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  1. Medicare Beneficiary Knowledge: Measurement Implications from a Qualitative Study

    PubMed Central

    Teal, Cayla R.; Paterniti, Debora A.; Murphy, Christi L.; John, Dolly A.; Morgan, Robert O.

    2006-01-01

    Medicare beneficiary knowledge about fee-for-service (FFS) Medicare versus managed care alternatives (MCA) has been studied extensively. However, these efforts might be compromised by lack of familiarity with common Medicare terminology. We used qualitative methods to examine beneficiaries' familiarity with Medicare Programs (FFS and MCA) and terminology. Twenty-one indepth, semi-structured beneficiary interview transcripts were analyzed through iterative review. Across sex, race/ethnicity, and benefits programs, participants found interview questions with Medicare terminology difficult to answer, potentially causing missing, incorrect, and inaccurate responses to interview questions. Assessment of beneficiary knowledge may be fundamentally impacted by absence of basic familiarity with Medicare Programs terminology. PMID:17290655

  2. 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

  3. 32 CFR 728.61 - Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... Disabled (Medicare) who reside in the 50 United States and the District of Columbia, Guam, Puerto Rico, the... attention could reasonably be expected to result in: (1) Placing the patient's health in serious jeopardy... and it is permissible from a medical standpoint, discharge or transfer the patient to a facility...

  4. Beneficiaries' perceptions of new Medicare health plan choice print materials.

    PubMed

    Harris-Kojetin, L D; McCormack, L A; Jaël, E M; Lissy, K S

    2001-01-01

    This article presents findings from a study involving seven focus groups with aged and disabled Medicare beneficiaries in the Kansas City area regarding their impressions of a pilot version of the Medicare & You 1999 handbook and the Medicare Consumer Assessment of Health Plans Study (CAHPS) survey report. Beneficiaries generally had positive reactions to both booklets and viewed the handbook as an important reference tool. Based on the findings, we present policy recommendations for the development and dissemination of Medicare health plan information to beneficiaries.

  5. Providing information to help Medicare beneficiaries choose a health plan.

    PubMed

    McCormack, L A; Burrus, B B; Garfinkel, S A; Gibbs, D; Harris-Kojetin, L D; Sangl, J A

    2001-01-01

    Many Medicare beneficiaries have limited knowledge of the Medicare program and related health insurance options. This is due in part to the complexity of the Medicare program and supplemental health insurance market. A recent congressional mandate through the Balanced Budget Act of 1997 called for broad dissemination of information to educate beneficiaries about their health plan options and to encourage informed health plan decision-making. In response, the Health Care Financing Administration (HCFA) launched the National Medicare Education Program (NMEP) to support the educational objectives of the BBA. This paper provides an overview of the components of the NMEP information campaign. We also review lessons learned from our experience in designing and testing a prototype consumer handbook that explains the different health plan options to Medicare beneficiaries. Through our discussion of the handbook, we highlight several ways to communicate information effectively about a complex publicly funded program to an older adult population.

  6. 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…

  7. Managed care and medical expenditures of Medicare beneficiaries.

    PubMed

    Chernew, Michael; Decicca, Philip; Town, Robert

    2008-12-01

    This paper investigates the impact of Medicare HMO penetration on the medical care expenditures incurred by Medicare fee-for-service (FFS) enrollees. We find that increasing penetration leads to reduced spending on FFS beneficiaries. In particular, our estimates suggest that the increase in HMO penetration during our study period led to approximately a 7% decline in spending per FFS beneficiary. Similar models for various measures of health care utilization find penetration-induced reductions consistent with our spending estimates. Finally, we present evidence that suggests our estimated spending reductions are driven by beneficiaries who have at least one chronic condition.

  8. Balance billing under Medicare: protecting beneficiaries and preserving physician participation.

    PubMed

    Colby, D C; Rice, T; Bernstein, J; Nelson, L

    1995-01-01

    Medicare's experience with balance billing provides valuable lessons for policy making for national or state health care reform. Medicare developed several policies to encourage physicians to become participating providers who accept Medicare-allowed charges as payment in full. Only nonparticipating physicians are permitted to bill for additional amounts beyond that paid by Medicare, and there are limits on the amount of balance billing per claim. As shown by the analysis of claims presented in this article, Medicare has successfully provided financial protection to beneficiaries. In 1986, more than 60 percent of expenditures for physician services were on assigned claims for which there could be no balance billing; by 1990, 80 percent of expenditures were on assigned claims. Balance billing decreased by about 30 percent during the same period. Although these policies have been successful in reducing total expenditures for balance billing, they may not provide financial protection to the most economically vulnerable beneficiaries. Using survey and claims data, we found that the poor have lower balance billing expenditures for services provided by primary care physicians, but that there is no relationship between poverty status and balance billing expenditures for services of nonprimary care physicians. In addition, most low-income beneficiaries are liable for balance bills. Under health care reform, adoption of Medicare's incentive-based approach with mandatory assignment for the poor would allow for some choice based on price and would provide financial protection for all consumers.

  9. Medicare beneficiary out-of-pocket costs: are Medicare Advantage Plans a better deal?

    PubMed

    Biles, Brian; Hersch Nicholas, Lauren; Guterman Stuart, Stuart

    2006-05-01

    The creators of the Medicare Advantage (MA) program envisioned that seniors would opt out of fee-for-service Medicare to take advantage of the lower premiums, lower cost-sharing, and additional benefits available in private plans. Earlier research, however, indicates that out-of-pocket costs for MA enrollees vary widely by health status and plan benefit package. This issue brief examines out-of-pocket costs for beneficiaries in good, fair, and poor health throughout the country. In 2005, annual out-of-pocket costs for plan members ranged from under $100 for beneficiaries in good health to over $6,000 for those in poor health. Costs for beneficiaries in poor health would actually have been higher than fee-for-service in 19 of the 88 MA plans examined. Despite the high payments, relative to fee-for-service costs, that MA plans receive from Medicare to enrich enrollee benefits, these plans may not always be a good deal for sicker beneficiaries who use more health services.

  10. 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…

  11. 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…

  12. Impact of HIV Infection on Medicare Beneficiaries with Lung Cancer.

    PubMed

    Lee, Jeannette Y; Moore, Page C; Lensing, Shelly Y

    2012-01-01

    The incidence of lung cancer among individuals infected with the human immunodeficiency virus (HIV) is elevated compared to that among the general population. This study examines the prevalence of HIV and its impact on outcomes among Medicare beneficiaries who are 65 years of age or older and were diagnosed with nonsmall cell lung cancer (NSCLC) between 1997 and 2008. Prevalence of HIV was estimated using the Poisson point estimate and its 95% confidence interval. Relative risks for potential risk factors were estimated using the log-binomial model. A total of 111,219 Medicare beneficiaries met the study criteria. The prevalence of HIV was 156.4 per 100,000 (95% CI: 140.8 to 173.8) and has increased with time. Stage at NSCLC diagnosis did not vary by HIV status. Mortality rates due to all causes were 44%, 76%, and 88% for patients with stage I/II, III, and IV NSCLC, respectively. Across stages of disease, there was no difference between those who were HIV-infected and those who were not with respect to overall mortality. HIV patients, however, were more likely to die of causes other than lung cancer than their immunocompetent counterparts.

  13. 77 FR 43496 - Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-25

    ... for Medicare prescription drug coverage premiums when they went into effect on January 1, 2011. DATES... Medicare Beneficiaries' Prescription Drug Coverage Premiums AGENCY: Social Security Administration. ACTION... prescription drug coverage (also known as Medicare Part D) premiums. This new subpart implemented changes...

  14. Geographic Variation in Use of Vestibular Testing among Medicare Beneficiaries.

    PubMed

    Adams, Meredith E; Marmor, Schelomo; Yueh, Bevan; Kane, Robert L

    2017-02-01

    Objective There is a lack of consensus regarding the indications for vestibular testing in the evaluation of dizziness and balance disorders. Geographic variation in health services utilization is associated with lack of consensus. To understand the variation in current practice, we investigated the patterns of use of vestibular testing and diagnosis codes for dizziness and balance disorders among individuals ≥65 years of age across different regions of the United States. Study Design Cross-sectional study. Setting Medicare administrative claims data. Subjects and Methods Using the Summarized Denominator file, a sample of the US population linked to the Surveillance, Epidemiology, and End Results (SEER)-Medicare files (years 2000-2010), we identified persons who were ≥65 years of age. We used multivariable analyses to determine the factors associated with vestibular testing and diagnoses. Results Of the 231,984 eligible Medicare beneficiaries, 27% were diagnosed with dizziness and balance disorders. Patterns of use of vestibular tests (eye movement recording for spontaneous nystagmus, caloric testing, and rotary chair testing) varied significantly by geographic region. Rotary chair test utilization varied most. We found significant geographic variation in vestibular testing and diagnoses after controlling for age, sex, race, Medicaid participation, and rurality. Conclusions There may be opportunities to improve the consistency and efficiency of care for dizziness and balance disorders. It will be important to define appropriate levels of vestibular diagnostic testing and which tests add sufficient value to justify the costs. Further work is needed to better characterize the causes and consequences of variation in vestibular test utilization.

  15. 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…

  16. 42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Ordering covered items and services for Medicare... services for Medicare beneficiaries. (a) Conditions for payment of claims for ordered covered imaging and... (DMEPOS)—(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To...

  17. 42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Ordering covered items and services for Medicare... services for Medicare beneficiaries. (a) Conditions for payment of claims for ordered covered imaging and... (DMEPOS)—(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To...

  18. 42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Ordering covered items and services for Medicare... services for Medicare beneficiaries. (a) Conditions for payment of claims for ordered covered imaging and... (DMEPOS)—(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To...

  19. 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.

  20. Viva La Vida: Helping Latino Medicare Beneficiaries With Diabetes Live Their Lives to the Fullest

    PubMed Central

    Olson, Rebecca; Sabogal, Fabio; Perez, Ana

    2008-01-01

    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

  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. Severe Adverse Events Following Cataract Surgery Among Medicare Beneficiaries

    PubMed Central

    Stein, Joshua D.; Grossman, Daniel S.; Mundy, Kevin M.; Sugar, Alan; Sloan, Frank A.

    2012-01-01

    Purpose To determine rates and risk factors associated with severe post-operative complications following cataract surgery and whether they have been changing over the past decade. Design Retrospective longitudinal cohort study Participants 221,594 Medicare beneficiaries who underwent cataract surgery during 1994–2006. Methods Beneficiaries were stratified into 3 cohorts, those who underwent initial cataract surgery during 1994-5, 1999–2000, or 2005-6. One year rates of post-operative severe adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) were determined for each cohort. Cox regression analyses determined the hazard of developing severe adverse events for each cohort with adjustment for demographic factors, ocular and medical conditions, and surgeon case-mix. Main Outcome Measures Time period rates of development of severe post-operative adverse events. Results Among the 221,594 individuals who underwent cataract surgery, 0.5% (1,086) had at least one severe post-operative complication. After adjustment for confounders, individuals who underwent cataract surgery during 1994-5 had a 21% increased hazard of being diagnosed with a severe post-operative complication (Hazard Ratio (HR): 1.21; [95% Confidence Interval (CI): 1.05–1.41]) relative to individuals who underwent cataract surgery during 2005-6. Those who underwent cataract surgery during 1999–2000 had a 20% increased hazard of experiencing a severe complication (HR: 1.20 [95% CI: 1.04–1.39]) relative to the 2005-6 cohort. Risk factors associated with severe adverse events include a prior diagnosis of proliferative diabetic retinopathy (HR: 1.62 [95% CI: 1.07–2.45]) and cataract surgery combined with another intraocular surgical procedure on the same day (HR: 2.51 [95% CI: 2.07–3.04]). Individuals receiving surgery by surgeons with the case-mix least prone to developing a severe adverse event (HR: 0.52 [95% CI: 0.44–0.62]) had a 48% reduced hazard of a severe

  3. 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

  4. 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.

  5. 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

  6. Racial Disparities in Poverty Account for Mortality Differences in US Medicare Beneficiaries.

    PubMed

    Kimmel, Paul L; Fwu, Chyng-Wen; Abbott, Kevin C; Ratner, Jonathan; Eggers, Paul W

    2016-12-01

    Higher mortality in Blacks than Whites has been consistently reported in the US, but previous investigations have not accounted for poverty at the individual level. The health of its population is an important part of the capital of a nation. We examined the association between individual level poverty and disability and racial mortality differences in a 5% Medicare beneficiary random sample from 2004 to 2010. Cox regression models examined associations of race with all-cause mortality, adjusted for demographics, comorbidities, disability, neighborhood income, and Medicare "Buy-in" status (a proxy for individual level poverty) in 1,190,510 Black and White beneficiaries between 65 and 99 years old as of January 1, 2014, who had full and primary Medicare Part A and B coverage in 2004, and lived in one of the 50 states or Washington DC. Overall, black beneficiaries had higher sex-and-age adjusted mortality than Whites (hazard ratio [HR] 1.18). Controlling for health-related measures and disability reduced the HR for Black beneficiaries to 1.03. Adding "Buy-in" as an individual level covariate lowered the HR for Black beneficiaries to 0.92. Neither of the residential measures added to the predictive model. We conclude that poorer health status, excess disability, and most importantly, greater poverty among Black beneficiaries accounts for racial mortality differences in the aged US Medicare population. Poverty fosters social and health inequalities, including mortality disparities, notwithstanding national health insurance for the US elderly. Controlling for individual level poverty, in contrast to the common use of area level poverty in previous analyses, accounts for the White survival advantage in Medicare beneficiaries, and should be a covariate in analyses of administrative databases.

  7. Rural and urban Medicare beneficiaries use remarkably similar amounts of health care services.

    PubMed

    Stensland, Jeffrey; Akamigbo, Adaeze; Glass, David; Zabinski, Daniel

    2013-11-01

    Medicare payment policies for rural health care providers are influenced by the assumption that the limited supply of physicians in rural areas causes rural Medicare beneficiaries to receive fewer health care services than their urban counterparts do. This assumption has contributed to the growth in special payments to rural providers. As a result, Medicare pays rural providers $3 billion more each year in special payments than they would receive under traditional payment rates. To test the validity of the assumption that rural beneficiaries systematically receive less care, we analyzed claims data for all Medicare fee-for-service beneficiaries in 2008, stratified by rural/urban status and region. After adjusting for health status, we found no significant differences between rural and urban beneficiaries in either the amount of health care received or satisfaction with access to care. Although there were systematic differences in the amount of care used across regions of the country, there was very little difference within a region between rural and urban areas. To the extent that Medicare payment policies are designed to ensure access, they should be assessed on the basis of achieving similar service use rather than similar local physician supply. They should also be targeted to isolated rural providers needed to preserve access to care.

  8. Health and Health Care of Medicare Beneficiaries in 2030.

    PubMed

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

    2015-12-01

    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.

  9. 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

  10. 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…

  11. 75 FR 32480 - Funding Opportunity: Affordable Care Act Medicare Beneficiary Outreach and Assistance Program...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-08

    ... Outreach and Assistance Program Funding for Title VI Native American Programs Purpose of Notice... Medicare Beneficiary Outreach and Assistance Program Funding for Title VI Native American Programs... Older Americans Act Title VI Native American program awardee. The purpose of these grants will be...

  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

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Calculation of national beneficiary copayment 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...

  13. 42 CFR 419.41 - Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Calculation of national beneficiary copayment 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...

  14. 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.

  15. 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

  16. 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…

  17. Disability Stage and Receipt of Recommended Care among Elderly Medicare Beneficiaries

    PubMed Central

    Na, Ling; Hennessy, Sean; Bogner, Hillary R.; Kurichi, Jibby E.; Stineman, Margaret; Streim, Joel E.; Kwong, Pui L.; Xie, Dawei; Pezzin, Liliana E.

    2017-01-01

    Background Receipt of recommended care among older adults is generally low. Findings regarding service use among persons with disabilities supports the notion of disparities but provides inconsistent evidence of underuse of recommended care. Objective To examine the extent to which receipt of recommended care among older Medicare beneficiaries varies by disability status, using a newly developed staging method to classify individuals according to disability. Methods In a cohort study, we included community-dwelling Medicare beneficiaries aged 65 and older who participated in the Medicare Current Beneficiary Survey between 2001 and 2008. Logistic regression modeling assessed the association of receiving recommended care on 38 indicators across different activity limitation stages. Results Nearly one out of every three elderly Medicare beneficiaries did not receive overall recommended care. Adjusted odds ratios (ORs) revealed a decrease in use of recommended care with increasing activity limitation stage. For instance, ORs (95% CIs) across mild, moderate, severe and complete limitation stages (stages I–IV) compared to no limitation (stage 0) in ADL were 0.99 (0.94–1.05), 0.89 (0.83–0.95), 0.81 (0.75–0.89) and 0.56 (0.46–0.68). Disparities in receipt of recommended care by disability stage were most marked for care related to post-hospitalization follow-up and, to a lesser degree, care of chronic conditions and preventive care. Conclusions Elderly beneficiaries at higher activity limitation stages experienced substantial disparities in receipt of recommended care. Tailored interventions may be needed to reduce disparities in receipt of recommended medical care in this population. PMID:27765676

  18. Geographic Variations in Incremental Costs of Heart Disease Among Medicare Beneficiaries, by Type of Service, 2012

    PubMed Central

    Ritchey, Matthew; Hockenberry, Jason; Casper, Michele

    2016-01-01

    Using 2012 data on fee-for-service Medicare claims, we documented regional and county variation in incremental standardized costs of heart disease (ie, comparing costs between beneficiaries with heart disease and beneficiaries without heart disease) by type of service (eg, inpatient, outpatient, post-acute care). Absolute incremental total costs varied by region. Although the largest absolute incremental total costs of heart disease were concentrated in southern and Appalachian counties, geographic patterns of costs varied by type of service. These data can be used to inform development of policies and payment models that address the observed geographic disparities. PMID:28033089

  19. 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

  20. Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries

    PubMed Central

    McWilliams, J. Michael; Chernew, Michael E.; Zaslavsky, Alan M.; Hamed, Pasha; Landon, Bruce E.

    2013-01-01

    Background The Medicare accountable care organization (ACO) programs rely on delivery system integration and provider risk sharing to lower spending while improving quality of care. Methods Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5,000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We compared spending and quality of care between larger and smaller provider groups and examined how size-related differences varied by 2 factors considered central to ACO performance: group primary care orientation (measured by the primary care share of large groups’ specialty mix) and provider risk sharing (measured by county health maintenance organization penetration and its relationship to financial risk accepted by different group types for managed care patients). Spending and quality of care measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Results Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference: +$849), higher 30-day readmission rates (+1.3% percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (−$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Conclusions Spending

  1. Is there disparity in physician service use? A comparison of Hispanic and white Medicare beneficiaries.

    PubMed

    Chen, Li-Mei

    2010-08-01

    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 physician's office visits. Racial and ethnic differences were found in the predictor variables of initial contact with the physician and volume of physician service use. Besides needs factors, poverty level and having Medicaid were also significant predictors. Oaxaca decomposition analysis indicated that Hispanic beneficiaries' being less likely to make the initial physician contact could not be explained only by racial and ethnic differences. Although findings point to the equitable and nondiscriminatory treatment of Hispanic beneficiaries already using physician services, there is variance in the entry point of contact with a general physician for this minority group. Implications for social work are discussed.

  2. 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

  3. Offering Lung Cancer Screening to High-Risk Medicare Beneficiaries Saves Lives and Is Cost-Effective: An Actuarial Analysis

    PubMed Central

    Pyenson, Bruce S.; Henschke, Claudia I.; Yankelevitz, David F.; Yip, Rowena; Dec, Ellynne

    2014-01-01

    Background By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening. Objective To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer. Methods Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures. Results Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life

  4. Medicare doesn't work as well for younger, disabled beneficiaries as it does for older enrollees.

    PubMed

    Cubanski, Juliette; Neuman, Patricia

    2010-09-01

    Medicare is not working as well for its eight million disabled beneficiaries under age sixty-five as it is for its older beneficiaries. We report on a 2008 survey that found significant differences between the two Medicare populations, with the younger group experiencing more problems of cost and access. Even with the Medicare Part D prescription drug program, the nonelderly disabled reported greater difficulty in affording medications, and more adverse health consequences as a result. One potential remedy is the Patient Protection and Affordable Care Act. The law includes reforms that could improve access to care and limit out-of-pocket expenses for the nonelderly disabled in Medicare-as well as those who are waiting to become eligible for the program.

  5. 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

  6. Prescription Opioid Use among Disabled Medicare Beneficiaries: Intensity, Trends and Regional Variation

    PubMed Central

    Munson, Jeffrey C.; Colla, Carrie H.; Skinner, Jonathan S.; Bynum, Julie P.W.; Zhou, Weiping; Meara, Ellen R.

    2014-01-01

    Background Prescription opioid use and overdose deaths are increasing in the U.S. Among under-age-65, disabled Medicare beneficiaries, the rise in musculoskeletal conditions as qualifying diagnoses suggests opioid analgesic use may be common and increasing, raising safety concerns. Methods From a 40% random-sample Medicare denominator, we identified fee-for-service beneficiaries under-age-65 and created annual enrollment cohorts 2007-2011 (6.4 million person-years). We obtained adjusted, annual opioid use measures: any use, chronic use (≥6 prescriptions), intensity of use (daily morphine equivalent dose (MED)), opioid prescribers per user. Geographic variation was studied across Hospital Referral Regions (HRRs). Results Most measures peaked in 2010. The adjusted proportion with any opioid use was 43.9% in 2007, 44.7% in 2010 and 43.7% in 2011. The proportion with chronic use rose from 21.4% in 2007 to 23.1%, in 2011. Among chronic users: mean MED peaked at 81.3 mg in 2010, declining to 77.4 mg in 2011; in 2011, 19.8% received ≥ 100 mg MED; 10.4% received ≥200 mg. In 2011 HRR-level measures varied broadly (5th to 95th percentile): any use: 33.0% to 58.6%, chronic use: 14.0% to 36.6%; among chronic users, mean MED ranged from 45 mg to 125 mg; mean annual opioid prescribers from 2.4 to 3.7. Conclusions Among these beneficiaries, opioid use was common. While intensity stabilized, the population using opioids chronically grew. Variation shows a lack of standardized approach and reveals regions with mean MED at levels associated with overdose risk. Future work should assess outcomes, chronic use predictors and policies balancing pain control and safety. PMID:25119955

  7. 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

  8. Local Population Characteristics and Hemoglobin A1c Testing Rates among Diabetic Medicare Beneficiaries

    PubMed Central

    Yasaitis, Laura C.; Bubolz, Thomas; Skinner, Jonathan S.; Chandra, Amitabh

    2014-01-01

    Background Proposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers' control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown. Methods HbA1c tests were recorded for 480,745 diabetic Medicare beneficiaries. Spatial analysis was used to create ZIP code-level estimated testing rates. Associations of testing rates with local population characteristics that are outside the control of providers – population density, the percent African American, with less than a high school education, or living in poverty – were assessed. Results In 2009, 83.3% of diabetic Medicare beneficiaries received HbA1c tests. Estimated ZIP code-level rates ranged from 71.0% in the lowest decile to 93.1% in the highest. With each 10% increase in the percent of the population that was African American, associated HbA1c testing rates were 0.24% lower (95% CI −0.32–−0.17); for identical increases in the percent with less than a high school education or the percent living in poverty, testing rates were 0.70% lower (−0.95–−0.46) and 1.6% lower (−1.8–−1.4), respectively. Testing rates were lowest in the least and most densely populated ZIP codes. Population characteristics explained 5% of testing rate variations. Conclusions HbA1c testing rates are associated with population characteristics, but these characteristics fail to explain the vast majority of variations. Consequently, even complete risk-adjustment may have little impact on some process of care quality measures; much of the ZIP code-related variations in testing rates likely result from provider-based differences and idiosyncratic local factors not related to

  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. Health insurance and access to care among Social Security Disability Insurance beneficiaries during the Medicare waiting period.

    PubMed

    Riley, Gerald F

    2006-01-01

    For most Social Security Disability Insurance (SSDI) beneficiaries, Medicare entitlement begins 24 months after the date of SSDI entitlement. Many may experience poor access to health care during the 24-month waiting period because of a lack of insurance. National Health Interview Survey data for the period 1994-1996 were linked to Social Security and Medicare administrative records to examine health insurance status and access to care during the Medicare waiting period. Twenty-six percent of SSDI beneficiaries reported having no health insurance, with the uninsured reporting many more problems with access to care than insured individuals. Access to health insurance is especially important for people during the waiting period because of their low incomes, poor health, and weak ties to the workforce.

  11. Regional Variation in Use of a New Class of Antidiabetic Medication Among Medicare Beneficiaries: The Case of Incretin Mimetics

    PubMed Central

    Marcum, Zachary A.; Driessen, Julia; Thorpe, Carolyn T.; Donohue, Julie M.; Gellad, Walid F.

    2016-01-01

    Background When incretin mimetic (IM) medications were introduced in 2005, their effectiveness compared other less-expensive second-line diabetes therapies was unknown, especially for older adults. Physicians likely had uncertainty about the role of IMs in the diabetes treatment armamentarium. Regional variation in uptake of IMs may be marker of such uncertainty. Objective To investigate the extent of regional variation in the use of IMs among beneficiaries and estimate the cost implications for Medicare. Methods This was a cross-sectional analysis of 2009–2010 claims from a nationally representative sample of 238 499 Medicare Part D beneficiaries aged ≥65 years, who were continuously enrolled in fee-for-service Medicare and Part D and filled ≥1 antidiabetic prescription. Beneficiaries were assigned to 1 306 hospital-referral regions (HRRs) using ZIP codes. The main outcome was adjusted proportion of antidiabetic users an HRR receiving an IM. Results Overall, 29 933 beneficiaries (12.6%) filled an IM prescription, including 26 939 (11. for sitagliptin or saxagliptin and 3718 (1.6%) for exenatide or liraglutide. The adjusted proportion of beneficiaries using varied more than 3-fold across HRRs, from 5th and 95th percentiles of 5.2% to 17.0%. Compared with non-IM users, users faced a 155% higher annual Part D plan ($1067 vs $418) and 144% higher patient ($369 vs $151) costs for antidiabetic prescriptions. Conclusion Among older Part D beneficiaries using antidiabetic drugs, substantial regional variation in the use of IMs, not accounted for by sociodemographics and health status. IM use was associated with substantially greater costs for Part D plans and beneficiaries. PMID:25515869

  12. Metal emissions and urban incident Parkinson disease: a community health study of Medicare beneficiaries by using geographic information systems.

    PubMed

    Willis, Allison W; Evanoff, Bradley A; Lian, Min; Galarza, Aiden; Wegrzyn, Andrew; Schootman, Mario; Racette, Brad A

    2010-12-15

    Parkinson disease associated with farming and exposure to agricultural chemicals has been reported in numerous studies; little is known about Parkinson disease risk factors for those living in urban areas. The authors investigated the relation between copper, lead, or manganese emissions and Parkinson disease incidence in the urban United States, studying 29 million Medicare beneficiaries in the year 2003. Parkinson disease incidence was determined by using beneficiaries who had not changed residence since 1995. Over 35,000 nonmobile incident Parkinson disease cases, diagnosed by a neurologist, were identified for analysis. Age-, race-, and sex-standardized Parkinson disease incidence was compared between counties with high cumulative industrial release of copper, manganese, or lead (as reported to the Environmental Protection Agency) and counties with no/low reported release of all 3 metals. Parkinson disease incidence (per 100,000) in counties with no/low copper/lead/manganese release was 274.0 (95% confidence interval (CI): 226.8, 353.5). Incidence was greater in counties with high manganese release: 489.4 (95% CI: 368.3, 689.5) (relative risk = 1.78, 95% CI: 1.54, 2.07) and counties with high copper release: 304.2 (95% CI: 276.0, 336.8) (relative risk = 1.1, 95% CI: 0.94, 1.31). Urban Parkinson disease incidence is greater in counties with high reported industrial release of copper or manganese. Environmental exposure to metals may be a risk factor for Parkinson disease in urban areas.

  13. Metal Emissions and Urban Incident Parkinson Disease: A Community Health Study of Medicare Beneficiaries by Using Geographic Information Systems

    PubMed Central

    Willis, Allison W.; Evanoff, Bradley A.; Lian, Min; Galarza, Aiden; Wegrzyn, Andrew; Schootman, Mario; Racette, Brad A.

    2010-01-01

    Parkinson disease associated with farming and exposure to agricultural chemicals has been reported in numerous studies; little is known about Parkinson disease risk factors for those living in urban areas. The authors investigated the relation between copper, lead, or manganese emissions and Parkinson disease incidence in the urban United States, studying 29 million Medicare beneficiaries in the year 2003. Parkinson disease incidence was determined by using beneficiaries who had not changed residence since 1995. Over 35,000 nonmobile incident Parkinson disease cases, diagnosed by a neurologist, were identified for analysis. Age-, race-, and sex-standardized Parkinson disease incidence was compared between counties with high cumulative industrial release of copper, manganese, or lead (as reported to the Environmental Protection Agency) and counties with no/low reported release of all 3 metals. Parkinson disease incidence (per 100,000) in counties with no/low copper/lead/manganese release was 274.0 (95% confidence interval (CI): 226.8, 353.5). Incidence was greater in counties with high manganese release: 489.4 (95% CI: 368.3, 689.5) (relative risk = 1.78, 95% CI: 1.54, 2.07) and counties with high copper release: 304.2 (95% CI: 276.0, 336.8) (relative risk = 1.1, 95% CI: 0.94, 1.31). Urban Parkinson disease incidence is greater in counties with high reported industrial release of copper or manganese. Environmental exposure to metals may be a risk factor for Parkinson disease in urban areas. PMID:20959505

  14. Food insecurity and medication adherence in low-income older Medicare beneficiaries with type 2 diabetes.

    PubMed

    Sattler, Elisabeth Lilian Pia; Lee, Jung Sun; Bhargava, Vibha

    2014-01-01

    Little is known about diabetes management among low-income older Americans. This study used statewide self-administered survey and Medicare claims data to examine the relationships of food insecurity and medication (re)fill adherence in a sample of Medicare Part D beneficiaries with type 2 diabetes in need of food assistance in Georgia in 2008 (n = 243, mean age 74.2 ± 7.8 years, 27.2% African American, 77.4% female). (Re)fill adherence to oral hypoglycemics was measured as Proportion of Days Covered. Food insecurity was assessed using a six-item validated standard measure. About 54% of the sample were food insecure. About 28% of the diabetic sample did not (re)fill any diabetes medication and over 80% had at least one diabetes complication. Food insecure participants showed comparable (re)fill adherence to food secure participants. However, 57% of food insecure participants were nonadherent to oral hypoglycemics. Underlying basic needs must be addressed to improve diabetes management in this population.

  15. Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings.

