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PubMed1998

Medicare Program; establishment of the Medicare+Choice Program--HCFA. Interim final rule with comment period.

The Balanced Budget Act of 1997 (BBA) establishes a new Medicare+Choice (M+C) program that significantly expands the health care options available to Medicare beneficiaries. Under this program, eligible individuals may elect to receive Medicare benefits through enrollment in one of an array of private health plan choices beyond the original Medicare program or the plans now available through managed care organizations under section 1876 of the Social Security Act. Among the alternatives that will be available to Medicare beneficiaries are M+C coordinated care plans (including plans offered by health maintenance organizations, preferred provider organizations, and provider-sponsored organizations), M+C "MSA" plans, that is, a combination of a high deductible M+C health insurance plan and a contribution to an M+C medical savings account (MSA), and M+C private fee-for-service plans. The introduction of the M+C program will have a profound effect on Medicare beneficiaries and on the health plans and providers that furnish care. The new provisions of the Medicare statute, set forth as Part C of title XVIII of the Social Security Act, address a wide range of areas, including eligibility and enrollment, benefits and beneficiary protections, quality assurance, participating providers, payments to M+C organizations, premiums, appeals and grievances, and contracting rules. This interim final rule explains and implements these provisions. In addition, we are soliciting letters of intent from organizations that intend to offer M+C MSA plans to Medicare beneficiaries and/or to serve as M+C MSA trustees.

Aged↗
PubMed1985

Treatment of diarrhoea in Indonesian children: what it costs and who pays for it.

The annual economic burden of diarrhoea in four subdistricts in Indonesia averaged $2.27 per child aged under 5 years when health centre, hospital, and private expenditures were all considered. The community itself spent $1.03 per child or 46% of the total; 96% of community payments went to the private sector, and 4% were for fees at government health centres and hospitals. The widespread availability of oral rehydration therapy has led to only partial abandonment of ineffective or marginally effective medications; non-rehydration medications amounted to 44% of total treatment expenditures. Most medication costs were for antimicrobial agents, such as tetracycline in the government sector and iodochlorhydroxyquin in the private sector. If the use of tetracycline at health centres could be restricted to 10% of episodes treated instead of the present 88%, their costs could be reduced by 50%.

Child↗
PubMed2001

A coordinated strategy for evaluating new vaccines for human and animal tuberculosis.

There is a remarkable convergence in the current efforts to develop and evaluate new tuberculosis (TB) vaccine candidates for use in humans, domestic animals, and wild animal reservoirs. It is quite likely that similar vaccination strategies will prove useful in these diverse host species. Many TB vaccine candidates are being screened for protective efficacy in conventional laboratory animals (e.g. mouse, guinea pig), in captive wild species under laboratory conditions (e.g. brushtail possum), and in the target hosts (e.g. cattle, deer). These systems share some important features, e.g. direct challenge infection of the lung by intratracheal or aerosol exposure, and the use of bacterial enumeration, and gross and microscopic histopathology, as the readouts. Some TB vaccine candidates have been tested in many models, yielding important insights into common mechanisms of resistance to Mycobacterium tuberculosis and M. bovis, and providing evidence of the vaccine's ability to induce protection under widely different circumstances. Coordination of this global search for better TB vaccines, irrespective of target species, would facilitate the rapid application of new technologies and maximize the sharing of materials and experiences between human and veterinary TB researchers. The creation of liaisons between TB vaccine research efforts of government-sponsored medical and agricultural research programs, international bodies such as the World Health Organization (WHO) and the European Community (EC), private foundations and the vaccine industry, will yield a high return.

Animals↗
PubMed1988

The long-term impact of a training program in maxillofacial prosthodontics.

A follow-up survey of trainees in a National Cancer Institute-sponsored program in maxillofacial prosthodontics was conducted. Information about the trainees' current professional activities indicated that the majority work in private practice or a dental school, are primarily involved in clinical work or teaching, and see few cancer patients. Inadequate reimbursement and lack of collaboration with surgeons were cited as barriers to involvement in cancer patient care. It is suggested that barriers to applying training expertise in actual practice settings require emphasis in the planning and curricula of training programs.

Career Choice↗
PubMed2004

Navigating the new Medicare drug benefit.

