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PubMedDate not supplied

Quality measurement in medicaid managed care and fee-for-service: the New York State experience.

New York State has transitioned 1.7 million Medicaid recipients from a fee-for-service delivery system to a managed care model. To evaluate whether managed care has had a positive effect on access and quality, the New York State Department of Health compared rates of performance across standardized measures of quality (ie, childhood immunization, well-child visits, prenatal care in the first trimester, cervical cancer screening, use of appropriate medications for people with asthma, and comprehensive diabetes care) in both systems. For almost all measures, Medicaid managed care rates were statistically higher than Medicaid fee-for-service.

Fee-for-Service Plans↗
PubMed1999

A tale of two bounties: the impact of competing fees on physician behavior.

This study examines how the volume of privately insured services provided in hospital inpatient and outpatient departments changes in response to reductions in Medicare physician payments. We hypothesize that physicians consider relative payment rates when choosing which patients to treat in their practices. When Medicare reduces its payments for surgical procedures, as it did in the late 1980s, physicians are predicted to treat more privately insured patients because they become more lucrative. We use data from 182 hospitals for seventeen major procedures groups, covering a forty-five-month period between 1988 and 1991 that encom passes a twenty-four-month period before the reduction in Medicare fees and twenty-one months after the reduction. Our findings are consistent with the predictions for a number of procedure groups, but not for all of them. One implication of the findings is that societal savings from Medicare fee reductions are overstated if one does not also consider spillover effects in the private insurance market.

Aged↗
PubMedDate not supplied

Realigning incentives in fee-for-service Medicare.

This paper proposes Medicare payment reform built on the fee-for-service system, with incentive payments to eligible provider organizations determined by their rate of increase in cost per patient compared to the overall growth rate in the community. By planning and monitoring how care patterns are altered to achieve greater efficiency, policy-makers can align the incentives of Medicare and the provider organization better than using either fee-for-service or capitation alone. This reform, unlike capitation, maintains Medicare's historical role as insurer and focuses providers on managing care.

Aged↗
PubMed1994

Survey findings on dental fees. A comparison from 1982-93.

The cost of health care services, including dental services, continues to rise at a rate higher than the prices of all goods and services included in the CPI for urban consumers. Increases for physician services, medical care and hospital room rates exceed those for dental care. Dentists generally do not raise their fees across-the-board, but vary increases from procedure to procedure. Increases for certain common dental procedures and services were close to the CPI for consumer goods and services. Fees for such basic preventive and diagnostic procedures--including oral exams, prophylaxes and X-rays--increased at rates well below the overall CPI for dental services.

Data Collection↗
PubMed1995

How fee and insurance changes could affect dentistry: results from a microsimulation model.

Dentists have become concerned about the possible impact of reductions in dental insurance coverage. The authors used a microsimulation model of the dental sector to assess the potential impact of reductions in the percentage of Americans with dental insurance, in universal dental insurance coverage for children and in fees paid to dentists for their services. The model predicted that reductions in dental insurance coverage would reduce per capita dental expenditures, but that the impact would not be large. Fee reductions had the greatest impact on dental expenditures of any change simulated by the model.

Adolescent↗
PubMed2006

Utilization and costs for compliant patients initiating therapy with pioglitazone or rosiglitazone versus insulin in a Medicaid fee-for-service population.