    PubMed

    Baker, Laurence C; Johnson, Scott J; Macaulay, Dendy; Birnbaum, Howard

    2011-09-01

    Treatment of chronically ill people constitutes nearly four-fifths of US health care spending, but it is hampered by a fragmented delivery system and discontinuities of care. We examined the impact of a care coordination approach called the Health Buddy Program, which integrates a telehealth tool with care management for chronically ill Medicare beneficiaries. We evaluated the program's impact on spending for patients of two clinics in the US Northwest who were exposed to the intervention, and we compared their experience with that of matched controls. We found significant savings among patients who used the Health Buddy telehealth program, which was associated with spending reductions of approximately 7.7-13.3 percent ($312-$542) per person per quarter. These results suggest that carefully designed and implemented care management and telehealth programs can help reduce health care spending and that such programs merit continued attention by Medicare. Meanwhile, mortality differences in the treatment and control groups suggest that the intervention may have produced noticeable changes in health outcomes, but we leave it to future research to explore these effects fully.

  16. The importance of lung cancer screening with low-dose computed tomography for Medicare beneficiaries.

    PubMed

    Wood, Douglas E

    2014-12-01

    The National Lung Screening Trial has provided convincing evidence of a substantial mortality benefit of lung cancer screening with low-dose computed tomography (CT) for current and former smokers at high risk. The United States Preventive Services Task Force has recommended screening, triggering coverage of low-dose CT by private health insurers under provisions of the Affordable Care Act. The Centers for Medicare & Medicaid Services (CMS) are currently evaluating coverage of lung cancer screening for Medicare beneficiaries. Since 70% of lung cancer occurs in patients 65 years or older, CMS should cover low-dose CT, thus avoiding the situation of at-risk patients being screened up to age 64 through private insurers and then abruptly ceasing screening at exactly the ages when their risk for developing lung cancer is increasing. Legitimate concerns include false-positive findings that lead to further testing and invasive procedures, overdiagnosis (detection of clinically unimportant cancers), the morbidity and mortality of surgery, and the overall costs of follow-up tests and procedures. These concerns can be mitigated by clear criteria for screening high-risk patients, disciplined management of abnormalities based on algorithms, and high-quality multidisciplinary care. Lung cancer screening with low-dose CT can lead to early diagnosis and cure for thousands of patients each year. Professional societies can help CMS responsibly implement a program that is patient-centered and minimizes unintended harms and costs.

  17. Falling into the doughnut hole: drug spending among beneficiaries with end-stage renal disease under Medicare Part D plans.

    PubMed

    Patel, Uptal D; Davis, Matthew M

    2006-09-01

    The Medicare Part D prescription drug benefit may facilitate provision of medications by subsidizing drug costs. However, beneficiaries with higher drug utilization may face higher out-of-pocket (OOP) costs under the benefit's "doughnut hole" provisions that substantially increase beneficiary cost-sharing. The Medicare Current Beneficiary Survey Cost and Use data for 1997 through 2001 were used to estimate the impact of the standard Part D benefit on drug expenditures. The sample consisted of adults who were not dually enrolled in Medicaid (41,617 without ESRD, 256 with ESRD). Outcomes were annual total and OOP drug spending projected to 2006, as well as estimates of individual spending changes under Part D. In 2006, ESRD beneficiaries will have mean annual total and OOP expenditures that are approximately twice that of their Medicare peers. The overall impact of Part D on OOP expenditures is similar among all beneficiaries; however, many individuals with employer-sponsored coverage and those with higher costs (especially those with ESRD) may face cost increases with significant monthly variability as a result of reaching the "doughnut hole," a no-coverage gap in the standard benefit. Therefore, ESRD beneficiaries face substantial total and OOP annual expenditures for medications, causing most to reach the Part D benefit gap. Higher OOP costs may lead to reductions in spending and medication use with subsequent treatment gaps that may lead to increased use of medical services. As the new legislation takes effect, policy makers who are considering modifications in the program may benefit from further research to monitor patterns and gaps in coverage, medication use and spending, and hospitalization and survival trends.

  18. Disability Stage Is an Independent Risk Factor for Mortality in Medicare Beneficiaries 65 Years of Age and Older

    PubMed Central

    Hennessy, Sean; Kurichi, Jibby E.; Pan, Qiang; Streim, Joel E.; Bogner, Hillary; Xie, Dawei; Stineman, Margaret G.

    2015-01-01

    Background Stages of activity limitation based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) have been found to predict mortality in those age 70 years and above but have not been examined in Medicare beneficiaries age 65 years and older using routinely collected data. Objective To examine the association between functional stages based on activities of ADLs and IADLs with three-year mortality in Medicare beneficiaries age 65 years and older, accounting for baseline sociodemographics, heath status, smoking, subjective health, and psychological well-being. Design Cohort study using the Medicare Current Beneficiary Survey (MCBS) and associated health care utilization data. Setting Community administered survey. Participants We included 9698 Medicare beneficiaries 65 years of age and older who entered the MCBS in 2005–07. Main outcome measures Death within three years of cohort entry. Results The overall mortality rate was 3.6 per 100 person years, and three-year cumulative mortality was 10.3%. Unadjusted three-year mortality was monotonically associated with both ADL stage and IADL stag. Adjusted three-year mortality was associated with ADL and IADL stages, except that in some models the hazard ratio for stage III (which includes persons with atypical activity limitation patterns) was numerically lower than that for stage II. Conclusion We found nearly monotonic relationships between ADL and IADL stage and adjusted three-year mortality. These findings could aid in the development of population health approaches and metrics for evaluating the success of alternative economic, social, or health policies on the longevity of older adults with activity limitations. PMID:26003869

  19. Frailty prior to Critical Illness and Mortality for Elderly Medicare Beneficiaries

    PubMed Central

    Hope, Aluko A.; Gong, Michelle N.; Guerra, Carmen; Wunsch, Hannah

    2016-01-01

    Background Health categories of elderly patients prior to critical illness may explain differences in mortality during and after admission to intensive care units (ICUs). Objectives To estimate the effect of pre-ICU health categories on mortality during and after critical illness, focusing specifically on the effect of pre-ICU frailty on short- and long-term mortality. Design Retrospective cohort study using linked Medicare claims data from 2004–2008. Participants A nationally representative sample of elderly Medicare beneficiaries who were admitted to an ICU in 2005. Measurements Patients were classified into four pre-ICU health categories (Robust; Cancer; Chronic Organ Failure; Frailty) using claims data from the year prior to admission, allowing for assignment to multiple categories. We assessed the association between pre-ICU health categories and hospital and 3-year mortality using multivariable logistic regression and Cox proportional Hazards models. Results Among 47,427 elderly ICU patients, 18.8% were Robust; 28.6% had pre-ICU Cancer; 68.1% Chronic Organ Failure and 34.0% Frailty; 41.3% qualified for multiple categories. Overall hospital mortality was 12.6%, with the lowest mortality for Robust patients (9.7%). Patients with pre-ICU Frailty had a higher hospital mortality compared to patients with the same pre-ICU health categories without frailty (adjusted Odds Ratios ranged from 1.27 (95% confidence interval (CI) 1.10–1.47) to 1.52 (95% CI 1.35–1.63)). Robust hospital survivors had the lowest 3-year mortality (24.6%). Pre-ICU Frailty conferred a higher 3-year mortality compared to pre-ICU categories without frailty (adjusted Hazard Ratios ranged from 1.54 (95% CI 1.45–1.64) to 1.84 (95% CI 1.70–1.99). Conclusion Critically ill elderly patients can be categorized by Pre-ICU health categories. These categories, particularly pre-ICU Frailty, may be important for understanding risk of death during and after critical illness. PMID:26096386

  20. Treatment and Survival of Medicare Beneficiaries with Colorectal Cancer: A Comparative Analysis Between a Rural State Cancer Registry and National Data.

    PubMed

    Rane, Pallavi B; Madhavan, S Suresh; Sambamoorthi, Usha; Sita, Kalidindi; Kurian, Sobha; Pan, Xiaoyun

    2017-02-01

    The aim was to examine and compare with "national" estimates, receipt of colorectal cancer (CRC) treatment in the initial phase of care and survival following a CRC diagnosis in rural Medicare beneficiaries. A retrospective study was conducted on fee-for-service Medicare beneficiaries diagnosed with CRC in 2003-2006, identified from West Virginia Cancer Registry (WVCR)-Medicare linked database (N = 2119). A comparative cohort was identified from Surveillance, Epidemiology, and End Results (SEER)-Medicare (N = 38,168). CRC treatment received was ascertained from beneficiaries' Medicare claims in the 12 months post CRC diagnosis or until death, whichever happened first. Receipt of minimally appropriate CRC treatment (MACT) was defined using recommended CRC treatment guidelines. All-cause and CRC-specific mortality in the 36-month period post CRC diagnosis were examined. Differences in usage of CRC surgery, chemotherapy, and radiation were observed between the 2 populations, with those from WVCR-Medicare being less likely to receive any type of CRC surgery (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI] = [0.73-0.93]). Overall, those from WVCR-Medicare had a lower likelihood of receiving MACT, (AOR = 0.85; 95% CI = [0.76-0.96]) compared to their national counterparts. Higher hazard of CRC mortality was observed in the WVCR-Medicare cohort (adjusted hazard ratio = 1.26; 95% CI = [1.20-1.32]) compared to the SEER-Medicare cohort. Although more beneficiaries from WVCR-Medicare were diagnosed in early-stage CRC compared to their SEER-Medicare counterparts, they had a lower likelihood of receiving MACT and a higher hazard of CRC mortality. This study highlights the need for an increased focus on improving access to care at every phase of the CRC care continuum, especially for those from rural settings.

  1. 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.

  2. 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.

  3. 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…

  4. 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

  5. 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.

  6. Examining the Association Between Comorbidity Indexes and Functional Status in Hospitalized Medicare Fee-for-Service Beneficiaries

    PubMed Central

    Graham, James E.; Resnik, Linda; Karmarkar, Amol M.; Deutsch, Anne; Tan, Alai; Al Snih, Soham; Ottenbacher, Kenneth J.

    2016-01-01

    Background Medicare data from acute hospitals do not contain information on functional status. This lack of information limits the ability to conduct rehabilitation-related health services research. Objective The purpose of this study was to examine the associations between 5 comorbidity indexes derived from acute care claims data and functional status assessed at admission to an inpatient rehabilitation facility (IRF). Comorbidity indexes included tier comorbidity, Functional Comorbidity Index (FCI), Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Hierarchical Condition Category (HCC). Design This was a retrospective cohort study. Methods Medicare beneficiaries with stroke, lower extremity joint replacement, and lower extremity fracture discharged to an IRF in 2011 were studied (N=105,441). Data from the beneficiary summary file, Medicare Provider Analysis and Review (MedPAR) file, and Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) file were linked. Inpatient rehabilitation facility admission functional status was used as a proxy for acute hospital discharge functional status. Separate linear regression models for each impairment group were developed to assess the relationships between the comorbidity indexes and functional status. Base models included age, sex, race/ethnicity, disability, dual eligibility, and length of stay. Subsequent models included individual comorbidity indexes. Values of variance explained (R2) with each comorbidity index were compared. Results Base models explained 7.7% of the variance in motor function ratings for stroke, 3.8% for joint replacement, and 7.3% for fracture. The R2 increased marginally when comorbidity indexes were added to base models for stroke, joint replacement, and fracture: Charlson Comorbidity Index (0.4%, 0.5%, 0.3%), tier comorbidity (0.2%, 0.6%, 0.5%), FCI (0.4%, 1.2%, 1.6%), Elixhauser Comorbidity Index (1.2%, 1.9%, 3.5%), and HCC (2.2%, 2.1%, 2.8%). Limitation Patients

  7. 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

  8. 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.

  9. 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 ...

  10. Rising Billing for Intermediate Intensive Care among Hospitalized Medicare Beneficiaries between 1996 and 2010

    PubMed Central

    Valley, Thomas S.; Prescott, Hallie C.; Wunsch, Hannah; Iwashyna, Theodore J.; Cooke, Colin R.

    2016-01-01

    Rationale: Intermediate care (i.e., step-down or progressive care) is an alternative to the intensive care unit (ICU) for patients with moderate severity of illness. The adoption and current use of intermediate care is unknown. Objectives: To characterize trends in intermediate care use among U.S. hospitals. Methods: We examined 135 million acute care hospitalizations among elderly individuals (≥65 yr) enrolled in fee-for-service Medicare (U.S. federal health insurance program) from 1996 to 2010. We identified patients receiving intermediate care as those with intensive care or coronary care room and board charges labeled intermediate ICU. Measurements and Main Results: In 1996, a total of 960 of the 3,425 hospitals providing critical care billed for intermediate care (28%), and this increased to 1,643 of 2,783 hospitals (59%) in 2010 (P < 0.01). Only 8.2% of Medicare hospitalizations in 1996 were billed for intermediate care, but billing steadily increased to 22.8% by 2010 (P < 0.01), whereas the percentage billed for ICU care and ward-only care declined. Patients billed for intermediate care had more acute organ failures diagnoses codes compared with general ward patients (22.4% vs. 15.8%). When compared with patients billed for ICU care, those billed for intermediate care had fewer organ failures (22.4% vs. 43.4%), less mechanical ventilation (0.9% vs. 16.7%), lower mean Medicare spending ($8,514 vs. $18,150), and lower 30-day mortality (5.6% vs. 16.5%) (P < 0.01 for all comparisons). Conclusions: Intermediate care billing increased markedly between 1996 and 2010. These findings highlight the need to better define the value, specific practices, and effective use of intermediate care for patients and hospitals. PMID:26372779

  11. Who you are and where you live: how race and geography affect the treatment of medicare beneficiaries.

    PubMed

    Baicker, Katherine; Chandra, Amitabh; Skinner, Jonathan S; Wennberg, John E

    2004-01-01

    The existence of overall racial and ethnic disparities in health care is well documented, but this average effect masks variation across regions and types of care. Medicare claims data are used to document the extent of these variations. Regions with high racial disparities in one procedure are not more likely to be high in other procedures. Unusually large racial disparities in surgery are often the result of high white rates rather than low black rates. Differences in end-of-life care are driven more by residence than by race. Policies should focus on getting the rates right, rather than solely on racial differences.

  12. Variables Associated With Inpatient and Outpatient Resource Utilization Among Medicare Beneficiaries With Nonalcoholic Fatty Liver Disease With or Without Cirrhosis

    PubMed Central

    Sayiner, Mehmet; Otgonsuren, Munkhzul; Cable, Rebecca; Younossi, Issah; Afendy, Mariam; Golabi, Pegah; Henry, Linda

    2017-01-01

    Background: Nonalcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease worldwide with tremendous clinical burden. The economic burden of NAFLD is not well studied. Goal: To assess the economic burden of NAFLD. Study: Medicare beneficiaries (January 1, 2010 to December 31, 2010) with NAFLD diagnosis by International Classification of Diseases, Ninth Revision codes in the absence of other liver diseases were selected. Inpatient and outpatient resource utilization parameters were total charges and total provider payments. NAFLD patients with compensated cirrhosis (CC) were compared with decompensated cirrhosis (DC). Results: A total of 976 inpatients and 4742 outpatients with NAFLD were included—87% were white, 36% male, 30% had cardiovascular disease (CVD) or metabolic syndrome conditions, and 12% had cirrhosis. For inpatients, median total hospital charge was $36,289. NAFLD patients with cirrhosis had higher charges and payments than noncirrhotic NAFLD patients ($61,151 vs. $33,863 and $18,804 vs. $10,146, P<0.001). Compared with CC, NAFLD patients with DC had higher charges and payments (P<0.02). For outpatients, median total charge was $9,011. NAFLD patients with cirrhosis had higher charges and payments than noncirrhotic NAFLD patients ($12,049 vs. $8,830 and $2,586 vs. $1,734, P<0.001). Compared with CC, DC patients had higher total charges ($15,187 vs. $10,379, P=0.04). In multivariate analysis, variables associated with increased inpatient resource utilization were inpatient mortality, DC, and CVD; for outpatients, having CVD, obesity, and hypertension (all P<0.001). Conclusions: NAFLD is associated with significant economic burden to Medicare. Presence of cirrhosis and CVD are associated with increased resource utilization. PMID:27332747

  13. Impact of Prostate Cancer Diagnosis on Non-Cancer Hospitalizations among Elderly Medicare Beneficiaries with Incident Prostate Cancer

    PubMed Central

    Raval, Amit D.; Madhavan, Suresh; Mattes, Malcolm D.; Salkini, Mohamad; Sambamoorthi, Usha

    2016-01-01

    OBJECTIVES To analyze the impact of cancer diagnosis on non-cancer hospitalizations (NCHs) by comparing these hospitalizations between the pre- and post-cancer period in a cohort of fee-for-service Medicare beneficiaries with incident prostate cancer. METHODS A population-based retrospective cohort study was conducted using the Surveillance, Epidemiology and End-Results (SEER) -Medicare linked database for the years 2000 to 2010. The study cohort consisted of 57,489 elderly men (≥ 67 years) with incident prostate cancer. NCHs were identified in six time periods (t1–t6) before and after the incidence of prostate cancer. Each time period consisted of 120 days. For each time period, NCHs were defined as inpatient admissions with primary diagnosis codes not related to prostate cancer, prostate cancer-related procedures or bowel, sexual and urinary dysfunction. Bivariate and multivariate comparisons on rates of NCHs between the pre- and post-cancer period accounted for the repeated measures design. RESULTS The rate of NCHs during the post-cancer period (5.1%) was higher as compared to the pre-cancer period (3.2%). In both unadjusted and adjusted models, elderly men were 37% (Odds Ratio, OR: 1.37, 95% Confidence Interval, CI: 1.32, 1.41) and 38% (Adjusted OR: 1.38, 95% CI: 1.33, 1.46) more likely to have any NCH during the post-cancer period as compared to the pre-cancer period. CONCLUSIONS Elderly men with prostate cancer had a significant increase in the risk of NCHs after the diagnosis of prostate cancer. The study highlights the need to design interventions for reducing the excess NCHs after diagnosis of prostate cancer among elderly men. PMID:26850489

  14. Validity of a Claims-Based Diagnosis of Obesity Among Medicare Beneficiaries.

    PubMed

    Lloyd, Jennifer T; Blackwell, Steve A; Wei, Iris I; Howell, Benjamin L; Shrank, William H

    2015-12-01

    Population-level data on obesity are difficult to obtain. Claims-based data sets are useful for studying public health at a population level but lack physical measurements. The objective of this study was to determine the validity of a claims-based measure of obesity compared to obesity diagnosed with clinical data as well as the validity among older adults who suffer from chronic disease. This study used data from the National Health and Nutrition Examination Survey 1999-2004 for adults aged ≥ 65 successfully linked to 1999-2007 Medicare claims (N = 3,554). Sensitivity, specificity, positive and negative predictive values, κ statistics as well as logistic regression analyses were computed for the claims-based diagnosis of obesity versus obesity diagnosed with body mass index. The claims-based diagnosis of obesity underestimates the true prevalence in the older Medicare population with a low sensitivity (18.4%). However, this method has a high specificity (97.3%) and is accurate when it is present. Sensitivity was improved when comparing the claim-based diagnosis to Class II obesity (34.2%) and when used in combination with chronic conditions such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, or depression. Understanding the validity of a claims-based obesity diagnosis could aid researchers in understanding the feasibility of conducting research on obesity using claims data.

  15. The Association of Longitudinal and Interpersonal Continuity of Care with Emergency Department Use, Hospitalization, and Mortality among Medicare Beneficiaries

    PubMed Central

    Bentler, Suzanne E.; Morgan, Robert O.; Virnig, Beth A.; Wolinsky, Fredric D.

    2014-01-01

    Background Continuity of medical care is widely believed to lead to better health outcomes and service utilization patterns for patients. Most continuity studies, however, have only used administrative claims to assess longitudinal continuity with a provider. As a result, little is known about how interpersonal continuity (the patient's experience at the visit) relates to improved health outcomes and service use. Methods We linked claims-based longitudinal continuity and survey-based self-reported interpersonal continuity indicators for 1,219 Medicare beneficiaries who completed the National Health and Health Services Use Questionnaire. With these linked data, we prospectively evaluated the effect of both types of continuity of care indicators on emergency department use, hospitalization, and mortality over a five-year period. Results Patient-reported continuity was associated with reduced emergency department use, preventable hospitalization, and mortality. Most of the claims-based measures, including those most frequently used to assess continuity, were not associated with reduced utilization or mortality. Conclusion Our results indicate that the patient- and claims-based indicators of continuity have very different effects on these important health outcomes, suggesting that reform efforts must include the patient-provider experience when evaluating health care quality. PMID:25531108

  16. Early Stage Breast Cancer Treatments for Younger Medicare Beneficiaries with Different Disabilities

    PubMed Central

    Iezzoni, Lisa I; Ngo, Long H; Li, Donglin; Roetzheim, Richard G; Drews, Reed E; McCarthy, Ellen P

    2008-01-01

    Objective To explore how underlying disability affects treatments and outcomes of disabled women with breast cancer. Data Sources Surveillance, Epidemiology, and End Results program data, linked with Medicare files and Social Security Administration disability group. Study Design Ninety thousand two hundred and forty-three incident cases of early-stage breast cancer under age 65; adjusted relative risks and hazards ratios examined treatments and survival, respectively, for women in four disability groups compared with nondisabled women. Principal Findings Demographic characteristics, treatments, and survival varied among four disability groups. Compared with nondisabled women, those with mental disorders and neurological conditions had significantly lower adjusted rates of breast conserving surgery and radiation therapy. Survival outcomes also varied by disability type. Conclusions Compared with nondisabled women, certain subgroups of women with disabilities are especially likely to experience disparities in care for breast cancer. PMID:18479411

  17. Explaining the increased health care expenditures associated with gastroesophageal reflux disease among elderly Medicare beneficiaries with chronic obstructive pulmonary disease: a cost-decomposition analysis

    PubMed Central

    Ajmera, Mayank; Raval, Amit D; Shen, Chan; Sambamoorthi, Usha

    2014-01-01

    Objective To estimate excess health care expenditures associated with gastroesophageal reflux disease (GERD) among elderly individuals with chronic obstructive pulmonary disease (COPD) and examine the contribution of predisposing characteristics, enabling resources, need variables, personal health care practices, and external environment factors to the excess expenditures, using the Blinder–Oaxaca linear decomposition technique. Methods This study utilized a cross-sectional, retrospective study design, using data from multiple years (2006–2009) of the Medicare Current Beneficiary Survey linked with fee-for-service Medicare claims. Presence of COPD and GERD was identified using diagnoses codes. Health care expenditures consisted of inpatient, outpatient, prescription drugs, dental, medical provider, and other services. For the analysis, t-tests were used to examine unadjusted subgroup differences in average health care expenditures by the presence of GERD. Ordinary least squares regressions on log-transformed health care expenditures were conducted to estimate the excess health care expenditures associated with GERD. The Blinder–Oaxaca linear decomposition technique was used to determine the contribution of predisposing characteristics, enabling resources, need variables, personal health care practices, and external environment factors, to excess health care expenditures associated with GERD. Results Among elderly Medicare beneficiaries with COPD, 29.3% had co-occurring GERD. Elderly Medicare beneficiaries with COPD/GERD had 1.5 times higher ($36,793 vs $24,722 [P<0.001]) expenditures than did those with COPD/no GERD. Ordinary least squares regression revealed that individuals with COPD/GERD had 36.3% (P<0.001) higher expenditures than did those with COPD/no GERD. Overall, 30.9% to 43.6% of the differences in average health care expenditures were explained by differences in predisposing characteristics, enabling resources, need variables, personal health care

  18. Contextual, Ecological and Organizational Variations in Risk-Adjusted COPD and Asthma Hospitalization Rates of Rural Medicare Beneficiaries.

    PubMed

    Wan, Thomas T H; Lin, Yi-Ling; Ortiz, Judith

    2016-01-01

    The purpose of this study is to examine what factors contributing to the variability in chronic obstructive pulmonary disorder (COPD) and asthma hospitalization rates when the influence of patient characteristics is being simultaneously considered by applying a risk adjustment method. A longitudinal analysis of COPD and asthma hospitalization of rural Medicare beneficiaries in 427 rural health clinics (RHCs) was conducted utilizing administrative data and inpatient and outpatient claims from Region 4. The repeated measures of risk-adjusted COPD and asthma admission rate were analyzed by growth curve modeling. A generalized estimating equation (GEE) method was used to identify the relevance of selected predictors in accounting for the variability in risk-adjusted admission rates for COPD and asthma. Both adjusted and unadjusted rates of COPD admission showed a slight decline from 2010 to 2013. The growth curve modeling showed the annual rates of change were gradually accentuated through time. GEE revealed that a moderate amount of variance (marginal R(2) = 0.66) in the risk-adjusted hospital admission rates for COPD and asthma was accounted for by contextual, ecological, and organizational variables. The contextual, ecological, and organizational factors are those associated with RHCs, not hospitals. We cannot infer how the variability in hospital practices in RHC service areas may have contributed to the disparities in admissions. Identification of RHCs with substantially higher rates than an average rate can portray the need for further enhancement of needed ambulatory or primary care services for the specific groups of RHCs. Because the risk-adjusted rates of hospitalization do not very by classification of rural area, future research should address the variation in a specific COPD and asthma condition of RHC patients. Risk-adjusted admission rates for COPD and asthma are influenced by the synergism of multiple contextual, ecological, and organizational factors

  19. Medicare

    MedlinePlus

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  20. The Incremental Hospital Cost and Length-of-Stay Associated With Treating Adverse Events Among Medicare Beneficiaries Undergoing THA During Fiscal Year 2013.

    PubMed

    Culler, Steven D; Jevsevar, David S; Shea, Kevin G; McGuire, Kevin J; Wright, Kimberly K; Simon, April W

    2016-01-01

    This paper estimates the incremental hospital resource consumption associated with treating selected adverse events experienced by Medicare beneficiaries (MBs) undergoing total hip arthroplasty (THA). This retrospective study, using the Medicare Provider Analysis and Review file, identified 174,167 MBs who underwent THA in 2013. Overall, 20.16% of MB undergoing THA experienced at least one adverse event. MB experiencing any adverse event consumed significantly higher hospital cost ($3429) and had longer length of stays (1.0 day). The risk-adjusted incremental cost of treating adverse events ranged from a high of $27,116 (pneumonia) to a low of $2626 (hemorrhage or post-operative shock requiring transfusion). Most major adverse events occurred infrequently, however when adverse events occurred, they add substantially to the hospital resource costs of treating MB.

  1. 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

  2. Association of Public Reporting for Percutaneous Coronary Intervention with Utilization and Outcomes among Medicare beneficiaries with Acute Myocardial Infarction

    PubMed Central

    Joynt, Karen E.; Blumenthal, Daniel M.; Orav, E. John; Resnic, Frederic S.; Jha, Ashish K.

    2013-01-01

    for the 6081 patients with cardiogenic shock or cardiac arrest (pre-reporting, 44.2% versus 36.6%, OR 1.40 [0.85, 2.37] post-reporting, 43.9% versus 44.8%, OR 0.92 [0.38, 2.22], p=.028 for difference in differences). There were no differences in overall mortality among acute MI patients in reporting versus non-reporting states. Conclusions Among Medicare beneficiaries with acute Ml, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute Ml mortality between states with and without public reporting. PMID:23047360

  3. Extending U.S. Medicare to Mexico

    PubMed Central

    Haims, Marla C.; Dick, Andrew W.

    2012-01-01

    Abstract There is a lack of hard data on the exact number of Medicare-eligible retirees residing in Mexico, but it is at least in the tens of thousands and is certainly rising as the baby boom generation reaches retirement. Because Medicare does not cover health services received outside the United States, these retirees must travel to the United States for health care or purchase alternative coverage for health services received in Mexico. There are several arguments for extending Medicare to Mexico—that is, allowing Medicare-eligible beneficiaries to receive their Medicare benefits in Mexico. Medicare-eligible retirees living in Mexico would certainly benefit, and Mexico might benefit from improved quality of care and an expanded health economy. Moreover, American taxpayers might benefit from a reduced total cost of Medicare: To the extent that extending Medicare to Mexico induces Medicare beneficiaries to substitute higher-cost U.S. health care services with lower-cost Mexican services, overall Medicare expenditures might be reduced. The authors outline four options for how this policy change might be implemented and describe a conceptual model that could be used to assess the effects of each option. PMID:28083264

  4. 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

  5. 42 CFR 422.314 - Special rules for beneficiaries enrolled in MA MSA plans.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Payments to Medicare Advantage Organizations § 422.314 Special rules for beneficiaries enrolled in MA MSA plans....

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

    PubMed

    2010-12-07

    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.

  7. 30-Day Mortality and Late Survival with Reinterventions and Readmissions after Open and Endovascular Aortic Aneurysm Repair in Medicare Beneficiaries

    PubMed Central

    Giles, Kristina A; Landon, Bruce E; Cotterill, Philip; O'Malley, A. James; Pomposelli, Frank B; Schermerhorn, Marc L

    2010-01-01

    Objectives Late survival is similar after EVAR and open AAA repair despite a perioperative benefit with EVAR. AAA-related reinterventions are more common after EVAR while laparotomy related reinterventions are more common after open repair. The impact of reinterventions on survival, however, is unknown. We therefore evaluate the rate of reinterventions and readmission after initial AAA repair along with 30-day mortality and the effect upon long term survival. Methods We identified AAA and laparotomy-related reinterventions for propensity score matched cohorts of Medicare beneficiaries (n=45,652) undergoing EVAR and open repair from 2001-2004. Follow-up was up to 6 years. Hospitalizations for ruptured AAA without repair and for bowel obstruction or ventral hernia without abdominal surgery were also recorded. Event rates were calculated per year and are also presented through 6 years of follow-up as events per 100 person years. Thirty day mortality was calculated for each reintervention or readmission. Results Through 6 years, overall reinterventions or readmissions were similar between repair methods but slightly more common after EVAR (7.6 vs. 7.0 per 100 person years, RR 1.1, P < .001). Overall 30 day mortality with any reintervention or readmission was 9.1%. EVAR patients had more ruptures (0.50 vs. 0.09, RR 5.7, P < .001) with a mortality of 28%, but these were uncommon. EVAR patients also had more AAA-related reinterventions through 6 years (3.7 vs. 0.9, RR 4.0, P < .001) (mortality 5.6%), the majority of which were minor endovascular reinterventions (2.4 vs. 0.2, RR 11.4, P < .001) with a 30 day mortality of 3.0%. However, minor open (0.8 vs. 0.5, RR 1.4, P < .001) (mortality 6.9%) and major reinterventions (0.4 vs. 0.2, RR 2.4, P < .001) (mortality 12.1%) were also more common after EVAR than open repair. Conversely, EVAR patients had fewer laparotomy related reinterventions than open patients (1.4 vs. 3.0, RR 0.5, P < .001) (mortality 8.1%) and readmissions

  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. 42 CFR 411.23 - Beneficiary's cooperation.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Beneficiary's cooperation. 411.23 Section 411.23 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Medicare Payment: General Provisions § 411.23 Beneficiary's cooperation. (a) If CMS takes action to...

