The relationship of Medicaid payment rates, bed constraint policies, and risk-adjusted pressure ulcers.
OBJECTIVE: To examine the effect of Medicaid reimbursement rates on nursing home quality in the presence of certificate-of-need (CON) and construction moratorium laws. DATA SOURCES/STUDY SETTING: A single cross-section of Medicaid certified nursing homes in 1999 (N = 13,736). STUDY DESIGN: A multivariate regression model was used to examine the effect of Medicaid payment rates and other explanatory variables on risk-adjusted pressure ulcer incidence. The model is alternatively considered for all U.S. nursing home markets, those most restrictive markets, and those high-Medicaid homes to isolate potentially resource-poor environments. DATA EXTRACTION METHODS: A merged data file was constructed with resident-level information from the Minimum Data Set, facility-level information from the On-Line, Survey, Certification, and Reporting (OSCAR) system and market- and state-level information from various published sources. PRINCIPAL FINDINGS: In the analysis of all U.S. markets, there was a positive relationship between the Medicaid payment rate and nursing home quality. The results from this analysis imply that a 10 percent increase in Medicaid payment was associated with a 1.5 percent decrease in the incidence of risk-adjusted pressure ulcers. However, there was a limited association between Medicaid payment rates and quality in the most restrictive markets. Finally, there was a strong relationship between Medicaid payment and quality in high-Medicaid homes providing strong evidence that the level of Medicaid payment is especially important within resource poor facilities. CONCLUSIONS: These findings provide support for the idea that increased Medicaid reimbursement may be an effective means toward improving nursing home quality, although CON and moratorium laws may mitigate this relationship. (+info)
Monopoly is not the answer.
Certificate-of-need (CON) regulation was originally intended to correct market failures that no longer afflict health care markets. It is ironic that Sujit Choudhry and colleagues now invoke it to deal with situations where, in their view, competition is working altogether too well. Protectionist regulation, long discredited in other areas, is particularly misguided in health care, where health insurance greatly increases the profitability of monopoly and imposes the resulting higher costs on unwilling premium payers. To use cross-subsidies to finance even worthy (let alone unworthy) health care projects is to put public burdens unfairly (regressively) on the backs of working Americans. (+info)
Medicare program; conditions for payment of power mobility devices, including power wheelchairs and power-operated vehicles. Interim final rule with comment period.
This interim final rule conforms our regulations to section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173). This rule defines the term power mobility devices (PMDs) as power wheelchairs and power operated vehicles (POVs or scooters). It sets forth revised conditions for Medicare payment of PMDs and defines who may prescribe PMDs. This rule also requires a face-to-face examination of the beneficiary by the physician or treating practitioner and a PMD prescription and pertinent parts of the medical record that the durable medical equipment supplier maintains in records and makes available to CMS or its agents upon request. Finally, this rule discusses CMS' policy on documentation that may be requested by CMS or its agents to support a Medicare claim for payment, as well as the elimination for the Certificate of Medical Necessity for PMDs. (+info)
Contemporary impact of state certificate-of-need regulations for cardiac surgery: an analysis using the Society of Thoracic Surgeons' National Cardiac Surgery Database.
BACKGROUND: Prior research using administrative data associated certificate-of-need (CON) regulation for open heart surgery with higher hospital coronary artery bypass grafting (CABG) volume and lower CABG operative mortality rates in elderly patients. It is unclear whether these findings apply in a general population and after controlling for detailed clinical characteristics and region. METHODS AND RESULTS: Using the Society of Thoracic Surgeons' (STS) National Cardiac Surgery Database, we examined isolated CABG surgery volume, operative mortality, and the composite end point of operative mortality or major morbidity for the years 2000 to 2003. The presence of CON regulations for open heart surgery was ascertained from the National Directory of the American Health Policy Association and by contacting CON administrators. Results were analyzed nationally, by state, and by region (West, Northeast, Midwest, South) and were adjusted for clinical factors and both population density and region with mixed-effects hierarchical logistic regression models. During 2000 to 2003, there were 314,710 isolated CABG surgeries performed at 294 STS hospitals in CON states (n=27, including Washington, DC) and 280 512 procedures at 343 STS hospitals in non-CON states (n=24). Patient clinical characteristics were similar among CON and non-CON hospitals. States with CON regulations tended to have higher population densities and had significantly higher median hospital annual CABG volumes in each of the years 2000 to 2003 (P<0.005). This difference remained significant after adjustment for region and population density. Operative mortality was 2.52% for CON versus 2.62% for non-CON states (P=0.32). There was a significant association between CON law and operative mortality in the South. After adjustment for patient risk factors and region, there was a marginally significant reduction of mortality risk in states with CON regulation (adjusted OR 0.92, 95% CI 0.86 to 1.00). However, this difference was not statistically significant when a revised model accounted for random state effects. Similar volume and outcomes results were seen when the analysis was repeated with data from the national Medicare database. CONCLUSIONS: CON states have significantly higher hospital CABG surgery volumes but similar mortality compared with non-CON states. CON regulation alone is not a sufficient mechanism to ensure quality of care for CABG surgery. (+info)
Certificate of need regulation and cardiac catheterization appropriateness after acute myocardial infarction.
