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PubMedDate not supplied

Can managed care and competition control Medicare costs?

Medicare+Choice (M+C) was conceived to bring managed care and competitive forces to bear on Medicare. Ultimately, M+C could not thrive under the conditions of the marketplace and the Balanced Budget Act of 1997. Here I review what went wrong and the lessons from the experience, concluding that M+C is a tool, not a strategy. While managed care in a multiple-choice environment may have the potential to generate limited savings, promoting managed care and competition alone will not preempt the need for a debate on Medicare's obligations and how to finance them.

Aged↗
PubMed1993

Charging for library and information services in medical libraries: a review of the literature and a survey of current practice.

A summary of some of the issues concerned with charging for library services (particularly information services and services provided by medical libraries) is given. The results of a survey carried out in July 1992 are presented. The survey asked respondents to indicate which library services they charged for, the level of charges and the extent to which charges to those outside the organization and those within it differed. Twenty-five libraries (response rate of 69%) replied to the survey. Some further areas for research and discussion are indicated.

Decision Making, Organizational↗
PubMed1987

Health status adjustments for Medicare capitation.

The issue of biased selection has taken on increased importance because of the growing numbers of Medicare beneficiaries enrolled in capitated systems. One way to deal with biased selection is through adjusting payment to health plans to reflect enrollee health status. This paper reviews proposed health status adjustors based on perceived health status, functional health status, health service use, program entitlement data, mortality, and risk factors. There is evidence that almost all of these could perform better in a statistical sense than the current Medicare HMO payment formula. For policy purposes, the most practical adjustors at present are measures based on prior use of services. These could be tested and perhaps implemented now as work proceeds on other adjustors.

Capitation Fee↗
PubMed1999

Adjusted community rate reforms to promote HMO participation in Medicare+Choice.

The authors review the financial regulations imposed on health maintenance organizations (HMOs) that participate in the Medicare+Choice program and identify elements of the regulations that may discourage HMO participation in the program. Modifications of the regulations are proposed that could encourage the participation of HMOs without affording them excessive profit. The modifications include smoothing and bounding profit estimates and authorizing and encouraging expanded use of benefit stabilization funds.

Aged↗
PubMed1991

Medicare program; update of ambulatory surgical center payment rates and additions to and deletions from the current list of covered surgical procedures--HCFA. Notice with comment period.

This notice implements section 1833(i)(2)(A) of the Social Security Act, which requires that the payment rates for ambulatory surgical center (ASC) services be reviewed and updated annually, and responds to the public comment we received concerning the ambulatory surgical center payment rate update notice with comment period published on July 5, 1990 (55 FR 27690). It also implements section 1833(i)(1) of the Social Security Act, which requires, in part, that the list of covered ambulatory surgical center procedures be reviewed and updated at least every 2 years. This notice announces additions to and deletions from the list of surgical procedures for which facility services are covered when the procedures are performed in an ASC. This notice also announces the assignment of payment groups for each procedure and responds to public comments received in response to the notice proposing additions to and deletions from the list of covered surgical procedures that was published on December 7, 1990.

Abstracting and Indexing↗
PubMed1988

Capitation payment: using predictors for medical utilization to adjust rates.

The current adjusted average per capita cost methodology has been strongly criticized because the subgroup classifications explain minimal interpatient variation in utilization, therefore providing incentives for biased selection. In this article, we review previous investigations of predictors of medical utilization that might be included in the adjusted average per capita cost: perceived health status, functional health status, prior utilization, clinical descriptors, sociodemographic characteristics, and other miscellaneous patient characteristics. The existing data are analyzed to assess what is known about the relative strength of various predictors. Gaps in the available literature and the implications for future research and policy are discussed.

Aged↗
PubMed1997

Dubin calls on CMPA to eliminate fee differentials, adopt flat fee for all physicians.

Charles Dubin's massive review of the Canadian Medical Protective Association supports the CMPA's policy of maintaining a large reserve for malpractice coverage, but calls for a major overhaul of the association's fee structure. Regardless of the risks their practices pose, says Dubin, all doctors should pay the same fee in order to keep physicians practising in high-risk specialties such as obstetrics and orthopedic surgery. The alternative, said CMPA president Dr. Bill Thomas, is an exodus from certain specialties because of massive bills for malpractice insurance.

Canada↗
PubMed1992

The courts and health policy: strengths and limitations.