  11. 42 CFR 411.23 - Beneficiary's cooperation.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Beneficiary's cooperation. 411.23 Section 411.23 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Medicare Payment: General Provisions § 411.23 Beneficiary's cooperation. (a) If CMS takes action to...

  12. 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 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Medicare Payment: General Provisions § 411.23 Beneficiary's cooperation. (a) If CMS takes action to...

  13. 42 CFR 411.23 - Beneficiary's cooperation.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Beneficiary's cooperation. 411.23 Section 411.23 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE... Medicare Payment: General Provisions § 411.23 Beneficiary's cooperation. (a) If CMS takes action to...

  14. 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.

  15. Impacts of a disease management program for dually eligible beneficiaries.

    PubMed

    Esposito, Dominick; Brown, Randall; Chen, Arnold; Schore, Jennifer; Shapiro, Rachel

    2008-01-01

    The LifeMasters Supported SelfCare demonstration program provides disease management (DM) services to Florida Medicare beneficiaries who are also enrolled in Medicaid and have congestive heart failure (CHF), diabetes, or coronary artery disease (CAD). The population-based program provides primarily telephonic patient education and monitoring services. Findings from the randomized, intent-to-treat design over the first 18 months of operations show virtually no overall impacts on hospital or emergency room (ER) use, Medicare expenditures, quality of care, or prescription drug use for the 33,000 enrollees. However, for beneficiaries with CHF who resided in high-cost South Florida counties, the program reduced Medicare expenditures by 9.6 percent.

  16. 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.

  17. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... services furnished in a teaching hospital. (g) Aggregate per diem methods of apportionment—(1) For the... furnished to beneficiaries in teaching hospitals. 415.162 Section 415.162 Public Health CENTERS FOR MEDICARE... BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN...

  18. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... furnished to beneficiaries in teaching hospitals. 415.162 Section 415.162 Public Health CENTERS FOR MEDICARE... BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS Physician Services in Teaching Settings § 415.162 Determining payment for physician...

  19. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... furnished to beneficiaries in teaching hospitals. 415.162 Section 415.162 Public Health CENTERS FOR MEDICARE...) SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS Physician Services in Teaching Settings § 415.162 Determining payment...

  20. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... furnished to beneficiaries in teaching hospitals. 415.162 Section 415.162 Public Health CENTERS FOR MEDICARE...) SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS Physician Services in Teaching Settings § 415.162 Determining payment...

  1. 42 CFR 415.162 - Determining payment for physician services furnished to beneficiaries in teaching hospitals.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... furnished to beneficiaries in teaching hospitals. 415.162 Section 415.162 Public Health CENTERS FOR MEDICARE...) SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS Physician Services in Teaching Settings § 415.162 Determining payment...

  2. Rural-Urban Differences in Satisfaction with Medicare Part D: Implications for Policy.

    PubMed

    Henning-Smith, Carrie; O'Connor, Heidi; Casey, Michelle; Moscovice, Ira

    2016-01-01

    Rural residents are more likely to be enrolled in traditional fee-for-service Part D Medicare prescription drug plans, and they face particular challenges in accessing pharmaceutical care. This study examines rural/urban differences in satisfaction with Medicare Part D coverage. Using data from the 2012 Medicare Current Beneficiary Survey (N = 3,107 beneficiaries aged 65 and older), we find that rural residents have significantly lower satisfaction with Part D coverage but that regional variation in satisfaction is largely explained by differences in health services use and type of Part D plan (stand-alone versus Medicare Advantage). We conclude by suggesting a multifaceted approach to improving satisfaction with Part D for rural residents.

  3. 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…

  4. 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…

  5. 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.

  6. 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

  7. 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.

  8. Trends in Aortic Dissection Hospitalizations, Interventions, and Outcomes among Medicare Beneficiaries in the United States, 2000–2011

    PubMed Central

    Mody, Purav S.; Wang, Yun; Geirsson, Arnar; Kim, Nancy; Desai, Mayur M.; Gupta, Aakriti; Dodson, John A.; Krumholz, Harlan M.

    2015-01-01

    Background The epidemiology of aortic dissection (AD) has not been well-described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes. Methods and Results The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32,057 initial AD hospitalizations were identified between 2000 and 2011. The overall hospitalization rate for AD remained unchanged at 10 per 100,000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2–6.5; adjusted, 6.4%; 95% CI, 5.7–6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1–5.2; adjusted, 6.2%; 95% CI, 5.3–6.7) respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3–10.2; adjusted, 7.3%; 95% CI, 5.8–7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5–9.1%; adjusted, 8.2%; 95% CI, 6.7 – 9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5–4.2; adjusted, 2.9%; 95% CI, 0.7–4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3–4.3; adjusted, 3.9%; 95% CI, 2.5–6.3) for surgical repair of type B dissection. Conclusions While AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair. PMID:25336626

  9. 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...

  10. Medicare's risk-adjusted capitation method.

    PubMed

    Grimaldi, Paul L

    2002-01-01

    Since 1997, the method to establish capitation rates for Medicare beneficiaries who are members of risk-bearing managed care plans has undergone several important developments. This includes the factoring of beneficiary health status into the rate-setting calculations. These changes were expected to increase the number of participating health plans, accelerate Medicare enrollment growth, and slice Medicare spending.

  11. Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures. Final rule.

    PubMed

    2017-01-17

    This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

  12. At least half of new Medicare advantage enrollees had switched from traditional Medicare during 2006-11.

    PubMed

    Jacobson, Gretchen A; Neuman, Patricia; Damico, Anthony

    2015-01-01

    With ongoing interest in rising Medicare Advantage enrollment, we examined whether the growth in enrollment between 2006 and 2011 was mainly due to new beneficiaries choosing Medicare Advantage when they first become eligible for Medicare. We also examined the extent to which beneficiaries in traditional Medicare switched to Medicare Advantage, and vice versa. We found that 22 percent of new Medicare beneficiaries elected Medicare Advantage over traditional Medicare in 2011; they accounted for 48 percent of new Medicare Advantage enrollees that year. People ages 65-69 switched from traditional Medicare to Medicare Advantage at higher-than-average rates. Dual eligibles (people eligible for both Medicare and Medicaid) and beneficiaries younger than age sixty-five with disabilities disenrolled from Medicare Advantage at higher-than-average rates. On average, in each year of the study period we found that fewer than 5 percent of traditional Medicare beneficiaries switched to Medicare Advantage, and a similar percentage of Medicare Advantage enrollees switched to traditional Medicare. These results suggest that initial coverage decisions have long-lasting effects.

  13. 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

  14. The national market for Medicare clinical laboratory testing: implications for payment reform.

    PubMed

    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.

  15. 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…

  16. 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...

  17. 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

    ... certain teaching hospitals, both members of Medicare GME affiliated groups and those that were not... them are members of Medicare GME affiliated groups. Many of these teaching hospitals have hundreds of... Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that...

  18. In the United States, "Opt-Out" States Show No Increase in Access to Anesthesia Services for Medicare Beneficiaries Compared with Non-"Opt-Out" States.

    PubMed

    Sun, Eric C; Miller, Thomas R; Halzack, Nicholas M

    2016-05-01

    In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of "opt-out" states likely experienced smaller growth in anesthesia utilization rates compared with non-"opt-out" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.

  19. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 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 §...

  20. Using a Spanish Surname Match to Improve Identification of Hispanic Women in Medicare Administrative Data

    PubMed Central

    Wei, Iris I; Virnig, Beth A; John, Dolly A; Morgan, Robert O

    2006-01-01

    Objective To assess the effectiveness of a Spanish surname match for improving the identification of Hispanic women in Medicare administrative data in which Hispanics are historically underrepresented. Data Sources We collected self-identified race/ethnicity data (N = 2,997) from a mailed survey sent to elderly Medicare beneficiaries who resided in 11 geographic areas consisting of eight metropolitan counties and three nonmetropolitan areas (171 counties) in the fall of 2004. The 1990 Census Spanish Surname list was used to identify Hispanics in the Medicare data. In addition, we used data published on the U.S. Census Bureau website to obtain estimates of elderly Hispanics. Study Design We used self-identified race/ethnicity as the gold standard to examine the agreement with Medicare race code alone, and with Medicare race code+Spanish surname match. Additionally, we estimated the proportions of Hispanic women and men, in each of the 11 geographic areas in our survey, using the Medicare race code alone and the Medicare race code+Spanish surname match, and compared those estimates with estimates derived from U.S. Census 2000 data. Principal Findings The Spanish surname match dramatically increased the accuracy of the Medicare race code for identifying both Hispanic and white women, producing improvements comparable with those seen for men. Conclusions We recommend the addition of a proxy race code in the Medicare data using the Spanish surname match to improve the accuracy of racial/ethnic representation. PMID:16899019

  1. 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.

  2. Examining Race and Ethnicity Information in Medicare Administrative Data.

    PubMed

    Filice, Clara E; Joynt, Karen E

    2016-07-29

    Racial and ethnic disparities are observed in the health status and health outcomes of Medicare beneficiaries. Reducing these disparities is a national priority, and having high-quality data on individuals' race and ethnicity is critical for researchers working to do so. However, using Medicare data to identify race and ethnicity is not straightforward. Currently, Medicare largely relies on Social Security Administration data for information about Medicare beneficiary race and ethnicity. Directly self-reported race and ethnicity information is collected for subsets of Medicare beneficiaries but is not explicitly collected for the purpose of populating race/ethnicity information in the Medicare administrative record. As a consequence of historical data collection practices, the quality of Medicare's administrative data on race and ethnicity varies substantially by racial/ethnic group; the data are generally much more accurate for whites and blacks than for other racial/ethnic groups. Identification of Hispanic and Asian/Pacific Islander beneficiaries has improved through use of an imputation algorithm recently applied to the Medicare administrative database. To improve the accuracy of race/ethnicity data for Medicare beneficiaries, researchers have developed techniques such as geocoding and surname analysis that indirectly assign Medicare beneficiary race and ethnicity. However, these techniques are relatively new and data may not be widely available. Understanding the strengths and limitations of different approaches to identifying race and ethnicity will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using these measures.

  3. Comparative effectiveness of high-dose versus standard-dose influenza vaccines in US residents aged 65 years and older from 2012 to 2013 using Medicare data: a retrospective cohort analysis

    PubMed Central

    Izurieta, Hector S; Thadani, Nicole; Shay, David K; Lu, Yun; Maurer, Aaron; Foppa, Ivo M; Franks, Riley; Pratt, Douglas; Forshee, Richard A; MaCurdy, Thomas; Worrall, Chris; Howery, Andrew E; Kelman, Jeffrey

    2016-01-01

    Summary Background A high-dose trivalent inactivated influenza vaccine was licensed in 2009 by the US Food and Drug Administration (FDA) on the basis of serological criteria. We sought to establish whether high-dose inactivated influenza vaccine was more effective for prevention of influenza-related visits and hospital admissions in US Medicare beneficiaries than was standard-dose inactivated influenza vaccine. Methods In this retrospective cohort study, we identified Medicare beneficiaries aged 65 years and older who received high-dose or standard-dose inactivated influenza vaccines from community pharmacies that offered both vaccines during the 2012–13 influenza season. Outcomes were defined with billing codes on Medicare claims. The primary outcome was probable influenza infection, defined by receipt of a rapid influenza test followed by dispensing of the neuraminidase inhibitor oseltamivir. The secondary outcome was a hospital or emergency department visit, listing a Medicare billing code for influenza. We estimated relative vaccine effectiveness by comparing outcome rates in Medicare beneficiaries during periods of high influenza circulation. Univariate and multivariate Poisson regression models were used for analyses. Findings Between Aug 1, 2012 and Jan 31, 2013, we studied 929 730 recipients of high-dose vaccine and 1 615 545 recipients of standard-dose vaccine. Participants enrolled in each cohort were well balanced with respect to age and presence of underlying medical disorders. The high-dose vaccine (1·30 outcomes per 10 000 person-weeks) was 22% (95% CI 15–29) more effective than the standard-dose vaccine (1·01 outcomes per 10 000 person-weeks) for prevention of probable influenza infections (rapid influenza test followed by oseltamivir treatment) and 22% (95% CI 16–27%) more effective for prevention of influenza hospital admissions (0·86 outcomes per 10 000 person-weeks in the high-dose cohort vs 1·10 outcomes per 10 000 person-weeks in the

  4. 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

  5. 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.

  6. 42 CFR 411.43 - Beneficiary's responsibility with respect to workers' compensation.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... workers' compensation. 411.43 Section 411.43 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.43 Beneficiary's responsibility with respect to workers' compensation. (a) The beneficiary is responsible...

  7. 42 CFR 411.43 - Beneficiary's responsibility with respect to workers' compensation.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... workers' compensation. 411.43 Section 411.43 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.43 Beneficiary's responsibility with respect to workers' compensation. (a) The beneficiary is responsible...

  8. 42 CFR 411.43 - Beneficiary's responsibility with respect to workers' compensation.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... workers' compensation. 411.43 Section 411.43 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.43 Beneficiary's responsibility with respect to workers' compensation. (a) The beneficiary is responsible...

  9. 42 CFR 411.43 - Beneficiary's responsibility with respect to workers' compensation.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... workers' compensation. 411.43 Section 411.43 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.43 Beneficiary's responsibility with respect to workers' compensation. (a) The beneficiary is responsible...

  10. 42 CFR 411.43 - Beneficiary's responsibility with respect to workers' compensation.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... workers' compensation. 411.43 Section 411.43 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES... PAYMENT Limitations on Medicare Payment for Services Covered Under Workers' Compensation § 411.43 Beneficiary's responsibility with respect to workers' compensation. (a) The beneficiary is responsible...

  11. 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...

  12. 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...

  13. 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...

  14. 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...

  15. 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...

  16. 42 CFR 411.402 - Indemnification of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... excluded services. (2) The beneficiary did not know and could not reasonably have been expected to know... is precluded because the conditions of § 411.400(a)(2) are not met. Medicare indemnifies the beneficiary (and recovers from the provider, practitioner, or supplier), if the following conditions are...

  17. Inappropriate Utilization in Fee-for-Service Medicare and Medicare Advantage Plans.

    PubMed

    Parashuram, Shriram; Kim, Seung; Dowd, Bryan

    2017-04-01

    This study uses a national multi-payer claims database to test for differences in potentially inappropriate emergency department (ED) visits and ambulatory care sensitive (ACS) admissions in fee-for-service (FFS) Medicare and Medicare Advantage (MA) plans. Rates of ACS admissions for MA enrollees were approximately one third those of FFS beneficiaries, controlling for covariates, which included the beneficiary's health status as represented by their risk score. This study then compared FFS and MA beneficiaries when they moved from one type of health plan to another. Again, controlling for covariates, potentially inappropriate ED visits and ACS admissions remained at their low baseline values for FFS beneficiaries who switched from FFS Medicare to MA plans, but rose for MA enrollees switching to FFS Medicare.

  18. Evaluation of the Medicare Competition Demonstrations

    PubMed Central

    Langwell, Kathryn M.; Hadley, James P.

    1989-01-01

    A summary of findings from the Evaluation of the Medicare Competition Demonstrations is presented in this article. The purpose of this evaluation was to examine the implementation and operational experiences of the 26 health maintenance organizations that operated as demonstrations from 1983 to 1985, their experiences in marketing their plans, the factors that affected beneficiaries' decisions to join or not join a plan, the extent to which beneficiaries were satisfied with their choice of plans, the quality of care provided by the plans, and the impact of the demonstrations on Medicare beneficiaries' use and cost of services. PMID:10313459

  19. 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.

  20. 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

  1. Medicare Advantage Enrollment Update 2016.

    PubMed

    Ullrich, Fred; Mueller, Keith

    2016-09-01

    Purpose. The RUPRI Center for Rural Health Policy Analysis reports annually on rural beneficiary enrollment in Medicare Advantage (MA) plans, noting any trends or new developments evident in the data. These reports are based on data through March of each year, capturing results of open enrollment periods. Key Findings. (1)The number of non-metropolitan beneficiaries enrolled in MA and other prepaid plans increased to 2,189,300 as of March 2016, representing 21.8 percent of all non-metropolitan Medicare beneficiaries compared with 31.5 percent of beneficiaries enrolled in MA and other prepaid plans nationally. (2) While non-metropolitan enrollment continued to increase through March 2016, the annual growth rate slowed to 5.5 percent, compared to 6.8 percent between March 2014 and March 2015. (3) Enrollment in private fee-for-service MA plans continued to decline, both nationally and in non-metropolitan counties, while enrollment in other types of MA plans increased. (4) The states with the highest percentage of non-metropolitan beneficiaries enrolled in MA plans continued to be Minnesota, Hawaii, Pennsylvania, Wisconsin, and New York, ranging from a high of 53.4 percent in Minnesota to 32.6 percent in New York. (5) Non-metropolitan beneficiary enrollment (counts) in MA plans declined in five states: Hawaii, Idaho, Ohio, Washington, and Wyoming.

  2. Effects of Resident Duty Hour Reform on Surgical and Procedural Patient Safety Indicators Among Hospitalized VA and Medicare Patients

    PubMed Central

    Rosen, Amy K.; Loveland, Susan A.; Romano, Patrick S.; Itani, Kamal MF; Silber, Jeffrey H.; Even-Shoshan, Orit O.; Halenar, Michael J.; Teng, Yun; Zhu, Jingsan; Volpp, Kevin G.

    2009-01-01

    Objective Improving patient safety was a strong motivation behind duty hour regulations implemented by ACGME on July 1, 2003. We investigated whether rates of Patient Safety Indicators (PSIs) changed following these reforms. Research Design Observational study of patients admitted to VA (N=826,047) and Medicare (N=13,367,273) acute-care hospitals from 7/1/2000–6/30/2005. We examined changes in patient safety events in more vs. less teaching-intensive hospitals before (2000–2003) and after (2003–2005) duty hour reform, using conditional logistic regression, adjusting for patient age, gender, comorbidities, secular trends, baseline severity, and hospital site. Measures Ten PSIs were aggregated into 3 composite measures based on factor analyses: “Continuity of Care,” “Technical Care,” and “Other” composites. Results “Continuity of Care” composite rates showed no significant changes post-reform in hospitals of different teaching intensity in either VA or Medicare. In the VA, there were no significant changes post-reform for the “Technical Care” composite. In Medicare, the odds of a Technical Care PSI event in more vs. less teaching-intensive hospitals in post-reform year 1 were 1.12 (95% CI; 1.01–1.25); there were no significant relative changes in post-reform year 2. “Other” composite rates increased in VA in post-reform year 2 in more vs. less teaching-intensive hospitals (OR, 1.63; 95% CI, 1.10–2.41), but not in Medicare in either post-reform year. Conclusions Duty hour reform had no systematic impact on PSI rates. In the few cases where there were statistically significant increases in the relative odds of developing a PSI, the magnitude of the absolute increases were too small to be clinically meaningful. PMID:19536029

  3. 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

  4. 42 CFR 422.314 - Special rules for beneficiaries enrolled in MA MSA plans.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Special rules for beneficiaries enrolled in MA MSA plans. 422.314 Section 422.314 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) MEDICARE ADVANTAGE PROGRAM Payments...

  5. Factors associated with access to rheumatologists for Medicare patients

    PubMed Central

    Schmajuk, Gabriela; Tonner, Chris; Yazdany, Jinoos

    2015-01-01

    Objective Despite looming rheumatologist shortages and a growing number of patients with arthritis and other rheumatic conditions, nationwide estimates of access to rheumatology care have never been reported. We aimed to measure travel times as a proxy to access to care and to determine the individual and area-level factors associated with long travel times to rheumatologists in the U.S. Methods We used Medicare Part B claims for the 2009 Medicare Chronic Condition Warehouse 5% rheumatoid arthritis/osteoarthritis cohort. Using Google Maps we estimated driving time from the center of a beneficiary’s home ZIP code to the center of their rheumatologist’s office ZIP code. We examined predictors of travel time ≥ 90 minutes in a series of generalized linear mixed models adjusting for rheumatologist supply, rurality, and individual patient characteristics including age, race, gender, and income. Results We included 41,693 Medicare beneficiaries with one or more visits to a rheumatologist in 2009. The median estimated beneficiary travel time to a rheumatologist was 22 minutes (interquartile range (IQR) 12–40 minutes). Seven percent of beneficiaries travelled 90 minutes or longer to visit a rheumatologist. Even after adjusting for covariates, independent predictors of long travel times included living in areas with no or low supply of rheumatologists and living in the Mountain region of the U.S. Conclusions A small but significant proportion of patients in the U.S. travelled very long distances to visit a rheumatologist, and most of these individuals resided in areas with no or low supplies of rheumatologists. These data suggest that addressing shortages in rheumatology care for patients in low-supply areas is a key target for improving access to rheumatologists. PMID:26319646

  6. Components of Medicare reimbursement.

    PubMed

    Malatestinic, William; Braun, LeeAnn; Jorgenson, James A; Eskew, Jim

    2003-11-01

    The history of the Medicare reimbursement system, how it works, and issues related to fraud and abuse are discussed. The statutory charge of Medicare is to ensure adequate reimbursement through a Prospective Payment System (PPS) to cover the costs for providing a given service to Medicare beneficiaries. The PPS was introduced as a way to change hospital behavior through financial incentives that encourage cost-efficient management of resources. The system utilizes a rate of payment in which a hospital is paid a fixed amount that is expected to cover the costs of care while treating a typical patient in a particular diagnosis-related group (DRG). The PPS uses DRGs as payment categories and Major Diagnostic Categories (MDCs) for classifying the DRGs into similar groupings. One of the first steps in DRG assignment is identification of the principal diagnosis represented by an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code. The secondary diagnoses (referred to as complications or comorbidities), presence or absence of surgery, age of the patient, and discharge status are the other pieces of information making up assignment of a specific DRG to a patient. A basic knowledge of the Medicare program will help in the understanding of how hospitals will be reimbursed for patient care, as well as how changes in Medicare payment may affect reimbursement. Medicare is one of the largest health insurance providers in the United States. A basic understanding of the Medicare system will provide valuable insights into Medicare reimbursement and the influence it has on a hospital's bottom line.

  7. 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.

  8. What Medicare Covers

    MedlinePlus

    ... your Medicare coverage — Original Medicare or a Medicare Advantage Plan (Part C). What Part A covers Medicare ... health plans cover Medicare health plans include Medicare Advantage, Medical Savings Account (MSA), Medicare Cost plans, PACE, ...

  9. 77 FR 9179 - Medicare Program; Reporting and Returning of Overpayments

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-16

    ...), HHS. ACTION: Proposed rule. SUMMARY: This proposed rule would require providers and suppliers... approximately 47 million enrolled beneficiaries. Providers and suppliers furnishing Medicare items and services... ``person'' as a provider of services, supplier, Medicaid managed care organization (MCO) (as defined...

  10. 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.

  11. Medicare physician payments and spending.

    PubMed

    Dummit, Laura A

    2006-10-09

    The Medicare program's physician payment method is intended to control spending while ensuring beneficiary access to physician services, but there are signs that it may not be working. The physician's role in the health care delivery system as the primary source of information and treatment options, together with growing demand for services and the imperfect state of knowledge about appropriate service use, challenge Medicare's ability to achieve these two goals. This issue brief describes the history of physician spending and the contribution of escalating service use and intensity of services to the rise in Medicare outlays, setting the stage for further discussion about the use of the Medicare payment system to control spending and ensure access.

  12. Understanding medicare

    MedlinePlus

    ... laws What Medicare decides is covered What local companies decide to cover It's important to always check ... drugs. MA plans are offered by private insurance companies provided who work along with Medicare. You pay ...

  13. Medicare means-testing: a skeptical view.

    PubMed

    Moon, Marilyn

    2004-01-01

    In response to claims that Medicare is unsustainable over time, Mark Pauly has suggested a means-testing approach as a solution to its financing problems. To obtain enough resources in this way, however, it is necessary to ask middle-class beneficiaries to pay much more for their health care, by subjecting them to vouchers. The spending limits Pauly suggests are arbitrary and would likely place an untenable burden on beneficiaries with modest incomes. A better approach to financing would be to examine the ability of both taxpayers and beneficiaries to pay in the future-likely resulting in a different outcome.

  14. 42 CFR 411.54 - Limitation on charges when a beneficiary has received a liability insurance payment or has a...

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer. 411.54 Section 411.54 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM EXCLUSIONS FROM MEDICARE...

  15. 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...

  16. Medicare Rights and Protections

    MedlinePlus

    ... about: Your rights & protections in: ■ ■ Original Medicare ■ ■ Medicare Advantage Plan or other Medicare health plans ■ ■ Medicare Prescription ... 11 Section 3: Your Rights in a Medicare Advantage Plan or Other Medicare Health Plan 13 Section ...

  17. 75 FR 37971 - Providing Stability and Security for Medicare Reimbursements

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-06-30

    ... request that you immediately take the following steps to minimize any disruption to, or administrative burden on, Medicare physicians and other affected providers and to minimize any disruption in the ability... necessary steps, to the extent permitted by law, to protect Medicare beneficiaries from any disruption...

  18. 42 CFR 422.108 - Medicare secondary payer (MSP) procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM Benefits and Beneficiary Protections § 422... enrollees with the benefits of the primary payers, including reporting, on an ongoing basis, information... instructions. (c) Collecting from other entities. The MA organization may bill, or authorize a provider to...

  19. 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.

  20. Use and knowledge of the new enrollee "welcome to Medicare" physical examination benefit.

    PubMed

    Petroski, Cara A; Regan, Joseph F

    2009-01-01

    The Medicare Current Beneficiary Survey (MCBS) is a large survey utilizing a nationally representative sample of the Medicare population. The MCBS collects data on a whole host of topics including health status, health insurance coverage and financing, access to care, knowledge and understanding of the Medicare Program, as well as use and effectiveness of new program benefits and changes.

  1. 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…

  2. 75 FR 73086 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the National Committee for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-29

    ... Deeming Authority of the National Committee for Quality Assurance for Medicare Advantage Health... application to renew the Medicare Advantage Deeming Authority of the National Committee for Quality Assurance... beneficiaries may receive covered services through a Medicare Advantage (MA) organization that contracts...

  3. 42 CFR 415.105 - Amounts of payment for physician services to beneficiaries in providers.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM SERVICES FURNISHED BY PHYSICIANS IN... services to beneficiaries in providers. (a) General rule. The carrier determines amounts of payment for physician services to beneficiaries in providers in accordance with the general rules governing...

  4. 42 CFR 415.105 - Amounts of payment for physician services to beneficiaries in providers.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) SERVICES FURNISHED BY... for physician services to beneficiaries in providers. (a) General rule. The carrier determines amounts of payment for physician services to beneficiaries in providers in accordance with the general...

  5. 42 CFR 424.64 - Payment after beneficiary's death: Bill has not been paid.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Payment after beneficiary's death: Bill has not been paid. 424.64 Section 424.64 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Whom Payment is Made in Special Situations § 424.64 Payment after beneficiary's death: Bill has...

  6. 42 CFR 424.64 - Payment after beneficiary's death: Bill has not been paid.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment after beneficiary's death: Bill has not been paid. 424.64 Section 424.64 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Made in Special Situations § 424.64 Payment after beneficiary's death: Bill has not been paid....

  7. 42 CFR 424.64 - Payment after beneficiary's death: Bill has not been paid.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Payment after beneficiary's death: Bill has not been paid. 424.64 Section 424.64 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Whom Payment is Made in Special Situations § 424.64 Payment after beneficiary's death: Bill has...

  8. 42 CFR 424.64 - Payment after beneficiary's death: Bill has not been paid.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Payment after beneficiary's death: Bill has not been paid. 424.64 Section 424.64 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Made in Special Situations § 424.64 Payment after beneficiary's death: Bill has not been paid....

  9. 42 CFR 424.64 - Payment after beneficiary's death: Bill has not been paid.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment after beneficiary's death: Bill has not been paid. 424.64 Section 424.64 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Whom Payment is Made in Special Situations § 424.64 Payment after beneficiary's death: Bill has...

  10. Examining Measures of Income and Poverty in Medicare Administrative Data.

    PubMed

    Samson, Lok Wong; Finegold, Kenneth; Ahmed, Azeem; Jensen, Matthew; Filice, Clara E; Joynt, Karen E

    2016-07-29

    Disparities by economic status are observed in the health status and health outcomes of Medicare beneficiaries. For health services and health policy researchers, one barrier to addressing these disparities is the ability to use Medicare data to ascertain information about an individual's income level or poverty, because Medicare administrative data contains limited information about individual economic status. Information gleaned from other sources-such as the Medicaid and Supplemental Security Income programs-can be used in some cases to approximate the income of Medicare beneficiaries. However, such information is limited in its availability and applicability to all beneficiaries. Neighborhood-level measures of income can be used to infer individual-level income, but level of neighborhood aggregation impacts accuracy and usability of the data. Community-level composite measures of economic status have been shown to be associated with health and health outcomes of Medicare beneficiaries and may capture neighborhood effects that are separate from individual effects, but are not readily available in Medicare data and do not serve to replace information about individual economic status. There is no single best method of obtaining income data from Medicare files, but understanding strengths and limitations of different approaches to identifying economic status will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using measures of income.

  11. 42 CFR 413.53 - Determination of cost of services to beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 2 2011-10-01 2011-10-01 false Determination of cost of services to beneficiaries. 413.53 Section 413.53 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE...

  12. 42 CFR 413.53 - Determination of cost of services to beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 2 2014-10-01 2014-10-01 false Determination of cost of services to beneficiaries. 413.53 Section 413.53 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE...

  13. 42 CFR 413.53 - Determination of cost of services to beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 2 2013-10-01 2013-10-01 false Determination of cost of services to beneficiaries. 413.53 Section 413.53 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE...

  14. 42 CFR 413.53 - Determination of cost of services to beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 2 2012-10-01 2012-10-01 false Determination of cost of services to beneficiaries. 413.53 Section 413.53 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE...

  15. 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...

  16. 42 CFR 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 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 (CONTINUED) HEALTH MAINTENANCE...

  17. 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.... Subject to the requirements of the Assignment of Claims Act (31 U.S.C. 3727), Medicare may pay...

  18. 42 CFR 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 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...

  19. 42 CFR 417.460 - Disenrollment of beneficiaries by an HMO or CMP.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 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 HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) HEALTH MAINTENANCE...

  20. 42 CFR 478.40 - Beneficiary's right to a hearing.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 478.40 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) QUALITY IMPROVEMENT ORGANIZATIONS RECONSIDERATIONS AND APPEALS Utilization and Quality Control Quality Improvement Organization (QIO) Reconsiderations and Appeals § 478.40 Beneficiary's right to...

  1. 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...

  2. A Note on Income Effects and Health Care Cost Growth in Medicare

    PubMed Central

    McGuire, Thomas G.

