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PubMed1993

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1994--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1993. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (for example, assigning or reassigning providers of services to an intermediary, or designating regional or national intermediaries). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act. We are publishing for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.

Contract Services↗
PubMed1980

Health Care Financing Administration--Medicare program; intermediary nominations, contracts, evaluations, and notices. Final regulation.

These final regulations establish criteria and standards for evaluating the performance of agencies or organizations serving or desiring to serve as fiscal intermediaries under the Medicare program. They also authorize the Administrator to assign or reassign providers of services to particular intermediaries or to designate a single intermediary to serve a class of providers on a regional or national basis after considering intermediary performance measured against the criteria and standards. Affected providers and intermediaries will be given a notice of assignment or reassignment and intermediaries will be afforded a hearing. The purpose of these regulations is to promote increased efficiency in the administration of the Medicare program.

Insurance↗
PubMed1993

Medicare. An administrative viewpoint.

Medicare was the first significant legislation that provided a health insurance program for a segment of our nation's population, initially for the elderly population and then expanded to include other chronically ill patients that in a sense are high risk. It provided a recognition for the special services of doctors of podiatric medicine as equivalent to the services provided by other practitioners. What we fail to recognize many times is that Congress, as representatives of the people, projected a need for podiatric care in this particular entitlement program. It provides a scope of practice for podiatrists that is governed by state law, which also is a mandate of the people. The individual state practice acts are again the will of the people through their state legislatures, which established the need and recognition for podiatric care. The system designed by Medicare provides for fiscal intermediaries, who are the insurance carriers that administer the program. Each carrier then establishes its own guidelines to deal with the medical policies of the program. The local guidelines for each state or area are additional documents that need to be reviewed for local modifications of the Medicare regulations. There are four options for patient payment: assignment, direct payment by the patient, billing the patient followed by patient payment upon receipt of his or her Medicare payment, or the selection of a health maintenance organization or similar private insurance option. Under this fourth option, the patient gives up his or her right to direct podiatric care, which is clearly a violation of the intent of the legislation that added podiatric medicine to Medicare in 1967. Given the changes that take place in any system, the original intent of Medicare was to provide an availability and access for podiatric care as required by the patient. To modify the system to change that intent without a change in law is morally, ethically, and legally questionable.

Aged↗
PubMed1989

Act now to maximize Medicare payments for capital.

Anticipating a change in the way Medicare pays for capital costs, healthcare organizations should evaluate their capital expenditure plans. To maximize payments under the current system, they should create an equipment acquisition plan that brings the greatest capital costs during the equipment's early life. They then should determine a cost allocation method that assigns the greatest allowable capital costs to Medicare.

Capital Expenditures↗
PubMed1988

Medicare program; conditions for Medicare payment--HCFA. Final rule with comment period.

These rules are part of our ongoing project to assign a separate part of this chapter for each major aspect of the Medicare program. They also--Modify the requirements that a home health agency (HHA) must meet to be classified as a "sole community HHA". Clarify and simplify previous regulations (without substantive change) so that they are easier to understand and apply. Incorporate procedural changes that were put into effect to reduce paperwork and permit more efficient processing of Medicare claims.

Aged↗
PubMed2000

Hospital cost of endovascular versus open repair of abdominal aortic aneurysms: a multicenter study.

BACKGROUND: Technology-driven innovation in medicine is frequently associated with higher costs than conventional therapy. A significantly higher cost for endovascular ($21,250, n = 190) versus open abdominal aortic aneurysm (AAA) repair ($12,342, n = 60) was suggested by a direct cost analysis of patients in a multicenter trial. Estimated inpatient costs (not charges) incurred nationwide by hospitals for endovascular and open repair of AAA were studied to validate these observed trends. METHODS: A retrospective analysis of 131 patients undergoing endovascular AAA repair was compared with 49 patients undergoing open repair as part of a Food and Drug Administration phase II prospective multicenter clinical investigation (AneuRx-Medtronic). A model to estimate costs was constructed using important clinical descriptors of these patients. These clinical characteristics where then matched with those from 22, 460 patients undergoing AAA repair obtained from a large national database (Medicare Provider Analysis and Review). Estimated hospital cost was then assigned to each study patient according to the national average of the total hospital costs for the respective matched patients in Medicare Provider Analysis and Review. RESULTS: Total inpatient hospital costs of endovascular repair were significantly higher than that of open repair ($19,985 +/- 7396 versus $12,546 +/- 5944, respectively, P =.0001). Endograft device cost ($10,400) accounted for 52% of the total cost of endovascular repair. The 1999 mean blended Medicare reimbursement for AAA repair was $18,989. CONCLUSION: In this early development stage, hospital cost for endovascular AAA repair is significantly greater than open repair when device cost greatly exceeds $5000. Although incremental reductions in cost of endovascular repair may be anticipated if use of diagnostic studies, operating time, and length of stay decrease, device cost has the single greatest impact on the expense of endovascular AAA repair. At current device pricing, mean blended Medicare reimbursement does not cover the cost of endovascular AAA repair.

