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PubMed2006

Nurse care coordination in community-based long-term care.

PURPOSE: To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO). DESIGN: A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination. METHODS: Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes. FINDINGS: At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months. CONCLUSIONS: Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

Activities of Daily Living↗
PubMed1997

The effects of predetermined payment rates for Medicare home healthcare.

OBJECTIVE: To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING: Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms. STUDY DESIGN: The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences. PRINCIPAL FINDINGS: Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services. CONCLUSION: Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1981

A priority assignment model for standards and conditions in a long term care survey.

Presently a survey document is used in New York State to enforce Federal and State regulatory standards for long term care facilities (skilled nursing facilities and related facilities). This document is used to establish Medicare and Medicaid certification for these facilities. This study describes the creation of a new survey process---a first stage consisting of a screening survey followed, if necessary, by an intensive survey. A priority assignment model which utilizes the judgments of experts from the New York State Office of Health Systems Management (OHSM) has been developed. This model is employed to develop ranks, priority weights and classifications for the various standards and the Federal conditions which the standards comprise (as well as equivalent State regulations). Saaty's Analytical Hierarchy Process is used to obtain the ranks and priority weights. The consistency of the experts' judgements is measured using Kendall's coefficient of agreement. An optimal split algorithm is used to subdivide the standards and conditions according to impact (high, moderate or low) on patient care, health and safety. The results are to be used as a management tool in developing decision rules for defining the scope of the intensive survey on the basis of screening survey results.

Aged↗
PubMedDate not supplied

Health promotion and disease prevention for older adults: opportunity for change or preaching to the converted?

Health promotion and disease prevention for the elderly offer the potential for improving the quality of life for the growing population of older adults, while reducing the economic burden on the health system. Whether this potential can be realized depends, in part, on whether those older adults whose health behaviors put them at risk actually use preventive services when offered the opportunity. In 1988 the Health Care Financing Administration began a series of health promotion demonstrations to address health issues related to older adults. This article reports on program participation at one of the five demonstration sites. Over 1,900 community-dwelling Medicare beneficiaries who receive their health care through fee-for-service providers were enrolled in the demonstration. These enrollees were randomly assigned to control and experimental groups, with the latter offered health screening and promotion services. Nine hundred-seventy-three of the experimental subjects and 938 of the control subjects completed a lengthy telephone interview, which determined each person's use of preventive services and practices. Although all 973 experimental subjects were invited by letter and follow-up telephone calls to attend these free-of-charge, Medicare-provided sessions, not everyone attended. We analyzed 17 health behaviors of those who attended the first session and those who did not. Those engaging in these preventive behaviors were neither more nor less likely to attend the screening services. Thus, we found neither "favorable" nor "unfavorable" selection bias in the use of these preventive services.

Adult↗
PubMed1994

Is cost a barrier to screening mammography for low-income women receiving Medicare benefits? A randomized trial.

BACKGROUND: In 1991, Medicare began covering screening mammograms subject to copayment and deductible. This study evaluated the effectiveness of Medicare in removing financial barriers to screening mammography among low-income older women. METHODS: In an inner-city public hospital's General Medicine Clinic, 119 consecutive, eligible, and consenting Medicare-enrolled women without known risk factors for breast cancer other than age, and no mammogram in the previous 2 years, were entered into a randomized controlled trial with follow-up after 2 months. The mean age was 71 years; 77% were black, 92% had an annual income below $10,000, and 52% had had a previous mammogram. All patients were counseled concerning indications for screening mammograms and Medicare coverage, and all were referred to a low-cost mammography facility. Sixty-one subjects were randomly assigned a voucher for a free screening mammogram at the referral facility. Obtaining a mammogram within 60 days of study entry was the main outcome measure. RESULTS: Of the women given vouchers, 27 (44%) obtained screening mammograms, compared with six (10%) of those without vouchers (P < .001). Adjustment by multiple logistic regression confirmed this association, yielding an adjusted odds ratio of 7.4 (95% confidence interval, 2.5 to 21.4). Knowledge concerning mammography and breast cancer increased significantly overall (and within randomization groups) between initial interview and follow-up; fear did not change. For women without the voucher, the main reason for not obtaining a mammogram was financial; the main reason for women with the voucher was transportation. CONCLUSION: In a low-income, inner-city population of older women, financial barriers to screening mammography persist despite Medicare coverage.

Aged↗
PubMed1985

Community based analysis of Medicare inpatient utilization: DRG 468.

