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PubMed1992

Medicare program; offset of Medicare payments to individuals to collect past-due obligations arising from breach of scholarship and loan contracts--HCFA. Final rule.

This final rule sets forth the procedures to be followed for collection of past-due amounts owed by individuals who breached contracts under certain scholarship and loan programs. The programs that would be affected are the National Health Service Corps Scholarship, the Physician Shortage Area Scholarship, and the Health Education Assistance Loan. These procedures would apply to those individuals who breached contracts under the scholarship and loan programs and who-- Accept Medicare assignment for services; Are employed by or affiliated with a provider, Health Maintenance Organization, or Competitive Medical Plan that receives Medicare payment for services; or Are members of a group practice that receives Medicare payment for services. This regulation implements section 1892 of the Social Security Act, as added by section 4052 of the Omnibus Budget Reconciliation Act of 1987.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1983

Impact of an all-or-nothing assignment requirement under Medicare.

In an effort to raise assignment rates, some policymakers have considered dropping Medicare's case-by-case assignment option. Physicians would have to decide whether to accept all of their patients on assignment, or none of them. In a 1976 national survey, over two-thirds of the physicians stated they would take none of their patients on assignment if forced to choose. Simulation analysis showed that in that event, assignment rates nationwide would fall almost 10 percent. The mean supply of assigned visits would actually increase 11 percent for general practitioners, while decreasing 12-25 percent for general surgeons, internists, and obstetricians/gynecologists.

Decision Making↗
PubMed2006

What is the economic value of digoxin therapy in congestive heart failure patients? Results from the DIG trial.

BACKGROUND: The Digitalis Investigation Group (DIG) clinical train randomized 6800 congestive heart failure patients (ejection fraction > or =45%) to a daily regimen of either digoxin or placebo. At 37 months average follow-up, patients in both groups had similar mortality. We determined the incremental costs associated with the use of digoxin in this high-risk population. METHODS AND RESULTS: Hospitalizations and medical costs were compared by using a societal perspective. Hospitalizations were assigned Medicare DRG codes by using descriptive information from the clinical trial. Digoxin use was assigned a cost by using the 1998 average wholesale price as reported by Red Book. On average, there were fewer hospitalizations in digoxin-treated patients. These patients had lower heart failure yet higher non-heart failure hospitalization costs than placebo patients. Digoxin therapy was cost saving versus placebo in only 27% of 1000 bootstrap samples using Medicare costs (mean costs 12,648 dollars vs. 12,362 dollars) and in 44% of samples using commercial carrier costs (mean costs 17,400 dollars vs. 17,306 dollars). How ever, digoxin was cost saving in >50% of samples for several higher-risk patient subgroups. CONCLUSIONS: The use of digoxin therapy versus placebo was associated with reduced hospitalizations. Moreover, the resulting cost-savings could cover the costs of this inexpensive therapy in selected subgroups of higher-risk patients. In the remainder, there is a modest cost associated with this therapy.

Aged↗
PubMed1985

Medicare physicians' services: the composition of spending and assignment rates.

Medicare spending for physicians' services, the second largest component of the Medicare program (24.5 percent), represents 1.3 percent of the Federal budget, 0.41 percent of the gross national product, and 19.4 percent of national spending for physicians' services. Interest in reforming the Medicare physician payment system is growing. Detailed information on patterns of Medicare spending for physicians' services and assignment rates according to physician specialty, place of service, type of service, and procedure are presented here.

Economics, Medical↗
PubMed1983

Physician acceptance of Medicare patients on assignment.

The determinants of the assignment rates of physician services under Medicare are analyzed in this paper. A theoretical model of physician behavior is developed to capture the carrot and stick nature of the assignment decision resulting from the uncertainty of patient payment. The optimization conditions of the physician's problem indicate that assignment rates are determined by market prices, Medicare fees, and physicians' assessments of their patients' payment likelihoods. The theoretical findings are tested using an empirical model based on observed prices and selected proxy variables for the probability of payment. Results, based on a Tobit analysis that predicts elasticities for the price and proxy variables, are consistent with the theoretical model implying that economic incentives and patient payment probabilities are important determinants of assignment rates.

