Multiple payers,commonality and free-riding in health care: Medicare and private payers

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US.     

Watching your wait: evidence-informed strategies for reducing health care wait times

Nobody wants the health care system to be characterized by long, involuntary waits for treatment. Both a strong theoretical rationale and a growing number of case studies support approaches that address the root cause of long waits-usually a poorly designed system, rather than an absolute lack of capacity. This structured review of both peer-reviewed and "gray" literature on waitlist management identifies the 7 common problems that underlie long waitlists and describes remedies that have been successfully applied, using Canadian and British examples with international relevance. Understanding these issues can help administrators and providers develop effective wait-reduction strategies in diverse health care settings.     

The effect of cancer diagnosis on switching health insurance in medicare

Because health insurance is intended to protect patients in the event of a health shock, it is important to evaluate health insurance policy in the context of patients who experience health shocks. I measure the effect of cancer diagnosis on health insurance switching in order to compare cancer patient's preferences among private and publicly administered Medicare. I estimate that a cancer diagnosis increases the probability a patient will leave a private Medicare plan, for the public plan, by 0.8% points (41%). Similarly, a cancer diagnosis decreases the probability a patient will leave the public Medicare plan, for a private plan, by 0.5% points (16%). The implication is that private Medicare plans are relatively less attractive to cancer patients than they are to noncancer patients.     

The Effect of Medicare Eligibility on Spousal Insurance Coverage

A majority of married couples in the USA take advantage of the fact that employers often provide health insurance coverage to spouses. When older spouses become eligible for Medicare, however, many of them can no longer provide their younger spouses with coverage. In this paper, we study how spousal eligibility for Medicare affects the health insurance and health care access of younger spouses. We find that spousal eligibility for Medicare results in younger spouses no longer having employers pay for their insurance and being less likely to have employer‐sponsored coverage. Instead, younger spouses switch to privately purchased coverage, which tends to be worse than what they had before their spouses became eligible for Medicare. We also find suggestive evidence that younger spouses are less likely to use health care services after their older spouses become eligible for Medicare. Copyright © 2015 John Wiley & Sons, Ltd.     

Trends in Medicare home health care use: 1997-2001

The Balanced Budget Act of 1997 mandated a major overhaul in Medicare payment for home health care with an interim payment system (IPS) preceding a prospective payment system (PPS). This study extends an earlier analysis of the impact of the IPS to determine whether home health use and spendingtrends changed after the introduction of the PPS. The rapid decline in the incidence of use and visits per user under the IPS slowed in its final year and then picked up again in the first year of the PPS. In addition, average payment per visit increased sharply under the PPS. Little is known about the impact of continued large reductions in home health services since 1999.     

Health plan enrollment and mortality in the Medicare program

Prior studies have found that Medicare health maintenance organization (HMO) enrollees have lower mortality (over a fixed observation period) than beneficiaries in traditional fee‐for‐service (FFS) Medicare. We use Medicare Current Beneficiary Survey (MCBS) data to compare 2‐year predicted mortality for Medicare enrollees in the HMO and FFS sectors using a sample selection model to control for observed beneficiaries characteristics and unobserved confounders. The difference in raw, unadjusted mortality probabilities was 0.5% (HMO lower). Correcting for numerous observed confounders resulted in a difference of ?0.6% (HMO higher). Further adjustment for unobserved confounders resulted in an estimated difference of 3.7 and 4.2% (HMO lower), depending on the specification of geographic‐fixed effects. The latter result (4.2%) was statistically significant and consistent with prior studies that did not adjust for unobserved confounding. Our findings suggest there may be unobserved confounders associated with adverse selection in the HMO sector, which had a large effect on our mortality estimates among HMO enrollees. An important topic for further research is to identify such confounders and explore their relationship to mortality. The methods presented in this paper represent a promising approach to comparing outcomes between the HMO and FFS sectors, but further research is warranted. Copyright © 2010 John Wiley & Sons, Ltd.     

Medicare expenditures for residents in assisted living: data from a national study

OBJECTIVE: To provide preliminary data on Medicare expenditures for assisted living facility (ALF) residents and to investigate whether ALF characteristics were related to Medicare expenditures for ALF residents. DATA SOURCES/STUDY SETTING: Data from the National Study of Assisted Living for the Frail Elderly conducted in 1998-1999. This analysis was restricted to the 40 percent of ALFs in that sample that adhered to the assisted living (AL) philosophy by offering more than minimal levels of services and privacy. This study involved the approximately 1,200 residents who remained in an ALF from baseline to follow-up data collection. Six months of postbaseline Medicare claims were acquired for 545 of these residents, who did not differ significantly from the larger sample. DATA COLLECTION: Baseline individual and facility data were collected in personal interviews with residents and a combination of personal and telephone interviews with facility staff. Medicare claims data were acquired from the Centers for Medicare and Medicaid Services. STUDY DESIGN: Cross-sectional analyses using logistic and ordinary least squares regression techniques were used to determine the relationships among individual and facility characteristics and Medicare utilization and expenditures. PRINCIPAL FINDINGS: On an annualized basis, AL residents incurred Medicare costs of approximately US dollars 4,800. Just less than 15 percent of AL residents accounted for over 75 percent of total Medicare costs. Both the likelihood of utilizing Medicare-covered services and the intensity of service use were largely unaffected by the characteristics of the ALF in which residents lived. Utilization was largely a function of individual characteristics. The only exception to this general finding was that those individuals who utilized services and resided in smaller ALFs had significantly lower average expenditures than did individuals in larger ALFs. CONCLUSIONS: These preliminary data imply that both the level and distribution of Medicare expenditures among ALF residents were similar to those among the general community-dwelling Medicare beneficiary population. No significant relationships were observed between ALF characteristics and Medicare expenditures, except the effect of facility size. This result may imply that how the AL industry eventually defines itself in terms of services and amenities, other than size, may have little impact on Medicare expenditures for ALF residents. However, this is a single, initial study, so caution must be exercised when considering the implications of these results.     