This study of Medicare inpatients in Syracuse, New York; demonstrated that most DRG 468 discharges were produced by a limited range of procedures and diagnoses. It also showed that patients were assigned to DRG 468 because of procedures wholly unrelated to the principal diagnoses, procedures that resulted from systemic difficulties, and procedures clinically unrelated to principal diagnoses which were assigned to different MDCs by DRG logic.

Catchment Area, Health↗
PubMed1991

Laboratory data predicts survival post hospitalization.

From a database of 93,077 in-patient admissions, patients assigned to catastrophic, very severe, moderately severe, and average 30-day mortality risk categories (as defined in Medicare Hospital Mortality Information, 1989 release, from the Health Care Financing Administration (HCFA] were selected for study. These admissions account for 30% of all admissions, but 70% of all deaths up to 1 year post admission. To determine whether laboratory information adds to the predictive power of the information used by HCFA, we compare the performance of 1 year survival predictors (Cox model) that use only diagnostic, demographic, and comorbidity information, with the performance of predictors that also include laboratory information. Using a separate set of patients not used for model definition, we find that laboratory data contain significant prognostic information independent of that already available in non-laboratory data. In HCFA's catastrophic disorders for example, non-laboratory information reduces the average risk of predicting a wrong outcome by 17% relative to considering only catastrophic group membership, and adding laboratory data reduces this risk by a further 21%. These improvements result primarily from considering the outcomes of a small set of routine laboratory tests (maximum BUN, AST, and WBC, and minimum CO2, hematocrit, and sodium).

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

Health plan budget impact analysis for pimecrolimus.

OBJECTIVE: Budget impact models are useful tools for managed care organizations to make drug formulary decisions. The objective of this study was to estimate the incremental budgetary change in per-member-per-month (PMPM) medical and pharmacy costs for atopic dermatitis (AD) or eczema after the introduction of pimecrolimus cream 1%, a topical calcineurin inhibitor. METHODS: Estimates of the percentage of patients seeking care, treatment patterns, and quantities of medications dispensed for AD were measured using 2001 and 2002 medical and pharmacy records in a proprietary database for health plans distributed throughout the United States. Approximately 2.5 million health plan members had continuous health insurance coverage during the study period. Costs for medications were assigned using the 2003 wholesale acquisition cost, and costs for physician visits were based on average 2003 Medicare reimbursement rates. Efficacy data from clinical trials were used to model the impact of pimecrolimus on subsequent physician visits. Sensitivity analyses were performed to evaluate the impact of varying the percentage of patients seeking care, practice patterns, medication quantities, percentage of pimecrolimus users, and levels of patient cost sharing. RESULTS: The estimated percentage of health plan members seeking care for AD in 2001 was 3.2%. The estimated total cost PMPM for AD treatment prior to introduction of pimecrolimus was 0.362 dollars for all covered lives, assuming no patient cost sharing. In the year after its introduction, 5.2% of the AD population filled a prescription for pimecrolimus. The incremental increase in pharmacy benefit cost was 0.008 dollars PMPM in 2003 dollars, but the total incremental medical and pharmacy cost was 0.002 dollars PMPM after accounting for the projected reduction in physician visit costs, representing a 0.7% increase in all AD-related costs. Based on sensitivity analyses, the incremental total cost PMPM after the introduction of pimecrolimus ranged from -0.004 dollars to 0.026 dollars. CONCLUSION: Using claims data for the medical treatment of AD in 2001-2002 and the utilization of pimecrolimus, the addition of pimecrolimus as a treatment option for AD had a minimal impact on PMPM costs for AD-related care in 2003 dollars. As with all pharmacoeconomic models, health plans should perform their own budget forecasting using assumptions derived from their own pharmacy and medical claims data.

Budgets↗
PubMed1998

DRG benchmarking study establishes national coding norms.

With the increase in fraud and abuse investigations, healthcare financial managers should examine their organization's medical record coding procedures. The Federal government and third-party payers are looking specifically for improper billing of outpatient services, unbundling of procedures to increase payment, assigning higher-paying DRG codes for inpatient claims, and other abuses. A recent benchmarking study of Medicare Provider Analysis and Review (MEDPAR) data has established national norms for hospital coding and case mix based on DRGs and has revealed the majority of atypical coding cases fall into six DRG pairs. Organizations with a greater percentage of atypical cases--those more likely to be scrutinized by Federal investigators--will want to conduct suitable review and be sure appropriate documentation exists to justify the coding.