OBJECTIVE: To compare health care utilization and costs for type 2 diabetes patients initiating therapy with one of two thiazolidinediones (TZDs, pioglitazone or rosiglitazone) or insulin in a Medicaid population. METHODS: The study used a retrospective cohort design and included type 2 diabetes patients who initiated therapy with TZDs or insulin treatment during the 3-year period (1999-2001). These patients were identified from a Medicaid administrative claims database for approximately 230,000 fee-for-service Medicaid recipients using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 250.0x-250.9x, where x = 0 or 2). The first pharmacy claim for a TZD or insulin was treated as an index pharmacy claim, and utilization and costs were assessed for each patient for a 12-month follow-up period after the index date of the first pharmacy claim. A 12-month preperiod without a pharmacy claim for a TZD or insulin confirmed that the patient was newly prescribed with these medications. Analysis was restricted to a compliant sample receiving at least 6 pharmacy claims for either TZD or insulin in the 12-month follow-up period. The propensity matching technique was used to control for selection bias and potential imbalances between these groups at baseline. Patients initiating therapy with insulin or TZD were matched on the basis of demographics, year of index pharmacy claim, presence of microvascular/macrovascular complications, comorbidity, type 2 diabetes-related medical utilization and costs in the 12-month preperiod, overall health care utilization and costs in the preperiod, and type of oral hypoglycemic agents/other medications in the preperiod. Nonparametric bootstrapping was used to estimate the impact of therapy on both overall and type 2 diabetes-related health care utilization and costs in the matched sample. RESULTS: A total of 2,842 patients with type 2 diabetes patients met the inclusion criteria prior to exclusion of 881 patients (31.0%) who did not receive at least 6 pharmacy claims for either TZD or insulin in the 12 months following the index pharmacy claim, leaving 1,961 type 2 diabetes patients who initiated therapy with one of the two TZDs or insulin in the 3-year enrollment period (TZDs = 1,523; insulin = 438). Propensity matching eliminated 1,271 patients (64.8%), resulting in a final sample consisting of 690 patients.345 patients per treatment group.with comparable demographic and utilization parameters at baseline. In the 12-month follow-up period for the measures of overall utilization, patients initiated on TZDs did not differ significantly in the number of emergency room (ER)/hospitalization episodes and the number of pharmacy claims compared with the patients initiated on insulin, but they did have an average of 1.2 fewer physician office visits (9.3 vs. 10.5, P <0.05). Compared with the insulin group, the TZD group incurred 35% lower costs for ER visits/hospitalization (dollar 3,727 vs. dollar 5,793, P <0.01) and 18% lower total health care costs (dollar 12,737 vs. dollar 15,563, P <0.05). No significant differences were observed between the groups in overall outpatient and pharmacy costs. When the analysis was restricted to type 2 diabetes-related utilization and costs, patients initiating therapy with TZDs had 0.8 fewer physician office visits (3.6 vs. 4.4, P <0.05). However, TZD patients had 2.7 (14.1%) more diabetes pharmacy claims than patients initiating therapy with insulin (P <0.01), but there was no difference in the number of type 2 diabetes-related ER visits/hospitalizations between the groups. The TZD group had 53% higher type 2 diabetes-related pharmacy costs than the insulin group (dollar 1,678 vs. dollar 1,096, P <0.01). However, these costs were offset by lower costs for ER visits and hospitalization for the TZD group as compared with the insulin group (dollar 2,855 vs. dollar 5.090, P <0.01) resulting in 25% lower total type 2 diabetes-related costs for the TZD group compared with the insulin group (dollar 5,425 vs. dollar 7,255, P <0.05). CONCLUSION: Medicaid fee-for-service patients initiated on either pioglitazone or rosiglitazone incurred higher diabetes-related pharmacy costs, which were offset by lower total type 2 diabetes-related medical costs, contributed primarily by lower costs for ER visits and hospitalizations in this 12-month analysis.

Diabetes Mellitus, Type 2↗
PubMed1988

Patterns of mental health utilization over time in a fee-for-service population.

This paper examines the multi-year patterns of ambulatory mental health care in a population of individuals continuously eligible to receive care in a fee-for-service setting. Among the 14,000 individuals eligible for all three years, 14 per cent used outpatient mental health services during at least one of the three years. Almost 70 per cent of the individuals with some use in 1980 used services during 1981 or 1982. The heaviest use of outpatient mental health and other physician services is among the persons using services in all three years. Our data are compared with three years of data reported by Kessler in an HMO (health maintenance organization) setting. The probability that a non-user becomes a user in roughly the same in the fee-for-service and HMO populations, but the probability of continuing use in the next year is much less in the HMO. This finding, that the "HMO effect" on mental health care is primarily on the visits per user rather than on the number of users, is consistent with other research.

