio requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit Programs.

    PubMed

    2013-05-23

    This final rule implements new medical loss ratio (MLR) requirements for the Medicare Advantage Program and the Medicare Prescription Drug Benefit Program established under the Patient Protection and Affordable Care Act.

  2. The financial status of Medicare.

    PubMed Central

    Foster, R S

    1998-01-01

    Medicare is the largest health care program in the country, providing medical care to 38 million aged and disabled Americans. Concerns over rapid cost increases and the imminent insolvency of the Medicare Hospital Insurance trust fund led to enactment of sweeping Medicare legislation as part of the Balanced Budget Act of 1997. Preliminary estimates indicate that this legislation will result in program savings of $150 billion in the first five years and will postpone the depletion of the Hospital Insurance fund from the year 2001 until about 2010. While the Balanced Budget Act significantly reduces Hospital Insurance expenditure in the long range, serious deficits are still expected when the "baby boom" generation reaches retirement. The Medicare Supplementary Medical Insurance trust fund is automatically in financial balance, but policy makers remain concerned about continuing rapid cost increases. A new National Bipartisan Commission on the Future of Medicare will attempt to determine effective solutions to these long-range problems. Images p110-a p111-a p111-b PMID:9719810

  3. Adverse and Advantageous Selection in the Medicare Supplemental Market: A Bayesian Analysis of Prescription drug Expenditure.

    PubMed

    Li, Qian; Trivedi, Pravin K

    2016-02-01

    This paper develops an extended specification of the two-part model, which controls for unobservable self-selection and heterogeneity of health insurance, and analyzes the impact of Medicare supplemental plans on the prescription drug expenditure of the elderly, using a linked data set based on the Medicare Current Beneficiary Survey data for 2003-2004. The econometric analysis is conducted using a Bayesian econometric framework. We estimate the treatment effects for different counterfactuals and find significant evidence of endogeneity in plan choice and the presence of both adverse and advantageous selections in the supplemental insurance market. The average incentive effect is estimated to be $757 (2004 value) or 41% increase per person per year for the elderly enrolled in supplemental plans with drug coverage against the Medicare fee-for-service counterfactual and is $350 or 21% against the supplemental plans without drug coverage counterfactual. The incentive effect varies by different sources of drug coverage: highest for employer-sponsored insurance plans, followed by Medigap and managed medicare plans. PMID:25504934

  4. Adverse and Advantageous Selection in the Medicare Supplemental Market: A Bayesian Analysis of Prescription drug Expenditure.

    PubMed

    Li, Qian; Trivedi, Pravin K

    2016-02-01

    This paper develops an extended specification of the two-part model, which controls for unobservable self-selection and heterogeneity of health insurance, and analyzes the impact of Medicare supplemental plans on the prescription drug expenditure of the elderly, using a linked data set based on the Medicare Current Beneficiary Survey data for 2003-2004. The econometric analysis is conducted using a Bayesian econometric framework. We estimate the treatment effects for different counterfactuals and find significant evidence of endogeneity in plan choice and the presence of both adverse and advantageous selections in the supplemental insurance market. The average incentive effect is estimated to be $757 (2004 value) or 41% increase per person per year for the elderly enrolled in supplemental plans with drug coverage against the Medicare fee-for-service counterfactual and is $350 or 21% against the supplemental plans without drug coverage counterfactual. The incentive effect varies by different sources of drug coverage: highest for employer-sponsored insurance plans, followed by Medigap and managed medicare plans.

  5. 76 FR 52955 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-24

    ... HUMAN SERVICES Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports.... SUMMARY: This notice announces public meetings of the Technical Advisory Panel on Medicare Trustee Reports... assumptions in projecting Medicare health spending for Parts C and D and may make recommendations to...

  6. New Directions for Medicare Payment Systems

    PubMed Central

    Goody, Brigid; Friedman, Maria A.; Sobaski, William

    1994-01-01

    This overview discusses articles published in this issue of the Health Care Financing Review, entitled “Medicare Payment Systems: Moving Toward the Future.” These articles focus on the onjoing development of Medicare payment methodologies, their adoption by non-Medicare payers, and issues to be addressed in the development of all-payer systems based on these methodologies. PMID:10142366

  7. 5 CFR 1651.19 - Beneficiary participant accounts.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... balance and the beneficiary participant's age, using the IRS Single Life Table, 26 CFR 1.401(a)(9)-9, Q&A... participant must use the transfer form provided by the TSP. (h) Periodic statements. The TSP will furnish beneficiary participants with periodic statements in a manner consistent with part 1640 of this chapter....