    2015-01-01

    This paper sets out a model of technical change and health care cost growth for a representative Medicare beneficiary facing a budget constraint. Derivation of an explicit expression for health care cost growth shows how technological change and preferences, including income effects, affect cost growth. The analysis highlights the role of the 76% percent subsidy from current taxpayers to Medicare beneficiaries for purchase of health insurance. This subsidy insulates beneficiaries from the income effects of cost growth by shifting the costs and income effects to taxpayers. Simulations show that over the next 10-20 years, income effects will have little effect on cost growth in Medicare. PMID:26316878

  3. 76 FR 5755 - Medicare and Medicaid Programs; Patient Notification of Right To Access State Survey Agencies and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-02

    ...This proposed rule would set forth new requirements for Medicare certified providers and suppliers. This proposed rule would require that the Medicare certified providers and suppliers make available to their Medicare beneficiaries information about their right to file a written complaint with the Quality Improvement Organization (QIO) in the State where healthcare services are being or were......

  4. Medicare coverage for oncology services.

    PubMed

    Bagley, G P; McVearry, K

    1998-05-15

    Medicare's mission is to assure health care security for our beneficiaries. Title XVIII of the Social Security Act (the Act) provides the Health Care Financing Administration (HCFA) with the authority to fulfill this mission. Although Medicare is considered a defined benefit program, the Act vested Medicare with the discretionary authority to make specific policy decisions when necessary. HCFA's discretionary authority, which is found at section 1862(a)(1)(A) of the Act, enables HCFA to provide coverage for services that are reasonable and necessary for the treatment and diagnosis of illness or injury or to improve the functioning of a malformed body member. To determine whether a service is reasonable and necessary, HCFA relies on authoritative evidence. This evidence includes, but is not limited to, approvals from appropriate federal agencies, such as the Food and Drug Administration, and systematic evaluations of scientific literature via technology assessments. HCFA also may decide that a service warrants a unique type of coverage policy, which is referred to as coverage with conditions. This form of coverage is a middle ground between strict noncoverage and general coverage for a medical service that appears promising, but still is evolving. All these policy specifications effect Medicare coverage of oncology services. This means that reasonable and necessary diagnostic and therapeutic cancer-related services that are not otherwise prohibited by Medicare's statute, regulations, and manual instructions are covered and paid for by the program. Prior to the Balanced Budget Act of 1997 (BBA '97), Medicare provided coverage for some beneficiaries to undergo mammography and Papanicolaou smear screening. As a result of BBA '97, Congress has mandated expanding coverage for these services as well as adding coverage for pelvic examinations, prostate cancer screening, colorectal screening, and antiemetic drugs used as part of an anticancer chemotherapy regimen. Other

  5. Medicare program: changes to the Medicare claims appeal procedures. Interim final rule with comment period.

    PubMed

    2005-03-08

    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 under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

  6. Wheelchairs, walkers, and canes: what does Medicare pay for, and who benefits?

    PubMed

    Wolff, Jennifer L; Agree, Emily M; Kasper, Judith D

    2005-01-01

    Medicare's role in the distribution of mobility-related assistive technology has not been well documented, yet rapid growth and regional variation in spending, and concerns over "in-the-home" coverage criteria, highlight the need for facts. Using the 2001 Medicare Current Beneficiary Survey, we find that 6.2 percent percent of beneficiaries obtained mobility assistive technology under the Medicare durable medical equipment (DME) benefit. These beneficiaries were disproportionately poor, disabled, and users of both acute and postacute services. Average per item spending ranged from $52 for canes to $6,208 for power wheelchairs. Among beneficiaries who acquired such technology through the DME benefit, these devices comprised just 2 percent of overall Medicare spending.

  7. Governmental efforts to improve quality of care for nursing home residents and to protect them from mistreatment: a survey of federal and state laws.

    PubMed

    Gittler, Josephine

    2008-10-01

    There are many federal and state laws addressing, directly and indirectly, the quality of care provided to nursing home residents and the protection of residents from mistreatment. They include: (a) state laws that govern the licensing of nursing homes, (b) federal laws that govern the certification of nursing homes for participation in the Medicare and Medicaid programs, (c) elder abuse laws prohibiting mistreatment of older adults in nursing homes and other settings, (d) health care fraud abuse laws that are increasingly being used to combat the provision of substandard care to Medicare and Medicaid beneficiaries in nursing homes, and (e) laws that have established long-term care ombudsman programs to promote the health, safety, well-being, and rights of nursing home residents. While these laws are generally viewed as having improved the care and treatment of nursing home residents, much remains to be done, particularly with respect to the implementation of these laws.

  8. 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.

  9. 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

  10. Sensitivity and Specificity of the Minimum Data Set 3.0 Discharge Data Relative to Medicare Claims

    PubMed Central

    Rahman, Momotazur; Tyler, Denise; Acquah, Joseph Kofi; Lima, Julie; Mor, Vincent

    2016-01-01

    Objective The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents. Design We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes. Settings All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011. Results Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS discharge records. More than 99% of the variation in nursing home–level 30-day rehospitalization rate calculated using claims data can be explained by the same rates calculated using MDS. Nursing home structural characteristics explain only 5% of the variation in nursing home–level sensitivity and 3% of the variation in nursing home–level specificity. Conclusion The new MDS 3.0 discharge record matches Medicare enrollment and hospitalization claims events with a high degree of accuracy, meaning that hospitalization rates calculated based on MDS offer a good proxy for the “gold standard” Medicare data. PMID:25179533

  11. The Star Rating System and Medicare Advantage Plans.

    PubMed

    Sprague, Lisa

    2015-05-05

    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.

  12. What Is Medicare?

    MedlinePlus

    ... supplies, and preventive services. Medicare Part C (Medicare Advantage Plans) A type of Medicare health plan offered ... your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, ...

  13. Medicare Hospice Benefits

    MedlinePlus

    ... include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare ... Medicare coverage. Original Medicare —Original Medicare is a fee-for-service health plan that has two parts: ...

  14. 42 CFR 413.35 - Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... charge an individual entitled to benefits under Medicare for such more expensive items or services even... charges the provider is authorized to impose on individuals entitled to benefits under Medicare on account... beneficiaries if cost limits are applied to services. 413.35 Section 413.35 Public Health CENTERS FOR...

  15. 42 CFR 413.35 - Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... charge an individual entitled to benefits under Medicare for such more expensive items or services even... charges the provider is authorized to impose on individuals entitled to benefits under Medicare on account... beneficiaries if cost limits are applied to services. 413.35 Section 413.35 Public Health CENTERS FOR...

  16. 42 CFR 413.35 - Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... charge an individual entitled to benefits under Medicare for such more expensive items or services even... charges the provider is authorized to impose on individuals entitled to benefits under Medicare on account... beneficiaries if cost limits are applied to services. 413.35 Section 413.35 Public Health CENTERS FOR...

  17. 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

    ... charge an individual entitled to benefits under Medicare for such more expensive items or services even... charges the provider is authorized to impose on individuals entitled to benefits under Medicare on account... beneficiaries if cost limits are applied to services. 413.35 Section 413.35 Public Health CENTERS FOR...

  18. 2014: Rural Medicare Advantage Enrollment Update.

    PubMed

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

    2015-01-01

    Key Data Findings. (1) Reclassification of rural and urban county designations (due to the switch from 2000 census data to 2010 census data) resulted in a 10 percent decline in the number of Medicare eligible Americans living in rural counties in 2014 (from roughly 10.7 million to 9.6 million). These changes also resulted in a decline in the number of MA enrollees considered to be living in a rural area, from 2.19 million to 1.95 million. However, the percentage of Medicare beneficiaries enrolled in MA and prepaid plans in rural areas declined only slightly from 20.6 percent to 20.3 percent. (2) Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2014 was nearly 1.95 million, or 20.3 percent of all rural Medicare beneficiaries, an increase of more than 216,000 from March 2013. Enrollment increased to 1.99 million (20.4 percent) in October 2014. (3) In March 2014, 56 percent of rural MA enrollees were enrolled in Preferred Provider Organization (PPO) plans, 29 percent were enrolled in Health Maintenance Organization (HMO) or Point-of-Service (POS) plans, 7 percent were enrolled in Private Fee-for-Service (PFFS) plans, and 8 percent were enrolled in other prepaid plans, including Cost plans and Program of All-Inclusive Care for the Elderly (PACE) plans. (4) States with the highest percentage of rural Medicare beneficiaries enrolled in MA and other prepaid plans include Minnesota (49.1 percent), Hawaii (41.1 percent), Pennsylvania (35.4 percent), Wisconsin (34.3 percent), New York (30.4 percent), and Ohio (30.1 percent).

  19. Medicare Catastrophic Loss Prevention Act of 1987. Report from the Committee on Finance (To Accompany S. 1127). 100th Congress, 1st Session.

    ERIC Educational Resources Information Center

    Congress of the U.S., Washington, DC. Senate Committee on Finance.

    The Medicare Catastrophic Loss Prevention Act of 1987, a bill which would protect Medicare beneficiaries from catastrophic expenses associated with covered Medicare services is reported on in this document from the Senate Committee on Finance. The report opens with the Committee's recommendations that the bill pass as amended. The background and…

  20. 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.

  1. Three decades of Medicare: what the numbers tell us.

    PubMed

    Davis, M H; Burner, S T

    1995-01-01

    The Medicare program was first implemented to meet a critical need in American society, and over its thirty-year history it has evolved into an integral part of the U.S. health care system. This DataWatch provides a broad overview of the program, outlining both historical and current trends in coverage, financing, payment mechanisms, beneficiary status, benefits, and spending.

  2. 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.

  3. 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.

  4. Receipt of Chemotherapy Among Medicare Patients With Cancer by Type of Supplemental Insurance

    PubMed Central

    Warren, Joan L.; Butler, Eboneé N.; Stevens, Jennifer; Lathan, Christopher S.; Noone, Anne-Michelle; Ward, Kevin C.; Harlan, Linda C.

    2015-01-01

    Purpose Medicare beneficiaries with cancer bear a greater portion of their health care costs, because cancer treatment costs have increased. Beneficiaries have supplemental insurance to reduce out-of-pocket costs; those without supplemental insurance may face barriers to care. This study examines the association between type of supplemental insurance coverage and receipt of chemotherapy among Medicare patients with cancer who, per National Comprehensive Cancer Network treatment guidelines, should generally receive chemotherapy. Patients and Methods This retrospective, observational study included 1,200 Medicare patients diagnosed with incident cancer of the breast (stage IIB to III), colon (stage III), rectum (stage II to III), lung (stage II to IV), or ovary (stage II to IV) from 2000 to 2005. Using the National Cancer Institute Patterns of Care Studies and linked SEER-Medicare data, we determined each Medicare patient's supplemental insurance status (private insurance, dual eligible [ie, Medicare with Medicaid], or no supplemental insurance), consultation with an oncologist, and receipt of chemotherapy. Using adjusted logistic regression, we evaluated the association of type of supplemental insurance with oncologist consultation and receipt of chemotherapy. Results Dual-eligible patients were significantly less likely to receive chemotherapy than were Medicare patients with private insurance. Patients with Medicare only who saw an oncologist had comparable rates of chemotherapy compared with Medicare patients with private insurance. Conclusion Dual-eligible Medicare beneficiaries received recommended cancer chemotherapy less frequently than other Medicare beneficiaries. With the increasing number of Medicaid patients under the Affordable Care Act, there will be a need for patient navigators and sufficient physician reimbursement so that low-income patients with cancer will have access to oncologists and needed treatment. PMID:25534387

  5. Health care use and expenditures of Medicare HMO disenrollees.

    PubMed

    Parente, Stephen T; Evans, William N; Schoenman, Julie A; Finch, Michael D

    2005-01-01

    We examine the impact of the first wave of Medicare health maintenance organization HMO withdrawals. With data from CMS and United Health Group, we estimate use and expenditure changes between 1998 and 1999 for HMO enrollees who were involuntarily dropped from their plan and returned to fee-for-service (FFS) Medicare using a difference-in-difference model. Compared to those who voluntarily left an HMO, involuntarily disenrolled beneficiaries had higher out-of-pocket expenditures, an 80 percent decrease in physician visits, 38 percent higher emergency room (ER) use and a higher probability of dying. The results suggest beneficiaries face significant costs and reduced health outcomes from unstable Medicare managed care markets.

  6. Medicare Special Needs Plan (SNP)

    MedlinePlus

    ... change plans Types of Medicare health plans Medicare Advantage Plans + Share widget - Select to show Subcategories Getting ... Types of Medicare health plans , current subcategory Medicare Advantage Plans , current page Medicare Medical Savings Account (MSA) ...

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

    PubMed

    Newhouse, Joseph P; 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.

  8. 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

  9. Effect of medicare payment on rural health care systems.

    PubMed

    McBride, Timothy D; Mueller, Keith J

    2002-01-01

    Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

  10. Paying Medicare Advantage plans by competitive bidding: how much competition is there?

    PubMed

    Biles, Brian; Pozen, Jonah; Guterman, Stuart

    2009-08-01

    Private health plans that enroll Medicare beneficiaries--known as Medicare Advantage (MA) plans--are being paid $11 billion more in 2009 than it would cost to cover these beneficiaries in regular fee-for-service Medicare. To generate Medicare savings for offsetting the costs of health reform, the Obama Administration has proposed eliminating these extra payments to private insurers and instituting a competitive bidding system that pays MA plans based on the bids they submit. This study examines the concentration of enrollment among MA plans and the degree to which firms offering MA plans actually face competition. The results show that in the large majority of U.S. counties, MA plan enrollment is highly concentrated in a small number of firms. Given the relative lack of competition in many markets as well as the potential impact on traditional Medicare, the authors call for careful consideration of a new system for setting MA plan payments.

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

    MedlinePlus

    ... Medicare Prescription Drug Coverage Works with a Medicare Advantage Plan or Medicare Cost Plan Medicare offers prescription ... elect the drug coverage. 2. Join a Medicare Advantage Plan— like a Health Maintenance Organization (HMO), Preferred ...

  12. 42 CFR 441.102 - Plan of care for institutionalized beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 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...

  13. 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...

  14. 42 CFR 405.1200 - Notifying beneficiaries of provider service terminations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Notifying beneficiaries of provider service terminations. 405.1200 Section 405.1200 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF.... (1) For purposes of §§ 405.1200 through 405.1204, the term, provider, is defined as a home...

  15. 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.

  16. Medicare Financial Stability for Beneficiaries Act of 2009

    THOMAS, 111th Congress

    Sen. Bingaman, Jeff [D-NM

    2009-06-04

    06/04/2009 Read twice and referred to the Committee on Finance. (text of measure as introduced: CR S6194-6201) (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

  17. 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:

  18. 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:

  19. 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.

  20. 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.

  1. 77 FR 32407 - Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-01

    ... Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for...; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year...), the final rule with comment period entitled ``Medicare Program; Changes to the Medicare Advantage...

  2. 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

    ...-AP77 Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...; Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... entitled ``Medicare Program; Policy and Technical Changes to the Medicare Advantage and the...

  3. The Effect of Hospice on Hospitalizations of Nursing Home Residents

    PubMed Central

    Zheng, Nan Tracy; Mukamel, Dana B.; Friedman, Bruce; Caprio, Thomas V.; Temkin-Greener, Helena

    2014-01-01

    Objectives Hospice enrollment is known to reduce risk of hospitalizations for nursing home residents who use it. We examined whether residing in facilities with a higher hospice penetration: 1) reduces hospitalization risk for non-hospice residents; and 2) decreases hospice-enrolled residents’ hospitalization risk relative to hospice-enrolled residents in facilities with a lower hospice penetration. Method Medicare Beneficiary File, Inpatient and Hospice Claims, Minimum Data Set Version 2.0, Provider of Services File and Area Resource File. Retrospective analysis of long-stay nursing home residents who died during 2005-2007. Overall, 505,851 non-hospice (67.66%) and 241,790 hospice-enrolled (32.34%) residents in 14,030 facilities nationwide were included. We fit models predicting the probability of hospitalization conditional on hospice penetration and resident and facility characteristics. We used instrumental variable method to address the potential endogeneity between hospice penetration and hospitalization. Distance between each nursing home and the closest hospice was the instrumental variable. Main Findings In the last 30 days of life, 37.63% of non-hospice and 23.18% of hospice residents were hospitalized. Every 10% increase in hospice penetration leads to a reduction in hospitalization risk of 5.1% for non-hospice residents and 4.8% for hospice-enrolled residents. Principal Conclusions Higher facility-level hospice penetration reduces hospitalization risk for both non-hospice and hospice-enrolled residents. The findings shed light on nursing home end-of-life care delivery, collaboration among providers and cost benefit analysis of hospice care. PMID:25304181

  4. 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...

  5. 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.

  6. 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

  7. Paying medicare advantage plans: To level or tilt the playing field.

    PubMed

    Glazer, Jacob; McGuire, Thomas G

    2016-12-29

    Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and subsidizes MA plans based on a "benchmark" for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Many analysts recommend equalizing Medicare's subsidy across the options - referred to in policy circles as a "level playing field." This paper studies the normative question of how to set the level of the benchmark, applying the versatile model developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic.

  8. Competition Among Medicare's Private Health Plans: Does It Really Exist?

    PubMed

    Biles, Brian; Casillas, Giselle; Guterman, Stuart

    2015-08-01

    Competition among private Medicare Advantage (MA) plans is seen by some as leading to lower premiums and expanded benefits. But how much competition exists in MA markets? Using a standard measure of market competition, our analysis finds that 97 percent of markets in U.S. counties are highly concentrated and therefore lacking in significant MA plan competition. Competition is considerably lower in rural counties than in urban ones. Even among the 100 counties with the greatest numbers of Medicare beneficiaries, 81 percent do not have competitive MA markets. Market power is concentrated among three nationwide insurance organizations in nearly two-thirds of those 100 counties.

  9. Impact of an Elective Course on Pharmacy Students’ Attitudes, Beliefs, and Competency Regarding Medicare Part D

    PubMed Central

    Patel, Rajul A.; Thai, Huong K.; Phou, Christine M.; Walberg, Mark P.; Woelfel, Joseph A.; Carr-Lopez, Sian M.; Chan, Emily K.

    2012-01-01

    Objective. To determine the impact of an elective course on pharmacy students’ perceptions, knowledge, and confidence regarding Medicare Part D, medication therapy management (MTM), and immunizations. Design. Thirty-three pharmacy students were enrolled in a Medicare Part D elective course that included both classroom instruction and experiential training. Assessment. Students’ self-reported confidence in and knowledge of Part D significantly improved upon course completion. End-of-course student perceptions about the relative importance of various aspects of MTM interventions and their confidence in performing MTM services significantly improved from those at the beginning of the course. Students’ confidence in performing immunizations also increased significantly from the start of the course. Conclusion. A classroom course covering Medicare Part D with an experiential requirement serving beneficiaries can improve students’ attitudes and knowledge about Medicare Part D and their confidence in providing related services to beneficiaries in the community. PMID:22761532

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

    PubMed

    2009-12-09

    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.

  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.

  12. 78 FR 43820 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-22

    ... Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug...; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit...-referencing errors in the Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and...

  13. Traditional Medicare Versus Private Insurance: How Spending, Volume, And Price Change At Age Sixty-Five.

    PubMed

    Wallace, Jacob; Song, Zirui

    2016-05-01

    To slow the growth of Medicare spending, some policy makers have advocated raising the Medicare eligibility age from the current sixty-five years to sixty-seven years. For the majority of affected adults, this would delay entry into Medicare and increase the time they are covered by private insurance. Despite its policy importance, little is known about how such a change would affect national health care spending, which is the sum of health care spending for all consumers and payers-including governments. We examined how spending differed between Medicare and private insurance using longitudinal data on imaging and procedures for a national cohort of individuals who switched from private insurance to Medicare at age sixty-five. Using a regression discontinuity design, we found that spending fell by $38.56 per beneficiary per quarter-or 32.4 percent-upon entry into Medicare at age sixty-five. In contrast, we found no changes in the volume of services at age sixty-five. For the previously insured, entry into Medicare led to a large drop in spending driven by lower provider prices, which may reflect Medicare's purchasing power as a large insurer. These findings imply that increasing the Medicare eligibility age may raise national health care spending by replacing Medicare coverage with private insurance, which pays higher provider prices than Medicare does.

  14. Early Performance of Accountable Care Organizations in Medicare

    PubMed Central

    McWilliams, J. Michael; Hatfield, Laura A.; Chernew, Michael E.; Landon, Bruce E.; Schwartz, Aaron L.

    2016-01-01

    BACKGROUND In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. METHODS Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was −$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P = 0.02), consistent with a 1.4% savings, but only −$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P = 0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P = 0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others. CONCLUSIONS The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in

  15. 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…

  16. Analysis of services received under Medicare by specialty of physician.

    PubMed

    Pine, P L; Gornick, M; Lubitz, J; Newton, M

    1981-09-01

    This paper examines use of physicians' services by Medicare beneficiaries according to the specialty of the physician providing care. The major objectives of this study were to determine which types of physicians are most frequently used, the average charge per service by specialty, the mix of physicians (by specialty) that patients saw during the year, and the amount Medicare reimburses in relation to total physician income. Data were studied for the total Medicare population and by age, sex, race, and geographic area. Claims data for 1975 and 1977 were used from the Part B Bill Summary System. This system collects information from bills from a 5 percent sample of Medicare enrollees. Major findings from this study indicate: (1) Physicians in general practice and internal medicine provided about the same number of services and each far outranked all other types of physicians in numbers of Medicare beneficiaries with reimbursed services. (2) There were marked differences by census region in the use of certain specialists, particularly pathologists, podiatrists, dermatologists, and the specialty group otology, laryngology, rhinology. (3) Average charges per service varied considerably by specialty. Internists' charges averaged 35 percent higher per service than charges by general practitioners. Charges submitted by the surgical specialties far outranked all others and showed the greatest increase during the period under study. (4) Of the total persons with reimbursement physicians' services in 1977, 85 percent saw a primary care physician during the year, while the remaining 15 percent received services from specialists only. (5) Of the total reimbursements made by Medicare, internists received 20 percent, general practitioners received 14 percent, and general surgeons 12 percent. Medicare's payments were estimated to be 21 percent of total gross income for internists, 20 percent for anesthesiologists, and 18 percent for surgical specialties.

  17. 42 CFR 489.29 - Special requirements concerning beneficiaries served by the Indian Health Service, Tribal health...

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Special requirements concerning beneficiaries... programs. 489.29 Section 489.29 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... amended, Public Law 93-638, 25 U.S.C. 450 et seq.; and (3) A program funded through a grant or contract...

  18. 42 CFR 489.29 - Special requirements concerning beneficiaries served by the Indian Health Service, Tribal health...

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Special requirements concerning beneficiaries... programs. 489.29 Section 489.29 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... amended, Public Law 93-638, 25 U.S.C. 450 et seq.; and (3) A program funded through a grant or contract...

  19. Physician trainees' decision making and information processing: choice size and Medicare Part D.

    PubMed

    Barnes, Andrew J; Hanoch, Yaniv; Martynenko, Melissa; Wood, Stacey; Rice, Thomas; Federman, Alex D

    2013-01-01

    Many patients expect their doctor to help them choose a Medicare prescription drug plan. Whether the size of the choice set affects clinicians' decision processes and strategy selection, and the quality of their choice, as it does their older patients, is an important question with serious financial consequences. Seventy medical students and internal medicine residents completed a within-subject design using Mouselab, a computer program that allows the information-acquisition process to be examined. We examined highly numerate physician trainees' decision processes, strategy, and their ability to pick the cheapest drug plan-as price was deemed the most important factor in Medicare beneficiaries' plan choice-from either 3 or 9 drug plans. Before adjustment, participants were significantly more likely to identify the lowest cost plan when facing three versus nine choices (67.3% vs. 32.8%, p<0.01) and paid significantly less in excess premiums ($60.00 vs. $128.51, p<0.01). Compared to the three-plan condition, in the nine-plan condition participants spent significantly less time acquiring information on each attribute (p<0.05) and were more likely to employ decision strategies focusing on comparing alternate plans across a single attribute (search pattern, p<0.05). After adjusting for decision process and strategy, numeracy, and amount of medical training, the odds were 10.75 times higher that trainees would choose the lowest cost Medicare Part D drug plan when facing 3 versus 9 drug plans (p<0.05). Although employing more efficient search strategies in the complex choice environment, physician trainees experienced similar difficulty in choosing the lowest cost prescription drug plans as older patients do. Our results add further evidence that simplifications to the Medicare Part D decision environment are needed and suggest physicians' role in their patients' Part D choices may be most productive when assisting seniors with forecasting their expected medication needs

  20. Medicare program; aggregation of Medicare claims for administrative appeals--HCFA. Final rule.

    PubMed

    1994-03-16

    Medicare beneficiaries and, under certain circumstances, providers, physicians and other entities furnishing health care services may appeal adverse determinations regarding certain claims for benefits payable under part A and part B of Medicare. For administrative appeals at the carrier or intermediary hearing level or administrative law judge (ALJ) level and for any subsequent judicial review, the amount remaining in dispute must meet or exceed threshold amounts set by statute. Section 1869(b)(2) of the Social Security Act permits claims to be aggregated to reach the ALJ hearing threshold amounts. This final rule establishes a system of aggregation under which individual appellants have one set of requirements for aggregating claims and two or more appellants have a different set of requirements for aggregating claims.

  1. Geography and destiny: local-market perspectives on developing Medicare Advantage regional plans.

    PubMed

    Hurley, Robert E; Strunk, Bradley C; Grossman, Joy M

    2005-01-01

    The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established regional preferred provider organizations (PPOs) as a new private-plan option for beneficiaries in the Medicare Advantage (MA) program, starting in 2006. Developing network-based Medicare products uniformly priced across statewide or multistate regions presents unprecedented challenges and opportunities for health insurers. We held discussions with local health plan and hospital informants in six of the twelve Community Tracking Study (CTS) communities to obtain their perspectives on key considerations in evaluating whether they can and will offer regional PPO products under the MA program.

  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. Physician acceptance of new Medicare patients stabilizes in 2004-05.

    PubMed

    Cunningham, Peter; Staiti, Andrea; Ginsburg, Paul B

    2006-01-01

    Despite an earlier Medicare payment rate reduction, the proportion of U.S. physicians accepting Medicare patients stabilized in 2004-05, with nearly three-quarters saying their practices were open to all new Medicare patients, according to a new study by the Center for Studying Health System Change (HSC). In 2004-05, 72.9 percent of physicians reported accepting all new Medicare patients, statistically unchanged from 71.1 percent in 2000-01. Only 3.4 percent of physicians reported that their practices were completely closed to new Medicare patients in 2004-05, also statistically unchanged from 2000-01. These trends indicate the decline in Medicare physician access observed between 1996-97 and 2000-01 leveled off in 2004-05. In fact, Medicare beneficiaries' access to primary care physicians increased between 2000-01 and 2004-05, reversing an earlier decline. Among privately insured patients, trends in physician access are similar to those for Medicare patients, suggesting that overall health system dynamics have played a larger role in physician decisions about accepting Medicare patients than have Medicare payment policies.

  4. 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…

  5. 75 FR 24437 - Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-05

    ... submit an enrollment application. A physician or eligible professional who is employed by the Public... eligible professionals to order and refer covered items and services for Medicare beneficiaries to be... Information Requirements'' section in this document. For information on viewing public comments, see...

  6. The Medicare Prospective Payment System: Intent and Future Direction

    PubMed Central

    Dobson, Allen

    1984-01-01

    Increases in health care expenditures, especially for hospital care, have been a persistent and growing problem for the Medicare program and the Nation for nearly two decades. Recognizing its potential as a pragmatic yet immediate solution to spiralling costs, Congress recently enacted the Prospective Payment System (PPS) for most inpatient hospital services covered by Medicare. The PPS legislation represents a fundamental change in the way hospitals are paid for care delivered to Medicare beneficiaries. Hospitals can be expected to respond to behavioral incentives created by the new payment approach with both immediate and long-term adjustments. Changes in the ways hospitals will manage themselves and conduct their business — present and future — are examined, and some initial data trends are presented. Significant future policy issues related to the PPS and the health care delivery system are lastly discussed.

  7. Medicare physician fees: the data behind the numbers.

    PubMed

    Dummit, Laura A

    2010-07-22

    Medicare's physician fee schedule distributes nearly $60 billion annually and is a critical determinant of individual physicians' incomes, beneficiaries' access to health care services, and Medicare spending, as well as the basis for physician fees used by many private payers. The Centers for Medicare & Medicaid Services (CMS) relies on data derived from expert judgment and other sources to update the fee schedule. Although CMS's methods and data for maintaining the fee schedule have improved over the years, concerns remain about medical specialty society involvement and the lack of an effective "counterweight" to vested interests in establishing and updating the relative values in the fee schedule. This issue brief reviews the data used in the fee schedule, including the new, multispecialty practice expense survey, and the role of the American Medical Association/Specialty Society Relative Value Scale Update Committee.

  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. 75 FR 71064 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-11-22

    ... Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit... Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2012 and Other... the Office of the Federal Register base the comment period closing date on the date the proposed...

  10. 78 FR 12427 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-22

    ... 42 CFR Parts 422 and 423 Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage... Loss Ratio Requirements for the Medicare Advantage and the Medicare Prescription Drug Benefit Programs... proposed rule would implement medical loss ratio (MLR) requirements for the Medicare Advantage Program...

  11. The reservation wages of Social Security Disability Insurance beneficiaries.

    PubMed

    Mitra, Sophie

    2007-01-01

    persons who have shifted to the Old-Age program and those who are still under the DI program have median reservation wage to the last wage ratios of 0.69 and 0.93, respectively. A significantly lower reservation wage for persons who have moved to the Old-Age program was also found in a regression framework. This heterogeneity between the two groups may result in part from the different program characteristics both groups face, for instance, in terms of benefit termination and Medicare eligibility rules. *Subjective reservation wage data can be useful to study populations that are out of the labor force. This article is innovative in that it focuses on a group of persons who are typically considered as being out of the labor force, and therefore are not asked reservation wages in general household surveys such as the Current Population Survey. It would be of great interest to collect more reservation wage data for DI beneficiaries in a longitudinal data set to expand this analysis, for instance, to assess conclusively the effects of changing program characteristics on reservation wages and return-to-work outcomes as beneficiaries transition to the Old-Age program or as new return-to-work programs are put in place.

  12. 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

  13. The continuing cost of privatization: extra payments to Medicare Advantage plans jump to $11.4 billion in 2009.

    PubMed

    Biles, Brian; Pozen, Jonah; Guterman, Stuart

    2009-05-01

    The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, MA plans have, for the past six years, been paid more for their enrollees than they would be expected to cost in traditional fee-for-service Medicare. Payments to MA plans in 2009 are projected to be 13 percent greater than the corresponding costs in traditional Medicare--an average of $1,138 per MA plan enrollee, for a total of $11.4 billion. Although the extra payments are used to provide enrollees additional benefits, those benefits are not available to all beneficiaries-- but they are financed by general program funds. If payments to MA plans were instead equal to the spending level under traditional Medicare, the more than $150 billion in savings over 10 years could be used to finance improved benefits for the low-income elderly and disabled, or for expanding health-insurance coverage.

  14. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Final rule.

    PubMed

    2012-04-27

    This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. Finally, it mandates document retention and provision requirements on providers and supplier that order and certify items and services for Medicare beneficiaries.

  15. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2013 rates; hospitals' resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers. final rule.

