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PubMed1992

Medicare program; payment change for home dialysis--HCFA. Final rule.

This final rule implements section 6203(b) of the Omnibus Budget Reconciliation Act of 1989, which limits Medicare payment for home dialysis equipment, supplies, and support services. Also, in accordance with section 6203(b), we are requiring that, for Medicare payments to be made to a supplier of home dialysis supplies and equipment when the patient's self-care home dialysis is not under the direct supervision of a Medicare approved renal dialysis facility, the patient must certify that the supplier is the sole supplier of his or her dialysis supplies and equipment. In addition, the supplier must agree to receive payment on an assignment basis only and must certify that it has entered into a written agreement with an approved dialysis facility, under which the facility agrees to furnish the patient with all home dialysis services. We are also providing a one-time-only opportunity for certain home dialysis patients to immediately change their current method of payment.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1992

Understanding the Medicare Fee Schedule and its impact on physicians under the final rule.

On January 1, 1992, the Medicare program unveiled a new method for paying physicians known as the Medicare Fee Schedule (MFS). The new fee schedule is a complex system of administrative pricing based on the resource inputs used in producing physician services. The MFS consists of three parts: 1) a Relative Value Scale, which assigns to each medical service a value relative to all other services; 2) a conversion factor, which converts the relative values into dollars; and 3) a geographic adjustment factor, which adjusts payments based on geographic differences in the cost of producing physician services. In this article, the following are addressed: how the relative values were determined; how the geographic adjustment factor was constructed; and how the conversion factor was calculated. In addition, balance billing limits and the Medicare Volume Performance Standards (MVPS) are described. Computer simulations of the impact of the MFS on payments to physicians are presented. The authors found that the MFS will 1) redistribute payments away from surgeons, radiologists, and other procedure-based specialties toward the primary care specialties; 2) redistribute payments away from urban areas toward rural areas; and 3) redistribute payments away from invasive procedures and diagnostic tests toward evaluation and management services. The authors conclude with a discussion of the future refinements of the MFS, its applicability to other payers, and whether it will accomplish its intended purposes.

Economics, Medical↗
PubMed1992

The Medicare Fee Schedule unveiled: an account of physician payment reform.

On January 1, 1992, the Medicare program unveiled a new method for paying physicians known as the Medicare Fee Schedule (MFS). The new fee schedule is a complex system of administrative pricing based on the resource inputs used in producing physician services. The MFS consists of three parts: (1) a Relative Value Scale (RVS) which assigns to each medical service a value relative to all other services; (2) a Conversion Factor (CF) which converts the relative values into dollars; and (3) a Geographic Adjustment Factor (GAF) which adjusts payments based on geographic differences in the cost of producing physician services. In the paper we explain: how the relative values were determined; how the GAF was constructed; and how the CF was calculated. In addition, we explain balancing billing limits and the Medicare Volume Performance Standards (MVPS). We then present computer simulations of the impact of the MFS on payments to physicians. We find that the MFS will: (1) redistribute payments away from surgeons, radiologists, and other procedure-based specialties toward the primary care specialties, (2) redistribute payment away from urban areas toward rural areas, (3) redistribute payments away from invasive procedures and diagnostic tests toward evaluation and management services. We conclude with a discussion of the future refinements of the MFS, its applicability to other payors, and whether it will accomplish its intended purposes.

Computer Simulation↗
PubMedDate not supplied

A consultation, by any other name.

The decision to report a consultation code is based on a number of factors, including: the existence of a request from a physician or other authorized source for opinion or advice, documentation of the face-to-face patient encounter, and a written report of the findings, opinions or advice to the attending physician. Depending upon practice location, relationship with the referring physician population, number of self-referred patients, and other factors, some practices will report primarily consultation codes, whereas others may assign more codes for new patient visits.

Ambulatory Care↗
PubMed1984

Deficit Reduction Act of 1984: provisions related to the Medicare and Medicaid programs.

This article summarizes the principal provisions of the Deficit Reduction Act of 1984 that relate to the Medicare and Medicaid programs. Among other things, the new legislation freezes customary and prevailing charges for physician services for 15 months at the June 1984 levels, reduces the allowable increase in hospital costs per case to one-fourth of 1 percentage point for fiscal years 1984-85, introduces new rules for the revaluation of a provider's assets, and establishes fee schedules for clinical diagnostic laboratory tests on a statewide, regional, or carrier-wide basis. It also normalizes the practice for trust fund transfers, waives the late enrollment surcharge and provides a special enrollment period for persons aged 65-69 who defer part B enrollment while participating in employer-sponsored group health insurance plans, makes changes in contracts for claims processing, and maintains the part B premium rate, through calendar year 1987, at the level necessary to produce income equal to one-fourth of program costs for aged enrollees. Under Medicaid, the coverage requirements for pregnant women and children have been modified, and applicants must now assign their rights to third-party payments to the State as a condition of eligibility.