In recent years the nation's courts have expanded their influence in health policy in four areas: reviewing insurers' coverage decisions, deciding the adequacy of Medicaid payment rates to hospitals and nursing homes, arbitrating hospital mergers, and assessing hospitals' tax-exempt status. The major problem with developing health policy through the courts is that the courts' focus will be the concerns of the individuals or groups involved in specific cases, not the broader implications and overall objectives of the health care system. As alternatives to litigation to resolve policy conflicts, scholars have suggested negotiation, binding arbitration, clarification of legislative language, administrative courts, contract revision, and general restructuring of the decision-making process.

Charities↗
PubMed2001

Paying for hospital emergency care under a single-payer system.

Hospital emergency services are one of the key drivers of hospital activity, yet there has been surprisingly little attention paid to appropriate funding models for single-payer systems, in which funders must be concerned with issues of access and financial viability of emergency departments. This article analyzes the dynamics of hospital emergency services in terms of the key products and cost drivers. It reviews the currently available systems for categorizing emergency activity and evaluates their applicability for funding purposes with particular emphasis on the susceptibility to gaming of both triage and disposition. It identifies and evaluates 3 models for use in single-payer health systems for funding hospital emergency services (fully variable, fully fixed, and mixed variable/fixed) in terms of the key products and cost drivers in the ED. Approaches to the setting and rebasing of fixed grants are considered. Problems of potential incentive effects and double payment for admitted patients make the setting of variable payments problematic, particularly for patients subsequently admitted as inpatients. Key characteristics of an ED funding model in single-payer systems are proposed.

Diagnosis-Related Groups↗
PubMed2004

Impact of the women's health initiative trial results on hormone replacement therapy.

STUDY OBJECTIVE: To describe the impact of the results of the Women's Health Initiative (WHI) on hormone replacement therapy (HRT) discontinuation rates. DESIGN: Retrospective chart review. SETTING: University-based family medicine clinic. SUBJECTS: Ninety-eight postmenopausal women (aged 50-79 yrs) with an intact uterus who were receiving HRT. MEASUREMENTS AND MAIN RESULTS: Two study periods were defined: pre-WHI (July 9, 2001-January 9, 2002) and post-WHI (July 9, 2002-January 9, 2003). Patient demographics and HRT discontinuation or persistence data were collected. Seven women were eligible for only for pre-WHI, 13 only for post-WHI, and 78 were eligible for both groups based on HRT use during both time periods. Forty-two of the 78 women were randomized to the pre-WHI group and 36 to the post-WHI group to yield equal groups of 49 each. No significant demographic differences existed between the groups. Time-to-event analysis revealed an increased probability of HRT discontinuation after WHI versus before WHI (log-rank test, p<0.01). A subset of 85 women taking HRT 1 year before WHI were followed for 18 months. Discontinuation rates were 8% (7 of 85 patients) during the 12 months before WHI and 38% (30 of 78) during the 6 months after WHI, with 80% (24 of 30) of these patients discontinuing within 3 months. CONCLUSION: Increased HRT discontinuation was temporally associated with release of WHI data, which implies that highly publicized, negative outcomes data can quickly influence pharmacotherapy decisions.

Aged↗
PubMed1982

Creating an efficient market for nursing home care.

This paper reviews the theoretical foundations of the common Medicaid nursing home reimbursement systems: Reasonable cost related, fixed rate and negotiated rate reimbursement. Each reimbursement system is examined in terms of the four reimbursement system design goals: allocative efficiency, appropriateness of care, quality of care and equity of economic rewards. None of the reimbursement approaches are found to be deficient on the theoretical level, but practical problems of implementation are shown to be very difficult. As an alternative, a competitive binding system is proposed which would bring competitive market efficiency to the allocation of Medicaid funds for nursing home care. A mathematical programming model is developed to process the bidding information and to allocate Medicaid funds to nursing homes.

Economic Competition↗
PubMed1998

State-funded medical assistance programs: sources of coverage for HIV-related health care.

Preliminary research found that a number of states implement medical assistance programs (MAPs) funded only with state and/or local government funds. A review of the literature was unable to discover any published research that discusses state-funded MAPs. The objective of this article is to describe these MAPs and to discuss how these programs can be used to provide health services to people infected with HIV who lack other coverage. A two-step survey process was used to identify 20 states implementing MAPs and to identify eligibility criteria, the health services covered, and payment-level policies. Typically, MAPs implement restrictive eligibility policies and set low reimbursement levels for the care covered. However, most MAPs cover a comprehensive range of health services needed by people inflected with HIV, including community-based care and support services.