Ambulatory Care↗
PubMed2001

A review of the direct costs of rheumatoid arthritis: managed care versus fee-for-service settings.

Rheumatoid arthritis (RA) is a prevalent condition associated with pain, joint destruction and morbidity. Direct healthcare costs are 2 to 3 times higher than average costs for individuals of similar age and gender. Furthermore, utilisation and costs rise with age and disease duration. Managed care has become an increasingly popular way to organise and finance the delivery of healthcare. Studies comparing the quality of care in health maintenance organisations and fee-for-service settings have found few differences in outcomes, although reduced costs have been attributed to lower hospitalisation rates in patients with RA. We reviewed 10 studies of the direct costs of RA. In 1996 dollars, direct costs ranged from $US 2,299 per person per year in Canada to $US 13,549 in a US study focusing on patients who have been hospitalised only. Surprisingly, the contributions to direct costs--hospital care, medications and physician visits--remained relatively stable over time and the setting of care. Hospitalisation costs were the highest component of direct costs accounting, generally, for 60% or more of costs while only approximately 10% of patients with RA were hospitalised. The only exception was a managed care setting where hospitalisation costs were 16% of total direct costs. In managed care settings, costs of medications were proportionately higher than in fee-for-service settings. We conclude that in studies of the direct costs of RA the components of costs have remained relatively stable over time. This may change with the development and growing use of new RA medications including cyclo-oxygenase 2 inhibitors, interleukins, cytokines, treatments that inhibit tumour necrosis factor, and combination therapies. The effectiveness of managed care in controlling direct costs needs to be evaluated in more targeted studies.

Adult↗
PubMed1992

Payment for diabetes care under the Medicare fee schedule.

The system Medicare uses to determine physician payment is inequitable to physicians who provide primarily evaluation and management (EM) services. This creates financial incentives that may discourage physicians from providing Medicare patients with care that meets the American Diabetes Association's standards. Under Medicare's resource-based fee schedule, which will be phased in beginning January 1992, payment for EM services should more accurately reflect the time, effort, and overhead costs involved in providing them. This article describes how physician payment will be determined under the Medicare fee schedule and examines the probable effects of changes in payment on the physicians who care for patients with diabetes and the quality of services they provide.

American Medical Association↗
PubMed2002

Valuing neurosurgery services: part I. The historical development and interrelationships of current procedural terminology and the medicare fee schedule.

Current Procedural Terminology (CPT) standardizes medical procedure coding for billing and reimbursement. Since adoption of CPT coding as the basis for the Medicare Fee Schedule (MFS) in 1992, CPT coding policies and policy changes have been influenced not only by medical necessity and customary practice, but also increasingly by Medicare payment policies. The MFS created regulatory price control in the United States medical market based on widespread adoption of modified MFS by private payers and benchmark MFS fees governed by federal budget limitations and set annually by government agency (Centers for Medicare and Medicaid Services).

Fee Schedules↗
PubMed1991

Physician fee schedule update for calendar year 1992 and physician performance standard rates of increase for federal fiscal year 1992--HCFA. Notice.

This notice announces the calendar year 1992 update to the Medicare physician fee schedule and the Federal fiscal year 1992 performance standard rates of increase for expenditures and volume of physician services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f) respectively of the Social Security Act. The fee schedule update for calendar year 1992 is 1.9 percent. The physician performance standard rates of increase for Federal fiscal year 1992 are 10.0 percent for all physician services, 6.5 percent for surgical services, and 11.2 percent for nonsurgical services.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1994

Medicare program; refinements to geographic adjustment factor values, revisions to payment policies, adjustments to the relative value units (RVUs) under the physician fee schedule for calendar year 1995, and the 5-year refinement of RVUs--HCFA. Final rule with comment period.

