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PubMed1997

Preventive services in a Medicare managed care environment.

The results of a four year demonstration project of preventive services for Medicare managed care enrollees suggest that health promotion programs can impact health behaviors and outcomes. The study provided selected preventive services to 1,800 Medicare enrollees in a managed care environment. Participants were randomly assigned to control and experimental groups with the experimental group receiving an intervention service package and the control group usual care. The results included enhanced health behavior practices, lower depression, and higher immunization rates among those individuals in the experimental group. This study suggests that selected preventive services can be provided in a managed care environment to Medicare enrollees with likely positive health status and utilization outcomes.

Aged↗
PubMed1996

The expanded racial and ethnic codes in the Medicare data files: their completeness of coverage and accuracy.

OBJECTIVES: This paper evaluates the new race/ethnicity codes for Asian Americans, Hispanics, and Native Americans that have recently been added to the Medicare enrollment database. METHODS: The race/ethnicity code revisions made by the Health Care Financing Administration are described and evaluated by (1) comparing the numbers of persons identified as Asian Americans, Hispanics, and Native Americans with corresponding population census projections and (2) determining whether Medicare enrollees born in Asian and Hispanic countries are assigned Asian and Hispanic codes. RESULTS: Among persons 65 years of age and older, approximately 24% of Hispanics, 17% of Native Americans, and 56% of Asian Americans are identifiable by the new codes. From 18% to 29% of enrollees 65 years old or older born in Mexico, Puerto Rico, and Cuba are coded as Hispanic, and from 14% to 73% of enrollees born in nine Asian countries are classified as Asian American. Classification is not random but is related to timing of migration and to country of origin. CONCLUSIONS: Researchers should resist the temptation to base analyses on the revised Health Care Financing Administration race/ethnicity codes, since coverage is incomplete and biased.

Adolescent↗
PubMed1992

Change in the Medicare case-mix index in the 1980s and the effect of the prospective payment system.

Persistent increases in the Medicare case-mix index over the 1980s have been ascribed to changes both in medical treatment ("real changes") and in the way medical information is recorded ("coding changes") in hospitals. These changes have been attributed, in the absence of appropriate data and analyses, to the incentives of the Medicare prospective payment system (PPS). Using data for 1980-1986 from 235 hospitals, we estimate the effect on the Medicare case-mix index of a series of variables that reflect medical treatments and coding practices. Each of these underlying real or coding variables was changing prior to PPS and would likely have continued to change even in the absence of PPS. Furthermore, PPS may have had a distinct effect on these variables. These underlying trends and the PPS effects must each be estimated. Thus, the analysis begins by developing separate estimates for each of these real and coding variables (1) in the absence of PPS (autonomous effects) and (2) as a result of PPS (induced effects). Then, changes in the case-mix index are regressed against all of these variables to determine the degree to which specific autonomous real or coding variables or induced real or coding variables actually influenced measured case mix. Results show that real and coding changes each accounted for about half of the change in the Medicare case-mix index between 1980 and 1986, with the influence of coding starting to wane by 1986. PPS-induced factors explain about 80 percent of the change in measured case mix over time, autonomous factors about 20 percent. Especially powerful determinants of case-mix change included PPS-induced substitution of surgical for medical care and PPS-induced improvements in the accuracy of coding that led to assignment of patients to higher-weighted DRGs. Also, stringent Medicare peer review organizations appeared to restrain rises in case-mix indexes for their hospitals. Outpatient substitution for inpatient treatment, which others attributed to PPS, was well underway before PPS was announced.

Abstracting and Indexing↗
PubMedDate not supplied

The cost-effectiveness of beta-radiation therapy for treatment of in-stent restenosis: an analysis at 290-day follow-up.

PURPOSE: We studied the cost-effectiveness of percutaneous coronary intervention (PCI) plus beta-radiation (Radiotherapy) vs. PCI alone for treating in-stent restenosis. METHODS AND MATERIALS: We analyzed medical resource data collected at US sites during the Intimal Hyperplasia Inhibition with beta In-stent Trial (INHIBIT) to compare the incremental costs between Radiotherapy and PCI alone for each repeat target lesion revascularization (TLR) avoided. Costs were assigned for cardiac-related medical services using the Medicare payer perspective. RESULTS: Radiotherapy increased initial inpatient costs by US$3360 (P<.001). In the Radiotherapy and PCI alone groups, the mean per-patient rates for TLR were 0.13 vs. 0.30 (P=.001), and mean per-patient total costs were US$19,286 vs. US$18,349 (P<.001), respectively. The incremental cost of Radiotherapy relative to PCI alone was US$5512 per TLR avoided, which compares favorably to the observed mean per-patient cost of treating restenosis (US$16,852). CONCLUSIONS: beta-radiation is a cost-effective adjunct to PCI in treating patients with in-stent restenosis.

