Infection control requirements for dialysis facilities and clarification regarding guidance on parenteral medication vials

In April 2008, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register its final rule on Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities. The rule establishes new conditions dialysis facilities must meet to be certified under the Medicare program and is intended to update CMS standards for delivery of quality care to dialysis patients. CDC's 2001 Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients have been incorporated by reference into the new CMS conditions for coverage. Thus, effective October 14, 2008, all ESRD facilities are expected to follow the CDC recommendations as a condition for receiving Medicare payment for outpatient dialysis services.     

Medicare's national coverage decisions, 1999-2003: quality of evidence and review times

In 1998 Medicare amended its procedures for making national coverage decisions for new technologies in an attempt to make the process more transparent and evidence based. We examined the quality of evidence for sixty-nine technologies reviewed by Medicare since then. Determinations by the Centers for Medicare and Medicaid Services (CMS) have generally been consistent with the strength of evidence. Good clinical evidence from rigorous studies is usually lacking for the technologies Medicare considers, although in most cases the CMS covers with conditions if there is at least fair evidence that benefits outweigh harms. Decisions referred to the external Medicare Coverage Advisory Committee (MCAC) have averaged eight months longer than non-MCAC decisions.     

Rule emphasizes quality and cost savings

The Centers for Medicare and Medicaid Services (CMS) emphasizes improving quality and efficiencies across settings in the Inpatient Prospective Payment System (IPPS) final rule for 2012. Hospitals will receive a 1% market basket increase in reimbursement. CMS announced a Medicare spending-per-beneficiary measures that will be used in the Value-Based Purchasing program and the Hospital Inpatient Quality Reporting program. CMS is adding new quality measures involving infection control in 2014 and 2015.     

Challenges and opportunities for Medicare's original prospective payment system

The Medicare program initiated prospective payment for inpatient hospital services in 1983. Although the payment system has achieved many of its goals, changes in the health care market and the public nature of the program will continue to present both challenges and opportunities for improvement. Looking forward, policymakers must consider how to balance paying accurately for services with using Medicare to achieve broader policy objectives. Paying for new technologies, responding to market segmentation and specialization, and encouraging quality improvement must also be addressed. To successfully navigate these issues, policymakers and program administrators need accurate and timely information.     

Effect of Medicare Dialysis Payment Reform on Use of Erythropoiesis Stimulating Agents

ObjectiveIn 2011, the Centers for Medicare and Medicaid Services (CMS) replaced fee-for-service reimbursement for erythropoiesis stimulating agents (ESAs) with a fixed-sum bundled payment for all dialysis-related care and pay-for-performance incentives to discourage maintaining patients'' hematocrits above 36 percent. We examined the impact of the new payment policy on the use of ESAs.ConclusionsCMS''s payment reform for dialysis care reduced the use of ESAs in patients who may not benefit from these agents.     

Failure to comply with CMS' new enrollment procedures could impact physicians' cash flow

The Centers for Medicare and Medicaid Services (CMS) has instituted big changes in its enrollment procedures that could have a major impact on physician groups that fail to comply with CMS' new requirements. First, tick ... tick ... tick ... time is quickly running out on the chance to obtain, and implement into the flow of your practice, a National Provider Identification number (NPI). The bad news is that the requirement to get an NPI is statutory, meaning it's not going to go away. Second, CMS revamped its Medicare provider enrollment processes in an attempt to reduce enrollment application processing delays. Unfortunately, rather than expedite the enrollment process, CMS' new regulations had the over-all effect of causing even more delays and backlogs in the enrollment process. Providers who do not have an NPI by the required deadline risk potential compliance penalties and payment delays. Therefore, not having an NPI or a Medicare Provider Number can have serious consequences on providers' ability to provide care as well as their bottom line (think cash flow!).     

Medicare cost controls and program compliance: the rationale of physician claims edits

This article attempts to demystify and create a context for the enactment of several Medicare cost control and compliance systems for physician reimbursement. The focus is on claims "edits" and Medicare compliance. Portions of Medicare, including health care provider reimbursement, remain fee-for-service programs that can be easily defrauded. To protect the Trust, the Centers for Medicare and Medicaid Services (CMS) has taken a multi-pronged approach, using program administration, enforcement, and rules-based claims editing systems. The Evaluation and Management codes, the Correct Coding Initiative (CCI), and medical necessity rules are claims edits that affect procedure codes. The Medicare program has a complicated system of billing procedures and an apparatus to enforce them. A solid compliance plan must incorporate proper claims editing, because consistent incorrect Medicare billing can be considered abuse. Many resources are available to aid physicians, including computerized tools, new CMS initiatives, and Internet materials.     