This final rule revises the geographic adjustment factor values and fee schedule payment areas, various payment policies for specific physician services, the relative value units (RVUs) for certain existing procedure codes, and establishes interim RVUs for new and revised procedure codes. It implements section 13518 of the Omnibus Budget Reconciliation Act of 1993 that requires payment for antigens under the physician fee schedule. This final rule also discusses the process for periodic review and adjustment of RVUs not less frequently than every 5 years as required by section 1848(c)(2)(B)(i) of the Social Security Act.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

Value-based formulas for purchasing. PEHP's designated service provider program: value-based purchasing through global fees.

In many circles, managed care and capitation have become synonymous; unfortunately, the assumptions informing capitation are based on a flawed unidimensional model of risk. PEHP of Utah has rejected the unidimensional model and has therefore embraced a multidimensional model of risk that suggests that global fees are the optimal purchasing modality. A globally priced episode of care forms a natural unit of analysis that enhances purchasing clarity, allows providers to more efficiently focus on the Marginal Rate of Technical Substitution, and conforms to the multidimensional reality of risk. Most importantly, global fees simultaneously maximize patient choice and provider cost consciousness.

Actuarial Analysis↗
PubMed1992

College responds to HCFA's final Medicare fee schedule.

On March 24, 1992, the American College of Surgeons submitted its official comments on the relative value units published in the final rule to implement the new Medicare fee schedule to the Health Care Financing Administration (HCFA). The following article provides background information on the Medicare fee schedule, describes the process the College used in developing its comments, and summarizes the comments themselves.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1992

Physician performance standard rates of increase for federal fiscal year 1993 and physician fee schedule update for calendar year 1993--HCFA. Final notice with comment period.

This notice announces the calendar year (CY) 1993 updates to the Medicare physician fee schedule and the Federal fiscal year (FY) 1993 performance standard rates of increase for expenditures and volume of physician services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848(d) and (f), respectively, of the Social Security Act. It also sets forth an "initial" procedure-specific list of surgical and nonsurgical services to be used in applying the CY 1993 updates. These surgical and nonsurgical designations are subject to public comment. The physician performance standard rates of increase for Federal FY 1993 are 10.0 percent for all physician services, 8.4 percent for surgical services, and 10.8 percent for nonsurgical services. The fee schedule update for CY 1993 is 3.1 percent for surgical services and 0.8 percent for nonsurgical services.

Abstracting and Indexing↗
PubMed1996

Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 1997--HCFA. Final rule with comment period.

This final rule makes several policy changes affecting Medicare payment for physician services, including payment for diagnostic services and transportation in connection with furnishing diagnostic tests. The final rule also makes changes in geographic payment areas (localities) and changes in the procedure status codes for a variety of services. Since we established the physician fee schedule on January 1, 1992, our experience indicates that some of our policies may need to be reconsidered. This final rule is intended to correct several inequities in physician payment. This final rule also makes changes to work relative value units (RVUs) affecting payment for physician services. Section 1848(c)(2)(B)(i) of the Social Security Act requires that we review all work RVUs no less often than every 5 years. Since we implemented the physician fee schedule effective for services furnished beginning January 1, 1992, we have completed the 5-year review of work RVUs that will be effective for services furnished beginning January 1, 1997. In addition, we are finalizing the 1996 interim RVUs and are issuing interim RVUs for new and revised procedure codes for 1997.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1996

Medicare program; physician fee schedule update for calendar year 1997 and physician volume performance standard rates of increase for Federal fiscal year 1997--HCFA. Final notice.

This final notice announces the calendar year 1997 updates to the Medicare physician fee schedule and the Federal fiscal year 1997 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and, (f), respectively, of the Social Security Act. The fee schedule updates for calendar year 1997 are 1.9 percent for surgical services, 2.5 percent for primary care services, and -0.8 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.6 percent increase in the update for all physicians' services for 1997. The physician volume performance standard rates of increase for Federal fiscal year 1997 are -3.7 percent for surgical services, 4.5 percent for primary care services, -0.5 percent for other nonsurgical services, and a weighted average of -0.3 percent for all physicians' services.

Centers for Medicare and Medicaid Services, U.S.↗