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PubMed1995

The effect among older persons of a general preventive visit on three health behaviors: smoking, excessive alcohol drinking, and sedentary lifestyle. The Medicare Preventive Services Research Team.

BACKGROUND: The U.S. Congress mandated evaluations, initiated in 1989, to determine whether extending Medicare benefits to include preventive services would improve health status, reduce costs of care, and improve health risk behaviors of beneficiaries. METHODS: The Johns Hopkins Medicare Preventive Services Demonstration was a randomized trial in which Medicare beneficiaries were assigned either to an intervention group that was offered yearly preventive visits for 2 years and optional counseling visits to their primary care provider or to a control group that received usual care. This report describes the effect of the intervention over a period of 2 years on smoking, problem alcohol use, and sedentary lifestyle. RESULTS: Differences were observed between the intervention and control groups in the extent to which changes occurred in smoking and problem alcohol use, but none of the differences was statistically significant. The proportion of smokers who quit was higher in the intervention group than in the control group (24.2 vs 17.9%, P = 0.09). However, a higher proportion of problem drinkers in the control group improved (67.1 vs 57.0%, P = 0.183). There was virtually no difference between the intervention and the control groups in the proportion with improvement in sedentary lifestyle. CONCLUSIONS: This study demonstrates the difficulty of bringing about health behavior change in older patients in the course of a yearly preventive visit for 2 years with their primary care physician when the visit encompasses screening and immunizations, as well as health behavior counseling directed by the physician. Further study is required to determine whether a more intense program of counseling for health behavior change among older persons by their primary care providers would be effective.

Aged↗
PubMed2004

Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times.

BACKGROUND: In 2002, the Centers for Medicare and Medicaid Services implemented a 5.4% cut in Medicare physician payments, and further reductions are expected in 2004. These cuts have raised concerns that beneficiaries of Medicare will face significant problems obtaining needed physician services. Although there is clear evidence of poor access to care for patients with Medicaid, data measuring access to physicians for patients with Medicare are sparse. Given current lengthy appointment wait times resulting from a relative shortage of dermatologists, we hypothesized that patients with lower-paying coverage might be more likely to experience appointment refusals, longer wait times, or both. METHODS: Because the ability to obtain timely appointments is a key measure of access, we surveyed dermatologists in 12 medium- and large-sized communities to assess wait times for routine new-patient visits. Dermatologists in these areas (or their staff) received a telephone call asking about the next available appointment for a hypothetical patient with a randomly assigned insurance type (ie, Medicaid, Medicare, or fee-for-service private insurance). RESULTS: Of 631 physicians (or staff members) contacted, 612 (97%) agreed to participate. Overall acceptance rates were similar for patients with Medicare (85%) and private insurance (87%), but were much lower for those with Medicaid (32%). Among patients whose insurance was accepted, mean wait times for patients with Medicare and private insurance were 37 days, but patients with Medicaid experienced significant queuing (50 days). There was dramatic geographic variation. In areas where Medicare payments are low relative to commercial payers, there were increases in Medicare rejection rates and wait times. In communities with relatively low Medicaid payment rates, patients with Medicaid faced higher rejection rates and longer wait times. There were also longer overall wait times for female dermatologists and in communities where the concentration of dermatologists was low. CONCLUSION: Although overall access to dermatologists appears comparable for patients with Medicare and private insurance, some access limitations in "hot spots" where Medicare payments are low relative to commercial insurers suggest that patients in these areas may be most sensitive to further payment reductions. Significant access problems for beneficiaries of Medicaid, particularly in areas where Medicaid payments are relatively low, may be a harbinger of the potential consequences of sustained declines in Medicare physician reimbursement.

Appointments and Schedules↗
PubMed1992

Will Medicare beneficiaries switch physicians? A test of economic competition.

We assess the potential of increased economic competition by examining whether Medicare beneficiaries are willing to switch to physicians who agree to accept all services on assignment. Data come from a survey of Medicare beneficiaries conducted in November 1988. Our principal finding is that beneficiaries are not sensitive to price when making decisions about whether or not to switch physicians. Less than one-half of 1 percent of the sample had switched physicians for economic reasons in the year prior to the survey. Furthermore, willingness to switch was not correlated with ability to pay. We conclude that policies aimed at altering consumer demand may not be the most effective way to control Medicare costs.