Abstracting and Indexing↗
PubMed1994

Do preset per visit payment rates affect home health agency behavior?

This article reports on preliminary impacts during the first year of a demonstration in which home health agencies (HHAs) were paid a prospectively set rate for each Medicare home health visit rendered, rather than being reimbursed for costs. Forty-seven agencies in five States participated. The evaluation compared the experiences of randomly assigned treatment agencies and their patients with those of control agencies and their patients and found no compelling evidence of any demonstration impact on agency cost per visit, the volume of home health services, agency revenue and profit, patient selection and retention, quality of care, or use and cost of Medicare services.

Costs and Cost Analysis↗
PubMed1985

Medicare program; utilization and quality control peer review organization (PRO) reconsiderations and appeals--HCFA. Final rule.

These regulations implement that portion of the Peer Review Improvement Act of 1982 that provides for reconsiderations and appeals of Utilization and Quality Control Peer Review Organization (PRO) initial determinations. We are establishing procedures for a PRO to reconsider both its initial denial determinations regarding the medical necessity, reasonableness and appropriateness of health care services furnished or proposed to be furnished to a Medicare beneficiary in a health care institution and the application of the limitation of liability provision. We are also including in this final rule procedures for administrative appeals to the Department following a PRO reconsidered determination and judicial review following administrative appeals. In addition, these regulations establish procedures for review of a PRO change in the diagnostic and procedural coding information that results in assignment of a discharge to a different diagnosis related group (DRG). This pertains to the review of claims for services furnished in hospitals reimbursed by Medicare under the prospective payment system.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1984

Medicare program; performance criteria and statistical standards for evaluating intermediary performance during fiscal year 1984--HCFA. Proposed notice.

This notice would update the performance criteria and statistical standards to be used for evaluating the performance of fiscal intermediaries in the administration of the Medicare program for fiscal year 1984. The performance criteria and statistical standards have been developed from available statistical data contained in routine intermediary reports; past performance results for the intermediaries; and from substantive input from the intermediary community, HCFA central office and HCFA regional offices. The results of these evaluations would be considered whenever we enter into, renew, or terminate an intermediary agreement; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries.

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

Questionnaire helps keep Medicare patients healthy.

An Illinois PHO association targets ill capitated Medicare enrollees early to prevent illnesses from getting worse and resulting in a high-cost medical episode. The health system does this by mailing a health status questionnaire to each new enrollee and assigning case managers to those in the poorest health.

Activities of Daily Living↗
PubMed2001

Disenrollment from Medicare HMOs.

BACKGROUND: Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. OBJECTIVES: To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. DESIGN: Cross-sectional analysis of 1994 Medicare data. PARTICIPANTS AND METHODS: Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. RESULTS: The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. CONCLUSIONS: On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

Aged↗
PubMed1987

Do frail, disabled, poor, and very old Medicare beneficiaries have higher hospital charges?

To determine whether basing payments on diagnosis related groups (DRGs) results in mispayment for certain classes of patients, we examined the relation between total Medicare charges per hospitalization and eight beneficiary characteristics (including admission from a nursing home, extreme age, Medicaid enrollment, and disability). We controlled for the hospital in which care was given and the DRG to which the discharge was assigned. The largest effects were that average charges were 6.7% higher for beneficiaries who were disabled before the age of 65 years, and 6.2% higher for patients admitted from a nursing home; charges were 1.5% lower for Medicare beneficiaries who were also enrolled in Medicaid, 3.8% higher for those older than 80 years, and 1.3% lower for those older than 85 years compared with those aged from 80 to 84 years. Because these differences are very small compared with the average variation within DRGs, we conclude that using these beneficiary characteristics in the DRG classification system would only slightly improve DRGs. Medicare's DRG-based payments seem to be substantially equitable with regard to these beneficiary characteristics.

Aged↗
PubMed1994

Using an expert system to ensure accurate third-party reimbursement.

Many hospitals experience difficulties with Medicare reimbursements tied to payments strictly related to a diagnosis related group (DRG) in which a patient's stay is grouped or assigned. Potentially compounding these difficulties, many large third-party payers have also adopted the DRG system. A lack of knowledge of the intricacies of the DRG system on the part of physicians, administrators, or medical records managers often can lead to hospitals receiving considerably less reimbursement than they are entitled. A computerized coding system that incorporates an expert system can substantially increase reimbursements by simplifying the coding process, identifying overlooked diagnoses, and identifying any missing procedures.

Diagnosis-Related Groups↗