Budgets↗
PubMed1993

Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1994--HCFA. Final rule with comment period.

This final rule revises the payment policy for specific physician services and supplies, revises the relative value units (RVUs) assigned to certain existing procedure codes, and establishes interim RVUs for new and revised procedure codes. Section 6102(a) of the Omnibus Budget Reconciliation Act of 1989, as amended by section 4118 of the Omnibus Budget Reconciliation Act of 1990, requires establishment of the physician fee schedule and periodic review and adjustment of the RVUs. Further changes concerning payment for certain physician services are required by sections 13513 through 13517 of the Omnibus Budget Reconciliation Act of 1993.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1991

Occupational exposure to electromagnetic fields and breast cancer in men.

Data from a population-based case-control study of breast cancer in men were used to examine the hypothesis that occupational exposure to electromagnetic fields increases the risk of breast cancer. Incident cases (n = 227) diagnosed between 1983 and 1987 were obtained from 10 population-based cancer registries of the Surveillance, Epidemiology, and End Results program of the National Cancer Institute. Controls (n = 300) were selected by random digit dialing and from Medicare eligibility lists. Exposure status, defined as ever having been employed in a job which has been classified as involving potential exposure to electromagnetic fields, was assigned without knowledge of case/control status. An elevated risk was found for any job with exposure (odds ratio (OR) = 1.8, 95 percent confidence interval (CI) 1.0-3.7), and risk was highest among electricians, telephone linemen, and electric power workers (OR = 6.0, 95 percent CI 1.7-21) and radio and communications workers (OR = 2.9, 95 percent CI 0.8-10). Risk did not vary with duration of exposed employment. The risk was highest among subjects who were first employed in jobs with exposure before the age of 30 years and who were initially exposed at least 30 years prior to diagnosis. These results lend support to the theory that electromagnetic fields may be related to breast cancer in men. The hypothesis warrants evaluation in women.

Adult↗
PubMed2002

Assessing the impact of Medicare payment changes.

A reduction in the conversion factor applied to Medicare's payment equation has many providers concerned about financial loss. Some of this concern is justified, as most practices will see a decline in revenue that could result in a similar decline in physician compensation. However, the impact of these payment changes may be offset somewhat by increases in the relative value units assigned to many commonly performed procedures. Providers also can take several operational steps to minimize effects on their bottom lines.

Abstracting and Indexing↗
PubMed2003

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVE: To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. DATA SOURCE/STUDY SETTING: The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). STUDY DESIGN: A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. DATA COLLECTION/EXTRACTION METHODS: Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. PRINCIPAL FINDINGS: The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. CONCLUSIONS: Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.

Aged↗
PubMed1986

Impact of selected diagnosis-related groups on regional neonatal care.

The evaluation and reimbursement of hospital use by means of diagnosis-related groups (DRGs) may have a major impact on the utilization of regional neonatal care. Medicare has already implemented the DRG system and other payors, including Medicaid, Blue Cross, and commercial insurance, are also considering adopting it. Under this approach, neonates are assigned to one of seven DRGs, each of which is reimbursed at a relatively fixed rate. An evaluation of hospital utilization by neonates focused on three of these DRGs in four regional neonatal systems located in Upstate New York. Calendar year 1983 data indicated that Level III, II, and I neonatal facilities generated substantially different mean stays for these DRGs in the four regions. The ranges of mean stays between Level III and Level I facilities were greatest for DRGs involving neonates who died or were transferred and those with extreme immaturity and/or respiratory distress syndrome. Federal length of stay and cost standards for these categories failed to address the different utilization experience of these levels of care. The analysis suggests that, as additional payors adopt DRGs, the standards relating to neonatal care must be modified.

Catchment Area, Health↗
PubMed1988

Medicare: criteria and standards for evaluating intermediary and carrier performance during fiscal year 1989--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 for the fiscal year beginning October 1, 1988. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier agreement or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. In addition, this notice describes the methodology for identifying contractors with performance over a period of time in the lowest 20th percentile that HCFA may replace using competitive bidding. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which require us to publish for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.

Contract Services↗
PubMed1994

Severity of illness measures derived from the Uniform Clinical Data Set (UCDSS).