    PubMed

    2012-08-31

    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. Some of the changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2012. 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) and implementing certain statutory changes made by the Affordable Care Act. Generally, these changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule. In addition, we are implementing changes relating to determining a hospital's full-time equivalent (FTE) resident cap for the purpose of graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We also are establishing new administrative, data completeness, and extraordinary circumstance waivers or extension requests requirements, as well as a reconsideration process, for quality reporting by ambulatory surgical centers

  16. Do Experiences with Medicare Managed Care Vary According to the Proportion of Same-Race/Ethnicity/Language Individuals Enrolled in One's Contract?

    PubMed Central

    Price, Rebecca Anhang; Haviland, Amelia M; Hambarsoomian, Katrin; Dembosky, Jacob W; Gaillot, Sarah; Weech-Maldonado, Robert; Williams, Malcolm V; Elliott, Marc N

    2015-01-01

    Objective To examine whether care experiences and immunization for racial/ethnic/language minority Medicare beneficiaries vary with the proportion of same-group beneficiaries in Medicare Advantage (MA) contracts. Data Sources/Study Setting Exactly 492,495 Medicare beneficiaries responding to the 2008–2009 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. Data Collection/Extraction Methods Mixed-effect regression models predicted eight CAHPS patient experience measures from self-reported race/ethnicity/language preference at individual and contract levels, beneficiary-level case-mix adjustors, along with contract and geographic random effects. Principal Findings As a contract's proportion of a given minority group increased, overall and non-Hispanic, white patient experiences were poorer on average; for the minority group in question, however, high-minority plans may score as well as low-minority plans. Spanish-preferring Hispanic beneficiaries also experience smaller disparities relative to non-Hispanic whites in plans with higher Spanish-preferring proportions. Conclusions The tendency for high-minority contracts to provide less positive patient experiences for others in the contract, but similar or even more positive patient experiences for concentrated minority group beneficiaries, may reflect cultural competency, particularly language services, that partially or fully counterbalance the poorer overall quality of these contracts. For some beneficiaries, experiences may be just as positive in some high-minority plans with low overall scores as in plans with higher overall scores. PMID:25752334

  17. Updating Medicare's physician fees: the sustainable growth rate methodology.

    PubMed

    Dummit, Laura A

    2006-11-10

    Medicare's method to annually update the fees it pays physicians has been under fire for some time--specifically, since the method determined that physician fees should be reduced rather than increased. The update method, called the sustainable growth rate (SGR), was implemented to control the growth in Medicare physician spending. Yet Congress, in response to physician concerns about beneficiary access to care, has acted to avert physician fee cuts since 2003. Although this signals dissatisfaction with the SGR methodology, there is yet to be a widely accepted physician fee update proposal that balances federal budgetary realities with the need to ensure beneficiary access. And the cost of changing the update method continues to mount, adding to the difficulties of developing a solution that meets the needs of all stakeholders. This issue brief describes the SGR methodology, the reasons why projected physician fee updates are negative, and some options that have been proposed to remedy the current situation. This issue brief is the second of two related papers on physician spending and Medicare's sustainable growth rate methodology. The companion paper was published on October 9, 2006 (see Issue Brief 815, available at www.nhpf.org/pdfs_ib/IB815_PhysicianSpending_10-09-06.pdf).

  18. The impact of PPS on hospital-sponsored post-acute services: a case study of Delaware Medicare providers.

    PubMed

    Kulesher, Robert R; Wilder, Margaret G

    2008-01-01

    Hospitals were the first providers to experience the change in Medicare reimbursement from a cost basis to the prospective payment system (PPS). In the 1980s, this switch was accomplished through the development of diagnosis-related groups, a unique formula for Medicare reimbursement of inpatient hospital services. During that time, the concern was that, with the anticipated reduced payments to hospitals, adverse impacts on Medicare beneficiaries were likely, including premature release of patients from hospital care resulting in medical complications, increased readmissions, prolonged episodes of recuperation, and preventable mortality. The Balanced Budget Act of 1997 (BBA) mandated the implementation of the PPS for Medicare providers of skilled nursing home care and home health care. This change from cost-based reimbursement to PPS raised concerns that these providers would react as hospitals had done-that is, skilled nursing homes might limit their admission of Medicare patients and home health agencies might cut back on visits. As a result of that, hospitals might be faced with providing care for these post-acute patients without receiving additional reimbursement, and these changes in utilization patterns would be of critical importance to both providers and Medicare beneficiaries. This article examines the decisions that providers made in response to the perceived impact of the BBA. Qualitative data were derived from provider interviews. The article concludes with a discussion of how changes in Medicare reimbursement policy have influenced providers of post-acute care services to alter their level of participation in Medicare and the impact this may have on the general public as well as on Medicare beneficiaries.

  19. 78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-18

    ... Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B... Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program) Dated: March 13, 2013..., Utilization and Quality Control Peer Review, private health insurance, and related matters. They are...

  20. Medicare Hospice Benefits

    MedlinePlus

    ... 4 Care for a condition other than your terminal illness ......................................... 4 How your Medicare hospice benefit works ..................................................... ... care, counseling, drugs, equipment, and supplies for the terminal illness and related conditions. ■■ Care is generally provided ...

  1. Medicare and Rural Health

    MedlinePlus

    ... health maintenance organization, preferred provider organization, or private fee-for-service plan. Part D (Prescription Drug Coverage) ... provisions and their effects through 2013: Medicare Physician Fee Schedule Update – the Geographic Practice Cost Indices were ...

  2. Claims and Appeals (Medicare)

    MedlinePlus

    ... gov Medicare forms Advance directives & long-term care Electronic prescribing Electronic Health Records (EHRs) Download claims with Medicare’s Blue ... to Disclose Personal Health Information form Access an electronic form so that someone who helps you with ...

  3. Medicare Financing of Graduate Medical Education

    PubMed Central

    Rich, Eugene C; Liebow, Mark; Srinivasan, Malathi; Parish, David; Wolliscroft, James O; Fein, Oliver; Blaser, Robert

    2002-01-01

    The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support. PMID:11972725

  4. Medicare financing of graduate medical education.

    PubMed

    Rich, Eugene C; Liebow, Mark; Srinivasan, Malathi; Parish, David; Wolliscroft, James O; Fein, Oliver; Blaser, Robert

    2002-04-01

    The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.

  5. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate.

    PubMed

    Chung, Sukyung; Lesser, Lenard I; Lauderdale, Diane S; Johns, Nicole E; Palaniappan, Latha P; Luft, Harold S

    2015-01-01

    Under the Affordable Care Act (ACA), Medicare coverage expanded in 2011 to fully cover annual preventive care visits. We assessed the impact of coverage expansion, using 2007-13 data from primary care patients of Medicare-eligible age at the Palo Alto Medical Foundation (204,388 patient-years), which serves people in four counties near San Francisco, California. We compared trends in preventive visits and recommended preventive services among Medicare fee-for-service and Medicare health maintenance organization (HMO) patients as well as non-Medicare patients ages 65-75 who were covered by private fee-for-service and private HMO plans. Among Medicare fee-for-service patients, the annual use of preventive visits rose from 1.4 percent before the implementation of the ACA to 27.5 percent afterward. This increase was significantly larger than was seen for patients in the other insurance groups. Nevertheless, rates of annual preventive care visit use among Medicare fee-for-service patients remained 10-20 percentage points lower than was the case for people with private coverage (43-44 percent) or those in a Medicare HMO (53 percent). ACA policy changes led to increased preventive service use by Medicare fee-for-service beneficiaries, which suggests that Medicare coverage expansion is an effective way to increase seniors' use of preventive services.

  6. 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.…

  7. Trends in physician assignment rates for Medicare services, 1968-85.

    PubMed

    McMillan, A; Lubitz, J; Newton, M

    1985-01-01

    This article provides an overview of trends in Medicare assignment rates. It covers changes over time in assignment by demographic characteristics and State and analyzes beneficiary liability. Although assignment rates were rising slowly from 1977 to 1983, beneficiary liability was also rising, primarily because of the rise in physician charges and the reduction on allowed charges. Substantial increases in the assignment rate have coincided with the implementation of provisions in the Deficit Reduction Act of 1984 to encourage assignment, and the assignment rate reached on all time high of 69 percent in 1985.

  8. 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.

  9. Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization.

    PubMed

    Alva, Maria L; Hoerger, Thomas J; Jeyaraman, Ravikumar; Amico, Peter; Rojas-Smith, Lucia

    2017-03-01

    The YMCA of the USA received a Health Care Innovation Award from the Centers for Medicare and Medicaid Services to provide a diabetes prevention program to Medicare beneficiaries with prediabetes in seventeen regional networks of participating YMCAs nationwide. The goal of the program is to help participants lose weight and increase physical activity. We tested whether the program reduced medical spending and utilization in the Medicare population. Using claims data to compute total medical costs for fee-for-service Medicare participants and a matched comparison group of nonparticipants, we found that the overall weighted average savings per member per quarter during the first three years of the intervention period was $278. Total decreases in inpatient admissions and emergency department (ED) visits were significant, with nine fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. These results justify continued support of the model.

  10. Attribute substitution in early enrollment decisions into Medicare prescription drug plans.

    PubMed

    Frakt, Austin B; Pizer, Steven D

    2008-04-01

    Stand-alone outpatient prescription drug plans (PDPs), introduced in January 2006, have become the most popular source for coverage of outpatient prescription drugs under Medicare relative to other available Medicare plan types (e.g. Medicare Advantage drug plans). Using county-level enrollment figures from the Centers for Medicare & Medicaid Services linked to other public sources, we study attribute substitution in beneficiary decision-making with respect to PDP enrollment. To do so, we relate county-level PDP market share to county-level political support for the administration implementing the new benefit (the Bush Administration), controlling for socio-demographic and market characteristics. We find statistically significant evidence that greater support for the Bush administration is associated with increased PDP market share.

  11. 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.

  12. Medicare: Better Controls Needed for Peer Review Organizations’ Evaluations.

    DTIC Science & Technology

    1987-10-01

    Peer Review Organizations’ performance during the 1984-86 contract period. It also discusses HCFA’S process for determining program funding for the 1986-88 contract period. The report contains recommendations to the Secretary of Health and Human Services. Professional Review Organizations (PROS) contract with the Medicare program to review the necessity, appropriateness, and quality of inpatient hospital services received by the program’s beneficiaries. From February through July 1986, the Department of Health and Human Services’ (HHS’S) Health

  13. 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.

  14. 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

  15. 42 CFR 483.10 - Resident rights.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Resident rights. 483.10 Section 483.10 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...) Exercise of rights. (1) The resident has the right to exercise his or her rights as a resident of...

  16. 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

  17. 76 FR 55917 - Medicare Program; Notification of Closure of St. Vincent's Medical Center; Extension of the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-09

    ... Medicare & Medicaid Services (CMS), HHS. ACTION: Notice of extension of the Deadline for Submission of... & Medicaid Services (CMS) to receive St. Vincent's Medical Center's full time equivalent (FTE) resident cap... apply to the Centers for Medicare & Medicaid Services (CMS) to receive St. Vincent's Medical...

  18. 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…

  19. Medicare Telehealth Services and Nephrology: Policies for Eligibility and Payment.

    PubMed

    Frilling, Stephanie

    2017-01-01

    The criteria for Medicare payment of telehealth nephrology services, and all other Medicare telehealth services, are set forth in section 1834(m) of the Social Security Act. There are just over 80 professional physician or practitioner services that may be furnished via telehealth and paid under Medicare Part B, when an interactive audio and video telecommunication system that permits real-time communication between a beneficiary at the originating site and the physician or practitioner at the distant site substitutes for an in-person encounter. These services include 16 nephrology billing codes for furnishing ESRD services for monthly monitoring and assessment and two billing codes for chronic kidney disease education. In recent years, many mobile health devices and other web-based tools have been developed in support of monitoring, observation, and collaboration for people living with chronic disease. This article reviews the statutory and program guidance that governs Medicare telehealth services, defines payment policy terms (e.g., originating site and distant site), and explains payment policies when telehealth services are furnished.

  20. Centers for Medicare & Medicaid Services

    MedlinePlus

    ... Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education CMS.gov Covering more Americans Making Americans healthier by ... Medicare coverage database CMS forms Transmittals MLN Homepage CMS covers 100 million people... ...through Medicare, Medicaid, the ...

  1. 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.

  2. 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

  3. Personal care satisfaction among aged and physically disabled Medicaid beneficiaries.

    PubMed

    Khatutsky, Galina; Anderson, Wayne L; Wiener, Joshua M

    2006-01-01

    We analyzed survey data from 2,325 Medicaid home and community-based services (HCBS) beneficiaries in six States to estimate satisfaction with personal care services. We constructed an eight-item scale rating various aspects of paid assistance and estimated satisfaction for the total sample and for older and younger persons with disabilities. Younger persons with significant health problems and those residing in group settings were less satisfied. Higher unmet need for assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs) was associated with decreased satisfaction, and matching race between a client and paid caregiver was associated with significantly increased satisfaction in all age groups.

  4. Medicare-Eligible Retiree Health Care Fund Audited Financial Statements. Fiscal Year 2013

    DTIC Science & Technology

    2013-12-09

    12. Disclosures Related to the Statement of Budgetary Resources .........................................44  Note 13. Reconciliation of Net Cost of... drugs covered by TRICARE went into effect February 1, 2013. TRICARE Plus. TRICARE Plus is an MTF primary care enrollment program that is offered at...utilization by the DoD Medicare-eligible beneficiaries and an increase in pharmaceutical expenses. Payables increased $147.4 million in the Mail Order

  5. 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 ...

  6. Medicare: Physician Compare

    MedlinePlus

    ... You” Handbook Help with file formats & plug-ins CMS & HHS Websites HealthCare.gov STOPMedicareFraud.gov InsureKidsNow.gov MyMedicare.gov Medicaid.gov CMS.gov HHS.gov Get Involved with Us Twitter ...

  7. Medicare Advantage Plans

    MedlinePlus

    ... You” Handbook Help with file formats & plug-ins CMS & HHS Websites HealthCare.gov STOPMedicareFraud.gov InsureKidsNow.gov MyMedicare.gov Medicaid.gov CMS.gov HHS.gov Get Involved with Us Twitter ...

  8. 75 FR 19677 - Medicare Program; Policy and Technical Changes to the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-04-15

    ... Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs; Final Rule... Parts 417, 422, 423, and 480 [CMS-4085-F] RIN 0938-AP77 Medicare Program; Policy and Technical Changes.... Provisions of the Proposed Rule and Analysis and Responses to Public Comments A. Changes to Strengthen...

  9. 42 CFR 422.262 - Beneficiary premiums.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... an MA plan (other than a MSA plan) is the sum of the MA monthly basic beneficiary premium (if any... beneficiary premium (if any). (2) Special rule for MSA plans. For an individual enrolled in an MSA plan... premium, the MA monthly prescription drug premium, and the monthly MSA premium of an MA organization...

  10. 5 CFR 1651.19 - Beneficiary participant accounts.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... traditional balance and the beneficiary participant's Roth balance. (d) Withdrawal elections. A beneficiary... traditional IRA, Roth IRA or eligible employer plan (including a civilian or uniformed services TSP...

  11. 77 FR 1877 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-01-12

    ...; Medicare Advantage and Prescription Drug Benefit Programs: Negotiated Pricing and Remaining Revisions..., governing what was renamed the Medicare Advantage (MA) program (formerly Medicare+Choice). The MMA...

  12. Favorable Selection, Risk Adjustment, and the Medicare Advantage Program

    PubMed Central

    Morrisey, Michael A; Kilgore, Meredith L; Becker, David J; Smith, Wilson; Delzell, Elizabeth

    2013-01-01

    Objectives To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees. Data From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. Study Design Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period. Findings Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries. Conclusions Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees. PMID:23088500

  13. Including a measure of health status in Medicare's health maintenance organization capitation formula: reliability issues.

    PubMed

    Lichtenstein, R; Thomas, J W

    1987-02-01

    Medicare's formula for determining capitation levels for risk-based HMOs, the Adjusted Average Per Capita Cost (AAPCC), has been criticized as a poor basis for establishing payments. Among new adjusting factors suggested for the formula is a measure of beneficiaries' functional health status. The ability of such a measure to improve predictions of Medicare costs has been demonstrated in several studies. In addition to possessing predictive validity, a measure considered for inclusion in the AAPCC must also be reliable. In this paper, the authors examine a measure of functional health status for intrarater reliability or, equivalently, stability over time. A sample of 1,616 Medicare beneficiaries was surveyed twice--in late 1982 and in January 1984. Using a five-point scale, functional health status scores were calculated for each of the beneficiaries at two points in time. For 68.4% of the sample, functional health scores were unchanged over the year, and second-year scores were within one point of first-year scores for 94.3% of the sample. Based on the intraclass correlation coefficient, the scores on this functional health scale demonstrated substantial to "almost perfect" agreement over the 1-year period.

  14. Nursing Homes That Increased The Proportion Of Medicare Days Achieved Gains In Quality

    PubMed Central

    Lepore, Michael; Leland, Natalie E.

    2017-01-01

    Nursing homes are increasingly serving short-stay rehabilitation residents under Medicare skilled nursing facility coverage, which is substantially more generous than Medicaid coverage for long-stay residents. In relation to increasing short-stay resident care, potential exists for beneficial or detrimental effects on long-stay resident outcomes. We employ panel multivariate regression analyses using facility fixed-effects models to determine how increasing the proportion of Medicare days in nursing homes relates to changes in quality outcomes for long-stay residents. We find increasing the proportion of Medicare days in a nursing home is significantly associated with improved quality outcomes for long-stay residents. Findings reinforce prior research indicating that quality outcomes tend to be superior in nursing homes with greater financial resources. This study bolsters arguments for financial investments in nursing homes, including increases in Medicaid payment rates, to support better care. PMID:26643633

  15. 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…

  16. The impact of weight loss among seniors on Medicare spending

    PubMed Central

    2013-01-01

    Objective To examine the impact of temporary and permanent weight loss of 10% and 15% on 10-year and lifetime Medicare spending among adults with overweight and obesity aged 65 years and older. Weight loss of this magnitude is consistent with next generation anti-obesity medications recently approved by the Food and Drug Administration. Methods We follow the approach of a longitudinal dynamic aging process model developed by our research team. This model considers the dynamic relationships between weight, chronic disease, acute medical events, functional status, mortality, health care utilization and spending among Medicare beneficiaries from age 65 until death. Using this model, we estimate baseline Medicare spending over the next decade and then over the lifetime of seniors with a body mass index (BMI) ≥ 27 with at least one weight-related comorbidity (overweight), and seniors with obesity having a BMI ≥ 30 and ≥ 35. We then estimate Medicare spending for this population between ages 65 and 70 over the course of a year, assuming 10% and 15% weight loss under alternative scenarios: with and without weight regain. (Weight regain is assumed to be 90% over a 10-year period.) The difference in spending between baseline (no weight-loss intervention) and the alternative scenarios represent potential gross savings to the Medicare program. Results Permanent weight loss of 10 to 15% will yield $9,445 to $15,987 in gross per capita savings throughout their lifetime, and $8,070 to $13,474 over ten years. Similarly, initial weight loss of 10 to 15% followed by 90% weight regain will result in gross per capita savings of $7,556 to $11,109 over their lifetime, and $6,456 to $8,911 over ten years. Targeting weight loss medications to adults with obesity (BMI ≥ 30) produces greater savings to the Medicare program. Conclusion Medicare can realize significant cost savings through anti-obesity medications that produce substantial weight loss, and as a result, reduce the

  17. Spurring enrollment in Medicare savings programs through a substitute for the asset test focused on investment income.

    PubMed

    Dorn, Stan; Shang, Baoping

    2012-02-01

    Fewer than one-third of eligible Medicare beneficiaries enroll in Medicare savings programs, which pay premiums and, in some cases, eliminate out-of-pocket cost sharing for poor and near-poor enrollees. Many beneficiaries don't participate in savings programs because they must complete a cumbersome application process, including a burdensome asset test. We demonstrate that a streamlined alternative to the asset test-allowing seniors to qualify for Medicare savings programs by providing evidence of limited assets or showing a lack of investment income-would permit 78 percent of currently eligible seniors to bypass the asset test entirely. This simplified approach would increase the number of beneficiaries who qualify for Medicare savings programs from the current 3.6 million seniors to 4.6 million. Such an alternative would keep benefits targeted to people with low assets, eliminate costly administrative expenses and obstacles to enrollment associated with the asset test, and avoid the much larger influx of seniors that would occur if the asset test were eliminated entirely.

  18. Changes in Patients’ Experiences in Medicare Accountable Care Organizations

    PubMed Central

    McWilliams, J. Michael; Landon, Bruce E.; Chernew, Michael E.; Zaslavsky, Alan M.

    2014-01-01

    BACKGROUND Incentives for accountable care organizations (ACOs) to limit health care use and improve quality may enhance or hurt patients’ experiences with care. METHODS Using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data covering 3 years before and 1 year after the start of Medicare ACO contracts in 2012 as well as linked Medicare claims, we compared patients’ experiences in a group of 32,334 fee-for-service beneficiaries attributed to ACOs (ACO group) with those in a group of 251,593 beneficiaries attributed to other providers (control group), before and after the start of ACO contracts. We used linear regression and a difference-in-differences analysis to estimate changes in patients’ experiences in the ACO group that differed from concurrent changes in the control group, with adjustment for the sociodemographic and clinical characteristics of the patients. RESULTS After ACO contracts began, patients’ reports of timely access to care and their primary physicians’ being informed about specialty care differentially improved in the ACO group, as compared with the control group (P = 0.01 and P = 0.006, respectively), whereas patients’ ratings of physicians, interactions with physicians, and overall care did not differentially change. Among patients with multiple chronic conditions and high predicted Medicare spending, overall ratings of care differentially improved in the ACO group as compared with the control group (P = 0.02). Differential improvements in timely access to care and overall ratings were equivalent to moving from average performance among ACOs to the 86th to 98th percentile (timely access to care) and to the 82nd to 96th percentile (overall ratings) and were robust to adjustment for group differences in trends during the preintervention period. CONCLUSIONS In the first year, ACO contracts were associated with meaningful improvements in some measures of patients’ experience and with unchanged performance in

  19. 42 CFR 422.53 - Eligibility to elect an MA plan for senior housing facility residents.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Eligibility to elect an MA plan for senior housing facility residents. 422.53 Section 422.53 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE ADVANTAGE PROGRAM...

  20. 5 CFR 870.909 - Designations and changes of beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... assignee(s) if the assignee(s) did not designate a beneficiary. (c) Benefits for assigned insurance are... (or the assignee's heirs) did not designate a beneficiary; or (2) The assignee's designated... designate a beneficiary; the right to designate beneficiaries transfers to the assignee. (2) Each...

  1. 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.

  2. Medicare program; physician fee freeze sanctions--HHS. Notice of proposed rulemaking.

    PubMed

    1985-09-13

    This notice of proposed rulemaking sets forth OIG procedures for the imposition of civil money penalties and Medicare program exclusions on physicians who choose not to be participating physicians and who raise charges to Medicare beneficiaries in violation of the freeze on such fees contained in Section 2306 of Pub. L. 98-369 (the Deficit Reduction Act of 1984). The proposed rule also modifies existing regulations to permit the OIG to impose civil money penalties and assessments on those who choose to be participating physicians under the Medicare program and who violate their participation agreements as set forth in Section 2306. This regulation does not pertain to HCFA's responsibility for the Physician Fee Freeze.

  3. Lessons for the new CMS innovation center from the Medicare health support program.

    PubMed

    Barr, Michael S; Foote, Sandra M; Krakauer, Randall; Mattingly, Patrick H

    2010-07-01

    The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

  4. 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.

  5. Medicare and Medicaid programs; changes in provider and supplier enrollment, ordering and referring, and documentation requirements; and changes in provider agreements. Interim final rule with comment period.

    PubMed

    2010-05-05

    This interim final rule with comment period implements several provisions set forth in the Patient Protection and Affordable Care Act (Affordable Care Act). It implements the provision which requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. This interim final rule with comment period also requires physicians and eligible professionals to order and refer covered items and services for Medicare beneficiaries to be enrolled in Medicare. In addition, it adds requirements for providers, physicians, and other suppliers participating in the Medicare program to provide documentation on referrals to programs at high risk of waste and abuse, to include durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), home health services, and other items or services specified by the Secretary.

  6. 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.

  7. Anesthesiologists Are Affiliated with Many Hospitals Only Reporting Anesthesia Claims Using Modifier QZ for Medicare Claims in 2013.

    PubMed

    Miller, Thomas R; Abouleish, Amr; Halzack, Nicholas M

    2016-04-01

    We examined hospitals that exclusively used the billing modifier QZ in anesthesia claims for a 5% sample of Medicare beneficiaries in 2013. We used a national Medicare provider file to identify physician anesthesiologists and nurse anesthetists affiliated with these hospitals. Among the 538 hospitals that exclusively reported the modifier QZ, 47.5% had affiliated physician anesthesiologists. These hospitals accounted for 60.4% of the cases. Our results illustrate the challenges of using modifier QZ to describe anesthesia practice arrangements in hospitals. The modifier QZ does not seem to be a valid surrogate for no anesthesiologist being involved in the care provided.

  8. 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

  9. Understanding the incomprehensible: a guide to the new Medicare prescription drug benefit for case managers.

    PubMed

    Marshall, Carter L

    2004-01-01

    Much of the health news over the last few months has centered on problems elderly patients encounter in obtaining and effectively using the prescription drug discount cards that became available on June 1 under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This article focuses on the next prescription drug newsmaker, Medicare Part D, that will supercede the discount cards on January 1, 2006. There are many complex issues that case managers must evaluate when assisting beneficiaries with queries about "what to do." This article attempts to clarify the "incomprehensible" twists and turns of these issues and provides access to a "Medicare Drug Prescription Benefit Calculator" that may assist the beneficiary and case manager in decision making. Case managers need to understand that there are many opposing viewpoints on this benefit, and it promises to become the subject of a major national debate. For this reason, substantial changes may occur prior to the launch of Part D. If you think discount drug cards are confusing, "you ain't seen nothin' yet!"

  10. Rural Medicare Advantage Market Dynamics and Quality: Historical Context and Current Implications.

    PubMed

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

    2016-07-01

    Purpose. In this policy brief, we assess variation in Medicare’s star quality ratings of Medicare Advantage (MA) plans that are available to rural beneficiaries. Evidence from the recent Centers for Medicare & Medicaid Services (CMS) quality demonstration suggests that market dynamics, i.e., firms entering and exiting the MA marketplace, play a role in quality improvement. Therefore, we also discuss how market dynamics may impact the smaller and less wealthy populations that are characteristic of rural places. Key Data Findings. (1) Highly rated MA plans serving rural Medicare beneficiaries are more likely to be health maintenance organizations (HMOs) and local preferred provider organizations (PPOs), as opposed to regional PPOs. HMOs and local PPOs may be better able to improve their quality scores strategically in response to the bonus payment incentive due to existing internal monitoring mechanisms. (2) On average, the rural enrollment rate is lower in plans with higher quality scores (59 percent) than the corresponding urban rate (71 percent). This differential is likely due, in part, to lack of availability of highly rated plans in rural areas: 17.8 percent of rural counties lacked access to a plan with four or more (out of five) stars, while just 3.7 percent of urban counties lacked such access. (3) MA plans with high quality scores have been operating longer, on average, and have a lower percentage of rural counties within their contract service areas than plans with lower quality scores.

  11. 26 CFR 1.884-5 - Qualified resident.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... income tax treaty in effect if, for the taxable year, the foreign corporation is a resident of that... taxable as a corporation, trust, fund, foundation, league or other entity operated exclusively for... individual beneficiaries or supporters do not reside at that address. (2) Rules for determining...

  12. 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

  13. Staying Healthy: Medicare's Preventive Services

    MedlinePlus

    ... counseling in a primary care setting. Bone Mass Measurement These tests help to see if you’re ... Medicare. You need a flu shot for the current virus each year. Glaucoma Tests These tests help ...

  14. Reform of the Medicare program.

    PubMed

    Rubin, R N

    1988-01-01

    Financing of the Medicare program is under stress because of national economic and demographic trends. A comprehensive overview of the required changes is imperative. The American Medical Association has proposed to place Medicare funding out of the political arena and to place it under the administration of an independent commission such as the Federal Reserve Board. Further, the plan would initiate a voucher system financed by a tax on adjusted gross income during the working years invested through a new public trust fund.

  15. Medicare and durable medical equipment.

    PubMed

    Coviello, Amy

    2002-01-01

    Medicare coverage of wheelchairs, hospital beds and other durable medical equipment (DME) is a major source of confusion for people with Medicare, their families and the professionals who work with them. Yet, consumer publications rarely touch on it. In this brief we offer an overview of DME coverage issues and payment policies, including potential costs for consumers and their rights to appeal denials of payment.

  16. 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...

  17. 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...

  18. 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...

  19. 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...

  20. 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...

  1. 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...

  2. 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...

  3. 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...

  4. Social Security Disability: Demographic and Economic Characteristics of New Beneficiaries.

    DTIC Science & Technology

    1988-01-01

    your offices, we are providing information on the demographic , health, and economic conditions of social security disability insurance program...new survey in a subsequent report. SSA conducted its New Beneficiary Survey between October and December 1982, collecting a wide range of demographic ...retired beneficiaries and the general population. DEMOGRAPHIC AND EMPLOYMENT CHARACTERISTICS The disabled beneficiaries surveyed consisted of

  5. 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....

  6. 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

  7. 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.

  8. Regulatory beneficiaries and informal agency policymaking.

    PubMed

    Mendelson, Nina A

    2007-03-01

    Administrative agencies frequently use guidance documents to set policy broadly and prospectively in areas ranging from Department of Education Title IX enforcement to Food and Drug Administration regulation of direct-to- consumer pharmaceutical advertising. In form, these guidances often closely resemble the policies agencies issue in ordinary notice-and-comment rulemaking. However, guidances are generally developed with little public participation and are often immune from judicial review. Nonetheless, guidances can prompt significant changes in behavior from those the agencies regulate. A number of commentators have guardedly defended the current state of affairs. Though guidances lack some important procedural safeguards, they can help agencies supervise low-level employees and supply valuable information to regulated entities regarding how an agency will implement a program. Thus far, however, the debate has largely ignored the distinct and substantial interests of regulatory beneficiaries--those who expect to benefit from government regulation of others. Regulatory beneficiaries include, among others, pharmaceutical consumers, environmental users, and workers seeking safe workplaces. When agencies make policy informally, regulatory beneficiaries suffer distinctive losses to their ability to participate in the agency's decision and to invoke judicial review. This Article argues that considering the interests of regulatory beneficiaries strengthens the case for procedural reform. The Article then assesses some possible solutions.

  9. 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 ...

  10. How Might the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Affect the Financial Viability of Rural Pharmacies? An Analysis of Preimplementation Prescription Volume and Payment Sources in Rural and Urban Areas

    ERIC Educational Resources Information Center

    Fraher, Erin P.; Slifkin, Rebecca T.; Smith, Laura; Randolph, Randy; Rudolf, Matthew; Holmes, George M.

