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The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans
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OBJECTIVE: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures. DATA SOURCE: Medicare administrative claims for 1994 and 1995. STUDY DESIGN: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. DATA EXTRACTION METHODS: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. PRINCIPAL FINDINGS: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. CONCLUSIONS: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. 相似文献
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Context
Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture.Methods
This article summarizes findings from our group''s work evaluating MA''s recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy.Findings
Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market''s functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM''s performance.Conclusions
Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA. 相似文献5.
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Andrew M. Ryan 《Health services research》2009,44(3):821-842
Objective. To evaluate the effects of the Premier Inc. and Centers for Medicare and Medicaid Services Hospital Quality Incentive Demonstration (PHQID), a public quality reporting and pay-for-performance (P4P) program, on Medicare patient mortality, cost, and outlier classification.
Data Sources. The 2000–2006 Medicare inpatient claims, Medicare denominator files, and Medicare Provider of Service files.
Study Design. Panel data econometric methods are applied to a retrospective cohort of 11,232,452 admissions from 6,713,928 patients with principal diagnoses of acute myocardial infarction (AMI), heart failure, pneumonia, or a coronary-artery bypass grafting (CABG) procedure from 3,570 acute care hospitals between 2000 and 2006. Three estimators are used to evaluate the effects of the PHQID on risk-adjusted (RA) mortality, cost, and outlier classification in the presence of unobserved selection, resulting from the PHQID being voluntary: fixed effects (FE), FE estimated in the subset of hospitals eligible for the PHQID, and difference-in-difference-in-differences.
Data Extraction Methods. Data were obtained from CMS.
Principal Findings. This analysis found no evidence that the PHQID had a significant effect on RA 30-day mortality or RA 60-day cost for AMI, heart failure, pneumonia, or CABG and weak evidence that the PHQID increased RA outlier classification for heart failure and pneumonia.
Conclusions. By not reducing mortality or cost growth, this study suggests that the PHQID has made little impact on the value of inpatient care purchased by Medicare. 相似文献
Data Sources. The 2000–2006 Medicare inpatient claims, Medicare denominator files, and Medicare Provider of Service files.
Study Design. Panel data econometric methods are applied to a retrospective cohort of 11,232,452 admissions from 6,713,928 patients with principal diagnoses of acute myocardial infarction (AMI), heart failure, pneumonia, or a coronary-artery bypass grafting (CABG) procedure from 3,570 acute care hospitals between 2000 and 2006. Three estimators are used to evaluate the effects of the PHQID on risk-adjusted (RA) mortality, cost, and outlier classification in the presence of unobserved selection, resulting from the PHQID being voluntary: fixed effects (FE), FE estimated in the subset of hospitals eligible for the PHQID, and difference-in-difference-in-differences.
Data Extraction Methods. Data were obtained from CMS.
Principal Findings. This analysis found no evidence that the PHQID had a significant effect on RA 30-day mortality or RA 60-day cost for AMI, heart failure, pneumonia, or CABG and weak evidence that the PHQID increased RA outlier classification for heart failure and pneumonia.
Conclusions. By not reducing mortality or cost growth, this study suggests that the PHQID has made little impact on the value of inpatient care purchased by Medicare. 相似文献
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Christopher C. Afendulis Mary Beth Landrum Michael E. Chernew 《Health services research》2012,47(6):2339-2352
Objective
To assess the impact of the Patient Protection and Affordable Care Act''s (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.Data Sources
Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010–2011.Study Design
We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.Principal Findings
Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.Conclusions
The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns. 相似文献13.
Objective. To update research on Medicare payments in the last year of life. Data Sources. Continuous Medicare History Sample, containing annual summaries of claims data on a 5 percent sample from 1978 to 2006. Study Design. Analyses were based on elderly beneficiaries in fee for service. For each year, Medicare payments were assigned either to decedents (persons in their last year) or to survivors (all others). Results. The share of Medicare payments going to persons in their last year of life declined slightly from 28.3 percent in 1978 to 25.1 percent in 2006. After adjustment for age, sex, and death rates, there was no significant trend. Conclusions. Despite changes in the delivery of medical care over the last generation, the share of Medicare expenditures going to beneficiaries in their last year has not changed substantially. 相似文献
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Kevin Callison 《Health economics》2016,25(7):873-887
Evidence suggests that the share of Medicare managed care enrollees in a region affects the costs of treating traditional fee‐for‐service (FFS) Medicare beneficiaries; however, little is known about the mechanisms through which these ‘spillover effects’ operate. This paper examines the relationship between Medicare managed care penetration and treatment intensity for FFS enrollees hospitalized with a primary diagnosis of AMI. I find that increased Medicare managed care penetration is associated with a reduction in both the costs and the treatment intensity of FFS AMI patients. Specifically, as Medicare managed care penetration increases, FFS AMI patients are less likely to receive surgical reperfusion and mechanical ventilation and to experience an overall reduction in the number of inpatient procedures. Copyright © 2015 John Wiley & Sons, Ltd. 相似文献
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Dana B. Mukamel Ph.D. Laura M. White M.S. Robert S. Nocon M.H.S. Elbert S. Huang M.D. M.P.H. F.A.C.P. Ravi Sharma Ph.D. Leiyu Shi Dr.P.H. M.B.A. M.P.A. Quyen Ngo‐Metzger M.D. M.P.H. 《Health services research》2016,51(2):625-644
Objective
To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics.Data Sources/Study Settings
Part A and B fee‐for‐service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC.Study Design
We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects.Data Collection
Data were obtained from the Centers for Medicare & Medicaid Services.Principal Findings
Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs.Conclusions
HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients. 相似文献17.
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Objective. To identify factors associated with the cost of treating high‐cost Medicare beneficiaries. Data Sources. A national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004–2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources. Study Design. Using 12 months of claims data from 2005 to 2006, the sample was divided into predicted high‐cost (top quartile) and lower cost beneficiaries using a risk‐adjustment model. For each group, total annual standardized costs of care were regressed on beneficiary, usual source of care physician, practice, and market characteristics. Principal Findings. Among high‐cost beneficiaries, health was the predominant predictor of costs, with most physician and practice and many market factors (including provider supply) insignificant or weakly related to cost. Beneficiaries whose usual physician was a medical specialist or reported inadequate office visit time, medical specialist supply, provider for‐profit status, care fragmentation, and Medicare fees were associated with higher costs. Conclusions. Health reform policies currently envisioned to improve care and lower costs may have small effects on high‐cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for “bending the cost curve.” 相似文献