The Health Care Financing Administration (HCFA) plans to use the Uniform Clinical Data Set System (UCDSS) to collect data on hospitalized Medicare patients. This study examined the value of UCDSS data for creating severity of illness measures. UCDSS data were obtained from a study hospital and from a national data set for patients with pneumonia (n = 528) and stroke (n = 565). Models to predict length of stay or an adverse event were derived for each condition using HCFA claims data alone, UCDSS data alone, and UCDSS data supplemented with additional information also abstracted from charts. The models were derived from one set of patients and validated on another. The R2 for predicting length of stay in the validation data for the UCDSS model was 0.29 for pneumonia and 0.19 for stroke compared to R2 values from the claims model of 0.09 for stroke and 0.06 for pneumonia. UCDSS models also were better than claims models for predicting adverse events. The best UCDSS models included International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and other information requiring clinical judgment, and were improved by adding more information on patient functional status. Some findings were more strongly associated with outcome for the study hospital than for the national data. These results suggest that UCDSS models will predict outcome much better than the claims based models currently used by HCFA for the analysis of hospitalization-related mortality; more functional status information should be added to UCDSS; and despite an extensive objective database, the most predictive UCDSS models require clinician-assigned diagnostic codes.

Aged↗
PubMed1997

Is Adam worth more than Eve? The financial impact of gender bias in the federal reimbursement of gynecological procedures.

PURPOSE: On January 1, 1992, Congress implemented a Medicare payment system based on relative value units (RVU). The RVU multiplied by a dollar conversion factor sets the reimbursement for all procedures covered by Medicare and many other private insurers. This study was undertaken to evaluate discrepancies in federal reimbursement for gender-specific procedures. METHODS: Using the December 1995 Federal Register and the regional Medicare conversion factor ($40.08/RVU), we compared the work RVU and total reimbursement of 24 groups of gender-specific surgical procedures. The groups were matched as carefully as possible so that the amount of work and level of difficulty would be similar, if not identical. Some examples of comparisons are as follows: biopsy of male vs female genitals, hysterectomy vs prostatectomy, staging for ovarian vs testicular cancer, and exenteration for cervical vs prostate cancer. RESULTS: In the 24 matched procedures, the male-specific procedures were reimbursed at a higher amount in 19 (79%) cases. The female-specific procedures were reimbursed at a higher amount in 3 (12%) cases (P = 0.004). There was no difference in reimbursement for two of the comparisons. Overall, we found that male-specific procedures are reimbursed at an amount which is 44% higher than female-specific procedures. Comparison of work RVU revealed that male-specific procedures were assigned higher values in 19 cases and, overall, male gender-related surgeries had work RVU that were 50% higher than female gender-related surgeries. CONCLUSION: There is significant gender bias against the Medicare reimbursement of female-specific services. This results in a lower net reimbursement for gynecologic procedures. In addition, since many private sector insurance carriers now use the resource-based relative value scale system, this gender bias is further potentiated.

Female↗
PubMed2003

Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema.

BACKGROUND: The National Emphysema Treatment Trial, a randomized clinical trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema, included a prospective economic analysis. METHODS: After pulmonary rehabilitation, 1218 patients at 17 medical centers were randomly assigned to lung-volume-reduction surgery or continued medical treatment. Costs for the use of medical care, medications, transportation, and time spent receiving treatment were derived from Medicare claims and data from the trial. Cost effectiveness was calculated over the duration of the trial and was estimated for 10 years of follow-up with the use of modeling based on observed trends in survival, cost, and quality of life. RESULTS: Interim analyses identified a group of patients with excess mortality and little chance of improved functional status after surgery. When these patients were excluded, the cost-effectiveness ratio for lung-volume-reduction surgery as compared with medical therapy was 190,000 dollars per quality-adjusted life-year gained at 3 years and 53,000 dollars per quality-adjusted life-year gained at 10 years. Subgroup analyses identified patients with predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation who had lower mortality and better functional status than patients who received medical therapy. The cost-effectiveness ratio in this subgroup was 98,000 dollars per quality-adjusted life-year gained at 3 years and 21,000 dollars at 10 years. Bootstrap analysis revealed substantial uncertainty for the subgroup and 10-year estimates. CONCLUSIONS: Given its cost and benefits over three years of follow-up, lung-volume-reduction surgery is costly relative to medical therapy. Although the predictions are subject to substantial uncertainty, the procedure may be cost effective if benefits can be maintained over time.