Rehabilitation therapy in skilled nursing facilities: effects of Medicare's new prospective payment system

In 1998 the Centers for Medicare and Medicaid Services (CMS) began phasing in a new prospective payment system (PPS) for Medicare payments to skilled nursing facilities (SNFs). I examine the effects of the new PPS on the level of rehabilitation therapy provided in SNFs. The percentage of residents of freestanding SNFs receiving extremely high levels of rehabilitation therapy dropped significantly, and the percentage receiving moderate levels increased. Freestanding SNFs, particularly for-profits, dramatically altered the services they provided in response to new financial incentives. This responsiveness underscores the importance of efforts now under way to refine the SNF PPS.     

Rules for Medical Markets: The Impact of Medicare Contractors on Coverage Policies

Objective. Examine Medicare's local contractors' claim payment rules, focusing on how technology affects the balancing of competing demands to respond to local medical markets (rule heterogeneity) with concerns about national consistency in payment rules (rule homogeneity).
Data Sources. Local medical review policies (LMRPs) posted in policy sets by contractor organizations on the Centers for Medicare and Medicaid Services (CMS) website and a survey of Contractor Medical Directors.
Study Design. We classified LMRPs based on type (NT=new technology; TE=technology extensions, and UM=utilization management), and examined the effect of technology type on LMRP focus, evidence use, policy revisions, implementation speed, and reference material citation characteristics of LMRPs using multivariate analysis.
Principal Findings. NT policies were more homogenous, as were policies among contractors related through multistate affiliation or through informal networks. UM policies were more heterogeneous. NT policies were more likely than UM policies to cite research journals as evidence while UM policies were more likely to cite medical reference materials.
Conclusions. Coverage policies associated with new technologies diffuse rapidly and are homogenous compared to utilization management coverage policies. This suggests that new technology policies are responsive to the development of new technologies at the national level. In contrast, utilization management policies are responsive to local heterogeneity in health care practice. Congress has mandated reforms to the contracting process to achieve consistency and reduce duplication. Our data elucidate the nature and sources of variation and will help policymakers strike a balance between homogeneity and local adaptation.     

Focus on overall quality to succeed under value-based purchasing

The move toward value-based purchasing by the Centers for Medicare & Medicaid Services means that hospitals need to focus on overall quality improvement rather than limiting their efforts to just a few conditions. To keep the initiative budget neutral, CMS is reducing the base operating DRG payment for all Medicare fee-for-service discharges, but hospitals can earn bonuses by performing well. CMS intends to add more measures in the future and can include any measures already being tracked in the Inpatient Quality Reporting Program. Medicare spending per beneficiary will be part of value-based purchasing in fiscal 2015 and will hold hospitals accountable for costs incurred by patients beginning three days before admission to 30 days after discharge.     

Kaiser-Permanente's Medicare Plus Project: a successful Medicare prospective payment demonstration.

The Medicare Plus project of the Oregon Region Kaiser-Permanente Medical Care Program was designed as a model for prospective payment to increase Health Maintenance Organization (HMO) participation in the Medicare program. The project demonstrated that it is possible to design a prospective payment system that costs the Medicare program less than services purchased in the community from fee-for-service providers; would provide appropriate payment to the HMO; and in addition, creates a "savings" to return to beneficiaries in the form of comprehensive benefits to motivate them to enroll in the HMO. Medicare Plus was highly successful in recruiting 5,500 new and 1,800 conversion members into the demonstration, through use of a media campaign, a recruitment brochure, and a telephone information center. Members recruited were a representative age and geographic cross section of the senior citizen population in the Portland, Oregon metropolitan area. Utilization of inpatient services by Medicare Plus members in the first full year (1981) was 1679 days per thousand members and decreased to 1607 in the second full year (1982). New members made an average of eight visits per year to ambulatory care facilities.     

Measuring beneficiary knowledge in two randomized experiments

This article reports results of two studies that measured beneficiaries' knowledge of the Medicare program and related health insurance options using pre- and post-experimental designs. Knowledge was measured using multiple item indexes before and after receiving new informational materials developed by the Centers for Medicare & Medicaid Services (CMS) as part of the National Medicare Education Program (NMEP). Beneficiaries in both studies showed statistically significant gains in knowledge after receiving the new materials. Policy implications for the measurement of knowledge and creation of future versions of the materials are discussed.     