Aged↗
PubMed1993

Quality of care problems among Medicare patients in New York State.

The Island Peer Review Organization is the peer review organization in New York State and is under contract with the Health Care Financing Administration to monitor the quality of care rendered to Medicare patients. A severity level III is assigned when a confirmed quality problem with significant adverse effects for the patient is confirmed. A severity level II is assigned when a confirmed quality problem with the potential for significant adverse effects on the patient is found. The purpose of this study was to retrospectively analyze all 85 severity level III citations and a 12% (223) random sample of the 1,880 severity level II citations for 1991. Another objective was to characterize the providers involved in each of these two levels of quality of care problems. Among the 85 severity level III citations, 34 (40.0%) involved premature death and 33 (38.8%) readmission. Treatment (45.0%), diagnostic (16.9%), and monitoring (16.4%) problems accounted for 78.3% of the 189 problems identified in severity level III citations. The leading problem areas were the treatment of infections and the use of antibiotics (21.2%), fluid and electrolyte management (21.2%), drug use (9.4%), the use of endotracheal tubes (5.9%), the management of diabetes mellitus (5.9%), and the management of hematologic disorders (5.9%). Attending physicians (65.9%), nursing departments (16.5%), and resident physicians (7.1%) were involved in the vast majority (89.5%) of severity level III citations. Treatment problems comprised 60.5% of the 243 problems found in severity level II citations, followed by inadequate work-up (20.2%), and incomplete documentation (12.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

Health Services Misuse↗
PubMed2002

"My patients are sicker:" using the Pra risk survey for case finding and examining primary care site utilization patterns in a medicare-risk MCO.

BACKGROUND: The probability of repeat admissions (Pra) survey is a case-finding tool designed to identify elderly persons at risk for hospitalization. Little is known about the ability of the Pra to assess utilization patterns in a managed care setting. OBJECTIVES: To assess the ability of the Pra survey to identify elders at risk for increased healthcare costs and to determine the utility of this tool in predicting mean per member per year (PMPY) claims among primary care sites in a managed care setting. STUDY DESIGN: Mean PMPY paid claims, inpatient admissions, and inpatient days were compared for survey respondents with high, medium, and low Pra scores. Linear regression was used to examine the correlation (R2) between the mean Pra score for respondents and the percentage of high Pra score respondents at each primary care site in the HMO and the sites' mean PMPY paid claims. METHODS: From a single Medicare-risk health maintenance organization (HMO) with approximately 25,000 members and 234 primary care sites in northeastern and central Pennsylvania, we contacted 24,947 enrollees about the Pra survey. A total of 17,484 (70.1%) patients in 159 of 234 (67.9%) primary care sites responded to the survey. Of these, 17,469 (99%) surveys could be scored. RESULTS: The mean Pra score in this population was 0.27 (standard deviation = 0.108). Pra scores were stratified as follows: 4.5%, 24.1%, and 71.4% of respondents scored high (20.5), moderate (> or = 0.3 and <0.5), and low (<0.3), respectively. Patients with high Pra scores had a mean of $12,611 in PMPY claims, versus $6944 and $3038 for moderate and low scores respectively (P < .0001). The R2 between the mean Pra score for respondents at each primary care site and the sites' mean PMPY Medicare-risk claims was 0.042. If survey respondents assigned to 6 specialty care sites (hematology, oncology, rheumatology, endocrinology, nephrology, and pulmonary medicine) are included, the R2 increased to 0.176. The R2 between the percentage of high-risk individuals with a Pra score of 0.5 or higher at each primary care site and the sites' mean PMPY Medicare-risk claims was 0.0005. CONCLUSIONS: In this Medicare-risk HMO population, the Pra survey successfully performed 2 functions: (1) the prospective identification of enrollees at risk for increased healthcare utilization and (2) identification of patient factors that accounted for as much as 17.6% of the variation in utilization between primary sites.

