CONTEXT: The Medicare program is encouraging its beneficiaries to enroll in capitated health plans. OBJECTIVE: To determine how prepared these plans are to handle chronically ill and frail elderly persons. DESIGN: Telephone survey of 28 health plans that together serve about one fourth of all enrollees of the Medicare Risk program. MEASURES: The degree of readiness (high, intermediate, or low) of health plans in seven domains that experts believe are important to the management of an elderly population. RESULTS: None of the 28 health plans had high readiness scores for all seven domains. The two domains for which the plans were most prepared were risk assessment and member self-care. The plans were least prepared for the domains of cooperative team care and geriatric consultations. CONCLUSIONS: Many plans do not offer the programs that experts believe are important for Medicare enrollees. They may hesitate to adopt strategies that lack data on effectiveness. (+info)
Capitation among Medicare beneficiaries.
CONTEXT: The Medicare program has promoted capitation as a way to contain costs. About 15% of Medicare beneficiaries nationwide are currently under capitation, but tremendous regional variation exists. PRACTICE PATTERN EXAMINED: The proportion of Medicare beneficiaries who have enrolled in risk-contract plans in individual states and in the 25 largest metropolitan areas in the United States. DATA SOURCE: Health Care Financing Administration data files. RESULTS: Medicare beneficiaries are most likely to be under capitation in Arizona (38%) and California (37%). Eight other states have capitation rates greater than 20%: Colorado, Florida, Rhode Island, Oregon, Washington, Pennsylvania, Massachusetts, and Nevada. Thirty states, largely in the Great Plains area and the southern United States, have capitation rates less than 10%. Four major metropolitan areas have market penetration rates greater than 40%: San Bernardino, California; San Diego, California; Phoenix, Arizona; and Miami, Florida. Little penetration exists outside of metropolitan areas. CONCLUSION: Capitation in Medicare is a regional and predominantly an urban phenomenon. (+info)
Variation in the use of echocardiography.
CONTEXT: Geographic variation in population-based rates of invasive cardiac procedures has been described. However, little is known about variation in rates of noninvasive testing for cardiovascular disease. Echocardiography is the second most common cardiac diagnostic procedure. PRACTICE PATTERN EXAMINED: Population-based rates of echocardiography, adjusted for age, sex, and race, in the United States. DATA SOURCE: 5% sample of Medicare Part B. RESULTS: 1 in 10 Medicare beneficiaries underwent echocardiography in 1995. Rates of echocardiography varied by state from 5% in Oregon to 15% in Michigan. Rates tended to be lowest in the Northern Great Plains, the Pacific Northwest, and the Rocky Mountains states. Among the 25 largest metropolitan areas, substantial variation was also apparent. For example, one fourth of Medicare beneficiaries in Miami, Florida, received echocardiography, and this proportion was more than four times greater than that seen in Seattle, Washington. CONCLUSION: The likelihood of Medicare beneficiaries having echocardiography is influenced by where they live. (+info)
Disenrollment from Medicare HMOs.
BACKGROUND: Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. OBJECTIVES: To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. DESIGN: Cross-sectional analysis of 1994 Medicare data. PARTICIPANTS AND METHODS: Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. RESULTS: The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. CONCLUSIONS: On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased. (+info)
Differences in the structure of CAHPS measures among the medicare fee-for-service, medicare managed care, and privately insured populations.
OBJECTIVE: To confirm in a new population, the Medicare fee-for-service population, the factor structure previously found in two Consumer Assessment of Health Plans Study (CAHPS) field-test surveys with Medicare HMO and adult privately insured populations. DATA SOURCES: Primary data were collected in the fall of 1998. Survey responses from the Medicare Fee-for-Service CAHPS survey field test were compared to results from the Medicare HMO and adult privately insured field-test studies conducted in the fall of 1996. STUDY DESIGN: Respondents for the field-test survey were a random sample of Medicare beneficiaries in five states who had opted for the original Medicare plan (fee-for-service). DATA COLLECTION: Data were collected by a mailed survey with a telephone follow-up survey to those who did not return the mailed survey. PRINCIPAL FINDINGS: A confirmatory factor analysis in two different samples of Medicare fee-for-service beneficiaries provided basic support for a previously reported three-factor structure underlying the CAHPS reports and rating items: (1) quality of provider or staff communications; (2) timely access to quality health care; and (3) quality of plan administration. An exploratory factor analysis revealed a variant three-factor structure. CONCLUSION: Because of differences in the factor structures among the different populations discussed, caution needs to be exercised in any composite development, based on factor analysis or any other basis, by which cross-population comparisons will be made. Comparisons should only be made on composites representing stable structure across all populations concerned. (+info)
Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2001. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.