  8. 38 CFR 8.27 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2011-07-01 2011-07-01 false Conditional designation of beneficiary. 8.27 Section 8.27 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Conditional designation of beneficiary. If the insured by notice in writing to the Department of...

  9. 38 CFR 6.5 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2014-07-01 2014-07-01 false Conditional designation of beneficiary. 6.5 Section 6.5 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Veterans Affairs during his or her lifetime has provided that a designated beneficiary shall be entitled...

  10. 38 CFR 6.5 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2013-07-01 2013-07-01 false Conditional designation of beneficiary. 6.5 Section 6.5 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Veterans Affairs during his or her lifetime has provided that a designated beneficiary shall be entitled...

  11. 38 CFR 6.5 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2011-07-01 2011-07-01 false Conditional designation of beneficiary. 6.5 Section 6.5 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Veterans Affairs during his or her lifetime has provided that a designated beneficiary shall be entitled...

  12. 38 CFR 8.27 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2014-07-01 2014-07-01 false Conditional designation of beneficiary. 8.27 Section 8.27 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Conditional designation of beneficiary. If the insured by notice in writing to the Department of...

  13. 38 CFR 8.27 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2013-07-01 2013-07-01 false Conditional designation of beneficiary. 8.27 Section 8.27 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Conditional designation of beneficiary. If the insured by notice in writing to the Department of...

  14. 38 CFR 6.6 - Change of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... GOVERNMENT LIFE INSURANCE Beneficiary of United States Government Life Insurance § 6.6 Change of beneficiary. The insured under United States Government life insurance shall have the right at any time and from... privilege given under the provisions of a United States Government life insurance policy without the...

  15. 38 CFR 6.5 - Conditional designation of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... AFFAIRS UNITED STATES GOVERNMENT LIFE INSURANCE Beneficiary of United States Government Life Insurance § 6... the proceeds of United States Government life insurance only if such beneficiary shall survive him or... specified period, payment of the proceeds of United States Government life insurance will be made as if...

  16. 32 CFR 728.59 - Peace Corps beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ...) Immunizations. Immunizations, as requested, may be provided all beneficiaries listed in paragraph (a) of this...; however, help may be required of naval MTFs for ancillary services. (2) Immunizations. When requested, immunizations may be provided all beneficiaries listed in paragraph (a) of this section. (3) Medical care....

  17. 32 CFR 728.59 - Peace Corps beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ...) Immunizations. Immunizations, as requested, may be provided all beneficiaries listed in paragraph (a) of this...; however, help may be required of naval MTFs for ancillary services. (2) Immunizations. When requested, immunizations may be provided all beneficiaries listed in paragraph (a) of this section. (3) Medical care....

  18. 5 CFR 1651.19 - Beneficiary participant accounts.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... balance and the beneficiary participant's age, using the IRS Single Life Table, 26 CFR 1.401(a)(9)-9, Q&A... distributed pro rata from all sources; (4) A beneficiary participant may transfer or roll over all or...

  19. 5 CFR 1651.19 - Beneficiary participant accounts.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... balance and the beneficiary participant's age, using the IRS Single Life Table, 26 CFR 1.401(a)(9)-9, Q&A... distributed pro rata from all sources; (4) A beneficiary participant may transfer or roll over all or...

  20. Employment among Social Security disability program beneficiaries, 1996-2007.

    PubMed

    Mamun, Arif; O'Leary, Paul; Wittenburg, David C; Gregory, Jesse

    2011-01-01

    We use linked administrative data from program and earnings records to summarize the 2007 employment rates of Social Security disability program beneficiaries at the national and state levels, as well as changes in employment since 1996. The findings provide new information on the employment activities of beneficiaries that should be useful in assessing current agency policies and providing benchmarks for ongoing demonstration projects and future return-to-work initiatives. The overall employment rate--which we define as annual earnings over $1,000--was 12 percent in 2007. Substantial variation exists within the population. Disability Insurance beneficiaries and those younger than age 40 were much more likely to work relative to other Social Security beneficiaries. Additionally, substantial regional variation exists across states; employment rates ranged from 7 percent (West Virginia) to 23 percent (North Dakota). Moreover, we find that the employment rates among beneficiaries were sensitive to the business cycle and persistent over time.