    2005-01-01

    Passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) has created interest in how the legislation will affect access to prescription drugs among rural beneficiaries. Policy attention has focused to a much lesser degree on the implications of the MMA for the financial viability of rural pharmacies. This article…

  11. The Center For Medicare And Medicaid Innovation's blueprint for rapid-cycle evaluation of new care and payment models.

    PubMed

    Shrank, William

    2013-04-01

    The Affordable Care Act established the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models. The goal is to reduce program expenditures while preserving or improving the quality of care provided to beneficiaries of Medicare, Medicaid, and the Children's Health Insurance Program. Central to the success of the Innovation Center is a new, rapid-cycle approach to evaluation. This article describes that approach--setting forth how the Rapid Cycle Evaluation Group aims to deliver frequent feedback to providers in support of continuous quality improvement, while rigorously evaluating the outcomes of each model tested. This article also describes the relationship between the group's work and that of the Office of the Actuary at the Centers for Medicare and Medicaid Services, which plays a central role in the assessment of new models.

  12. 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:

  13. 42 CFR 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... limitation (under the authority of section 4106 of Public Law 100-230). (d) For purposes of paragraph (b)(1...)(5) of Public Law 98-369 as amended by section 9 of Public Law 100-93) an amount for individuals that... § 435.831(a) and (c) exceeds the following amounts, rounded to the next higher multiple of $100. (c)...

  14. 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:

  15. MEDICARE: Orthotics Ruling Has Implications for Beneficiary Access and Federal and State Costs

    DTIC Science & Technology

    2002-05-01

    system K0114 Prefabricated back support system, with inner frame, for use with wheelchair. $616.56-725.36 Shoulder elbow orthosis L3964...Prefabricated mobile arm support attached to wheelchair. Cost includes fitting and adjustment. $505.08-594.21 Shoulder elbow orthosis L3965...Prefabricated Rancho type mobile arm support attached to wheelchair. Cost includes fitting and adjustment. $805.96-948.19 Shoulder elbow orthosis

  16. 42 CFR 424.507 - Ordering and referring covered items and services for Medicare beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... of claims for ordered covered home health services. (1) Home health provider claims. To receive payment for ordered, covered Part A or Part B home health services, a provider's home health services... have been ordered by a physician; (ii) The claim from the provider of home health services must...

  17. 75 FR 75884 - Regulations Regarding Income-Related Monthly Adjustment Amounts to Medicare Beneficiaries...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-07

    ... experienced the death of your spouse, a marriage or divorce, or other major life-changing events that we... reference to the rules we follow under subpart B of this part. Major life-changing events include marriage... recognize: Death of a spouse; Marriage; Marriage ended by divorce or annulment; Partial or full...

  18. MEDICAL COSTS OF OSTEOPOROSIS IN THE ELDERLY MEDICARE POPULATION

    PubMed Central

    Blume, Steven W; Curtis, JR

    2013-01-01

    Introduction National cost estimates of osteoporosis and fractures in the U.S. have been based on diverse sets of provider data or selected commercial insurance claims. We sought to characterize prevalence and costs for osteoporosis using a random population-based sample of older adults. Methods A cross-sectional estimate of medical cost was made with 2002 data from the Medicare Current Beneficiary Survey (MCBS). MCBS combines health interviews with claims information from all payers to profile a random sample of 12,700 Medicare recipients. Three cohorts aged 65 or over were defined: 1) patients experiencing a fracture-related claim in 2002; 2) patients with a diagnosis, medication, or self-report for osteoporosis or past hip fracture; and 3) non-case controls. The total cost of patient claims was compared to that of controls using multivariate regression. Results Of 30.2 million elderly Medicare recipients in 2002, 1.6 million (5%) were treated for a fracture that year and an additional 7.2 million (24%) have osteoporosis without a fracture. The estimated mean impact of fractures on annual medical cost was $8600 (95%CI: $6400 to $10,800), implying a U.S. cost of $14 billion ($10 to $17 billion). Half of the non-fracture osteoporosis patients received drug treatment, averaging $500 per treated patient, or $2 billion nationwide. Conclusions The annual cost of osteoporosis and fractures in the U.S. elderly was estimated at $16 billion, using a national 2002 population-based sample. This amount corroborates previous estimates based on substantially different methodologies. Projected to 2008, the national cost of osteoporosis and fractures was $22 billion. PMID:21165602

  19. Are women better off because of the new Medicare drug legislation?

    PubMed

    Moon, Marilyn

    2005-01-01

    The passage of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 will help to reduce the out-of-pocket burdens women will face in 2006 once the full drug benefit is introduced. Nonetheless, the legislation is less than ideal and creates a number of issues that should be improved to meet women's needs. Three key elements of the legislation that were essential in gaining its passage stand in the way of such improvements: limits on the amount spent on the benefit, requirements to rely on the private sector, and a failure to adequately arrange for future financing. A major overhaul is unlikely, but it is possible that modest improvements to aid Medicare beneficiaries will be considered in the future. Several of those improvements are described here.

  20. Proportion of beneficiaries and factors affecting Janani Suraksha Yojana direct cash transfer scheme in Puducherry, India

    PubMed Central

    Rajarajan, K.; Kumar, S. Ganesh; Kar, Sitanshu Sekhar

    2016-01-01

    Introduction: Janani Suraksha Yojana (JSY) direct benefit transfer scheme was launched in the year 2013 in India and there is a paucity of information affecting it. The study aimed to assess the proportion of eligible beneficiaries utilizing JSY direct cash benefit transfer in Puducherry and to identify its barriers and facilitating factors. Methods: This cross sectional study was conducted from January to March 2015 among 152 eligible JSY beneficiaries residing in rural and urban field practice areas of a tertiary care institution in Puducherry, India. Data were collected using a pretested semi structured questionnaire and presented as proportion or percentages. Results: About 144 beneficiaries participated in the study with a response rate of 94.7%. About 46% (66) of them availed cash transfer benefit. The mean time of receiving the benefit is 95.8 days (interquartile range 60–120 days). Among those who have not received (78), about 49 (62.8%) had not applied and 29 (37.18%) filled applications were rejected due to various reasons. About 77.1% (111) of beneficiaries were informed about JSY scheme through health workers. About 52.1% (75/144) still preferred direct bank transfer through the bank. The reasons for not availing benefits includes not having a bank account (24.3%), followed by not having Aadhaar number (9.7%), 11.8% had no ration card, and 13.8% stayed in their mother house. Conclusion: Majority of the beneficiaries did not receive direct cash transfer benefits in urban area than rural area and there is a need to simplify the procedures to improve the uptake of services to this group. PMID:28348997

  1. Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

    PubMed Central

    Pampati, Vidyasagar; Hirsch, Joshua A

    2016-01-01

    Objective To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. Design A retrospective cohort. Methods The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. Results Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. Conclusions Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections. PMID:27965254

  2. Effects of post-hospital Medicare home health and informal care on patient functional status.

    PubMed Central

    Penrod, J D; Kane, R L; Finch, M D; Kane, R A

    1998-01-01

    OBJECTIVE: To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures. STUDY SETTING/DATA SOURCES: Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS). ANALYSIS: The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status. DATA COLLECTION/EXTRACTION METHODS: Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care. PRINCIPAL FINDINGS: More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status. CONCLUSIONS: Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes. PMID:9685120

  3. 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... Health Expenditures and Medicare expenditures. The Panel's discussion is expected to be very technical...

  4. Will invalid because beneficiary prepared the document.

    PubMed

    1996-04-19

    The mother of a man who died of AIDS-related complications successfully challenged the validity of her son's will. An Alabama appeals court refused to allow the will of [name removed] to stand, citing that his partner and beneficiary, [name removed], exercised undue influence over [name removed]'s decisions. Less than 1 year before his death, [name removed] granted [name removed] power of attorney and named him as beneficiary of his life insurance policy. Thirteen days prior to [name removed]'s death, papers were signed conveying his real estate to [name removed]. Writing for the court, retired Judge L. Charles Wright noted that [name removed]'s medical condition might have affected the soundness of his judgment.

  5. 42 CFR 436.403 - State residence.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...) Definition. For purposes of this section—Institution has the same meaning as Institution and Medical... Social Security Act, the State of residence is the State where the child lives. (g) Individuals under...

  6. 42 CFR 435.403 - State residence.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... set forth in § 431.52 of this chapter. (b) Definition. For purposes of this section—Institution has... Act, the State of residence is the State where the child lives. (h) Individuals under Age 21. (1)...

  7. 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...

  8. 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...

  9. 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...

  10. 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...

  11. Amendments to regulations regarding eligibility for a Medicare prescription drug subsidy. Final rule.

    PubMed

    2012-01-18

    This final rule adopts, without change, the interim final rule with request for comments we published in the Federal Register on December 29, 2010. The interim final rule incorporated changes to the Medicare prescription drug coverage low-income subsidy (Extra Help) program made by the Patient Protection and Affordable Care Act (Affordable Care Act) enacted in March 2010. Under our interpretation of section 3304 of the Affordable Care Act, if the death of a beneficiary's spouse would decrease or eliminate the subsidy provided by the Extra Help program, we will extend the effective period of eligibility for the most recent determination or redetermination until one year after the month following the month we are notified of the death of the spouse. The effective date of this provision was January 1, 2011. We also revised our regulations to incorporate changes made by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) which affect the way we account for income and resources when determining eligibility for the Extra Help program. The statute provides that we no longer count the value of any life insurance policy as a resource for Extra Help effective on and after January 1, 2010. As of that date, we also no longer count as income the help a beneficiary receives when someone else provides food and shelter, or pays household bills for food, mortgage, rent, electricity, water, property taxes, or heating fuel or gas. These revisions updated our rules to reflect these statutory changes.

  12. 78 FR 31283 - Medicare Program; Medical Loss Ratio Requirements for the Medicare Advantage and the Medicare...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-05-23

    ..., and others. Overall, commenters supported our decision to model Medicare MLR policy after the commercial MLR rules. In this final rule, we address comments and concerns regarding the policies included in... applicability to various plan types. Part 422 of the Code of Federal Regulations (CFR) regulates the MA...

  13. 76 FR 63017 - Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-11

    ... the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes... Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to... (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations...

  14. 77 FR 34326 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-11

    ... 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident... Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term...

  15. 75 FR 65282 - Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-22

    ... skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid..., approximately 1.4 million elderly and disabled nursing home residents are receiving care in nearly 16,000... percent of older Americans die in nursing homes. (Johnson, Sandra H., Hastings Center Report, Making...

  16. 77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-03

    ...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...

  17. 78 FR 15882 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-13

    ...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...

  18. Medicare and Graduate Medical Education.

    DTIC Science & Technology

    1995-09-01

    cost were adapted by the Congressional Budget Office (CBO) from Monica Noether , "The Growing Supply of Physicians: Has the Market Become More...spurred by the introduc- tion and expansion of the Medicaid and Medicare programs (and precursors of those programs), which 16. See Monica Noether ...competitive (see Monica Noether , "The Growing Supply of Physicians: Has the Market Be- come More Competitive?"./«?«/-««/ of Labor Economics vol. 4

  19. Warfarin usage among elderly atrial fibrillation patients with traumatic injury, an analysis of United States Medicare fee-for-service enrollees.

    PubMed

    Liu, Xinggang; Baumgarten, Mona; Smith, Gordon; Gambert, Steven; Gottlieb, Stephen; Rattinger, Gail; Albrecht, Jennifer; Langenberg, Patricia; Zuckerman, Ilene

    2015-01-01

    This study examined warfarin usage for elderly Medicare beneficiaries with atrial fibrillation (AF) who suffered traumatic brain injury (TBI), hip fracture, or torso injuries. Using the 5% Chronic Condition Data Warehouse administrative claims data, this study included fee-for-service Medicare beneficiaries who had a single injury hospitalization (TBI, hip fracture, or major torso injury) between 1/1/2007 and 12/31/2009, with complete Medicare Parts A, B (no Medicare Advantage), and D coverage 6 months before injury, and who were aged 66 years or older and diagnosed with AF at least 1 year before injury. About 45% of the AF patients were using warfarin before TBI or torso injury, and 35% before hip fracture. After injury, there was a dramatic and persistent decrease in warfarin use in TBI and torso injury groups (30% for TBI and 37% for torso injury at 12 months after injury). Warfarin usage in hip fracture patients also dropped after injury but returned to pre-injury level within 4 months. TBI and torso injury lead to significant decreases in warfarin usage in elderly AF patients. Further research is needed to understand reasons for the pattern and to develop evidence-based management strategies in the post-acute setting.

  20. 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....

  1. 76 FR 66135 - Investment Advice-Participants and Beneficiaries

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-25

    ...This document contains a final rule under the Employee Retirement Income Security Act, and parallel provisions of the Internal Revenue Code of 1986, relating to the provision of investment advice to participants and beneficiaries in individual account plans, such as 401(k) plans, and beneficiaries of individual retirement accounts (and certain similar plans). The final rule affects sponsors,......

  2. 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....

  3. 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....

  4. 42 CFR 421.304 - Medicare integrity program contractor functions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... services for which Medicare payment may be made either directly or indirectly. (b) Auditing, settling and.... 421.304 Section 421.304 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM MEDICARE CONTRACTING Medicare Integrity...

  5. Society for Health Psychology (APA Division 38) and Society of Behavioral Medicine joint position statement on the Medicare Diabetes Prevention Program.

    PubMed

    Fitzpatrick, Stephanie L; Wilson, Dawn K; Pagoto, Sherry L

    2017-01-31

    Beginning in January 2018, the Centers for Medicare and Medicaid Services (CMS) plans to cover the Diabetes Prevention Program (DPP), also referred to as Medicare DPP. The American Psychological Association Society for Health Psychology (SfHP) and the Society for Behavioral Medicine (SBM) reviewed the proposed plan. SfHP and SBM are in support of the CMS decision to cover DPP for Medicare beneficiaries but have a significant concern that aspects of the proposal will limit the public health impact. Concerns include the emphasis on weight outcomes to determine continued coverage and the lack of details regarding requirements for coaches. SfHP and SBM are in strong support of modifications to the proposal that would remove the minimum weight loss stipulation to determine coverage and to specify type and qualifications of "coaches."

  6. A comprehensive analysis of Medicare trends in utilization and hospital economics for total knee and hip arthroplasty from 2005 to 2011.

    PubMed

    Nwachukwu, Benedict U; McCormick, Frank; Provencher, Matthew T; Roche, Martin; Rubash, Harry E

    2015-01-01

    The purpose of this study was to determine annual Medicare utilization and hospital reimbursement rates for total knee arthroplasty (TKA) and total hip arthroplasty (THA). A PearlDiver review of the entire Medicare database was conducted: 2,040,667 TKAs and 855, 899 THAs performed between 2005 and 2011 were identified. There was a +0.05% and +1.3% year over year growth in the utilization in hospital reimbursement for TKA and THA respectively. There has only been a modest increase in joint arthroplasty utilization for Medicare beneficiaries. Supply side issues, insurance mix and possible prior over-projection may explain this finding. Reimbursement trends suggest that joint arthroplasty may not be a major cost driver for the healthcare system.

  7. 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.

  8. Medicare program; Medicare Shared Savings Program: Accountable Care Organizations. Final rule.

    PubMed

    2015-06-09

    This final rule addresses changes to the Medicare Shared Savings Program including provisions relating to the payment of Accountable Care Organizations participating in the Medicare Shared Savings Program. Under the Medicare Shared Savings Program, providers of services and suppliers that participate in an Accountable Care Organizations continue to receive traditional Medicare fee-for-service payments under Parts A and B, but the Accountable Care Organizations may be eligible to receive a shared savings payment if it meets specified quality and savings requirements.

  9. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program

    PubMed Central

    Schwartz, Aaron L.; Chernew, Michael E.; Landon, Bruce E.; McWilliams, J. Michael

    2016-01-01

    Importance Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. Objective To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. Design, Setting and Participants In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other providers (control group) before (2009–2011) vs. after (2012) Pioneer ACO contracts began. We adjusted comparisons for beneficiaries’ sociodemographic and clinical characteristics and for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs. lower baseline use of low-value services. Main Outcomes and Measures Use of, and spending on, 31 services in instances that provide minimal clinical benefit. Results During the pre-contract period, trends in use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction of 0.8 low-value services per 100 beneficiaries for the ACO group (95% CI: −1.2, −0.4; P<0.001), corresponding to a 1.9% reduction in service quantity (95% CI: −2.9%, −0.9%) and a 4.5% differential reduction in spending on low-value services (95% CI: −7.5%, −1.4%; P=0.004). Differential reductions were similar for services less vs. more sensitive to patient preferences and for higher- vs. lower-priced services. ACOs with higher than their markets average baseline levels of low-value service use experienced greater service reductions (−1.2 services

  10. 75 FR 29555 - Medicare Program; Medicare Coverage Gap Discount Program Model Manufacturer Agreement and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-05-26

    ... Services [CMS-4151-NC] RIN 0938-AQ04 Medicare Program; Medicare Coverage Gap Discount Program Model... contains a draft model agreement for use by the Secretary and manufacturers under the Medicare Coverage Gap Discount Program established by section 3301 of the Patient Protection and Affordable Care Act, as...

  11. 76 FR 58514 - Medicare Program; Meeting of the Technical Advisory Panel on Medicare Trustee Reports

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-21

    ... 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... spending in the long run. The Panel's discussion is expected to be very technical in nature and will...

  12. 78 FR 57800 - Medicare Program; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-20

    ...; Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal AGENCY: Centers for... Medicare Secondary Payer (MSP) Web portal to conform to section 201 of the Medicare IVIG and Strengthening... MSP Web portal. It also requires that we add functionality to the existing MSP Web portal that...

  13. 76 FR 54599 - Medicare Program; Medicare Advantage and Prescription Drug Benefit Programs

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-01

    ... 42 CFR Parts 417, 422, and 423 Medicare Program; Medicare Advantage and Prescription Drug Benefit... Prescription Drug Benefit Programs AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final... (MA) program (Part C), prescription drug benefit program (Part D) and section 1876 cost...

  14. 76 FR 21372 - Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-04-15

    ... beneficiaries at high risk for readmission, including those with multiple chronic conditions, depression, or... basis for the remaining 3 years based on performance. Applicants must identify root causes...

  15. Your Guide to Medicare Special Needs Plans (SNPs)

    MedlinePlus

    ... are approved by Medicare and run by private companies. When you join a Medicare SNP, you get ... available in different parts of the country. Insurance companies decide where they will do business, so Medicare ...

  16. Medication Adherence and Readmission In Medicare Myocardial Infarction

    PubMed Central

    Zhang, Yuting; Kaplan, Cameron M.; Baik, Seo Hyon; Chang, Chung-Chou H.; Lave, Judith R.

    2014-01-01

    Objectives To examine the relationship between 6-month medication adherence and 1-year down-stream heart-disease related readmission among patients who survived a myocardial infarction (MI). Study Design Retrospective, nested case-control analysis of Medicare fee-for-service beneficiaries who were discharged alive post-MI in 2008 (n = 168,882). Methods Patients in the case group had their first heart-disease related readmission post-MI discharge during 6-9 months and/or 9-12 months. We then used propensity score matching mechanism to identify patients in the control group who had similar characteristics, but did not have a readmission in the same time window. Adherence was defined as the average 6-month medication possession ratio (MPR) prior to the first date of the time-window of defining readmission. Results After controlling for demographic, insurance coverage and clinical characteristics, patients who had a heart-disease related readmission had worse adherence, with MPR of 0.70 and 0.74 in the case and control groups. Odds ratio of MPR ≥0.75 was 0.79 (95% CI 0.75-0.83) among those with a readmission relative to those without. Conclusion Our study shows that better 6-month medication adherence may reduce heart-disease related readmissions within a year after an MI. PMID:25651604

  17. Impact of Medicare's prospective payment system on hospitals, skilled nursing facilities, and home health agencies: how the Balanced Budget Act of 1997 may have altered service patterns for Medicare providers.

    PubMed

    Kulesher, Robert R

    2006-01-01

    The prospective payment system is one of many changes in reimbursement that has affected the delivery of health care. Originally developed for the payment of inpatient hospital services, it has become a major factor in how all health insurance is reimbursed. The policy implications extend beyond the Medicare program and affect the entire health care delivery system. Initially implemented in 1982 for payments to hospitals, prospective payment system was extended to payments for skilled nursing facility and home health agency services by the Balanced Budget Act of 1997. The intent of the Balanced Budget Act was to bring into balance the federal budget through reductions in spending. The decisions that providers have made to mitigate the impact are a function of ownership type, organizational mission, and current level of Medicare participation. This article summarizes the findings of several initial studies on the Balanced Budget Act's impact and discusses how changes in Medicare reimbursement policy have influenced the delivery of health care for the general public and for Medicare beneficiaries.

  18. March 2013: Medicare Advantage update.

    PubMed

    Sayavong, Sarah; Kemper, Leah; Barker, Abigail; McBride, Timothy

    2013-09-01

    Key Data Findings. (1) From March 2012 to March 2013, rural enrollment in Medicare Advantage (MA) and other prepaid plans increased by over 200,000 enrollees, to more than 1.9 million. (2) Preferred provider organization (PPO) plan enrollment increased to nearly one million enrollees, accounting for more than 51% of the rural MA market (up from 48% in March 2012). (3) Health maintenance organization (HMO) enrollment continued to grow in 2013, with over 31% of the rural MA market, while private fee-for-service (PFFS) plan enrollment decreased to less than 10% of market share. (4) Despite recent changes to MA payment, rural MA enrollment continues to increase.

  19. Health Care Access, Use, and Satisfaction Among Disabled Medicaid Beneficiaries

    PubMed Central

    Coughlin, Teresa A.; Long, Sharon K.; Kendall, Stephanie

    2002-01-01

    Despite being a vulnerable and costly population, little is known about disabled Medicaid beneficiaries. Using data from a 1999-2000 survey, we describe the population and their health care experiences in terms of access, use, and satisfaction with care. Results indicate that disabled beneficiaries are a unique population with wide-ranging circumstances and health conditions. Our results on access to care were indeterminate: by some measures, they had good access, but by others they did not. Beneficiaries' assessments of their health care were more clear: The bulk of the sample rated one or more area of care as being fair or poor. PMID:12690698

  20. Your Guide to Medicare's Preventive Services

    MedlinePlus

    ... primary care setting (like a doctor’s office). Your costs if you have Original Medicare You pay nothing if the doctor or other qualified primary care provider accepts PS assignment. Bone mass measurements Medicare covers bone mass measurements to see if ...

  1. Medicare Resources That You Should Use

    PubMed Central

    Schaum, Kathleen Dianne

    2013-01-01

    Wound care scientists, manufacturers, and wound care professionals should take time to visit the Centers for Medicare & Medicaid Services' website. It is easy to navigate and contains information for all wound care stakeholders. This article reviews some of the most popular Medicare website pages that should prove useful to wound care stakeholders. The links to those pages are also provided. PMID:24761329

  2. Medicare Resources That You Should Use.

    PubMed

    Schaum, Kathleen Dianne

    2013-12-01

    Wound care scientists, manufacturers, and wound care professionals should take time to visit the Centers for Medicare & Medicaid Services' website. It is easy to navigate and contains information for all wound care stakeholders. This article reviews some of the most popular Medicare website pages that should prove useful to wound care stakeholders. The links to those pages are also provided.

  3. Medicare Pays for Chronic Care Management.

    PubMed

    Sorrel, Amy Lynn

    2015-09-01

    As of January, the Centers for Medicare & Medicaid Services began paying for chronic care management of patients with two or more conditions under its Chronic Care Management program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements. Texas Medical Association leaders caution the program has some hefty requirements.

  4. 26 CFR 1.662(c)-2 - Death of individual beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 26 Internal Revenue 8 2010-04-01 2010-04-01 false Death of individual beneficiary. 1.662(c)-2... Corpus § 1.662(c)-2 Death of individual beneficiary. If an amount specified in section 662(a) (1) or (2... not end with or within the last taxable year of a beneficiary (because of the beneficiary's...

  5. 38 CFR 6.9 - Election of optional settlement by beneficiary.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... provisions. (Authority: 38 U.S.C. 1952) (a) If the insured has selected Option 1, the beneficiary may elect.... (d) If the insured has selected Option 3, and named no contingent beneficiary, the beneficiary may... beneficiary who does not survive the period certain shall be in full and complete discharge of all...

  6. Comparative Effectiveness of Endovascular versus Open Repair of Ruptured Abdominal Aortic Aneurysm in the Medicare Population

    PubMed Central

    Edwards, Samuel T.; Schermerhorn, Marc L.; O’Malley, A. James; Bensley, Rodney P.; Hurks, Rob; Cotterill, Philip; Landon, Bruce E.

    2015-01-01

    Objectives Endovascular abdominal aortic aneurysm repair (EVAR) is increasingly used for emergent treatment of ruptured abdominal aortic aneurysm (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications and rates of re-intervention of EVAR versus open aortic repair of rAAA in Medicare beneficiaries. Methods We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a US hospital from 2001–2008. Patients were propensity score matched on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair and sensitivity analyses were performed to evaluate the impact of bias that might have resulted from unmeasured confounders Results Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality for EVAR and open repair were 33.8% and 47.7% respectively (p<0.001) and this difference persisted for more than four years. EVAR patients had higher rates of AAA-related reinterventions when compared with open repair patients (endovascular reintervention at 36 months 10.9% vs 1.5%, p<0.001), whereas open patients had more laparotomy related complications (incisional hernia repair at 36 months 1.8% vs. 6.2% p<0.001, all surgical complications at 36 months 4.4% vs. 9.1%, p<0.001). Use of EVAR for rAAA has increased from 6% of cases in 2001 to 31% of cases in 2008, while over the same time period overall 30-day mortality for admission for rAAA regardless of treatment has decreased from 55.8% to 50.9%. Conclusions EVAR for rAAA is associated with lower perioperative and long term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized

  7. 32 CFR 728.59 - Peace Corps beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... pain or prevent imminent loss of teeth. All beneficiaries seeking dental care will be requested... emergencies. Render only that care essential to relieve pain or prevent imminent loss of teeth....

  8. 32 CFR 728.59 - Peace Corps beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... pain or prevent imminent loss of teeth. All beneficiaries seeking dental care will be requested... emergencies. Render only that care essential to relieve pain or prevent imminent loss of teeth....

  9. 32 CFR 728.59 - Peace Corps beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... pain or prevent imminent loss of teeth. All beneficiaries seeking dental care will be requested... emergencies. Render only that care essential to relieve pain or prevent imminent loss of teeth....

  10. Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico

    PubMed Central

    Rivera-Hernandez, Maricruz; Leyva, Bryan; Keohane, Laura M.; Trivedi, Amal N.

    2016-01-01

    IMPORTANCE Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA). OBJECTIVE To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6 289 374), Hispanic enrollees in the United States (n = 795 039), and Hispanic enrollees in Puerto Rico (n = 267 016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016. MAIN OUTCOMES AND MEASURES Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a β-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs). RESULTS Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease

  11. Beneficiary Decisionmaking: The Impact of Labeling Health Plan Choices

    PubMed Central

    Fyock, Jack; Koepke, Christopher P.; Meitl, John; Sutton, Sharyn; Thompson, Elizabeth; Engelberg, Moshe

    2001-01-01

    One critical health plan decision concerns choosing an original Medicare plan or a Medicare managed care plan. Evidence suggests that people are confused by the phrase “Original Medicare plan.” Using focus group and Q-sort methodology, the authors sought to identify a name for the Medicare fee-for-service (FFS) product. Two key insights were gained. First, participants used the word “Medicare” to name the FFS product. Second, participants did not choose between two plans. Rather, they decided between supplemental insurance and a managed care product. These factors should influence how CMS “brands” not only the FFS product but also the overall Medicare program. PMID:12500363

  12. The Association Between Residency Training and Internists’ Ability to Practice Conservatively

    PubMed Central

    Sirovich, Brenda E.; Lipner, Rebecca S.; Johnston, Mary; Holmboe, Eric S.

    2014-01-01

    IMPORTANCE Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians’ ability to minimize the provision of unnecessary care. OBJECTIVE To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients’ care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357). EXPOSURES Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program’s hospital referral region. MAIN OUTCOMES AND MEASURES The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM(or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier. RESULTS Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores

  13. Medicare program; End-Stage Renal Disease prospective payment system, quality incentive program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. Final rule.

    PubMed

    2014-11-06

    This final rule will update and make revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2015. This rule also finalizes requirements for the ESRD quality incentive program (QIP), including for payment years (PYs) 2017 and 2018. This rule will also make a technical correction to remove outdated terms and definitions. In addition, this final rule sets forth the methodology for adjusting Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule payment amounts using information from the Medicare DMEPOS Competitive Bidding Program (CBP); makes alternative payment rules for certain DME under the Medicare DMEPOS CBP; clarifies the statutory Medicare hearing aid coverage exclusion and specifies devices not subject to the hearing aid exclusion; will not update the definition of minimal self-adjustment; clarifies the Change of Ownership (CHOW) and provides for an exception to the current requirements; revises the appeal provisions for termination of a CBP contract, including the beneficiary notification requirement under the Medicare DMEPOS CBP, and makes a technical change to the regulation related to the conditions for awarding contracts for furnishing infusion drugs under the Medicare DMEPOS CBP.

  14. Amendments to regulations regarding eligibility for a Medicare prescription drug subsidy. Interim final rule with request for comments.

    PubMed

    2010-12-29

    We are revising our regulations to incorporate changes to the Medicare prescription drug coverage low-income subsidy (Extra Help) program made by the Affordable Care Act which was enacted on March 23, 2010. Under our interpretation of section 3304 of the Affordable Care Act and this interim final rule, if the death of a beneficiary's spouse would decrease or eliminate the subsidy provided by the Extra Help program, we will, based on a determination, or redetermination, extend the effective period of eligibility for the most recent determination or redetermination until 1 year after the month following the month we are notified of the death of the spouse. These regulatory changes will allow us to implement this provision of the Affordable Care Act when it goes into effect on January 1, 2011. We are also revising our regulations to incorporate changes made by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which affect the way we account for income and resources when determining eligibility for the Extra Help program. The statute provides that we no longer count as a resource the value of any life insurance policy for Extra Help applications filed, or redeterminations that are effective, on or after January 1, 2010. In addition, we will no longer count as income the help a beneficiary receives when someone else provides food and shelter, or pays household bills for food, mortgage, rent, electricity, water, property taxes, or heating fuel or gas. These revisions will update our rules to reflect these statutory changes.

  15. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Deactivation of Medicare billing privileges. 424... Establishing and Maintaining Medicare Billing Privileges § 424.540 Deactivation of Medicare billing privileges. (a) Reasons for deactivation. CMS may deactivate a provider or supplier's Medicare billing...

  16. 42 CFR 424.540 - Deactivation of Medicare billing privileges.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Deactivation of Medicare billing privileges. 424... Establishing and Maintaining Medicare Billing Privileges § 424.540 Deactivation of Medicare billing privileges. (a) Reasons for deactivation. CMS may deactivate a provider or supplier's Medicare billing...