Aged↗
PubMed2003

Potential impact of the new medicare prospective payment system on reimbursement for traumatic brain injury inpatient rehabilitation.

OBJECTIVE: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation. DESIGN: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria. SETTING: Fourteen urban rehabilitation facilities throughout the United States. PARTICIPANTS: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes. RESULTS: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients. CONCLUSIONS: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.

Adult↗
PubMed1989

DRG "creep". Pitfalls and sanctions to avoid.

In 1983, with the advent of the Medicare prospective payment system, the physician's role became crucial in determining a hospital's reimbursement for treatment of a Medicare patient. The correct diagnosis-related group assignment depends upon the physician's accurate designation of the primary and secondary discharge diagnoses. Manipulation of this information can result in an inaccurate payment, and the physician is ultimately responsible for the misrepresentation. Physicians' recognition of the importance of their responsibility to designate complete and accurate diagnostic and procedural information can help avoid problems, including the potential for sanctions against physicians who unwittingly contribute to fraud and abuse.

Crime↗
PubMed2002

Health insurance knowledge among Medicare beneficiaries.

OBJECTIVE: To assess the effect of new consumer information materials about the Medicare program on beneficiary knowledge of their health care coverage under the Medicare system. DATA SOURCE: A telephone survey of 2,107 Medicare beneficiaries in the 10-county Kansas City metropolitan statistical area. STUDY DESIGN: Beneficiaries were randomly assigned to a control group and three treatment groups each receiving a different set of Medicare informational materials. The "handbook-only" group received the Health Care Financing Administration's new Medicare & You 1999 handbook. The "bulletin" group received an abbreviated version of the handbook, and the "handbook + CAHPS" group received the Medicare & You handbook plus the Consumer Assessment of Health Plans (CAHPS) survey report comparing the quality of health care provided by Medicare HMOs. Beneficiaries interested in receiving information were oversampled. DATA COLLECTION METHODS: Data were collected during two separate telephone surveys of Medicare beneficiaries: one survey of new beneficiaries and another survey of experienced beneficiaries. The intervention materials were mailed to sample members in advance of the interviews. Knowledge for the treatment groups was measured shortly after beneficiaries received the intervention materials. PRINCIPAL FINDINGS: Respondents' knowledge was measured using a psychometrically valid and reliable 15-item measure. Beneficiaries who received the intervention materials answered significantly more questions correctly than control group members. The effect on beneficiary knowledge of providing the information was modest for all intervention groups but varied for experienced beneficiaries only, depending on the intervention they received. CONCLUSIONS: The findings suggest that all of the new materials had a positive effect on beneficiary knowledge about Medicare and the Medicare + Choice program. While the absolute gain in knowledge was modest, it was greater than increases in knowledge associated with traditional Medicare information sources.

Aged↗
PubMed2002

Costs of treatment for elderly women with early-stage breast cancer in fee-for-service settings.

PURPOSE: This study provides population-based estimates of the treatment costs for elderly women with early-stage breast cancer, with emphasis on costs of modified radical mastectomy (MRM) compared with breast-conserving surgery (BCS) and radiation therapy (RT). PATIENTS AND METHODS: Women with breast cancer from the Surveillance, Epidemiology, and End Results cancer registries were linked with their Medicare claims, 1990 through 1998. Each claim was assigned to an initial, continuing, or terminal care phase after a cancer diagnosis. Mean monthly phase-specific costs were determined for all health care and for treatment related only to cancer. Cumulative long-term costs of care that accrue during a women's remaining lifetime were calculated by treatment group. RESULTS: Initial care costs for the 6 months after diagnosis for women who underwent BCS with RT were approximately $450 per month higher than for women with MRM. During the continuing-care phase, costs for women undergoing BCS with RT were significantly less expensive than for MRM cases. The two groups had similar costs in the terminal-care phase. Assuming the same survival distributions, long-term costs for women undergoing BCS with RT were not statistically different than for women undergoing MRM. CONCLUSION: Although mastectomy was less costly in the initial phase, the lifetime costs of BCS with RT and mastectomy were equivalent. Thus, women's preferences, resources to cover out-of-pocket costs, and life situations should be the major factors addressed in shared decision making about treatment options.

Aged↗
PubMed1995

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes.