BACKGROUND: Certificate of need (CON) regulation was introduced to control healthcare costs and improve quality of care in part by limiting the number of facilities providing complex medical care. Our objective was to examine whether rates of appropriate cardiac catheterization after admission for acute myocardial infarction varied between states with and without CON regulation of cardiac catheterization. METHODS AND RESULTS: We performed a retrospective analysis of chart-abstracted data for 137,279 Medicare patients admitted for acute myocardial infarction between 1994 and 1996 at 4179 US acute-care hospitals. Using 3-level hierarchical generalized linear modeling adjusted for patient sociodemographic and clinical characteristics and physician and hospital characteristics, we compared catheterization rates within 60 days of admission for states (and the District of Columbia) with (n=32) and without (n=19) CON regulation in the full cohort and stratified by catheterization appropriateness. Appropriateness was categorized as strongly, equivocally, or weakly indicated. We found CON regulation was associated with a borderline-significant lower rate of catheterization overall (45.8% versus 46.5%; adjusted risk ratio [RR] 0.91, 95% confidence interval 0.82 to 1.00, P=0.06). After stratification by appropriateness, CON regulation was not associated with a significantly lower rate of catheterization among 63,823 patients with strong indications (49.9% versus 50.3%; adjusted RR 0.94, 95% confidence interval 0.86 to 1.02, P=0.17). However, CON regulation was associated with significantly lower rates of catheterization among 65,077 patients with equivocal indication (45.0% versus 46.0%; adjusted RR 0.88, 95% confidence interval 0.78 to 1.00, P=0.05) and among 8379 patients with weak indications (19.8% versus 21.8%; adjusted RR 0.84, 95% confidence interval 0.71 to 0.98, P=0.04). Associations were weakened substantially after adjustment for hospital coronary artery bypass graft surgery or cardiac catheterization capability. CONCLUSIONS: CON regulation was associated with modestly lower rates of equivocally and weakly indicated cardiac catheterization after admission for acute myocardial infarction, but no significant differences existed in rates of strongly indicated catheterization. (+info)
Home oxygen therapy under Medicare. A primer.
Medicare recently implemented a new, strict, and complex home oxygen policy and a new oxygen prescription form. Unfortunately, the lack of instructions for the form has led to confusion, frustration, and suboptimal treatment. Long-term oxygen therapy prolongs survival, ameliorates hypoxic organ dysfunction, and improves exercise endurance. Indications for therapy include hypoxemia caused by cardiopulmonary diseases, hypoxemia that occurs with sleep or exercise, and hypoxemic organ dysfunction. Patients should be stable and have an arterial blood oxygen tension (PaO2) of 55 mm of mercury (7.3 kPa) or less or arterial blood oxygen saturation (SaO2) of 88% or less. There should be evidence of hypoxic organ dysfunction when the (PaO2) is 56 to 59 mm of mercury (7.4 to 7.8 kPa) or the SaO2 is 89%. A medical review by the insurance carrier is required if oxygen is to be prescribed when hypoxemia is less severe--if the PaO2 is 60 mm of mercury (8.0 kPa) or more or if the SaO2 is 90% or more. The instructions for oxygen flow, duration, and equipment must be explicit to ensure adequate therapy. An oxygen concentrator with a small oxygen cylinder portable system fulfills most needs. Oxygen cylinders may be used at low flows for patients who require therapy only during sleep or where electrical power is unreliable. A liquid oxygen system may be prescribed for active patients. Portable equipment should be provided in addition to stationary equipment when patients have resting hypoxemia. Portable equipment alone is sufficient when there is exercise-related hypoxemia with normal oxygenation at rest. Newly developed oxygen-conserving devices may offer longer ambulatory times and possibly lower operating costs. When home oxygen therapy is started in the hospital, the Certificate of Medical Necessity should be completed and patients should be trained to use the equipment before discharge. (+info)
Cardiac Certificate of Need regulations and the availability and use of revascularization services.
BACKGROUND: Many states enforce Certificate of Need (CON) regulations for cardiac procedures, but little is known about how CON affects utilization. We assessed the association between cardiac CON regulations, availability of revascularization facilities, and revascularization rates. METHODS: We determined when state cardiac CON regulations were active and obtained data for Medicare beneficiaries > or = 65 years old who received coronary artery bypass graft surgery (CABG) or a percutaneous coronary intervention (PCI) between 1989 and 2002. We compared the number of hospitals performing revascularization and patient utilization in states with and without CON regulations, and in states which discontinued CON regulations during 1989 to 2002. RESULTS: Each year, the per capita number of hospitals performing CABG and PCI was higher in states without CON (3.7 per 100,000 elderly for CABG, 4.5 for PCI in 2002), compared with CON states (2.5 for CABG, 3.0 for PCI in 2002). Multivariate regressions that adjusted for market and population characteristics found no difference in CABG utilization rates between states with and without CON (P = .7). However, CON was associated with 19.2% fewer PCIs per 1000 elderly (P = .01), equivalent to 322,526 fewer PCIs for 1989 to 2002. Among most states that discontinued CON, the number of hospitals performing PCI rose in the mid 1990s, but there were no consistent trends in the number of hospitals performing CABG or in PCIs or CABGs per capita. CONCLUSIONS: Certificate of Need restricts the number of cardiac facilities, but its effect on utilization rates may vary by procedure. (+info)
Certificate of Need (CON) for cardiac care: controversy over the contributions of CON.