Aged↗
PubMedDate not supplied

A six sigma approach to maximizing productivity in the cardiac cath lab.

Cardiac catheterization laboratories represent one of the most significant capital investments for hospitals. Historically, hospitals could achieve an economic return fairly rapidly on this capital investment because of the relatively high contribution margin on many of the procedures performed in the department. However, recent changes in DRG assignments, declines in Medicare reimbursement, and the advent of new technologies, such as drug-coated stents, pose a threat to achieving planned economic return. In response, many hospitals are pursuing strategies to improve throughput in the cardiac cath lab and maximize the number of procedures performed. The case example in this article describes how a busy cardiac catheterization lab in the southeastern United States successfully applied the Six Sigma methodology to improving productivity and increasing available capacity.

Cardiac Catheterization↗
PubMed2001

Health plan decision making with new medicare information materials.

OBJECTIVE: To examine the effect of providing new Medicare information materials on consumers' attitudes and behavior about health plan choice. DATA SOURCE: New and experienced Medicare beneficiaries who resided in the Kansas City metropolitan statistical area during winter 1998-99 were surveyed. More than 2,000 computer-assisted telephone interviews were completed across the two beneficiary populations with a mean response rate of 60 percent. STUDY DESIGN: Medicare beneficiaries were randomly assigned to a control group or one of three treatment groups that received varying amounts and types of new Medicare information materials. One treatment group received the Health Care Financing Administrations's pilot Medicare & You 1999 handbook, a second group received the same version of the handbook and a Medicare version of the Consumer Assessment of Health Plans (CAHPS) report, and a third treatment group received the Medicare & You bulletin, an abbreviated version of the handbook. PRINCIPAL FINDINGS: Results of the study suggest that the federal government's new consumer information materials are having some influence on Medicare beneficiaries' attitudes and behaviors about health plan decision making. Experienced beneficiary treatment group members were significantly more confident with their current health plan choice than control group members, but new beneficiaries were significantly less likely to use the new materials to choose or change health plans than control group members. In general the effects on confidence and health plan switching did not vary across the different treatment materials. CONCLUSIONS: The 1999 version of the Medicare & You materials contained a message that it is not necessary to change health plans. This message appears to have decreased the likelihood of using the new materials to choose or change plans, whereas other materials to which beneficiaries are exposed may encourage plan switching. Because providing more information to beneficiaries did not result in commensurate increases in confidence levels or rate of health plan switching, factors other than the amount of information, such as how the information is presented, may be more critical than volume.

Aged↗
PubMed1995

Access to care under physician payment reform: a physician-based analysis.

This article reports physician-based measures of access to care during the 3 years surrounding the 1989 physician payment reforms. Analysis was facilitated by a new system of physician identifiers in Medicare claims. Access measures include caseload per physician and related measures of the demographic composition of physicians' clientele, the proportion of physicians performing surgical and other procedures, and the assignment rate. The caseload and assignment measures were stable or improving over time, suggesting that reforms did not harm access. Procedure performance rates tended to decline between 1992 and 1993, but reductions were inversely related to the estimated fee changes, and several may be explainable by other factors.

Black or African American↗
PubMed1984

Determinants of physician assignment rates by type of service.

In this article, the determinants of physician assignment rates under the Medicare program are examined separately for medical, surgical, laboratory, and radiology services. Data for this study include copies of all Medicare claims submitted by over 1,200 Colorado general practitioners, internists, and general surgeons during the periods both before and after they experienced a substantial change in program reimbursement rates. The results indicate that there is a significant positive relationship between changes in reimbursement and changes in assignment rates for medical, laboratory, and radiology services, but the relationship for surgical service is not significant. Furthermore, for laboratory and radiology services, only the change in medical service reimbursement is significant--reimbursement rates for laboratory and radiology services are not.

Colorado↗
PubMed1986

Medicare program; freestanding home health agencies to designated regional intermediaries; assignment and reassignment--HCFA. Final notice.

Section 1816(e)(4) of the Social Security Act (the Act) (as amended by section 2326(b) of the Deficit Reduction Act of 1984, Pub. L. 98-369) requires that the number of regional intermediaries designated to service freestanding home health agencies (HHAs) be limited to not more than ten. In accordance with section 1816(e)(4) of the Act and existing regulations, this notice announces our designation of regional intermediaries to process the workload of these HHAs, the States each intermediary would service, the general criteria used to select these intermediaries, and the procedures we will use during the change-over period. The goal of this initiative and the legislation on hich it is based is to achieve more consistent and effective administration of the home health benefit under the Medicare program.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1999

Definition of race and ethnicity in older people in Medicare and Medicaid.