Aged↗
PubMed2002

Vasopeptidase inhibitor reduces inhospital costs for patients with congestive heart failure: results from the IMPRESS trial. Inhibition of Metallo Protease by BMS-186716 in a Randomized Exercise and Symptoms Study in Subjects With Heart Failure.

BACKGROUND: The Inhibition of Metallo Protease by BMS-186716 in a Randomized Exercise and Symptoms Study in Subjects With Heart Failure (IMPRESS) clinical trial randomized patients with congestive heart failure to a daily regimen of either omapatrilat or lisinopril. At 24 weeks, patients randomized to omapatrilat had a significant reduction in the combined end point of death, hospitalization, or discontinuation of study drug for worsening heart failure when compared with patients randomized to lisinopril. They also had significantly fewer serious cardiac adverse events. OBJECTIVE: This study sought to determine the economic consequences of the lower event rates of patients who were given omapatrilat. METHODS: Economic outcomes (major hospitalizations and their associated medical costs) were compared between treatment groups and assessed by use of the societal perspective. Hospitalization information was obtained from the IMPRESS trial's standardized case report and serious adverse event forms. Hospital costs were evaluated by means of assigning each hospital admission a diagnosis-related group and an average cost for physician and hospital services. Emergency department visits were included only when they were made for worsening heart failure and were assigned costs equivalent to the average hospital and physician Medicare reimbursement for these visits in Duke University Medical Center's heart failure program. Drug costs were not assessed. RESULTS: Although the typical patient in both treatment groups was event-free, there was a trend toward a greater number of hospitalizations in the patients given lisinopril than in the patients given omapatrilat (P =.07). Differences in the distribution of cardiac hospitalizations between patients given lisinopril and patients given omapatrilat were significant (P =.03). There was a trend toward lower medical costs at 24 weeks in patients given omapatrilat versus patients given lisinopril ($1930 vs $2002, P =.09). Considering only cardiac medical costs, this trend toward reduced medical costs was significant ($1240 vs $1442, P =.03). CONCLUSIONS: At 24 weeks, patients with heart failure treated with omapatrilat had fewer hospitalizations and lower medical costs than patients treated with lisinopril. However, drug treatment costs were not available for this analysis.

Cardiotonic Agents↗
PubMed1998

In their own words. Practice expenses and the resource-based relative value scale.

Dr. Opelka is a member of the College's CPT/RUC Committee, which makes recommendations about general surgery codes that should be added to, revised, or deleted from the CPT Manual. The committee also develops recommendations for the relative work values assigned to the general surgery services listed in the Medicare fee schedule. Because of his deep knowledge of the Medicare payment system, Dr. Opelka has frequently represented the College on panels convened by the federal government and in meetings with federal officials. In particular, he served recently on expert panels convened by the Health Care Financing Administration (HCFA) to develop direct cost data for the purpose of calculating resource-based practice expense relative values, which are scheduled to be incorporated into the Medicare fee schedule over a four-year period beginning in 1999. Dr. Opelka also participated in meetings that the General Accounting Office (GAO) requested with the College as part of its review of the methods being used by HCFA to generate the new practice expense values. Following are some of Dr. Opelka's thoughts about the federal government's efforts in this area.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Payment for using new technologies. Why it's hard to find the essential information that you need.

As methods of paying for care grow in complexity, estimating a new technology's potential for generation of revenue becomes more difficult. Among the important factors are the inpatient DRG that is assigned, the device's FDA approval status, and whether Medicare and other third parties will pay the physician fee that is often involved with the device's use. Finding precise information about some of these factors is difficult; hospital associations could help by seeking improvements in the ways in which payment decisions are made.

Diagnosis-Related Groups↗
PubMed1989

Does the dissemination of comparative data on physician fees affect consumer use of services?

The purpose of this study is to empirically examine the effect of disseminating physician-fee information on consumer behavior. Using an experimental design, the effect of access to physician-fee information on rates of doctor-office visits, expenditures for ambulatory care, and costs per visit are examined. The study includes two research samples: a random sample of 658 state government employees and a random sample of 717 Medicare Part B enrollees. Respondents in each sample were randomly assigned to experimental and control groups, with members of the experimental groups receiving a directory listing the fees charged by local physicians for common procedures. Longitudinal archival and survey data are used in the analysis. Findings reveal that the dissemination of fee data does not yield significant reductions in utilization or expenditures. Policy and research implications are discussed.

Adult↗
PubMed1998

TRICARE senior demonstration of military managed care--DOD. Notice of demonstration project.