  17. Modeling Medicare Costs of PACE Populations

    PubMed Central

    Robinson, James; Karon, Sarita L.

    2000-01-01

    Historically, Medicare has paid PACE providers a monthly capitated rate equal to 95 percent of the site's county AAPCC multiplied by a PACE-specific frailty adjuster of 2.39. The Balanced Budget Act of 1997 makes PACE a permanent provider category and mandates that future Medicare payments be based upon the rate structure of the Medicare+Choice payment system, adjusted for the comparative frailty of PACE enrollees and other factors deemed to be appropriate by the Secretary of Health and Human Services. This study revisits the calculation of the PACE frailty adjuster and explores the effect of risk adjustment on that frailty adjuster. PMID:11481753

  18. Regional variation in physician adoption of antipsychotics: Impact on US Medicare expenditures

    PubMed Central

    Donohue, Julie M.; Normand, Sharon-Lise T.; Horvitz-Lennon, Marcela; Men, Aiju; Berndt, Ernst R.; Huskamp, Haiden A.

    2016-01-01

    Background Regional variation in US Medicare prescription drug spending is driven by higher prescribing of costly brand-name drugs in some regions. This variation likely arises from differences in the speed of diffusion of newly-approved medications. Second-generation antipsychotics were widely adopted for treatment of severe mental illness and for several off-label uses. Rapid diffusion of new psychiatric drugs likely increases drug spending but its relationship to non-drug spending is unclear. The impact of antipsychotic diffusion on drug and medical spending is of great interest to public payers like Medicare, which finance a majority of mental health spending in the U.S. Aims We examine the association between physician adoption of new antipsychotics and antipsychotic spending and non-drug medical spending among disabled and elderly Medicare enrollees. Methods We linked physician-level data on antipsychotic prescribing from an all-payer dataset (IMS Health's Xponent™) to patient-level data from Medicare. Our physician sample included 16,932 U.S. psychiatrists and primary care providers with ≥10 antipsychotic prescriptions per year from 1997-2011. We constructed a measure of physician adoption of 3 antipsychotics introduced during this period (quetiapine, ziprasidone and aripiprazole) by estimating a shared frailty model of the time to first prescription for each drug. We then assigned physicians to one of 306 U.S. hospital referral regions (HRRs) and measured the average propensity to adopt per region. Using 2010 data for a random sample of 1.6 million Medicare beneficiaries, we identified 138,680 antipsychotic users. A generalized linear model with gamma distribution and log link was used to estimate the effect of region-level adoption propensity on beneficiary-level antipsychotic spending and non-drug medical spending adjusting for patient demographic and socioeconomic characteristics, health status, eligibility category, and whether the antipsychotic was

  19. 78 FR 16795 - Medicare and Medicaid Programs; Requirements for Long-Term Care (LTC) Facilities; Notice of...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-19

    ... addressing health care inequalities for racial and ethnic minorities that rely on Medicare and Medicaid for... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND... overall health of residents. Therefore, having an organized process that facilities must follow in...

  20. The cost of privatization: extra payments to Medicare Advantage plans.

    PubMed

    Biles, Brian; Nicholas, Lauren Hersch; Cooper, Barbara S

    2004-05-01

    The recently enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) includes a broad set of provisions intended to enlarge the role of private health plans (called Medicare Advantage plans) in Medicare. This issue brief examines the payments that private plans are receiving in 2004 relative to costs in traditional fee-for-service Medicare, using data from the 2004 Medicare Advantage Rate Calculation Data spreadsheet. The authors find that, for 2004, Medicare Advantage payments will average 8.4 percent more than costs in traditional fee-for-service Medicare: $552 for each of the 5 million Medicare enrollees in managed care, for a total of more than $2.75 billion. In some counties, extra payments by Medicare are more than double this amount. Although the stated objective of efforts to increase enrollment in private plans is to lower costs, the policies of MMA regarding private plans explicitly increase Medicare costs in 2004 and through 2013.

  1. Understanding Regional Variation in Medicare Expenditures for Initial Episodes of Prostate Cancer Care

    PubMed Central

    Wang, Shi-Yi; Wang, Rong; Yu, James B.; Ma, Xiaomei; Xu, Xiao; Kim, Simon P.; Soulos, Pamela R.; Saraf, Avantika; Gross, Cary P.

    2014-01-01

    Objectives To evaluate the contributions of patient and treatment factors to overall expenditures and regional variation for initial treatment of localized prostate cancer (CaP) in the Medicare program. Research Design Using the Surveillance, Epidemiology, and End Results–Medicare database, we identified 47,517 beneficiaries with localized CaP during 2005–2009 and matched non-cancer controls. We employed hierarchical generalized linear models to estimate risk-standardized cancer-related expenditures for each hospital referral region. To identify key contributors to the variation, we sequentially added patient characteristics, treatment intensity (the percentage of patients receiving curative treatments), ancillary procedures (biopsy, hormone therapy, and imaging), and specific treatment modalities into the model. We categorized the expenditures according to the type of services to identify their relative impact on the expenditure variations. Results The mean expenditure on CaP-related care per CaP beneficiary was $15,900, including $1,800 on surgery, $11,200 on radiotherapy, and $1,900 on ancillary procedures. The expenditure difference between quintiles 5 and 1 was $6,200. Patient characteristics explained 8.4% of this difference. Treatment intensity and treatment modalities accounted for an additional 21.2% and 31.2% of the variation, respectively. Between the highest and lowest expenditure quintiles, the difference in radiotherapy expenditure was $5,000, whereas that in surgery or ancillary procedures was less than $200. Conclusions There is substantial geographic variation in CaP expenditures, and the specific modality of radiotherapy is the most important contributor to this variation. Efforts to address the CaP care costs, such as bundled payment development, require targeting both treatment intensity and use of costly modalities. PMID:25023913

  2. Medicare program; Medicare Shared Savings Program: Accountable Care Organizations. Final rule.

    PubMed

    2011-11-02

    This final rule implements section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program. Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, and be eligible for additional payments if they meet specified quality and savings requirements.

  3. 42 CFR 408.21 - Reduction in Medicare Part B premium as an additional benefit under Medicare+Choice plans.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Reduction in Medicare Part B premium as an additional benefit under Medicare+Choice plans. 408.21 Section 408.21 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE Amount of Monthly Premiums...

  4. Medicare Advantage Members’ Expected Out-Of-Pocket Spending For Inpatient And Skilled Nursing Facility Services

    PubMed Central

    Keohane, Laura M.; Grebla, Regina C.; Mor, Vincent; Trivedi, Amal N.

    2015-01-01

    Inpatient and skilled nursing facility (SNF) cost sharing in Medicare Advantage (MA) plans may reduce unnecessary use of these services. However, large out-of-pocket expenses potentially limit access to care and encourage beneficiaries at high risk of needing inpatient and postacute care to avoid or leave MA plans. In 2011 new federal regulations restricted inpatient and skilled nursing facility cost sharing and mandated limits on out-of-pocket spending in MA plans. After these regulations, MA members in plans with low premiums averaged $1,758 in expected out-of-pocket spending for an episode of seven hospital days and twenty skilled nursing facility days. Among members with the same low-premium plan in 2010 and 2011, 36 percent of members belonged to plans that added an out-of-pocket spending limit in 2011. However, these members also had a $293 increase in average cost sharing for an inpatient and skilled nursing facility episode, possibly to offset plans’ expenses in financing out-of-pocket limits. Some MA beneficiaries may still have difficulty affording acute and postacute care despite greater regulation of cost sharing. PMID:26056208

  5. Medicare Advantage Members' Expected Out-Of-Pocket Spending For Inpatient And Skilled Nursing Facility Services.

    PubMed

    Keohane, Laura M; Grebla, Regina C; Mor, Vincent; Trivedi, Amal N

    2015-06-01

    Inpatient and skilled nursing facility (SNF) cost sharing in Medicare Advantage (MA) plans may reduce unnecessary use of these services. However, large out-of-pocket expenses potentially limit access to care and encourage beneficiaries at high risk of needing inpatient and postacute care to avoid or leave MA plans. In 2011 new federal regulations restricted inpatient and skilled nursing facility cost sharing and mandated limits on out-of-pocket spending in MA plans. After these regulations, MA members in plans with low premiums averaged $1,758 in expected out-of-pocket spending for an episode of seven hospital days and twenty skilled nursing facility days. Among members with the same low-premium plan in 2010 and 2011, 36 percent of members belonged to plans that added an out-of-pocket spending limit in 2011. However, these members also had a $293 increase in average cost sharing for an inpatient and skilled nursing facility episode, possibly to offset plans' expenses in financing out-of-pocket limits. Some MA beneficiaries may still have difficulty affording acute and postacute care despite greater regulation of cost sharing.

  6. The Budget Control Act implications for Medicare.

    PubMed

    Perez, Ken

    2012-07-01

    The Budget Control Act of 2011 created a 12-member bipartisan congressional committee to develop proposed legislation aimed at reducing the federal deficit. When the committee failed to produce a bill, automatic across-the-board cuts were triggered that include cuts to Medicare. The Medicare cuts would be covered by reduced reimbursements to hospitals. If Congress does not vote to override the automatic cuts, they will take effect on Jan. 2, 2013.

  7. Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm

    PubMed Central

    Sachs, Teviah; Schermerhorn, Marc; Pomposelli, Frank; Cotterill, Philip; O’Malley, James; Landon, Bruce

    2015-01-01

    Objectives This study assessed trends in open and endovascular repair (EVAR) of intact and ruptured abdominal aortic aneurysm (AAA) in the Medicare population and evaluated recent trends in AAA repair at vascular fellowship training programs. Methods We identified all Medicare beneficiaries with a diagnosis of AAA who underwent repair or had a primary diagnosis of rupture (1995–2008). Cohorts were compared by type of repair (open vs EVAR) and presentation (intact vs ruptured AAA). Demographics of age, sex, and race were evaluated. We used unique hospital identifier codes to compare trends and 30-day mortality between hospitals that participate in vascular surgery fellowship training and those that do not. American Council on Graduate Medical Education data, only available for the years 1999 to 2008, were further used to better understand the changes in number of EVAR and open repairs of AAA performed each year for vascular fellows and general surgery residents, over time. Results We identified 449,122 patients (76% men), with 376,355 intact AAAs (84%) and 72,767 ruptured AAAs (16%). Mean age was 75.1 years. Use of EVAR for intact AAA rose to from 35% in 2001 to 63% in 2005 and comprised 78% of repairs by 2008. During the same period, the number of ruptured AAAs decreased by 40% overall, with nonoperative ruptured AAAs decreasing by 29% and EVAR increasing to 31% of rupture repairs. Hospitals training vascular fellows were quicker to adopt EVAR (2-year lag time) for intact AAA and had higher rates of EVAR for ruptured AAA (41.1% vs 29.2%; P = .001) than did hospitals without fellows. Mortality rates for open repairs of intact (4.0% vs 5.0%; P = .01) and ruptured AAA (34.1% vs 41.0%; P = .031) were lower at fellowship hospitals. The average number of open AAA repairs performed by vascular fellows dropped 50% (44.1 to 21.6/year) from 1999 to 2008. Conclusions Contrary to the expectation of a plateau, use of EVAR for intact AAA continues to rise at fellowship and

  8. Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents With Advanced Dementia and Intensive Care Unit Beds

    PubMed Central

    Teno, Joan M.; Gozalo, Pedro; Khandelwal, Nita; Curtis, J. Randall; Meltzer, David; Engelberg, Ruth; Mor, Vincent

    2016-01-01

    IMPORTANCE Mechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit. OBJECTIVE To describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients’ demographic characteristics, function, and comorbidities. MAIN OUTCOMES AND MEASURES Mechanical ventilation. RESULTS From 2000 to 2013, a total of 635 008 hospitalizations of 380 060 eligible patients occurred (30.5% male and 69.5% female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95% CI, 1.05–1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2% vs 64.6%; P = 54). CONCLUSIONS AND RELEVANCE Among hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time

  9. A Survey On Spine Surgeons’ Opinions On The Release Of The Centers for Medicare and Medicaid Services Data

    PubMed Central

    Koerner, John D.; Shah, Anuj; Arnold, Paul M.; Isaacs, Robert E.; Hilibrand, Alan S.; Vaccaro, Alexander R.; Radcliff, Kristen E.

    2015-01-01

    Background In April 2014 the Centers for Medicare and Medicaid Services (CMS) released a dataset for the public which included information on services provided by physicians and healthcare providers for Medicare beneficiaries in the 2012 calendar year. The objective of this study is to determine spine surgeons’ opinions on the release of the CMS data, and determine how they feel this information may affect patient care. Methods A survey was sent to members of the Association for Collaborative Spine Research (ACSR) regarding their practice patterns and opinions on the release of the CMS data. Determinants included surgical subspecialty, practice setting, years in practice and region. The average response was collected for each question and compared across groups. Additionally, questions in which greater than 75% of respondents either agreed (agree or strongly agree) or disagreed (disagree or strongly disagree) were identified. Results Seventy-six surgeons completed the survey, and while the overall interobserver reliability between each question was only slight (κ = 0.11), more than 75% of respondents either agreed or strongly agreed with five statements and, more than 75% of respondents either disagreed or strongly disagreed with six statements. While 86% of surgeons are in favor of more transparency, 83% of respondents felt that without the proper context, the data released does not accurately portray spine surgery. Additionally, 96% of spine surgeons do not believe the CMS data helps patients decide which spine surgeon is best for them. Conclusions The small percentage of spine surgeons who responded to this survey are in favor of more transparency but do not feel the release of the CMS data either accurately represents spine surgeons or will help patients better identify the appropriate surgeon. In spite of these concerns, it is unlikely the release of the CMS data will significantly impact the accessibility of a spine surgeon to a Medicare beneficiary. PMID

  10. Review of stem-cell transplantation for myelodysplastic syndromes in older patients in the context of the Decision Memo for Allogeneic Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndrome emanating from the Centers for Medicare and Medicaid Services.

    PubMed

    Giralt, Sergio A; Horowitz, Mary; Weisdorf, Daniel; Cutler, Corey

    2011-02-10

    Myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal hematopoietic stem-cell disorders that result in varying degrees of cytopenia and risk of transformation into acute leukemia. Allogeneic stem-cell transplantation (SCT) is the only known cure for this disease. The treatment is routinely used for younger patients, but only a minority of patients older than the age of 60 undergo this procedure. The overall MDS incidence is 3.3 per 100,000, but the incidence in patients older than age 70 is between 15 and 50 per 100,000. The median age at presentation is 76 years. Medicare-age patients 65 or older represent 80% of the total population receiving an MDS diagnosis. In the United States, one of the obstacles to SCT for older patients with MDS has been lack of third party reimbursement. On August 4, 2010, the Centers for Medicare and Medicaid Services released their Decision Memo for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome. This memo states: "Allogeneic HSCT for MDS is covered by Medicare only for beneficiaries with MDS participating in an approved clinical study that meets the criteria below…. " In this review, we will summarize what is known regarding the role of allogeneic SCT in older patients as well as other elements that should be included within clinical trials that can provide the evidence necessary to demonstrate that allogeneic SCT should be a covered benefit for Medicare beneficiaries.

  11. Permanent resident.

    PubMed

    Fisher, John F

    2016-01-01

    The training of physicians in the past century was based primarily on responsibility and the chain-of-command. Those with the bulk of that responsibility in the fields of pediatrics and internal medicine were residents. Residents trained the medical students and supervised them carefully in caring for patients. Most attending physicians supervised their teams at arm's length, primarily serving as teachers of the finer points of diagnosis and treatment during set periods of the day or week with a perfunctory signature on write-ups or progress notes. Residents endeavored to protect the attending physician from being heavily involved unless they were unsure about a clinical problem. Before contacting the attending physician, a more senior resident would be called. Responsibility was the ultimate teacher. The introduction of diagnosis-related groups by the federal government dramatically changed the health care delivery system, placing greater emphasis on attending physician visibility in the medical record, ultimately resulting in more attending physician involvement in day-to-day care of patients in academic institutions. Without specified content in attending notes, hospital revenues would decline. Although always in charge technically, attending physicians increasingly have assumed the role once dominated by the resident. Using biographical experiences of more than 40 years, the author acknowledges and praises the educational role of responsibility in his own training and laments its declining role in today's students and house staff.

  12. Disease management and the Medicare Modernization Act: "It's the insurance, stupid".

    PubMed

    Sidorov, Jaan; Schlosberg, Claudia

    2005-12-01

    While definitions of "disease management" (DM) emphasize quality of care for populations with chronic illness, proponents argue it reduces healthcare costs. Buyers may find disease management organizations' (DMOs') use of clinical guidelines, physician collaboration, and promotion of patient self-management intuitively sound, but it is performance guarantees, combined with retrospective effectiveness cost studies, that have driven DMOs' penetration of the commercial insurance market with revenues that exceed $500 million per year. The success of DMOs contributed to the creation of the Chronic Care Improvement Program (CCIP), which is designed to prospectively test the impact of DM on both the quality and cost of care for fee-for-service Medicare beneficiaries with chronic illness. This may lead to an expansion of DM in Medicare, and even greater opportunities for DMOs beyond the $10 billion in 10- year projected growth. For community-based physicians caring for patients with chronic illness, the sharpened focus on chronic care and the growth of DMOs creates some potential advantages. These include more time to treat more patients with acute illness, lower practice costs, opportunities to collaborate over quality, and a greater ability to achieve quality targets set by pay-for-performance arrangements.

  13. Emergency care and the national quality strategy: highlights from the Centers for Medicare & Medicaid Services.

    PubMed

    Venkatesh, Arjun K; Goodrich, Kate

    2015-04-01

    The Centers for Medicare & Medicaid Services (CMS) of the US Department of Health and Human Services seeks to optimize health outcomes by leading clinical quality improvement and health system transformation through a variety of activities, including quality measure alignment, prioritization, and implementation. CMS manages more than 20 federal quality measurement and public reporting programs that cover the gamut of health care providers and facilities, including both hospital-based emergency departments (EDs) and individual emergency physicians. With more than 130 million annual visits, and as the primary portal of hospital admission, US hospital-based EDs deliver a substantial portion of acute care to Medicare beneficiaries. Given the position of emergency care across clinical conditions and between multiple settings of care, the ED plays a critical role in fulfilling all 6 priorities of the National Quality Strategy. We outline current CMS initiatives and future opportunities for emergency physicians and EDs to effect each of these priorities and help CMS achieve the triple aim of better health, better health care, and lower costs.

  14. 78 FR 78802 - Medicare Program; Right of Appeal for Medicare Secondary Payer Determination Relating to...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-27

    ... plan shall reimburse the appropriate Medicare Trust Fund for Medicare's payments for items and services... to such items and services. The responsibility for payment on the part of workers' compensation... right under MSP of an individual or any other entity to payment for items or services under a...

  15. 76 FR 76541 - Medicare Program; Availability of Medicare Data for Performance Measurement

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-07

    ...This final rule implements Section 10332 of the Affordable Care Act regarding the release and use of standardized extracts of Medicare claims data for qualified entities to measure the performance of providers of services (referred to as providers) and suppliers. This rule explains how entities can become qualified by CMS to receive standardized extracts of claims data under Medicare Parts A,......

  16. Medicare program; application of certain appeals provisions to the Medicare prescription drug appeals process. Final rule.

    PubMed

    2009-12-09

    This final rule will implement the procedures that the Department of Health and Human Services will follow at the Administrative Law Judge and Medicare Appeals Council levels in deciding appeals brought by individuals who have enrolled in the Medicare prescription drug benefit program. In addition, it will implement the reopening procedures that will be followed at all levels of appeal.

  17. 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

    ..., respectively, for Medicare Part A and Part B appeals. Section 940 of the Medicare Prescription Drug... the consumer price index for all urban consumers (U.S. city average) for July 2003 to July of the year... (Prescription Drug Plan) Appeals The annually adjusted AIC threshold amounts for ALJ hearings and...

  18. The health care experiences of rural Medicaid beneficiaries.

    PubMed

    Long, Sharon K; King, Jennifer; Coughlin, Teresa A

    2006-08-01

    Medicaid plays a vital role in rural America, yet, because of data limitations, little research exists on the health care experiences of low-income rural adults. We use data from the National Survey of America's Families, with its oversample of low-income populations, to examine differences in access to and use of care between urban and rural Medicaid beneficiaries, and between Medicaid beneficiaries and low-income privately insured adults in urban and rural areas. We find evidence that access to care under Medicaid is worse than under private insurance in both urban and rural areas; however, Medicaid beneficiaries have a more consistent level of access across urban and rural areas than do low-income privately insured people.

  19. Value-based interventional pain management: a review of medicare national and local coverage determination policies.

    PubMed

    Manchikanti, Laxmaiah; Falco, Frank J E; Benyamin, Ramsin M; Helm, Standiford; Singh, Vijay; Hirsch, Joshua A

    2013-01-01

    Major policies, regulations, and practice patterns related to interventional pain management are dependent on Medicare policies which include national coverage policies - national coverage determinations (NCDs), and local coverage policies - local coverage determinations (LCDs). The NCDs are Medicare coverage policies issued by the Centers for Medicare and Medicaid Services (CMS). The process used by the CMS in deciding what is and what is not medically necessary is lengthy, involving a review of evidence-based literature on the subject, expert opinion, and public comments. In contrast, LCDs are rules and Medicare coverage that are issued by regional contractors and fiscal intermediaries when an NCD has not addressed the policy at issue. The evidence utilized in preparing LCDs includes the highest level of evidence which is based on published authoritative evidence derived from definitive randomized clinical trials or other definitive studies, and general acceptance by the medical community (standard of practice), as supported by sound medical evidence. In addition, the intervention must be safe and effective and appropriate including duration and frequency that is considered appropriate for the item or service in terms of whether it is furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function. In addition, the safe and effective provision includes that service must be furnished in a setting appropriate to the patient's medical needs and condition, ordered and furnished by qualified personnel, the service must meet, but does not exceed, the patient's medical need, and be at least as beneficial as an existing and available medically appropriate alternative. The LCDs are prepared with literature review, state medical societies, and carrier advisory committees (CACs) of which interventional pain management is a member. The LCDs may be appealed by beneficiaries. The NCDs are

  20. Utilization of Facet Joint and Sacroiliac Joint Interventions in Medicare Population from 2000 to 2014: Explosive Growth Continues!

    PubMed

    Manchikanti, Laxmaiah; Hirsch, Joshua A; Pampati, Vidyasagar; Boswell, Mark V

    2016-10-01

    Increasing utilization of interventional techniques in managing chronic spinal pain, specifically facet joint interventions and sacroiliac joint injections, is a major concern of healthcare policy makers. We analyzed the patterns of utilization of facet and sacroiliac joint interventions in managing chronic spinal pain. The results showed significant increase of facet joint interventions and sacroiliac joint injections from 2000 to 2014 in Medicare FFS service beneficiaries. Overall, the Medicare population increased 35 %, whereas facet joint and sacroiliac joint interventions increased 313.3 % per 100,000 Medicare population with an annual increase of 10.7 %. While the increases were uniform from 2000 to 2014, there were some decreases noted for facet joint interventions in 2007, 2010, and 2013, whereas for sacroiliac joint injections, the decreases were noted in 2007 and 2013. The increases were for cervical and thoracic facet neurolysis at 911.5 % compared to lumbosacral facet neurolysis of 567.8 %, 362.9 % of cervical and thoracic facet joint blocks, 316.9 % of sacroiliac joints injections, and finally 227.3 % of lumbosacral facet joint blocks.

  1. 78 FR 36035 - Proposed Information Collection Activity: [Beneficiary Travel Mileage Reimbursement Application...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-14

    ... AFFAIRS Proposed Information Collection Activity: [Beneficiary Travel Mileage Reimbursement Application... expense in traveling to healthcare. DATES: Written comments and recommendations on the proposed collection... to ``OMB Control No. 2900--NEW (Beneficiary Travel Mileage Reimbursement Application Form)'' in...

  2. 78 FR 78342 - Extension of Autism Services Demonstration Project for TRICARE Beneficiaries Under the Extended...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-26

    ... of the Secretary Extension of Autism Services Demonstration Project for TRICARE Beneficiaries Under... Access to Autism Services Demonstration Project (Autism Demonstration) under the Extended Care Health Option (ECHO) for beneficiaries diagnosed with an Autism Spectrum Disorder (ASD). Under the...

  3. 78 FR 53507 - Agency Information Collection (Beneficiary Travel Mileage Reimbursement Application Form...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-08-29

    ... AFFAIRS Agency Information Collection (Beneficiary Travel Mileage Reimbursement Application Form) Activity Under OMB Review AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION: Notice..._submission@omb.eop.gov . Please refer to ``OMB Control No. 2900- NEW (Beneficiary Travel...

  4. Medicare program; fraud and abuse; civil monetary penalties and exclusions for assistants at cataract surgery--HHS. Final rule with comment period.

    PubMed

    1987-04-10

    This final rule implements section 9307 of Pub. L. 99-272, the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended by section 1895(b)(16) of Pub. L. 99-514, the Tax Reform Act of 1986, by providing the imposition of civil monetary penalties (CMPs) and exclusions against physicians billing the Medicare program or program beneficiaries for services of an assistant at surgery for cataract operations where prior approval has not been granted. The purpose of these regulations is to strengthen existing OIG penalty and exclusion authorities, and to prevent specific abusive and fraudulent practices against the Medicare program with regard to the use of assistants at surgery where not medically necessary.

  5. Medicare program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B). Notice of CMS ruling.

    PubMed

    2013-03-18

    This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register, we published a proposed rule entitled, "Medicare Program; Part B Inpatient Billing in Hospitals,'' to propose a permanent policy that would apply on a prospective basis.

  6. 76 FR 16793 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the National Committee for...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-25

    ... Deeming Authority of the National Committee for Quality Assurance for Medicare Advantage Health... Medicare Advantage Deeming Authority of the National Committee for Quality Assurance (NCQA) for Health... through a Medicare Advantage (MA) organization that contracts with the Centers for Medicare &...

  7. Feasibility Analysis of Adopting Medicare’s Mental Health Prospective Payment System for Tricare Beneficiaries Treated in Inpatient Psychiatric Facilities

    DTIC Science & Technology

    2005-12-01

    restricting the sample of this criterion is that the military inpatient psychiatric population tends to be concentrated in military catchment areas...determined by CMS using regression. For purposes of this analysis, the teaching adjustment was not 29 applied due to restrictions in the data, but is...584.5 (acute renal failure with lesion of tabular necrosis), 391.0 (acute rheumatic pericarditis ), and 041.1 (staphylococcus). The patient did not

  8. Impact of Local Resources on Hospitalization Patterns of Medicare Beneficiaries and Propensity to Travel outside Local Markets

    ERIC Educational Resources Information Center

    Basu, Jayasree; Mobley, Lee R.

    2010-01-01

    Purpose: To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum. Methods: Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York,…

  9. Decreasing the length of residency training: a public policy perspective.

    PubMed

    Whitcomb, Michael E

    2013-12-01

    It is widely recognized that the United States is going to experience a serious shortage of physicians in the coming years unless the number of physicians completing residency training and entering practice is greatly increased. Members of the academic medicine community have approached this issue by calling on Congress to eliminate the cap that currently limits the number of residency positions that Medicare will support. Simply eliminating the cap, however, will not ensure an adequate supply of physicians. In this commentary the author argues that decreasing the length of training required in core clinical specialties will be required to effectively address the workforce shortage by allowing more residents to be trained in core specialties without greatly increasing the number of training programs and the aggregate amount that Medicare currently spends on graduate medical education.

  10. 7 CFR 1710.104 - Service to non-RE Act beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 7 Agriculture 11 2010-01-01 2010-01-01 false Service to non-RE Act beneficiaries. 1710.104 Section... GUARANTEES Loan Purposes and Basic Policies § 1710.104 Service to non-RE Act beneficiaries. (a) To the... consumers that are RE Act beneficiaries. When it is determined by the Administrator to be necessary in...

  11. 19 CFR 10.177 - Cost or value of materials produced in the beneficiary developing country.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 19 Customs Duties 1 2010-04-01 2010-04-01 false Cost or value of materials produced in the... produced in the beneficiary developing country. (a) “Produced in the beneficiary developing country” defined. For purposes of §§ 10.171 through 10.178, the words “produced in the beneficiary...

  12. 26 CFR 1.652(c)-3 - Termination of existence of other beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 26 Internal Revenue 8 2010-04-01 2010-04-01 false Termination of existence of other beneficiaries. 1.652(c)-3 Section 1.652(c)-3 Internal Revenue INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY... Termination of existence of other beneficiaries. If the existence of a beneficiary which is not an...

  13. 26 CFR 1.662(c)-2 - Death of individual beneficiary.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 26 Internal Revenue 8 2014-04-01 2014-04-01 false Death of individual beneficiary. 1.662(c)-2... Distribute Corpus § 1.662(c)-2 Death of individual beneficiary. If an amount specified in section 662(a) (1... death), the extent to which the amount is included in the gross income of the beneficiary for his...

  14. 26 CFR 1.662(c)-2 - Death of individual beneficiary.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 26 Internal Revenue 8 2013-04-01 2013-04-01 false Death of individual beneficiary. 1.662(c)-2... Distribute Corpus § 1.662(c)-2 Death of individual beneficiary. If an amount specified in section 662(a) (1... death), the extent to which the amount is included in the gross income of the beneficiary for his...

  15. 26 CFR 1.662(c)-2 - Death of individual beneficiary.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 26 Internal Revenue 8 2012-04-01 2012-04-01 false Death of individual beneficiary. 1.662(c)-2... Distribute Corpus § 1.662(c)-2 Death of individual beneficiary. If an amount specified in section 662(a) (1... death), the extent to which the amount is included in the gross income of the beneficiary for his...

  16. 26 CFR 1.662(c)-2 - Death of individual beneficiary.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 26 Internal Revenue 8 2011-04-01 2011-04-01 false Death of individual beneficiary. 1.662(c)-2... Distribute Corpus § 1.662(c)-2 Death of individual beneficiary. If an amount specified in section 662(a) (1... death), the extent to which the amount is included in the gross income of the beneficiary for his...

  17. 42 CFR 424.62 - Payment after beneficiary's death: Bill has been paid.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 3 2012-10-01 2012-10-01 false Payment after beneficiary's death: Bill has been... Whom Payment is Made in Special Situations § 424.62 Payment after beneficiary's death: Bill has been... services with their own funds, before or after the beneficiary's death. (2) The legal representative of...

  18. 42 CFR 424.62 - Payment after beneficiary's death: Bill has been paid.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 3 2014-10-01 2014-10-01 false Payment after beneficiary's death: Bill has been... Whom Payment is Made in Special Situations § 424.62 Payment after beneficiary's death: Bill has been... services with their own funds, before or after the beneficiary's death. (2) The legal representative of...

  19. 42 CFR 424.62 - Payment after beneficiary's death: Bill has been paid.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Payment after beneficiary's death: Bill has been... Made in Special Situations § 424.62 Payment after beneficiary's death: Bill has been paid. (a) Scope... their own funds, before or after the beneficiary's death. (2) The legal representative of...