BACKGROUND: Race and ethnicity are important predictors of health care access and outcomes, but quality of their documentation in the healthcare system is often problematic. OBJECTIVES: To study the agreement between Medicare and Medicaid descriptions of race and ethnicity in older beneficiaries. DESIGN: Quasiexperimental design in a natural practice setting. SETTING: New Jersey. PARTICIPANTS: 153,241 dually enrolled participants in Medicare and Medicaid. MEASUREMENTS: Agreement rates between administrative databases on recipients' race and ethnicity. RESULTS: Agreement between Medicare and Medicaid on the recipients' race and ethnicity was modest (kappa = .58; 95% CI, .57-.58) for men and women alike and across different age groups. Depending on whether Medicare or Medicaid was used as the reference standard, the relative agreement rates for race and ethnic group assignments varied. For example, using Medicare as the reference, the relative agreement rate was 84% for whites, 74% for blacks, 61% for others, 23% for Hispanics, and only 5% for Asians. Using Medicaid as the reference, a different pattern emerged. However, such gradients of agreement rates across racial groups were observed in both programs. Medicare and Medicaid reported different percentages of all race and ethnicity groups, with Medicaid reporting greater proportions of White and Black beneficiaries, and Medicare reporting greater proportions of Hispanic, Asian, and Other groups. CONCLUSIONS: Depiction of race and ethnicity data in large government health insurance programs is approximate at best and often contradictory from one program to another. This can impede efforts to study the relationship between these important characteristics and health care utilization and outcomes.

Aged↗
PubMedDate not supplied

Incidence and costs of acute medical conditions in long-stay incontinent nursing home residents.

OBJECTIVES: To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment DESIGN: Prospective, cohort study. SETTING: Three community nursing homes. PARTICIPANTS: 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). MEASUREMENTS: Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement. RESULTS: The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). CONCLUSION: Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Acute Disease↗
PubMed2005

Osteoporosis action: design of the healthy bones project trial.

Although osteoporosis is common in older adults, it is often under-diagnosed and under-treated. We developed community-based patient- and physician-directed interventions for fracture prevention and compared them in a 2 x 2 factorial randomized controlled trial. The study population included older adults who were enrolled in a state-run pharmacy benefits program (The Pharmaceutical Assistance Contract for the Elderly in Pennsylvania) for Medicare beneficiaries. We randomly assigned 826 primary care physicians and their 31,715 patients to one of four trial arms--no patient and no physician intervention, patient but no physician intervention, physician but no patient intervention, both patient and physician interventions. The patient intervention consisted of targeted communication about fall and fracture prevention and osteoporosis diagnosis and treatment. It was delivered through several mailings. The physician intervention entailed one-on-one academic detailing encounters covering the same topics. The composite primary endpoint consisted of use of osteoporosis medication or a bone mineral density test. Other endpoints included patient's knowledge and attitudes towards fractures and osteoporosis, use of lower extremity strengthening to prevent falls, and the occurrence of fractures. All outcomes will be analyzed using random effects models accounting for clustering of subjects within physicians' practices.

Aged↗
PubMed1998

Factors Associated With Hospital Utilization in the Elderly: From the Cardiovascular Health Study.

OBJECTIVE: Analyze clinical, accepted biochemical, physiologic, and socioeconomic risk factors and correlate them with hospital utilization in an elderly population. DESIGN: Prospective, observational study in a defined, randomly recruited population. PARTICIPANTS: 5201 Medicare participants enrolled in the Cardiovascular Health Study (CHS). METHODS: Medicare recipients were randomly assigned to participate in an observational study. Baseline data were compared to hospital admissions and days of hospitalization over four years. DATA ANALYSIS: Data were grouped by type of risk factor and analyzed by Tobit analysis and logistic regression. RESULTS: Baseline variables associated with hospital use (p is less than 0.0001) were history of CHF, stroke, angina, hypertension, ln (timed walk), ln (blocks walked/week), age, gender, and clinic site. Factors not entering the model (p is greater than 0.05) were income, education, smoking, diabetes, weight, dietary fat, marital status, depression, and measures of mental function. CONCLUSIONS: In the elderly, existing health status is the major determinant of hospitalization and overwhelms many classic "risk factors" for morbidity.