BACKGROUND: Medicare beneficiaries have had to wait 40 years for an outpatient prescription drug benefit. On December 8, 2003, President Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003 that will provide at least limited drug coverage to all beneficiaries who sign up for it. OBJECTIVE: The aim of this commentary is to provide a basic appreciation of the mechanics of the new drug benefit and an analysis of why it looks the way it does. CONCLUSIONS: A combination of ideology and spending constraints led Congress to develop a benefit package that while generous for low-income beneficiaries with limited assets, has significant gaps in coverage for everyone else. After a transitional program of discount cards that will carry them through 2005, beneficiaries will have to choose their source of prescription benefits from private stand-alone drug plans, managed care organizations, or (if available to them) employer-sponsored plans. The structure of the benefit is a radical departure from the way other Medicare benefits are provided and paid for, and raises a number of important questions. Will sufficient numbers of risk-bearing private drug plans enroll in the program for competition to work? Will employers maintain retiree drug coverage? Will the new program stop the slide in Medicare managed care? How will beneficiaries react when the law is explained in ways they truly understand? The answers to these questions will help determine the success or failure of drug coverage under Medicare.

Drug Costs↗
PubMed1985

Career orientations of medical and pediatric residents.

Educators have expressed concern about the declining percentage of graduating residents who choose an academic career. This study identifies characteristics of postgraduate physicians that are associated with intentions to pursue an academic career or a full-time private practice. Data were obtained from 299 residents in pediatrics and internal medicine at five academic medical centers in Southern California, using self-report questionnaires. Preference for an academic career was strongest among residents who were most satisfied with their work, were frequently sponsored by faculty, had published, or who either lived alone or were married to another professional. The likelihood of full-time private practice was strongest among residents who were less frequently sponsored by faculty, had not published, lived with others, were from certain medical schools, or were females. Training programs may wish to consider some of these factors in the selection of residents and in program development.

Academic Medical Centers↗
PubMed2005

Medicare reimbursement for clinical trial services: understanding Medicare coverage in establishing a clinical trial budget.

In designing and setting up a clinical trial, investigators and private sponsors must take into account what costs will or will not be covered by third-party insurers and government payment programs like Medicare and Medicaid. Failure to "cost out" the clinical trials accurately can yield one of two results: either third-party payors are billed improperly, or even illegally, for experimental care, or significant research-related care is not billed, with either the investigating institution, or the research subjects themselves, shouldering the cost. Unfortunately, because Medicare has established different coverage principles to be applied depending on the type of trial being conducted, costing out the trial is not an easy task. This Article looks at the various Medicare coverage principles as they apply to clinical trials, including the 2000 National Coverage Decision and the recent expansion in coverage for Class A Investigational Devices created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The Article then examines how the Medicare secondary payor rule, which states that providers may not bill Medicare for items or services when another party has primary responsibility for those services, relates to clinical trails in light of recent commentary. The Article concludes with the presentation of a general framework that investigators can use to establish a clinical trial budgeting and billing system.

Budgets↗
PubMed1992

Covering the costs of care in neonatal intensive care units.

The continued rise of health care costs, despite private and governmental control efforts, has sustained cost containment as a central issue for health care researchers and policy makers. In keeping with these concerns, the Florida Health Care Cost Containment Board conducted a study of neonatal intensive care units (NICUs) in Florida to ascertain the costs, charges, and net revenues associated with NICU services in individual hospitals, to document cost shifting and cross-subsidization as a means of financing NICU care for indigent populations, and to assess the fiscal impact of NICUs in state-sponsored vs non-state-sponsored Regional Perinatal Intensive Care Center hospitals providing NICU care. Hospitals in the state-sponsored program reported a loss of approximately $16.5 million in contrast to the non-state-sponsored hospitals, which reported a gain of $1 million. Payment being generated by private-pay patients amounted to almost 60% of total revenues but constituted less than one third of the costs in state-sponsored hospitals, indicating a high level of cost shifting. Government support of state-sponsored NICUs, while substantial, has been insufficient; increasing constraints on this funding source would likely worsen the deficit and increase the necessity of cost shifting.

Ancillary Services, Hospital↗
PubMed2000

Privatizing indigent health services in Los Angeles County: understanding the effects on community-based providers.