Access to health insurance and the use of inpatient medical care: Evidence from the Affordable Care Act young adult mandate

The Affordable Care Act of 2010 expanded coverage to young adults by allowing them to remain on their parent's private health insurance until they turn 26 years old. While there is evidence on insurance effects, we know very little about use of general or specific forms of medical care. We study the implications of the expansion on inpatient hospitalizations. Given the prevalence of mental health needs for young adults, we also specifically study mental health related inpatient care. We find evidence that compared to those aged 27–29 years, treated young adults aged 19–25 years increased their inpatient visits by 3.5 percent while mental illness visits increased 9.0 percent. The prevalence of uninsurance among hospitalized young adults decreased by 12.5 percent; however, it does not appear that the intensity of inpatient treatment changed despite the change in reimbursement composition of patients.     

奥地利医疗保健特点的启示与思考

奥地利医疗保健工作有四个特点：一是有十分健全的医疗保障机制;二是医院服务处处体现以人为本的理念;三是医院后勤保障十分现代化;四是卫生资讯工作非常扎实。这些特点带给我们的启示是：一是军队医疗保障制度改革势在必行;二是医院在费用控制方面的作用不可忽视;三是卫生信息建设必须全面系统、注重实用;四是现代医院管理者必须学会关心员工。     

农村医疗保险前后住院费用统计分析

目的对比分析2003年和2004年上半年本地农村户口住院病人在农村医疗保险实施前后疗效、疗程、费用的变化情况,以助于更有效的利用医保资金和医疗资源.方法以儿科几种常见单病种为例,应用SPSS统计软件进行统计分析.结果其治愈率、平均住院天数、平均医疗费用、平均药费及药费占总费用构成差异均有显著性.结论加强管理,控制医疗费用,提高医疗质量和病人满意度.     

某院2010—2013年不同医保患者住院费用比较

目的比较不同类别医保患者(包括城镇职工医保、城镇居民医保、兵团医保、新农合以及自费患者)的住院费用,为控制住院费用不合理增长提供科学依据。方法运用整群抽样方法从某二甲综合性医院获取2010—2013年不同类别医保患者(包括城镇职工医保、城镇居民医保、兵团医保、新农合以及自费患者)的住院费用数据,用描述性统计对不同医保患者住院费用及各部分费用构成进行分析。结论新农合管理部门应加强对定点医疗机构的监管以控制住院费用的不合理使用。各类医保部门均应从控制患者住院天数、药品费用、其他费用等方面控制住院费用的增长。     

医保对象对职工医疗保险制度反应性的分析

该文对享受上海市城镇职工基本医疗保险的市民进行随机抽样调查,就其对医保政策的评价和就医行为反应性改变,分析医保改革的有效性和震荡度.提出加强医保法制建设,强化费用分担意识,完善医保政策,进一步体现福利性、公益性、公平性.     

Introducing managed care in Switzerland: impact on use of health services

The objectives of this study were to assess changes in the self-reported use of health care services after gatekeeping by general practitioners and a global budget were introduced in the health insurance plan for students at the University of Geneva, Switzerland, in October 1992. A random sample of 336 members of the University plan answered questions about their use of health care services during the year before (1992) and the year after (1993) the introduction of managed care. Similar data were collected among a random sample of 300 members of a comparison plan. All participants were 18–44 y old in 1992, spoke French and lived in Geneva. The proportion of insurees who visited specialists decreased by 10% in the University plan between 1992 and 1993 and remained unchanged in the comparison group. The proportion of insurees who visited general practitioners increased by 12% in the University plan and remained unchanged in the comparison group. No effects on the total number of health care visits, on hospitalisations or on use of medications were detected. The introduction of gatekeeping and of a global budget managed by physicians was associated with a transfer of patient visits from specialists to general practitioners.     

我国新生儿医疗保障的现状和政策建议

我国基本医疗保障已覆盖85.6%的人群,而在登记参合和参保（城镇居民）工作结束后,出生的新生儿医疗保障在政策设计上出现一定的空白,因而有必要在制度设计上加以解决。本文在分析我国新生儿医疗保障现状的基础上,就各地有代表性的新生儿医疗保障模式进行了介绍,并提出出台全国统一性政策建议。