OBJECTIVES: To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards. STUDY DESIGN: A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991. SETTING: All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980). PATIENTS: All elderly (> or = 65 years) Medicare patients seen by the study physicians and assigned a diagnosis of diabetes (n = 97,388) by any office-based physician during the year. MAIN OUTCOME MEASURES: The proportion of patients with diabetes receiving the following procedures (from any provider) at least once during the study period: hemoglobin A1C measurement, ophthalmologic examination, total cholesterol measurement, and blood glucose measurement. We considered the first three services to be optimally recommended and blood glucose measurement to be of limited use. RESULTS: Based on analyses of services provided in the ambulatory setting, we found that 84% of diabetics did not appear to receive the recommended hemoglobin A1C measurement, 54% did not see an ophthalmologist, and 45% received no cholesterol screening. Practice patterns varied considerably across the three states (up to 2.38-fold), even after adjusting for patient case mix and physician characteristics. Patients of general practitioners were less likely to meet recommended quality criteria than patients of internists or family practitioners. Patients receiving care from rural practitioners were less likely to receive services, either recommended or not, than those in urban locations. CONCLUSIONS: Elderly patients with diabetes do not appear to be receiving optimal care. This study underscores the value of practice guideline development and dissemination in the ambulatory arena. This study provides substantial evidence that existing administrative claims data can be used to support ambulatory quality improvement activities.

Aged↗
PubMed2005

Development and assessment of a Web-based evaluation and management coding curriculum for residents.

OBJECTIVE: The purpose was to assess a Web-based learning module for residents on evaluation and management coding, and to determine whether using a point system based on reimbursement is an effective way to measure improvement in performance. STUDY DESIGN: Nineteen residents at a university-based residency completed an online module on evaluation and management coding. Pretest and posttest were administered consisting of 10 actual patient notes from which to abstract the level of service. Tests were scored by percent correct as well as assigning points to correct responses equal to 2004 Medicare reimbursement for that item's level of service. Incorrect responses were debited points equal to the absolute difference in reimbursement between the incorrect and correct evaluation and management level. RESULTS: Average percent correct was 44.2 on the pretest and 45.3 on the posttest (P = 1.0), with only 47% of subjects improving their performance. The mean point score was 513.44 on the pretest and 555.87 on the posttest (P = .02), with 84% improving. Most subjects (84%) rated the module equal or superior to a didactic format and felt that their knowledge was improved by the exercise. CONCLUSION: An electronic learning module on evaluation and management coding for residents, using scoring based on reimbursement schedules, is effective for instruction and assessment and well accepted by learners.

Curriculum↗
PubMed1993

How accurate are hospital discharge data for evaluating effectiveness of care?

Demand for quality of care data has led to publication of adjusted mortality rates of hospitals and physicians. Yet the accuracy of databases used for this purpose is questionable, raising the possibility that consumer-oriented profiles of providers could be misleading. A stratified random sample of discharge abstract records of Medicare-aged patients hospitalized in California were audited by the state's health data agency. The results of the audit were analyzed to determine the effect that coding errors have on expected death rates assigned to hospitals as risk-adjustment measures in the annual Medicare hospital mortality report. Discharge abstracts of Medicare-aged patients contained many errors among coded risk factors used to calculate expected death rates. Comorbidities and transfers from nursing homes were seriously underreported and 'urgency of admission' was often miscoded. Hospitals differed with respect to error rates (P < .0001); these varying levels of miscoding caused measurement errors that ranged in size from 0.2 to 2.2 expected 30-day deaths per 100 admissions (10th vs. 90th percentile). Detailed knowledge of the limitations of claims data can help analysts minimize the impact of coding error. Beyond this, quality control of data used for outcomes research needs strengthening.

Abstracting and Indexing↗
PubMed2001

Medicare program; civil money penalties, assessments, and revised sanction authorities. Final rule with comment period.

This final rule with comment period is a technical rule that updates our civil money penalty (CMP) regulations to add CMP authorities already enacted as part of the Balanced Budget Act of 1997 (BBA) and delegated to us. The rule delineates our authority to assess penalties for: failure to bill outpatient therapy services or comprehensive outpatient rehabilitation services (CORS) on an assignment-related basis, failure to bill ambulance services on an assignment-related basis, failure to provide an itemized statement for Medicare items and services to a Medicare beneficiary upon his/her request, and failure of physicians or nonphysician practitioners to provide diagnostic codes for items or services they furnish or failure to provide this information to the entity furnishing the item or service ordered by the practitioner. The rule also contains technical changes to further conform our current CMP rules to changes in the statute enacted by the BBA.

Ambulances↗