Journal Article↗
PubMed2005

Diagnosis-related group assignment in laparoscopic and open colectomy: financial implications for payer and provider.

PURPOSE: In carefully matched patients, the length of hospital stay after laparoscopic colectomy is shorter than after open surgery. Higher operating room costs for laparoscopic surgery are offset by lower costs for hospitalization because of less utilization of pharmacy, laboratory, and nursing services. Clinical outcome is comparable. We examined the effect of the surgical approach for colectomy (open vs. laparoscopic) regarding the reasons for disease-related group assignment to disease-related group 148, and institutional cost under Part A of the U.S. Medicare system. METHODS: Colectomy patients were assigned to either disease-related group 148 (colorectal resection with complications) or disease-related group 149 (colorectal resection without complications) with significant institutional reimbursement implications (disease-related group 149, US 8,310 dollars; disease-related group 148, US 20,291 dollars). A total of 100 consecutive disease-related group 148 patients undergoing laparoscopic colectomy from July 2000 to September 2002 were identified from a prospective database and case-matched with 100 patients undergoing open colectomy. Patients were matched for gender, age, operative procedure, and pathology. A certified coder determined the reason(s) for disease-related group 148 assignment, which were grouped into: preoperative comorbidity, a combination of preoperative comorbidity/postoperative complications, or postoperative complications alone. RESULTS: Significantly more lapararoscopy patients were assigned to disease-related group 148 solely because of preoperative comorbidities (62 percent vs. 21 percent; P < 0.0001). Significantly more patients in the open surgery group were classified as disease-related group 148 solely because of postoperative complications (22 percent vs. 42 percent; P < 0.0001). An additional group of patients were assigned to the disease-related group 148 category based on a combination of preoperative and postoperative diagnoses (16 percent vs. 37 percent). The mean direct hospital costs were significantly less for laparoscopy patients (US 3971 dollars vs. US 5997 dollars; P = 0.0095). Increased cost to Part A of Medicare for 20 open surgery patients who "migrated" to disease-related group 148 because of postoperative complications was US 239,620 dollars. CONCLUSIONS: Our data are the first to demonstrate that disease related group assignment can change solely because of a differential rate of postoperative complications for two competing operative techniques. This change occurred at twice the rate for open colectomy and resulted in significantly increased cost to the insurer under a prospective payment program. The savings to the institution coupled with the shortened length of stay offset the potential loss in revenue to the institution.

Colectomy↗
PubMed2002

Medicare's fee schedule for hospital outpatient care.

Medicare's hospital outpatient prospective payment system (OPPS) went live on August 1, 2000, after a decade of developmental work. The new system introduced a fee schedule that replaced the cost-related methods that Medicare previously used to reimburse various hospital outpatient services. Hospitals are now paid predetermined rates or fees based on the Ambulatory Patient Classification (APC) groups assigned to the services that Medicare patients receive during outpatient encounters. The new system aims to simplify Medicare's intricate cost-based reimbursement policies, improve hospital efficiency, ensure that payments are sufficient to compensate hospitals for reasonable Medicare costs, and reduce Medicare coinsurance amounts for beneficiaries. Implementation of OPPS-related administrative and operational changes has been a major challenge for hospitals.

Accounting↗
PubMed2004

Medicare proposal may benefit insurers.

The proposed guidelines from U.S. Pharmacopeial Convention Inc., which was assigned the task by last year's Medicare law, seek a middle ground between pharmaceutical companies and insurers. The USP proposal is expected to result in a final plan after the organization takes comments. It is also supposed to define a list of classes of drugs--more formally divided into therapeutic areas and pharmacologic subcategories.

Drug Industry↗
PubMed2006

Economic evaluation of weekly epoetin alfa versus biweekly darbepoetin alfa for chemotherapy-induced anaemia: evidence from a 16-week randomised trial.