Cost-Benefit Analysis↗
PubMed2006

Rural hospitals and volume standards in surgery.

BACKGROUND: We sought to understand the potential impact of volume-based referral policy on rural hospitals by estimating the proportion of low-volume operations occurring in rural versus urban hospitals. METHODS: We performed an observational study using the national Medicare population who underwent one of 12 high-risk operations from 1999-2001. Low-volume hospitals were considered those in the 2 lowest quintiles for each procedure. Hospitals were assigned to 1 of 3 types of geographic locations on the basis of Rural-Urban Commuting Area Codes: urban areas, rural large towns, or rural small towns. For each of the 12 operations, we estimated the proportion of patients undergoing operation in low-volume hospitals within each type of geographic area. RESULTS: For all 12 operations, the majority of surgical cases were performed in urban areas (ranging from a low of 76% for colectomy to 96% for heart valve operations). Evaluation of only operations performed in low-volume hospitals showed that the majority of surgical cases were still located in urban areas (varying from a low of 55% for colectomy to a high of 94% for heart valve operations). Operations with a stronger effect of volume on outcome (eg, pancreatic and esophageal resection) were more concentrated in urban areas, compared with operations with a weaker effect (eg, colectomy). CONCLUSIONS: Most low-volume operations take place in urban hospitals. Efforts to direct patients to high-volume hospitals can exempt rural hospitals and still realize most of the potential benefits.

Aged↗
PubMed2005

The relation between patients' outcomes and the volume of cardioverter-defibrillator implantation procedures performed by physicians treating Medicare beneficiaries.

OBJECTIVES: The purpose of this study is to determine if implantable cardioverter-defibrillator (ICD) implantation should be limited to physicians with high procedural volume. BACKGROUND: Expanding indications for ICDs will result in an increasing number of physicians implanting these devices. METHODS: Using the 20% Part B Medicare files for 1999 through 2001, we identified new ICD implantations and the corresponding denominator files. We used Medicare Provider Analysis and Review hospital records and the appropriate International Classification of Diseases-9 diagnosis and procedure codes to define complications within 90 days. We defined physician volume categories by assigning one-quarter of the patients to each quartile. A logistic regression model was used to adjust outcomes for potential confounders. RESULTS: Ninety-day mortality did not differ between patients who had their ICD implanted by physicians with the highest volume of implants and those who had their ICD implanted by physicians with the lowest volume of implants (6.2% vs. 5.9%; odds ratio [OR] 0.99; 95% confidence interval [CI] 0.75 to 1.30). Within 90 days, mechanical complications were significantly higher in the lowest volume quartile (OR 1.47; 95% CI 1.09 to 1.99) but were comparable for physicians who implanted at least 11 ICDs per year. The risk of ICD infection was significantly higher in patients who had their ICD implanted by physicians with the lowest volume of implants (OR 2.47; 95% CI 1.18 to 5.17). CONCLUSIONS: We observed an association between a higher volume of ICD implants and a lower rate of mechanical complications and infections. This association suggests that ICD implantation should not be performed by physicians without regard to their procedural volume.

Aged↗
PubMed1987

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures.

We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significantly levels of inappropriate use: 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

Carotid Arteries↗
PubMed2004

A randomized study to decrease the use of potentially inappropriate medications among community-dwelling older adults in a southeastern managed care organization.

BACKGROUND: Despite progress in describing the problem of potentially inappropriate medication (PIM) use, there have been few prospective studies demonstrating that interventions with specific medication criteria can make a difference in decreasing the use of problematic drugs in older adults. OBJECTIVE: To design an intervention study to change physician behavior regarding PIM prescribing to older patients. STUDY DESIGN AND METHODS: A prospective randomized block design was used during an 18-month period from January 2001 to June 2002. The study population was primary care physicians (n = 355) in the Medicare + Choice product line of a southeastern managed care organization and their patients 65 years and older. There were 170 physicians in the treatment group and 185 in the control group. Physicians were assigned to the treatment or usual-care, groups using a randomization table, and each group included physicians who had and had not prescribed a PIM. RESULTS: Approximately 71% (84/118) of the physicians in the intervention group who prescribed a PIM completed and faxed back at least 1 potentially inappropriate medication form to the managed care organization. On 15.4% (260/1692) of the medication forms, physicians made some change regarding PIM use. CONCLUSIONS: Although many studies have addressed medication use among older adults, intervention studies aimed at influencing physician prescribing in this population are limited. This study describes a low-cost, replicable method to contact and educate physicians on drug therapy issues in older adults.

Academic Medical Centers↗