This notice is to advise interested parties of a demonstration project in which the Department of Defense (DoD) will provide health care services to Medicare-eligible military retirees in a managed care program, called TRICARE Senior, and receive reimbursement for such care from the Medicare Trust Fund. The program is authorized by section 1896 of the Social Security Act, amended by section 4015 of the Balanced Budget Act of 1997 (P.L. 105-33). The statue authorizes DoD and the Department of Health and Human Services (HHS) to conduct at six sites during January 1998 through December 2000, a three-year demonstration under which dual-eligible beneficiaries will be offered enrollment in a DoD-operated managed care plan, called TRICARE Senior Prime. The legislation also authorizes Medicare HMOs to make payments to DoD for care provided to HMO enrollees by military treatment facilities (MTFs) participating in the demonstration. This part of the demonstration, to be called Medicare Partners, will allow DoD to enter into contracts with Medicare HMOs to provide specialty and impatient care to dual-eligible beneficiaries currently provided on a space-available basis. Additional legal authority pertinent to this demonstration project is 10 U.S.C. section 1092. Under TRICARE Senior Prime, Medicare-eligible military retirees who enroll in the program will be assigned primary care manager (PCMs) at the MTF. Enrollees will be referred to specialty care providers at the MTF and to participating members of the existing TRICARE Prime network. TRICARE Senior Prime enrollees will be afforded the same priority access to MTF care as military retiree and retiree family member enrollees in TRICARE Prime. DoD will receive reimbursement from HCFA on a capitated basis at a rate which is 95 percent of the rate HCFA currently pays to Medicare-risk HMOs, less costs such as capital and graduate medical education, disproportionate share hospital payments, and some capital costs, which are already covered by DoD's annual appropriation. However, under the authorizing statute, DoD must meet its current level of effort for its Medicare-eligible beneficiaries before receiving payments from the Medicare Trust Fund. That is, DoD must continue to fund health care at a certain expenditure level for its Medicare-eligible population before it may be reimbursed by HCFA for care provided to TRICARE Senior Prime enrollees. The Balanced Budget Act of 1997 required DoD and HHS to complete a memorandum of agreement (MOA) specifying the operational requirements of the demonstration project. That MOA was completed on February 13, 1998, and is published below. Except as provided in the MOA, TRICARE Senior Prime will be implemented consistent with applicable provisions of the CHAMPUS/TRICARE regulation, particularly 32 CFR sections 199.17 and 199.18.

Aged↗
PubMed1985

Cost containment in medicine: why cardiology?

In 1984, expenditures for health care in the United States were nearly $350 billion, more than 10% of the gross national product, and continued increases exceeding the general economic growth are projected. Cardiology and cardiovascular surgery represent a large part of this cost, reflecting the many new diagnostic and therapeutic procedures developed over the past 2 decades. Previous cost containment attempts failed because they provided no incentive to reduce spending for advanced technologies and procedures. A method of payment based on a case mix of 467 diagnosis related groups (DRGs), average duration of hospital stay and location of hospitals has been developed for Medicare. A 4-year trial using this method in New Jersey resulted in lower hospital costs per capita than in the rest of the country. In October 1983, a 3-year phase-in for all Medicare payments by the DRG method began. The 43 DRGs assigned to cardiology and cardiovascular surgery are among the highest-weighted for large reimbursement; thus, with the great number of aging patients with cardiac diagnoses, cardiology represents a very large share of the cost of medical care today. Because the quality of care can be determined and compared directly with costs, cardiology DRGs lend themselves to careful analysis. Three components will be examined. Coronary bypass surgery is the largest single reimbursement, thus the rationale for its use should be carefully studied. Coronary care units have markedly increased hospital costs for acute myocardial infarction, but have also improved care.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiology↗
PubMed1992

Medicare and Medicaid programs; approved information collection requirements and HCFA's claims collection authority--HCFA. Final rule with comment period.

This final rule updates our display of control numbers assigned by the Office of Management and Budget (OMB) to approved "collection of information" requirements contained in regulations governing the Medicare and Medicaid programs. In addition, it incorporates a technical change to our regulations to reflect increased agency authority under the Federal Claims Collection Act, 31 U.S.C. 3711 et seq. This rule is issued in accordance with OMB regulations concerning approved collections of information and to conform to changes made by Public Law 101-552.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1982

Medicare program; statistical standards for evaluating intermediary performance during fiscal year 1982--Health Care Financing Administration. General notice with comment period.

This is HCFAs annual notice containing statistical standards to be used for evaluating the performance of fiscal intermediaries in the administration of the Medicare program for fiscal year 1982. The standards were developed from available statistical data contained in routine intermediary reports and consists of measures of timeliness and of cost of an intermediary's Medicare operations. The results of the evaluations are considered whenever we make, renew or terminate an intermediary agreement; assign or reassing providers of services to an intermediary; or designate regional or national intermediaries.

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