  20. 42 CFR 424.62 - Payment after beneficiary's death: Bill has been paid.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Payment after beneficiary's death: Bill has been... Made in Special Situations § 424.62 Payment after beneficiary's death: Bill has been paid. (a) Scope... their own funds, before or after the beneficiary's death. (2) The legal representative of...

  1. 42 CFR 424.62 - Payment after beneficiary's death: Bill has been paid.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Payment after beneficiary's death: Bill has been... Whom Payment is Made in Special Situations § 424.62 Payment after beneficiary's death: Bill has been... services with their own funds, before or after the beneficiary's death. (2) The legal representative of...

  2. 19 CFR 10.198b - Products of Puerto Rico processed in a beneficiary country.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... of Puerto Rico and that is by any means advanced in value or improved in condition in a beneficiary country, provided that: (a) If any materials are added to the article in the beneficiary country, those materials consist only of materials that are a product of a beneficiary country or the United States; and...

  3. 26 CFR 1.501(c)(8)-1 - Fraternal beneficiary societies.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 26 Internal Revenue 7 2010-04-01 2010-04-01 true Fraternal beneficiary societies. 1.501(c)(8)-1... beneficiary societies. (a) A fraternal beneficiary society is exempt from tax only if operated under the lodge... exempt it is also necessary that the society have an established system for the payment to its members...

  4. 26 CFR 1.501(c)(8)-1 - Fraternal beneficiary societies.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 26 Internal Revenue 7 2011-04-01 2009-04-01 true Fraternal beneficiary societies. 1.501(c)(8)-1... beneficiary societies. (a) A fraternal beneficiary society is exempt from tax only if operated under the lodge... exempt it is also necessary that the society have an established system for the payment to its members...

  5. 26 CFR 1.501(c)(8)-1 - Fraternal beneficiary societies.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 26 Internal Revenue 7 2012-04-01 2012-04-01 false Fraternal beneficiary societies. 1.501(c)(8)-1... beneficiary societies. (a) A fraternal beneficiary society is exempt from tax only if operated under the lodge... exempt it is also necessary that the society have an established system for the payment to its members...

  6. 26 CFR 1.501(c)(8)-1 - Fraternal beneficiary societies.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 26 Internal Revenue 7 2013-04-01 2013-04-01 false Fraternal beneficiary societies. 1.501(c)(8)-1... beneficiary societies. (a) A fraternal beneficiary society is exempt from tax only if operated under the lodge... exempt it is also necessary that the society have an established system for the payment to its members...

  7. 26 CFR 1.501(c)(8)-1 - Fraternal beneficiary societies.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 26 Internal Revenue 7 2014-04-01 2013-04-01 true Fraternal beneficiary societies. 1.501(c)(8)-1... beneficiary societies. (a) A fraternal beneficiary society is exempt from tax only if operated under the lodge... exempt it is also necessary that the society have an established system for the payment to its members...

  8. 42 CFR 422.314 - Special rules for beneficiaries enrolled in MA MSA plans.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules for beneficiaries enrolled in MA MSA... Advantage Organizations § 422.314 Special rules for beneficiaries enrolled in MA MSA plans. (a) Establishment and designation of medical savings account (MSA). A beneficiary who elects coverage under an...

  9. High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

    PubMed Central

    Rahman, Momotazur; Keohane, Laura; Trivedi, Amal N.; Mor, Vincent

    2015-01-01

    Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending. PMID:26438743

  10. High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare.

    PubMed

    Rahman, Momotazur; Keohane, Laura; Trivedi, Amal N; Mor, Vincent

    2015-10-01

    Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.

  11. Your Medicare Coverage: Durable Medical Equipment (DME) Coverage

    MedlinePlus

    ... Search Medicare.gov for covered items Durable medical equipment (DME) coverage How often is it covered? Medicare ... B (Medical Insurance) covers medically necessary durable medical equipment (DME) that your doctor prescribes for use in ...

  12. 76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-10-03

    ... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Comprehensive Primary Care... announces a solicitation for health care payer organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to improve primary care. DATES: Letter of...

  13. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. Final rule.

    PubMed

    2016-11-15

    This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies, such as changes to the Value Modifier, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also includes changes related to the Medicare Shared Savings Program, requirements for Medicare Advantage Provider Networks, and provides for the release of certain pricing data from Medicare Advantage bids and of data from medical loss ratio reports submitted by Medicare health and drug plans. In addition, this final rule expands the Medicare Diabetes Prevention Program model.

  14. Costs Associated With Residency Training.

    PubMed

    Bready, Lois L; Luber, M Philip

    2016-02-01

    Texas needs more physicians to care for a rapidly growing population, and new physicians who complete medical training in Texas are likely to remain in the state to practice. The expansion of existing Texas medical schools, along with the development of new schools, has created a need for a corresponding increase in residency and fellowship (graduate medical education, or GME) positions in Texas, and the 2013 and 2015 legislative sessions have funded expanded GME support. While the Centers for Medicare & Medicaid Services pays for the majority of GME positions nationally, those numbers were capped in 1997. Growing populations, particularly in the southern states, have led many institutions--when funds are available--to increase GME positions "over the cap." Texas physicians need to be aware of costs associated with development of accredited GME positions, as well as other measures being taken to support the growth of the physician workforce in the state.

  15. The Benefits Trap: Barriers to Employment Experienced by SSA Beneficiaries

    ERIC Educational Resources Information Center

    Olney, Marjorie F.; Lyle, Cindy

    2011-01-01

    In the first of two rounds of interviews, 12 Social Security Administration (SSA) beneficiaries, all of whom professed a desire to work, discussed their perspectives on barriers to employment. Two years later, 8 of the 12 engaged in a second round of interviews. Only 1 of the 8 participants had succeeded in becoming self-supporting. After a review…

  16. 32 CFR 220.9 - Rights and obligations of beneficiaries.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES... beneficiary will be required. (b) Availability of healthcare services unaffected. The availability of healthcare services in any facility of the Uniformed Services will not be affected by the participation...

  17. 32 CFR 220.9 - Rights and obligations of beneficiaries.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES... beneficiary will be required. (b) Availability of healthcare services unaffected. The availability of healthcare services in any facility of the Uniformed Services will not be affected by the participation...

  18. 32 CFR 220.9 - Rights and obligations of beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES... beneficiary will be required. (b) Availability of healthcare services unaffected. The availability of healthcare services in any facility of the Uniformed Services will not be affected by the participation...

  19. 32 CFR 220.9 - Rights and obligations of beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES... beneficiary will be required. (b) Availability of healthcare services unaffected. The availability of healthcare services in any facility of the Uniformed Services will not be affected by the participation...

  20. 32 CFR 220.9 - Rights and obligations of beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES... beneficiary will be required. (b) Availability of healthcare services unaffected. The availability of healthcare services in any facility of the Uniformed Services will not be affected by the participation...

  1. 26 CFR 54.4980B-3 - Qualified beneficiaries.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... Americans with Disabilities Act, 42 U.S.C. 12101-12213, the special enrollment rules of section 9801, or the... employee) are not qualified beneficiaries by virtue of the marriage, birth, or placement for adoption or by... law (such as the Americans with Disabilities Act, 42 U.S.C. 12101 through 12213, the...

  2. 26 CFR 54.4980B-3 - Qualified beneficiaries.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... Americans with Disabilities Act, 42 U.S.C. 12101-12213, the special enrollment rules of section 9801, or the... employee) are not qualified beneficiaries by virtue of the marriage, birth, or placement for adoption or by... law (such as the Americans with Disabilities Act, 42 U.S.C. 12101 through 12213, the...

  3. 32 CFR 728.52 - Veterans Administration beneficiaries (VAB).

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... eligible VABs medical and surgical care, including prostheses such as eyes and limbs and appliances such as... MEDICAL AND DENTAL CARE FOR ELIGIBLE PERSONS AT NAVY MEDICAL DEPARTMENT FACILITIES Beneficiaries of Other... have been determined by the Veterans Administration (VA) to be eligible for care at VA expense....

  4. 29 CFR 4.133 - Beneficiary of contract services.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 1 2010-07-01 2010-07-01 true Beneficiary of contract services. 4.133 Section 4.133 Labor Office of the Secretary of Labor LABOR STANDARDS FOR FEDERAL SERVICE CONTRACTS Application of the McNamara-O'Hara Service Contract Act Particular Application of Contract Coverage Principles §...

  5. Eligibility for the Medicare buy-in programs, based on a survey of income and program participation simulation.

    PubMed

    Rupp, K; Sears, J

    2000-01-01

    Medicare buy-in programs are designed to reduce out-of-pocket expenses of beneficiaries with modest income and assets. This article provides estimates of the size of the Medicare beneficiary population eligible for the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the Qualified Individual-1 (QI-1) program. The buy-in programs use the same resource limits (twice those used in the Supplemental Security Income (SSI) program) but different thresholds for determining income eligibility. The QMB program uses 100 percent of the poverty line as the cutoff, QI-1 covers persons above 120 percent but at or below 135 percent of the poverty line, and the SLMB program is in between. Making informed judgments about the rate of participation in the buy-in programs and the need for outreach requires an accurate estimate of the size of the eligible population. If that population is underestimated, policymakers might come to unduly optimistic conclusions about current buy-in participation. In contrast, an overestimate may make current participation seem too low. If policymakers react to an upwardly biased estimate of the eligible population by increasing outreach, they are bound to be disappointed by the results of that effort. Estimates of the eligible population from past studies of the QMB and SLMB programs range from 5.1 million to 9.1 million. In the absence of new information, it is difficult to judge the accuracy of those estimates because the methodologies had substantial shortcomings that might bias the results. The most common shortcomings include the lack of high-quality, monthly income data and the lack of information on assets from the same data file that was used to estimate participation and income eligibility for Medicare. The current study uses the most recently available (as of August 2000) Survey of Income and Program Participation (SIPP) file that is matched to the Social Security Administration

  6. Medicare case-mix index increase

    PubMed Central

    Ginsburg, Paul B.; Carter, Grace M.

    1986-01-01

    Medicare paid hospitals a higher amount per admission in 1984 than had been planned because the case-mix index (CMI), which reflects the proportion of patients in high-weighted DRG's versus low-weighted ones, increased more than had been projected. This study estimated the degree to which the increase in the CMI from 1981 reflected medical practice changes, the aging of the Medicare inpatient population, changes in coding practices of physicians and hospitals, and changes in the way that the Health Care Financing Administration collects the data on case-mix. All of the above, except for aging, contributed to the increase in the CMI. PMID:10311672

  7. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Medicare supplemental policy. 403.205 Section 403.205 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  8. Use of Medicare's Diabetes Self-Management Training Benefit

    ERIC Educational Resources Information Center

    Strawbridge, Larisa M.; Lloyd, Jennifer T.; Meadow, Ann; Riley, Gerald F.; Howell, Benjamin L.

    2015-01-01

    Medicare began reimbursing for outpatient diabetes self-management training (DSMT) in 2000; however, little is known about program utilization. Individuals diagnosed with diabetes in 2010 were identified from a 20% random selection of the Medicare fee-for-service population (N = 110,064). Medicare administrative and claims files were used to…

  9. 42 CFR 423.462 - Medicare secondary payer procedures.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICARE PROGRAM VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT Coordination of Part D Plans With Other Prescription Drug Coverage § 423.462 Medicare secondary payer procedures. (a) General... to Part D sponsors and Part D plans (with respect to the offering of qualified prescription...

  10. 42 CFR 412.110 - Total Medicare payment.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Total Medicare payment. 412.110 Section 412.110 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under...

  11. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2012-10-01 2012-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  12. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2014-10-01 2014-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  13. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2013-10-01 2013-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  14. 42 CFR 403.205 - Medicare supplemental policy.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Medicare. (b) The term policy includes both policy form and policy as specified in paragraphs (b)(1) and (b... 42 Public Health 2 2011-10-01 2011-10-01 false Medicare supplemental policy. 403.205 Section 403... GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Medicare Supplemental Policies General Provisions §...

  15. Medicare Spending and Evidence-based Approach in Surgical Treatment of Thumb Carpometacarpal Joint Arthritis: 2001–2010

    PubMed Central

    Mahmoudi, Elham; Yuan, Frank; Aliu, Oluseyi; Chung, Kevin C

    2016-01-01

    Background Despite equivalent outcomes among surgical treatments of thumb carpometacarpal (CMC) arthritis, little is known about variation in spending. Owing to its complexities, we hypothesized that trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when compared to other surgical procedures incurs the greatest cost to Medicare. Methods Using a random 5% sample of Medicare beneficiaries diagnosed with thumb CMC arthritis, we examined total and out-of-pocket spending for 3,530 patients who underwent a surgical treatment, between 2001 and 2010. We used generalized linear regression models, controlling for patients’ characteristics and place of surgery to examine variation in spending. Results 89% of patients who underwent surgery received trapeziectomy with LRTI, with total and out-of-pocket spending of $2,576 (CI: $2,333 – $2,843, p < 0.001) and $436 (CI: $429 – $531, p < 0.001), respectively. Simple complete trapeziectomy was the least expensive procedure, performed only among 5% of patients, with total and out-of-pocket spending of $1,268 (CI: $1,089 – $1,476, p < 0.001) and $236 (CI: $180 – $258, p < 0.001), respectively. Owing to increasingly higher facility costs, performing the same procedure in a hospital outpatient setting compared with an ambulatory center would increase Medicare spending by more than two folds (p < 0.001). Conclusions With a consistent rise of healthcare spending, adherence to evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with LRTI, the most expensive surgical option. Medicare could potentially save $74 million annually if simple complete trapeziectomy was the procedure of choice. PMID:27219267

  16. 78 FR 75304 - Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-12-11

    ... Washington, DC--Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G... of the building. A stamp- in clock is available for persons wishing to retain a proof of filing...

  17. 77 FR 38067 - Medicare Program; Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-26

    ... what Medicare pays for mail order supplies versus non-mail order supplies may encourage fraud and abuse... or other animals except Seeing Eye dogs and other dogs trained to assist the handicapped,...

  18. Medicare program; Medicare depreciation, useful life guidelines--HCFA. Final rule.

    PubMed

    1983-08-18

    These final rules amend Medicare regulations to clarify which useful life guidelines may be used by providers of health care services to determine the useful life of a depreciable asset for Medicare reimbursement purposes. Current regulations state that providers must utilize the Departmental useful life guidelines or, if none have been published by the Department, either the American Hospital Association (AHA) useful life guidelines of 1973 of IRS guidelines. We are eliminating the reference to IRS guidelines because these are now outdated for Medicare purposes since they have been rendered obsolete either by the IRS or by statutory change. We are also deleting the specific reference to the 1973 AHA guidelines since these guidelines are updated by the AHA periodically. In addition, we are clarifying that certain tax legislation on accelerated depreciation, passed by Congress, does not apply to the Medicare program.

  19. 77 FR 27778 - Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel-May 21, 2012

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-11

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program; Meeting of the Medicare Economic Index Technical Advisory Panel--May 21, 2012 Correction In notice document 2012-10702 appearing...

  20. 19 CFR 10.196 - Cost or value of materials produced in a beneficiary country or countries.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... raw, perishable skin of an animal grown in one beneficiary country is sent to another beneficiary..., perishable skin of an animal grown in a non-beneficiary country is sent to a beneficiary country where it is tanned to create nonperishable “crust leather”. The tanned skin is then imported directly into the...

  1. Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations

    PubMed Central

    Narvy, Steven J.; Didinger, Tracey C.; Lehoang, David; Vangsness, C. Thomas; Tibone, James E.; Hatch, George F. Rick; Omid, Reza; Osorno, Felipe; Gamradt, Seth C.

    2016-01-01

    Background: Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments. Hypothesis: The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients. Study Design: Cohort study; Level of evidence, 3. Methods: Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared. Results: There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients. Conclusion: Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery. PMID:27826595

  2. The private sector invades medicare's home town

    PubMed Central

    Gray, C

    1998-01-01

    If Canada's medicare system has a home town it is probably Ottawa, where the system was first welded together 30 years ago. Charlotte Gray reports that there is a certain irony now that examples of private health care are sprouting up in the nations's capital. PMID:9700332

  3. Paving the way for Medicare reform.

    PubMed

    Wofford, Dave

    2016-01-01

    Major changes set forth in the Medicare Access and CHIP Reauthorization Act are coming in 2019, but the time to prepare is now. The legislation includes three major changes: Pay-for-performance metrics. A two-track payment system. Consistent rate increases.

  4. Can health promotion programs save Medicare money?

    PubMed Central

    Goetzel, Ron Z; Shechter, David; Ozminkowski, Ronald J; Stapleton, David C; Lapin, Pauline J; McGinnis, J Michael; Gordon, Catherine R; Breslow, Lester

    2007-01-01

    The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program. PMID:18044084

  5. Medicare reimbursement for clinical trial services: understanding Medicare coverage in establishing a clinical trial budget.

    PubMed

    Barnes, Mark; Korn, Jerald

    2005-01-01

    In designing and setting up a clinical trial, investigators and private sponsors must take into account what costs will or will not be covered by third-party insurers and government payment programs like Medicare and Medicaid. Failure to "cost out" the clinical trials accurately can yield one of two results: either third-party payors are billed improperly, or even illegally, for experimental care, or significant research-related care is not billed, with either the investigating institution, or the research subjects themselves, shouldering the cost. Unfortunately, because Medicare has established different coverage principles to be applied depending on the type of trial being conducted, costing out the trial is not an easy task. This Article looks at the various Medicare coverage principles as they apply to clinical trials, including the 2000 National Coverage Decision and the recent expansion in coverage for Class A Investigational Devices created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The Article then examines how the Medicare secondary payor rule, which states that providers may not bill Medicare for items or services when another party has primary responsibility for those services, relates to clinical trails in light of recent commentary. The Article concludes with the presentation of a general framework that investigators can use to establish a clinical trial budgeting and billing system.

  6. Recommendations of the Medicare Payment Advisory Commission (MEDPAC) on the Health Care Delivery System: the impact on interventional pain management in 2014 and beyond.

    PubMed

    Manchikanti, Laxmaiah; Benyamin, Ramsin M; Falco, Frank J E; Hirsch, Joshua A

    2013-01-01

    echocardiogram, HOPD costs 141% more for the same service than a free-standing office ($188.31 versus $452.89). For interventional techniques, Medicare payments vary from physician office to HOPD setting, with $211.96 in an office setting, $407.28 in ASC setting, and $655.62 in HOPD for procedures such as epidural injections. The MedPAC proposal for changing HOPD payment rates for services would reduce program spending and result in beneficiary cost sharing by $900 million in one year. On average, hospitals' overall Medicare revenue will decline by 0.6% and HOPD revenue would fall by 2.7%. Further, MedPAC provided a specific example that aligning payment rates between HOPDs and free-standing offices only for cardiac imaging services would reduce program spending and beneficiary cost sharing by $500 million in one year. In estimating the savings that would be realized by equalizing payment rates between HOPDs and ASCs for certain ambulatory surgical procedures, MedPAC have shown potential Medicare program spending and beneficiary cost savings to be about $590 million per year. The impact of the proposed policies that are discussed in this manuscript would result in savings of approximately $1.5 billion per year for Medicare. MedPAC also has recommended a stop-loss policy that would limit the loss of Medicare revenue for those hospitals.

  7. 20 CFR 10.718 - Are payments to a beneficiary as a result of an insurance policy which the beneficiary has...

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... an insurance policy which the beneficiary has purchased a gross recovery that must be reported to OWCP or SOL? 10.718 Section 10.718 Employees' Benefits OFFICE OF WORKERS' COMPENSATION PROGRAMS... a result of an insurance policy which the beneficiary has purchased a gross recovery that must...

  8. The Ticket to Work Program and Beneficiaries with Blindness or Low Vision: Characteristics of Beneficiaries Who Assign Their Tickets and Preliminary Outcomes

    ERIC Educational Resources Information Center

    Capella-McDonnall, Michele

    2008-01-01

    Using Social Security Administration data, the author evaluated the characteristics of beneficiaries who were blind and visually impaired and who assigned their tickets, the characteristics of beneficiaries who assigned their tickets to employment networks (ENs), and preliminary employment outcomes. The characteristics that predicted assignment of…

  9. 42 CFR 412.42 - Limitations on charges to beneficiaries.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... benefits under subpart A of part 406 of this chapter (see paragraph (e) of this section for when charges may be made for items and services furnished when the patient is not entitled to benefits). (v) The exclusion of items and services furnished after Medicare Part A benefits are exhausted under § 409.61...

  10. 77 FR 35917 - Medicare Program; Medicare Secondary Payer and “Future Medicals”

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-15

    ... trauma,'' and ``major trauma,'' specifically, whether they are accurate and usable in terms of the... definition of ``major trauma.'' The Injury Severity Score (ISS) is one of several methods used to measure the.../beneficiary's settlement, judgment, award, or other payment. Physical Trauma: refers to an injury (as a...

  11. 76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-05-16

    ... Patient Protection and Affordable Care Act (Pub. L. 111-148, enacted on March 23, 2010, and Pub. L. 111... facility services when a dual eligible beneficiary requires skilled nursing care following a qualifying..., Medicaid may cover additional nursing facility services, including custodial nursing facility...

  12. Historical Perspective on Adding Drugs to Medicare

    PubMed Central

    Santangelo, Mark

    2005-01-01

    This article describes the lengthy background and debate leading up to the passage of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). Full implementation of the prescription drug aspect of the law will not be completed for some time, and final assessment of its impact awaits a history yet to be written. Instead, this article summarizes the efforts of supporters until they finally managed to succeed after being stymied so many times in the preceding four decades. PMID:17290634

  13. The Economics of Medicare Accountable Care Organizations

    PubMed Central

    Blackstone, Erwin A.; Fuhr, Joseph P.

    2016-01-01

    Background Accountable care organizations (ACOs) have been created to improve patient care, enhance population health, and reduce costs. Medicare in particular has focused on ACOs as a primary device to improve quality and reduce costs. Objective To examine whether the current Medicare ACOs are likely to be successful. Discussion Patients receiving care in ACOs have little incentive to use low-cost quality providers. Furthermore, the start-up costs of ACOs for providers are high, contributing to the minimal financial success of ACOs. We review issues such as reducing readmissions, palliative care, and the difficulty in coordinating care, which are major cost drivers. There are mixed incentives facing hospital-controlled ACOs, whereas physician-controlled ACOs could play hospitals against each other to obtain high quality and cost reductions. This discussion also considers whether the current structure of ACOs is likely to be successful. Conclusion The question remains whether Medicare ACOs can achieve the Triple Aim of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” Care coordination in ACOs and information technology are proving more complicated and expensive to implement than anticipated. Even if ACOs can decrease healthcare costs and increase quality, it is unclear if the current incentives system can achieve these objectives. A better public policy may be to implement a system that encompasses the best practices of successful private integrated systems rather than promoting ACOs. PMID:27066191

  14. An updated estimate of costs of endophthalmitis following cataract surgery among Medicare patients: 2010–2014

    PubMed Central

    Schmier, Jordana K; Hulme-Lowe, Carolyn K; Covert, David W; Lau, Edmund C

    2016-01-01

    Background Endophthalmitis, which can occur after ophthalmic surgery, is an inflammation of the intraocular cavity and causes temporary or permanent vision impairment. However, little is known about the cost of treatment. The objective of this analysis was to update and expand upon the results of a previously published report that estimated the direct medical cost of treatment for endophthalmitis. Methods Retrospective data analysis using 2010 through 2014 United States Medicare Limited Data Sets. Procedure codes were used to identify beneficiaries who underwent cataract surgery; demographic and clinical characteristics at the time of diagnosis were determined. Patients were stratified into cases (those who developed endophthalmitis) and controls (those who did not develop endophthalmitis) in the 3 months following surgery. Claims (ie, charges) and reimbursements (ie, costs) for cases and controls in the 6 months following cataract surgery were identified and compared. Results are presented in 2015 US dollars. Results Of a total of 153,860 cataract surgery patients, 181 were diagnosed with endophthalmitis following cataract surgery, at a rate of 1.2 per 1,000. Cases were more likely to be male and less likely to be white than controls; age was similar. Total medical claims and reimbursements as well as ophthalmic claims and reimbursements were significantly higher for cases compared with controls. Total reimbursements, adjusted for age, sex, and region, were $4,893 higher (83% greater) and adjusted ophthalmic reimbursements were $3,002 higher (156% greater) for cases than for controls. Claims and reimbursements were significantly higher across all types of Medicare cost components. Conclusion Postcataract surgery endophthalmitis is associated with a substantial cost. Successful prophylaxis with antibiotic agents would reduce the significant costs associated with treating endophthalmitis. PMID:27822008

  15. Service mix in the hospital outpatient department: implications for Medicare payment reform.

    PubMed Central

    Miller, M E; Sulvetta, M B; Englert, E

    1995-01-01

    OBJECTIVE. To determine if implementation of a PPS for Medicare hospital outpatient department (HOPD) services will have distributional consequences across hospital types and regions, this analysis assesses variation in service mix and the provision of high-technology services in the HOPD. DATA. HCFA's 1990 claims file for a 5 percent random sample of Medicare beneficiaries using the HOPD was merged, by hospital provider number, with various HCFA hospital characteristic files. STUDY DESIGN. Hospital characteristics examined are urban/rural location, teaching status, disproportionate-share status, and bed size. Two analyses of HOPD services are presented: mix of services provided and the provision of high-technology services. The mix of services is measured by the percentage of services in each of 14 type-of-service categories (e.g., medical visits, advanced imaging services, diagnostic testing services). Technology provision is measured by the percentage of hospitals providing selected high-technology services. FINDINGS/CONCLUSIONS. The findings suggest that the role hospital types play in providing HOPD services warrants consideration in establishing a PPS. HOPDs in major teaching hospitals and hospitals serving a disproportionate share of the poor play an important role in providing routine visits. HOPDs in both major and minor teaching hospitals are important providers of high-technology services. Other findings have implications for the structure of an HOPD PPS as well. First, over half of the services provided in the HOPD are laboratory tests and HOPDs may have limited control over these services since they are often for patients referred from local physician offices. Second, service mix and technology provision vary markedly among regions, suggesting the need for a transition to prospective payment. Third, the organization of service supply in a region may affect service provision in the HOPD suggesting that an HOPD PPS needs to be coordinated with payment

  16. Variation in the Cost of Radiation Therapy Among Medicare Patients With Cancer

    PubMed Central

    Paravati, Anthony J.; Boero, Isabel J.; Triplett, Daniel P.; Hwang, Lindsay; Matsuno, Rayna K.; Xu, Beibei; Mell, Loren K.; Murphy, James D.

    2015-01-01

    Purpose: Radiation therapy represents a major source of health care expenditure for patients with cancer. Understanding the sources of variability in the cost of radiation therapy is critical to evaluating the efficiency of the current reimbursement system and could shape future policy reform. This study defines the magnitude and sources of variation in the cost of radiation therapy for a large cohort of Medicare beneficiaries. Patients and Methods: We identified 55,288 patients within the SEER database diagnosed with breast, lung, or prostate cancer between 2004 and 2009. The cost of radiation therapy was estimated from Medicare reimbursements. Multivariable linear regression models were used to assess the influence of patient, tumor, and radiation therapy provider characteristics on variation in cost of radiation therapy. Results: For breast, lung, and prostate cancers, the median cost (interquartile range) of a course of radiation therapy was $8,600 ($7,300 to $10,300), $9,000 ($7,500 to $11,100), and $18,000 ($11,300 to $25,500), respectively. For all three cancer subtypes, patient- or tumor-related factors accounted for < 3% of the variation in cost. Factors unrelated to the patient, including practice type, geography, and individual radiation therapy provider, accounted for a substantial proportion of the variation in cost, ranging from 44% with breast, 43% with lung, and 61% with prostate cancer. Conclusion: In this study, factors unrelated to the individual patient accounted for the majority of variation in the cost of radiation therapy, suggesting potential inefficiency in health care expenditure. Future research should determine whether this variability translates into improved patient outcomes for further evaluation of current reimbursement practices. PMID:26265172

  17. Heat-related Emergency Hospitalizations for Respiratory Diseases in the Medicare Population

    PubMed Central

    Anderson, G. Brooke; Dominici, Francesca; Wang, Yun; McCormack, Meredith C.; Bell, Michelle L.

    2013-01-01

    Rationale: The heat-related risk of hospitalization for respiratory diseases among the elderly has not been quantified in the United States on a national scale. With climate change predictions of more frequent and more intense heat waves, it is of paramount importance to quantify the health risks related to heat, especially for the most vulnerable. Objectives: To estimate the risk of hospitalization for respiratory diseases associated with outdoor heat in the U.S. elderly. Methods: An observational study of approximately 12.5 million Medicare beneficiaries in 213 United States counties, January 1, 1999 to December 31, 2008. We estimate a national average relative risk of hospitalization for each 10°F (5.6°C) increase in daily outdoor temperature using Bayesian hierarchical models. Measurements and Main Results: We obtained daily county-level rates of Medicare emergency respiratory hospitalizations (International Classification of Diseases, Ninth Revision, 464–466, 480–487, 490–492) in 213 U.S. counties from 1999 through 2008. Overall, each 10°F increase in daily temperature was associated with a 4.3% increase in same-day emergency hospitalizations for respiratory diseases (95% posterior interval, 3.8, 4.8%). Counties’ relative risks were significantly higher in counties with cooler average summer temperatures. Conclusions: We found strong evidence of an association between outdoor heat and respiratory hospitalizations in the largest population of elderly studied to date. Given projections of increasing temperatures from climate change and the increasing global prevalence of chronic pulmonary disease, the relationship between heat and respiratory morbidity is a growing concern. PMID:23491405

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

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 26 Internal Revenue 8 2012-04-01 2012-04-01 false Trusts treated as having a U.S. beneficiary. 1...-2 Trusts treated as having a U.S. beneficiary. (a) Existence of U.S. beneficiary—(1) In general. The... treated as having a U.S. beneficiary unless during the taxable year of the U.S. transferor— (i) No part...

  19. Medicare Payment Systems: A Look Back and a Look Forward

    PubMed Central

    Schaum, Kathleen Dianne

    2013-01-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems. PMID:24761334

  20. Medicare Payment Systems: A Look Back and a Look Forward.

    PubMed

    Schaum, Kathleen Dianne

    2013-12-01

    Medicare is the major payer for patients with chronic wounds. Over the past 50 years, the Medicare payment systems have undergone numerous changes. At the beginning of the Medicare program, providers were paid based on fee-for-service. In 1997, many of the Medicare payment systems were converted to prospective payment systems (PPSs). Currently, Medicare is conducting many demonstration payment programs to provide the best quality outcomes, at the lowest total cost of care (not necessarily the lowest cost product or procedure), and with patient satisfaction. While the demonstration payment programs are being tested, providers may receive parallel Medicare payments: payment through current PPS and through the demonstration payment program. Wound care providers and manufacturers need to prepare now for the future payment systems.