INTRODUCTION: A 16-week, open-label, multicentre, randomised trial of weekly epoetin alfa 40 000 units versus biweekly darbepoetin alfa 200microg among 358 patients with solid-tumour cancers and chemotherapy-induced anaemia demonstrated superior haematological outcomes with epoetin alfa. We sought to compare resource use, costs and clinical outcomes between treatment groups and report the results using a cost-consequences framework. METHODS: Pre-specified methods were used to assign costs (US dollars, year 2004-5 values) to medical resources and patient time using a societal perspective. Costs for inpatient care, outpatient care and physician services were based on US Medicare reimbursement rates. Indirect costs assigned to patient time spent receiving study medication were based on the mean hourly wage in the US. In the base-case analysis, the average wholesale price was used to assign costs to medications. Clinical outcomes included all haemoglobin levels and transfusions recorded throughout the trial. Sensitivity analyses were performed to evaluate the impact of different costing methods, cost sources, perspectives and methods to assign haemoglobin values following a blood transfusion. RESULTS: Over a mean follow-up duration of 11.8 weeks, the average cost of study medications and their administration was the single largest component of total costs and was similar between groups (epoetin alfa 5979 US dollars and darbepoetin alfa 5935 US dollars, difference 44 US dollars; 95% CI -590, 692). There were no significant differences in the proportions of patients hospitalised (epoetin alfa 24.6%, darbepoetin alfa 22.0%; p = 0.57). Patients randomised to epoetin alfa experienced more inpatient days, on average, than patients randomised to darbepoetin alfa (2.6 vs 1.6, 95% CI for the difference, 0.07, 2.27). However, with regard to transfusions, patients in the epoetin alfa arm required fewer units of blood than patients in the darbepoetin alfa arm (0.46 vs 0.88, 95% CI for the difference -0.77, -0.08). Mean total costs, comprising costs for study medications and their administration, inpatient care, transfusions, unplanned radiation therapy, haematology and laboratory services, chemotherapy and non-chemotherapy drugs and indirect costs were 14,976 US dollars in the epoetin alfa arm compared with 14,101 US dollars in the darbepoetin alfa arm, a difference of 875 US dollars (95% CI for difference -849, 2607), of which 98% of the difference was attributable to higher inpatient costs in the epoetin alfa arm (2374 US dollars vs 1520 US dollars; 95% CI for difference -33, 1955). Assessments of multiple clinical measures demonstrated improved outcomes with epoetin alfa relative to darbepoetin alfa. CONCLUSION: Most clinical outcome measures suggested greater improvement with epoetin alfa relative to darbepoetin alfa, but most costs for both agents appeared similar. Decision makers must evaluate the differences in costs and efficacy measures that are most relevant from their perspectives.

Adolescent↗
PubMed1993

Cost implications to Medicare of recombinant erythropoietin therapy for the anemia of end-stage renal disease.

The purpose of this study was to estimate the net cost effect to Medicare of the increasing use of recombinant human erythropoietin (EPO) instead of red blood cell transfusions or androgens in the management of anemia for the approximately 100,000 hemodialysis patients in the U.S. End-Stage Renal Disease (ESRD) program. A computerized decision model that takes into account the effectiveness and possible side effects of transfusions, androgens, and EPO and predicts 1- and 5-yr direct medical costs to Medicare associated with each therapy was constructed. Probability estimates for clinical events were derived from the literature. Costs were assigned by use of the amounts Medicare pays providers of ESRD care for: (1) use of EPO, transfusions, and androgens; and (2) health care services related to the treatment of anemia (including complications of treatment and possible reductions in morbidity). For every 10,000 hemodialysis patients treated with EPO, net Medicare expenditures will be much greater than if only transfusions are used by $42,530,000 at 1 yr (6% of ESRD program costs) and by $118,050,000 at 5 yr and also much greater than if androgens are used (by $42,700,000 at 1 yr and $118,370,000 at 5 yr). The increase in cost was highly sensitive to the dose of EPO; moderately sensitive to changes in estimated anemia response rates for EPO, frequency of EPO-induced vascular access clotting, and reduction in cardiovascular or overall morbidity; and slightly sensitive to transfusion rates, estimated anemia response rates for androgens, frequency of EPO-induced seizure or hypertensive complications (stroke, myocardial infarction), frequency of transfusion-related viral infection, and frequency of androgen-induced virilization. Considering both effectiveness and side effects of alternative treatments for the anemia of ESRD, it was projected that the increasing use of EPO will markedly increase the cost to Medicare of ESRD medical care.

Androgens↗