Aged↗
PubMed1997

Medicare revenue in large medical groups.

The aged are the heaviest users of physician services. A ageing population and escalation in medical costs have pressured Medicare budgets, which have increased fastest in Part B physician reimbursement. Policy responses include adoption of the Resource Based Relative Value Scale (RBRVS) for physician payment. This paper considers receipt of Medicare revenues by large medical groups and expectations of how groups will fare under RBRVS. In a 73-percent sample of U.S. large group practices, Medicare coverage accounted for one-fourth of clients, Medicare-related revenues for slightly more than one-fourth of revenues, suggesting a slightly higher revenue intensity for Medicare clients, but showing no evidence of truly disproportionate revenues from Medicare users. Medicare shares of revenues are explained by factors related to Medicare clientele and geriatric service provision. Overly-strict Medicare assignment policy may control costs by limiting access to needed care, rather than by limiting overpayments to physicians. Expectations as to how groups will fare under RBRVS are not found to be related to reliance on Medicare, rather to group auspices and ability to contain costs under Medicare payment. The findings are important not only to physician payment under RBRVS but also under health care reform.

Aged↗
PubMed1993

Will universal health insurance assure universal access to ongoing primary care for adults?

OBJECTIVE: To assess the impact of current public insurance status (Medicare and Medicaid) and hypothetical payment levels of a new insurance program on physician acceptance of adult primary care patients desiring continuing care. METHOD: Survey of 175 primary care physicians in a medium-sized city and six surrounding counties in North Carolina. MAIN OUTCOME MEASURE: Likelihood of accepting new continuing care patients covered by Medicare, Medicaid, or a hypothetical health insurance system mandated to cover the uninsured. RESULTS: The response rate was 80%; 86% of the respondents were accepting new patients with private insurance. Of the remaining physicians, 72% were not accepting new continuing care patients covered by Medicaid and 55% were not accepting patients who paid via Medicare assignment alone. Seventy-nine percent of respondents were unlikely to accept new continuing care patients insured by a hypothetical public plan that reimbursed physicians at 60% of reimbursement levels provided by privately insured patients, compared with only 25% who were unlikely to accept patients if the reimbursement was 80% of the private level. CONCLUSIONS: Medicaid and Medicare do not assure access to continuing primary care. Also, physician reimbursement is an important determinant in any new health care system designed to provide universal and consistent access to regular primary care services.

Adult↗
PubMed2002

Medicare program; fee schedule for payment of ambulance services and revisions to the physician certification requirements for coverage of nonemergency ambulance services. Final rule with comment period.

This final rule establishes a fee schedule for the payment of ambulance services under the Medicare program, implementing section 1834(l) of the Social Security Act. As required by that section, the proposed rule on which this final fee schedule for ambulance services is based was the product of a negotiated rulemaking process that was carried out consistent with the Federal Advisory Committee Act and the Negotiated Rulemaking Act of 1990. The fee schedule described in this final rule will replace the current retrospective reasonable cost payment system for providers and the reasonable charge system for suppliers of ambulance services. In addition, this final rule requires that ambulance suppliers accept Medicare assignment; codifies the establishment of new Health Care Common Procedure Coding System (HCPCS) codes to be reported on claims for ambulance services; establishes increased payment under the fee schedule for ambulance services furnished in rural areas based on the location of the beneficiary at the time the beneficiary is placed on board the ambulance; and revises the certification requirements for coverage of nonemergency ambulance services.

Ambulances↗
PubMed2006

Medicare reimbursement: an orthopedic primer.

Since 1992, Medicare has paid physicians and other practitioners by using a resource-based relative value scale system (RBRVS). The Center for Medicare Services updates the RBRVS annually and reviews the work portion for each procedure every 5 years. The calculation of the work units is done by using a survey. This survey polls the average amount of time spent in each portion of the case. The survey process is quite complex. Some of the specific biases that can be found include rank lists, multidimensional, hypothetical items, and complexity and memory overload bias. Survey errors are easy to make over and above item bias. With this system, surgeons are encouraged to be slower to increase their compensation. Surveying methodology is not the most appropriate way to tabulate time and work. Unless this methodology changes, orthopedic surgeons will continue to be shortchanged.