This final rule with comment period makes several changes affecting Medicare Part B payment. The changes include: refinement of resource-based practice expense relative value units (RVUs); the geographic practice cost indices; resource-based malpractice RVUs; critical care RVUs; care plan oversight and physician certification and recertification for home health services; observation care codes; ocular photodynamic therapy and other ophthalmological treatments; electrical bioimpedance; antigen supply; and the implantation of ventricular assist devices. This rule also addresses the comments received on the May 3, 2000 interim final rule on the supplemental survey criteria and makes modifications to the criteria for data submitted in 2001. Based on public comments we are withdrawing our proposals related to the global period for insertion, removal, and replacement of pacemakers and cardioverter defibrillators and low intensity ultrasound. This final rule also discusses or clarifies the payment policy for incomplete medical direction, pulse oximetry services, outpatient therapy supervision, outpatient therapy caps, HCPCS "G" Codes, and the second 5-year refinement of work RVUs for services furnished beginning January 1, 2002. In addition, we are finalizing the calendar year (CY) 2000 interim physician work RVUs and are issuing interim RVUs for new and revised codes for CY 2001. We are making these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule also announces the CY 2001 Medicare physician fee schedule conversion factor under the Medicare Supplementary Medical Insurance (Part B) program as required by section 1848(d) of the Social Security Act. The 2001 Medicare physician fee schedule conversion factor is $38.2581. (+info)
Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.
This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments concerning the ownership and investment exceptions in paragraphs (c) and (d) and the compensation exceptions in paragraph (e) of section 1877 of the Act. Phase II of this rulemaking will also address comments concerning the reporting requirements and sanctions provided by paragraphs (f) and (g) of the Act, respectively, and include further consideration of the general exception to the referral prohibition related to both ownership/investment and compensation for services furnished in an ambulatory surgical center (ASC), end-stage renal dialysis facility, or by a hospice in section 411.355(d) of the regulations (this exception presently is in force and effect as to clinical laboratory services). In addition, Phase II of this rulemaking will address section 1903(s) of the Act, which extends aspects of the referral prohibition to the Medicaid Program. Phase II will also address comments received in response to this rulemaking, as appropriate, and certain proposals for new exceptions to section 1877 of the Act not included in the 1998 proposed rulemaking, but suggested in the public comments. (+info)
Cardiologists performing peripheral angioplasties: impact on utilization.
CONTEXT: Angioplasty and stent placement for peripheral arterial occlusive disease has traditionally been performed by radiologists and surgeons. However, cardiologists have recently begun to perform these procedures. It is unknown whether this has affected how often the procedure is done. OBJECTIVE: To assess how the proportion of peripheral angioplastics performed by cardiologists in a geographic area relates to population-based angioplasty rates. DESIGN: Cross-sectional analysis of all U.S. Medicare beneficiaries undergoing peripheral arterial (i.e., renal, iliac, or lower extremity) angioplasty in 1996 using Part B (physician) claims for cardiovascular procedures. Physician specialty was obtained from the American Medical Association's masterfile and Medicare. MEASURES: For each of the 306 U.S. hospital referral regions (HRRs), we calculated the proportion of procedures performed by cardiologists and rates of peripheral arterial angioplasty (adjusted for age, sex, and race). RESULTS: More than 37,000 peripheral arterial angioplastics were performed on Medicare beneficiaries in 1996 (50% for lower extremity, 33% iliac, and 17% renal arterial disease). Cardiologists performed 26% of these procedures overall, including 37% of the renal angioplastics. Few (12%) procedures were done as part of a cardiac catheterization; instead, most were done as a separate procedure. Use of peripheral angioplasty varied more than 14-fold across HRRs (median, 12 procedures per 10,000 beneficiaries; 10th to 90th percentile, 4.1 to 57.9). The mean angioplasty rate in HRRs where cardiologists performed 50% or more of the procedures was almost double that of regions where they performed none (21.9 vs. 12.1 procedures per 10,000 beneficiaries; P < 0.001). CONCLUSIONS: Cardiologists are performing a substantial proportion of peripheral angioplasties. Rates of these procedures are highest in regions where cardiologists do most of the angioplasties. (+info)