Faced with imminent financial collapse of its public healthcare system, the Los Angeles County Department of Health Services solicited community-based providers to supply primary care health services to the medically indigent. This study highlights the effects that participation in the programme has had on these community providers. While strongly committed to the programme's objectives, community providers tended to overextend themselves financially, putting their organizations at substantial risk of failure should contractual expectations or patient demand forecasts not be met. Because of this risk, policymakers involved in public-private partnerships with community-based providers must exercise extreme caution owing to the unique status many of these providers hold as centrally positioned actors in their communities. On the positive side, we found evidence of increased levels of co-operation and innovation between community providers outside their formal roles in the county-sponsored public-private partnership programme.

Community Health Centers↗
PubMed1999

Racial and ethnic differences in health insurance coverage for adults with diabetes.

OBJECTIVE: To evaluate the extent and types of health insurance coverage in a representative sample of adults with diabetes in the U.S. RESEARCH DESIGN AND METHODS: The Third National Health and Nutrition Examination Survey included national samples of non-Hispanic whites, non-Hispanic blacks, and Mexican-Americans aged > or = 20 years. Information on medical history and treatment of diabetes was obtained to determine subjects who had been diagnosed with diabetes by a physician before the survey (n = 1,503) and subjects without diagnosed diabetes (n = 17,319). Information on health insurance coverage was obtained via a structured questionnaire for 96% of participants. RESULTS: A total of 93% of all adults with diabetes had some form of health insurance. Of these subjects, 73% had private insurance, 48% had Medicare coverage, 15% had Medicaid coverage, and 5% had Champus/Veterans Affairs coverage. Approximately 52% of adults with diabetes had multiple types of health insurance, and 54% had health care coverage through one or more government-sponsored programs. A greater proportion of non-Hispanic whites (91%) and non-Hispanic blacks (89%) than Mexican-Americans (66%) had health insurance among subjects aged 20-64 years. For those aged > or = 65 years, coverage was virtually 100% for all racial and ethnic groups. Non-Hispanic whites had the highest rate of coverage through private insurance (81%), with non-Hispanic blacks having an intermediate rate (56%) and Mexican-Americans having the lowest rate (45%). Rates of coverage were similar for adults with and without diabetes in each racial and ethnic group for any type of insurance and for private insurance. CONCLUSIONS: There are marked racial and ethnic differences in health insurance coverage for adults with diabetes, although these differences are similar to those for adults without diabetes. Whether these racial and ethnic disparities influence access to care, quality of care, or health outcomes for people with diabetes remains to be determined.

Adult↗
PubMed2000

Development of biotechnology in India.

India has embarked upon a very ambitious program in biotechnology with a view to harnessing its available human and unlimited biodiversity resources. It has mainly been a government sponsored effort with very little private industry participation in investment. The Department of Biotechnology (DBT) established under the Ministry of Science and Technology in 1986 was the major instrument of action to bring together most talents, material resources, and budgetary provisions. It began sponsoring research in molecular biology, agricultural and medical sciences, plant and animal tissue culture, biofertilizers and biopesticides, environment, human genetics, microbial technology, and bioprocess engineering, etc. The establishment of a number of world class bioscience research institutes and provision of large research grants to some existing universities helped in developing specialized centres of biotechnology. Besides DBT, the Department of Science & Technology (DST), also under the Ministry of S&T, sponsors research at universities working in the basic areas of life sciences. Ministry of Education's most pioneering effort was instrumental in the creation of Biochemical Engineering Research Centre at IIT Delhi with substantial assistance from the Swiss Federal Institute of Technology, Zurich, Switzerland to make available state-of-the-art infrastructure for education, training, and research in biochemical engineering and biotechnology in 1974. This initiative catalysed biotechnology training and research at many institutions a few years later. With a brief introduction, the major thrust areas of biotechnology development in India have been reviewed in this India Paper which include education and training, agricultural biotechnology, biofertilizers and biopesticides, tissue culture for tree and woody species, medicinal and aromatic plants, biodiversity conservation and environment, vaccine development, animal, aquaculture, seri and food biotechnology, microbial technology, industrial biotechnology, biochemical engineering and associated activities such as creation of biotechnology information system and national repositories. Current status of intellectual property rights has also been discussed. Contribution to the India's advances in biotechnology by the industry, excepting a limited few, has been far below expectations. The review concludes with some cautious notes.