Aged↗
PubMed2002

Management of flexor tendon sheath ganglions: a cost analysis.

The purpose of this study was to determine success rates of 1 or more aspirations on flexor tendon sheath ganglions compared with surgical excision and to determine what treatment method is most cost-effective. Data were collected from documented history and physical examinations, operative reports, billing records, and telephone interviews. Of the 259 patients coded as having flexor tendon sheath ganglions, 175 met the inclusion criteria. In addition, 2001 Medicare-assigned relative value units and fees were used to calculate the most cost-effective treatment. Of the 141 patients treated with aspiration, 66% exhibited no recurrence after 2 consecutive treatments. Thirteen of 14 patients (93%) who had ganglions excised without prior aspiration showed no recurrence. All 29 patients who had excision after 1 (n = 24) or 2 (n = 5) failed aspirations were cured. Because few patients require excision after 2 aspirations, the most cost-effective treatment for recurrent flexor tendon sheath ganglions is 2 aspirations before excision.

Adult↗
PubMed1993

Assessing the implementation of physician-payment reform.

BACKGROUND: The Medicare program fundamentally changed its system of payment for physicians' services in 1992. Controversy over the new Medicare fee schedule has focused on three issues: the adequacy of the conversion factor used to translate resource-based relative-value units into fees; the ability of the new payment system to capture differences in work between surgeons and physicians in other specialties; and the allocation of practice expenses across services. METHODS: Using a standard service in each specialty, we developed simulation methods to assess the implementation of physician-payment reform. With these methods we calculated the potential net income for each specialty, as generated by different payment scenarios, including the Medicare fee schedule. RESULTS: We found that Medicare's current monetary-conversion factor yields an unreasonably low level of income for most specialties. Furthermore, the Medicare fee schedule misallocates practice expenses; invasive services are reimbursed for more than actual expenses, and medical services are reimbursed for less. Thus, physicians continue to be paid more generously for invasive services. Finally, the Medicare fee schedule does recognize the wide differences in the intensity of work performed by physicians in various specialties. CONCLUSIONS: The misallocation of practice expenses in the Medicare fee schedule results in serious underpayment for medical services. We think it likely that physicians compensate by performing more lucrative services, such as diagnostic tests. Even if legislation is passed to deal with the misallocation of expenses, the current conversion factor still produces unreasonably low levels of payment overall, which could dissuade those considering a career in medicine from entering the field. Finally, the simulation method we developed can be used as a tool for fee negotiations.

Economics, Medical↗
PubMed1990

Physician satisfaction with career choices in geriatrics.

In a national survey of fellows who had trained in geriatric medicine and psychiatry, the vast majority of former fellows expressed satisfaction with their current work. Satisfaction with a career choice in geriatrics was significantly greater among those physicians who had practices with large numbers of patients over 75, accepted Medicare assignment, spent their time as clinician-researchers, and had a medical school appointment. Physician job satisfaction may have important consequences, and attention to maximizing satisfaction is warranted.

Career Choice↗
PubMed1993

Would eliminating differences in physician practice style reduce geographic variations in cataract surgery rates?

This study uses Medicare physician-claims data to examine patient and physician contributions to variations in cataract surgery rates across U.S. metropolitan areas. Utilization is modelled as having two phases: the decision to seek an ophthalmologist's care, which is made by patients, and the decision to perform surgery on patients who seek care, which is partially controlled by ophthalmologists. Under this model, the effect of physician practice style on cataract surgery rates occurs through the influence of practice style on the second phase of utilization. Variation in patient care-seeking behavior contributed to the variation in the rate of cataract surgery. Moreover, multivariate regression analyses found that cataract surgery rates were influenced by economic and sociodemographic variables in predictable ways. Using the regression results, a "purged" cataract surgery rate that was free of any possible influence of physician practice style was calculated. Variation in the purged surgery rate was only slightly lower than variation in the observed surgery rate, suggesting that eliminating practice style as a factor in physician decision making (e.g., through practice guidelines) would reduce variations in cataract surgery rates by only a small amount.