Integration demonstration. The CMS' latest pay-for-performance initiative will test the power of integrated delivery systems to alter doc practice patterns

Linda Magno of the CMS says the Medicare Health Care Quality Demonstration project is one of the agency's boldest initiatives yet. She says the project is a chance for providers to "redesign the healthcare system." The project will feature "a lot of latitude" in payment and waivers of Medicare provisions. And the CMS needs a few good volunteer providers to participate.     

Is case-mix adjustment necessary for an expanded dialysis bundle?

Congress has required CMS to expand the Medicare outpatient prospective payment system (PPS) for dialysis services to include as many drugs and diagnostic procedures provided to end stage renal disease (ESRD) patients as possible. One important implementation question is whether dialysis facility case mix should be reflected in payment. We use fiscal year (FY) 2000 cost report and patient billing and clinical data to determine the relationship between costs and case mix, as represented by several patient demographic, diagnostic, and clinical characteristics. Results indicate considerable variability in costs and case mix across facilities and a significant and substantial relationship between case mix and facility cost, suggesting case mix payment adjustment may be important.     

Medicare's national coverage decisions for technologies, 1999-2007

An analysis of Medicare national coverage decisions (NCDs) from 1999 through 2007 reveals that the Centers for Medicare and Medicaid Services (CMS) considers the available evidence as no better than fair for most of the technologies considered. Still, the CMS issues favorable decisions in 60 percent of the cases it takes on, although almost always with conditions placed on coverage. Since enactment of the 2003 Medicare Modernization Act, which legislated maximum review times for NCDs, the CMS has eliminated "long duration" decisions (more than one year) and has issued several "coverage with evidence development" decisions, which promise flexibility but also carry implementation challenges.     

'Never' land

It's a whole new era for patient safety and payment. The Centers for Medicare & Medicaid Services says it will soon halt Medicare payments for treating eight so-called preventable medical errors, ranging from pressure ulcers to falls. Private insurers are likely to follow that lead and CMS is expected to expand its no-pay list, possibly to include moreof the National Quality Forum's 28 "never events." However, knowing whether patients have certain conditions upon admission can be tricky, requiring a slew of additional tests. And that's not all that worries hospitals.     

Do financial incentives matter? Effects of Medicare price shocks on skilled nursing facility care

Skilled nursing facility (SNF) spending has been one of the fastest growing categories of Medicare spending over the past few decades, and reductions in SNF payments are often recommended as part of Medicare cost containment efforts. Using a quasi‐experiment resulting from a policy‐driven and facility‐specific Medicare payment change, we provide new evidence on how Medicare payment changes affect the amount of SNF care provided to Medicare patients. Specifically, we examine a one‐time, plausibly exogenous change in the hospital wage index, an area‐level adjustment to SNF payments that affected the majority of SNFs nationwide. Using a panel dataset of SNFs, we model the effects of these payment changes on more than 12,000 SNFs across the United States. We find that increases in Medicare payment rates to SNFs increased the total number of Medicare resident days at SNFs. Specifically, a 5% payment increase raised Medicare resident days by 2.33% at facilities with a 10% Medicare share relative to 0%. Further, the effects were asymmetric: Although Medicare payment increases affected Medicare days, payment decreases did not. Our results have important implications for policies that alter the Medicare base payment rates to SNFs and other health care providers.     

Payment generosity and physician acceptance of Medicare and Medicaid patients

Using 2008 physician survey data, we estimate the relationship between the generosity of fees paid to primary care physicians under Medicaid and Medicare and his/her willingness to accept new patients covered by Medicaid, Medicare, or both programs (i.e., dually enrolled patients). Findings reveal physicians are highly responsive to fee generosity under both programs. Also, their willingness to accept patients under either program is affected by the generosity of fees under the other program, i.e., there are significant spillover effects between Medicare and Medicare fee generosity. We also simulate how physicians in 2008 would have likely responded to Medicaid and Medicare payment reforms similar to those embodied in the 2010 Affordable Care Act, had they been permanently in place in 2008. Our findings suggest that “Medicaid Parity” for primary care physicians would have likely dramatically improved physician willingness to accept new Medicaid patients while only slightly reducing their willingness to accept new Medicare patients. Also, many more primary care physicians would have been willing to treat dually enrolled patients.