Agriculture↗
PubMed1989

A cost-effectiveness evaluation of primary health care projects for the poor.

A cost-effectiveness analysis was conducted to determine the relative efficacy of nine primary health care projects serving low income persons in urban and rural areas of Texas. The projects were created as part of a government program to provide services in medically underserved areas of the state by contracting with local public and private providers. While they vary widely in terms of sponsoring organizations, service strategy, and scope of services, the projects share a similar goal of providing an array of basic medical and preventive care services to the poor. This study compares the average cost per encounter for diagnosis/treatment, emergency, family planning, and preventive health screening services provided by the various projects during the first year of operation. After adjusting for differences in input prices and patient volume, the cost differences are examined and related to organizational model and personnel mix. Those projects with the highest ratio of nonphysician to physician practitioners proved more cost-effective, as did those projects following the public clinic model of service delivery.

Community Health Centers↗
PubMed1993

Health insurance and the elderly.

The effectiveness of proposed changes to the Medicare program depends on consumers' responses to different market incentives, which vary according to the coverage the elderly possess to supplement their Medicare coverage. This Data Watch explores the extent of supplemental insurance among the elderly, based on a new data set from the Medicare Current Beneficiary Survey. Only 11 percent of Medicare beneficiaries have only Medicare as their source of coverage; the rest of the elderly population is covered by either private coverage (employer-sponsored retiree coverage or individually purchased coverage) or Medicaid. An increase in Medicare cost sharing would likely affect one-third of elderly beneficiaries, which calls into question the effectiveness of this approach to Medicare program reform.

Aged↗
PubMed2006

Crowd-in: the effect of private health insurance markets on the demand for Medicaid.

OBJECTIVE: To investigate the effects of local labor market conditions and the availability of employer-sponsored health insurance on exits from the Medicaid program. DATA SOURCE: Data for this project come from a unique administrative database containing a 2 percent sample of all cases on California's Medicaid program in 1987 and a 2 percent sample of all new cases starting each year between 1987 and 1995. STUDY DESIGN: The results are estimated using a discrete duration model where the monthly exit probability is a function of demographic characteristics, local labor market variables, the probability of having employer-sponsored insurance, and fixed year and county effects. PRINCIPAL FINDINGS: Improvements in labor market opportunities (i.e., employment growth, wage growth, and increases in the availability of employer-sponsored health insurance) promote exits off the Medicaid program. A 2.5 percentage point increase in the availability of employer-sponsored insurance leads to a 6 percent increase in the probability that a completed spell lasts no more than 2 years. It would take a 2 percentage point decrease in unemployment rates or a 10 percent increase in average quarterly earnings to yield an equivalent increase in the likelihood of exiting Medicaid within 2 years. These effects are robust to the inclusion of county-level fixed effects and time effects. CONCLUSIONS: Medicaid expenditures and caseloads are sensitive to local economic fluctuations and secular trends in the availability of health insurance. Continued decreases in employer-based health insurance coverage will greatly increase the demand for public insurance coverage and the financial pressures on state governments.

Adolescent↗
PubMed1998

Reducing the burden of diabetes. The National Diabetes Education Program.

The National Diabetes Education Program (NDEP) is a joint initiative sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health and the Division of Diabetes Translation of the Centers for Disease Control and Prevention. The program will develop a partnership of public and private organizations and implement educational activities to help reduce the morbidity and mortality associated with diabetes and its complications. Participating public and private organizations include the Indian Health Service, the Department of Veterans Affairs, the American Diabetes Association, the American College of Physicians, the American Dietetic Association, and the American Association of Diabetes Educators. Key program activities will include (1) ongoing public awareness and education (2) and identification and dissemination of existing educational tools and resources for patients and their families, health care providers, and payers and purchasers of health care. The NDEP will also sponsor the development and dissemination of new educational tools and resources, including science-based guidelines, efforts to improve quality and access to diabetes care, and program evaluation.

Centers for Disease Control and Prevention, U.S.↗