Comprehensive Health Care↗
PubMed1991

All-payer ratesetting: down but not out.

In the United States, when the cost-containment paradigm shifted from regulation to competition, all-payer hospital ratesetting went out of favor. After reviewing the published literature and supplementing the existing literature with more current information, the author concludes that all-payer ratesetting is able to meet its multiple objectives of cost containment, reduction of the amount of cost shifting, improvement of access to the uninsured, and increased productivity. At the same time, all-payer ratesetting has not stifled the diffusion of competitive health care systems or new technology, and any impact on length of stay, admissions, and quality of care is small, if it exists at all.

Cost Allocation↗
PubMed1992

The legality of state limitations on medical malpractice tort damage awards.

This study reviews the legal status of state medical malpractice damage limitations or "caps" now being challenged regularly on federal and state constitutional grounds. The case law resulting from the many state tort damage control laws passed during the mid-1980s in response to the "tort-insurance" crisis is examined, and the legal and economic implications of that litigation are analyzed. This study concludes that (1) the outcome of litigation depends largely on whether the challenge is heard in a federal or state court, (2) challenges based on the right to a jury trial are more likely to be successful, and (3) the influence of cap laws on insurance rates and availability to date has been minimal.

Data Collection↗
PubMed1987

The first DRG: lessons from the end stage renal disease program for the prospective payment system.

When Medicare implemented the diagnosis related group (DRG) method of reimbursement for hospitals in 1983, it already had a decade of experience using a prospective payment arrangement for its end stage renal disease (ESRD) program. We reviewed this experience to determine the lessons for Medicare's reimbursement of hospital services. The use of a fixed price for renal dialysis encouraged the introduction of cost-saving techniques. Failure to reduce the price for dialysis in keeping with the cost reductions, however, prevented the government from realizing the full benefits of prospective payment. In addition, there were important changes in medical practice that had independent effects on the program. Similar influences are likely to shape the impact of prospective payment on hospital behavior.

Diagnosis-Related Groups↗
PubMed2004

Competition in medical services and the quality of care: concepts and history.

This paper reviews the concept of optimal quality in medical care from an economic viewpoint. It also provides some data on recent trends in competition in the health care sector. Economically optimal quality reflects a tradeoff of marginal benefits against (minimized) marginal cost. Actual quality may be suboptimal either because of technical inefficiency in the production of quality or because consumers fail to make proper choices. In concept, competition, if supplemented by adequate information, can help. Overall competition in the hospital industry has declined modestly in recent years, but competition in markets for more generously reimbursed specific services, such as coronary artery bypass grafting, has increased.

Benchmarking↗
PubMed1988

Working toward a more rational pattern of fees.

Following its congressional mandate to reform physician payment, the Physician Payment Review Commission has been examining the concept of a fee schedule. The commission, which operates almost entirely in public, has extensive contact with physician groups and beneficiary organizations, and provides extensive opportunities for formal testimony at public meetings and for frequent informal interactions at the staff level. By sending various organizations a draft outline of issues it hopes to take up in its next report to Congress, it is soliciting suggestions from them long before any decisions are made. Such issues as geographic variation in payment, the ways in which CPT codes are used, a relative-value scale, and the increasing volume of services are being subjected to intense scrutiny, and the commission is drawing conclusions.

Abstracting and Indexing↗
PubMed2004

A comprehensive snapshot of States' small group market reforms on insurer pricing & rating practices, 1999.

This paper presents a qualitative analysis of states' small group health insurance reforms that impact small group premiums, mostly enacted by the states during 1996-99, following the federal Health Insurance Portability and Accountability Act in 1996. It draws from an intensive review of statutes of 48 states and the District of Columbia as of 1999. It analyses regulations related to insurer pricing and rating practices concerning rating criteria and rating bands, pricing incentives, premium stability from year to year, minimum loss rations, reinsurance and carve-out coverage for the medically uninsurable. It also covers regulations targeting employer purchasing and coverage practices such as pooled purchasing and adverse selection. This is the second of a two-part series analyzing states' small group market reforms, the first being devoted to state reforms to promote access and improving the value of health plans offered in this market (Xirasagar et al. 2004). The variety in pricing and rating reforms illustrate the differences in the depth of reforms across states, and represent a far wider range of potential actuarial combinations than the sample of reforms documented in past literature.

Health Care Reform↗