Cataract Extraction↗
PubMed1997

Factors affecting primary care physician participation in Medicare.

OBJECTIVES: This study investigates the levels of participation and the relative association of economic and noneconomic factors on primary care physician participation in the Medicare program. METHODS: Demographic information, participation in Medicare, and attitudes toward both the Medicare program and Medicare patients were collected in a written survey mailed to half the primary care physicians in Iowa. Ordinary least squares and logistic regression analyses were conducted to determine factors associated with the percentage of Medicare patients in a practice and the acceptance of all new Medicare patients, respectively. RESULTS: Two thirds of physicians were accepting all new Medicare patients, whereas 16% were accepting no new Medicare patients. Factors associated with having a higher percentage of Medicare patients in a practice were as follows: (1) a larger proportion of Medicare recipients in the county, (2) practice as a general internal medicine physician, (3) more years in practice at the current location, (4) greater enjoyment treating elderly patients, (5) less concern about having too many Medicare patients, and (6) a stronger belief that the Medicare program respects their professional judgment. Physicians less concerned about having too many Medicare patients in their practice and physicians in counties with a higher percentage of Medicare patients were significantly more likely to accept all new Medicare patients. CONCLUSIONS: These results suggest that as Medicare reforms are discussed, careful consideration of the impact of these reforms on noneconomic issues is important to ensure adequate physician participation and access for elderly patients through the Medicare program.

Adult↗
PubMed2004

An analysis of Medicare's Incentive Payment program for physicians in health professional shortage areas.

CONTEXT: Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. PURPOSE: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program's utilization and which types of physicians received payments. METHODS: Retrospective cohort design, utilizing complete 1998 Medicare Part B data. Physician specialty was determined through American Medical Association data. Rural status was determined by linking the physician business ZIP code to its Rural-Urban Commuting Area code (RUCA). FINDINGS: There were 2,220,275 patients and 39,749 providers in the cohort, including 9,769 (24.6%) generalists, 21,331 (53.7%) specialists, and 8,649 (21.8%) nonphysician providers. Over $4 million in bonus payments (median payment = $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites. CONCLUSIONS: The MIP bonus payments given to providers are small. Many providers who should have claimed the bonus did not, and many providers who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers, rather than rewarding all providers equally. Policy makers should also consider a system that prospectively determines provider eligibility.

Alaska↗
PubMedDate not supplied

Medicare physician payment changes: impact on physicians and beneficiaries.

The Balanced Budget Act (BBA) of 1997 generally reduced Medicare payments for surgical services while increasing them for other services. Concern about implications of these fee reductions prompted the Medicare Payment Advisory Commission to sponsor a national survey of physicians to learn their views on Medicare payment and whether access to care has changed for Medicare beneficiaries. Results suggest that beneficiaries' access to care has not declined. While physicians are concerned about Medicare reimbursement, they are more concerned about reimbursement from managed care plans and Medicaid. Continued monitoring will be important to detect any emerging access problems accompanying upcoming payment reductions.

Aged↗
PubMedDate not supplied

Shortcomings in Medicare bonus payments for physicians in underserved areas.

This study examines trends in Medicare spending for basic payments and bonus payments for physician services provided to beneficiaries residing in nonmetropolitan counties. For our analysis, we used Medicare Part B physician/supplier claims data for 1992, 1994, 1996, and 1998. Payments under the congressionally mandated bonus payment program acccounted for less than 1 percent of expenditures for physician services in nonmetropolitan, underserved counties. Physician payments increased from 1992 to 1998, while bonus payments increased through 1996 but then declined by 13 percent by 1998. The share of bonus payments to primary care physicians declined throughout the decade, but the share for primary care services increased.

Humans↗