Can Medicare beneficiaries pay outpatient drug bills?
This article updates nurse managers on the social and political aspects of how Medicare beneficiaries pay for outpatient drug bills.
Ambulatory Care↗
Biomedical subjects
P L Grimaldi
Publications and source records attributed to P L Grimaldi.
Unraveling Medicare's prospective payment system for hospital outpatient care.
This article explains the construction and principal components of Medicare's new hospital outpatient prospective payment system. Examples illustrate the calculation of the payment rates and other amounts that hospitals are paid under the new system. The article concludes with observations about the new system's construction, and operational steps hospitals will likely take to comply with its reporting requirements and optimize Medicare payments.
Aged↗
New skilled nursing facility payment scheme boosts Medicare risk.
Medicare's cost-based reimbursement method for skilled nursing facility care has been replaced with a prospective payment system that includes a case-mix adjustment based on resource utilization groups. The changeover will reduce Medicare payments for most skilled nursing facilities. The financial risk of operating these facilities will be far greater if state Medicaid programs that reimburse nursing facilities on a cost basis follow Medicare's lead.
Diagnosis-Related Groups↗
Medicare increases managed care's accountability, Part 2.
In Part 1, the author explained Medicare's Quality Improvement System for Managed Care, Medicare's first consistent set of standards to monitor and evaluate the quality of managed care for its members. This month, read about the plans' need to meet certain patient-focused standards and the strain this places on plans' administrations.
Humans↗
Managed care's move to rural areas.
Medicare, Medicaid, and urban-based commercial health plans are attempting to increase managed care's presence in the nation's rural areas, prompting rural-based providers to sponsor their own managed-care plans.
Humans↗
Hospital outpatient PPS evolving slowly.
Explore the source record for details and available documents.
Ambulatory Care↗
New risk adjustment may cut Medicare payments.
A medicare proposal to adjust capitation rates according to health factors would boost the predictability of care costs and capitation accuracy, but lower payments to managed care organizations.
Capitation Fee↗
New managed-care glossary.
EverCare, cherry picking, premium support, S/HMO--get the explanations behind the fast-changing terminology of managed care in this third annual update.
Humans↗
Medicare increases managed care's accountability, Part 1.
This year marks the beginning of Medicare's Quality Improvement System for Managed Care (QISMC), a tool that monitors the quality of care that managed health plans give their Medicare and Medicaid members. QISMC, which requires health plans to demonstrate improvements in the quality of care, will increase health plans' administrative costs without increasing capitation rates.
Humans↗
Estimating Medicare payment cuts for three outpatient services.
A change in the method used to determine Medicare outpatient payment to hospitals for outpatient ambulatory surgery, radiology, and other diagnostic procedures will lower payments to most U.S. hospitals. Using the equations provided in this article, healthcare financial managers can estimate Medicare payments under both the old and the new methods and determine the percentage payment reduction resulting from the new method.
Ambulatory Surgical Procedures↗
Capitation is changing and expanding.
Capitated payment arrangements are changing and expanding. The private sector is paying growing attention to capitating dental care and paying capitation rates for specialty services. The federal government plans to experiment with global purchasing and competitive bidding to establish capitation rates for Medicare beneficiaries.
Capitation Fee↗
PSO requirements taking shape.
Federal legislation recently established a new type of managed care plan known as a provider sponsored organization. As a result, hospitals, physicians and other providers can now contract directly with the federal government for Medicare members rather than through health maintenance organizations. Standards for the new health plans are being developed, including the contentious solvency standards.
Contract Services↗
Risk adjustment for health status.
A managed care plan's capitation payments should include an adjustment for its members' health status. Demographic and diagnostic information can be used to make the adjustment, which would help to minimize a health plan's potential financial liabilities. Without the adjustment, health plans have an incentive not to enroll persons with the heaviest care needs.
Health Status↗
HEDIS 3.0 updated for 1998.
The third version of the Health Plan Employer Data and Information Set (HEDIS) has been revised for 1998. Many changes affect either the clinical codes that determine whether a member received a service or the content of the service being measured. The updated version contains 15 fewer measures than did its predecessor.
Databases, Factual↗
Two steps to enhance managed care quality.
National concern about the quality of managed care organizations (MCOs) is evident in two recent developments: (1) the new application form that MCOs must complete to become Medicare risk contractors; and (2) the National Committee for Quality Assurance (NCQA) plans to launch performance-based accreditation for MCOs, beginning mid-1999.
Accreditation↗
Medicare wants more encounter data.
Two years ago, the federal government began requiring managed health plans to submit encounter data for their Medicare members. This data requirement has been expanded for 1998. Encounter data are intended to replace the claims-based information that Medicare loses when beneficiaries switch from fee-for-service providers to managed care plans. Encounter data are needed for a variety of purposes.
Data Collection↗
Physicians may opt out, not MCOs.
Physicians and other practitioners can now contract privately with Medicare beneficiaries for services that Medicare covers and charge more than Medicare pays. Private contracting means more treatment choices for beneficiaries. It also means that practitioners can charge whatever the market will bear, but at the cost of having to withdraw from Medicare for 2 years. For private contracting to become popular, the law will have to be changed to lower the associated cost.
Contract Services↗
The versatile medical loss ratio.
Despite its growing popularity, the medical loss ratio (MLR) does not measure the quality of care that a managed health plan provides to its members. This ratio also does not fulfill other purposes for which it is used. Conclusions based on MLRs alone may be wrong and result in flawed public policy.
Health Expenditures↗