HIV infection treatment costs under Medicaid in Michigan.

The Michigan Medicaid Program payment records generated in the period 1985-89 by 783 persons were analyzed for services related to human immunodeficiency virus (HIV) infection. Other data from death records and the Michigan AIDS Surveillance Registry were available for a subset of those persons. The average monthly payment in 1989 dollars for HIV-related services was $1,302.57. Services determined to be unrelated to HIV infection accounted for 12.5 percent of the total amount for health care received and another 2.5 percent was questionable. The average monthly expenditure for men was roughly twice that for women. The discrepancy did not exist among persons identified in the AIDS Surveillance Registry. Sex differences ceased to exist when Medicaid eligibility (disability versus Aid to Families with Dependent Children) was controlled for by analysis of variance. There were no significant differences between payments to those infected through male-to-male sexual contact and those infected through intravenous drug use. Payments for HIV treatments rose with age to about 40 years, and declined slightly among older adults. The sharpest rise was for those ages 19-25 years and 26-35 years. Large sex differences existed among those who received zidovudine (AZT), 61.4 percent of the men and 19.1 percent of the women. Controlling for Medicaid eligibility moderated those differences, but they remained statistically significant. Differences in zidovudine usage were not found between men and women in the subset identified in the AIDS Surveillance Registry nor among persons infected through male-to-male sexual contact and intravenous drug use.     

Medicaid expenditures for maternity and newborn care in America

An Alan Guttmacher Institute (AGI) survey of the Medicaid programs in each state and the District of Columbia found that some 542,000 low-income women have a Medicaid-subsidized delivery each year--about 15 percent of all women who give birth. The proportion ranges from three percent in Alaska to 25 percent in Michigan. The federal and state governments spend almost $1.2 billion annually for maternity care (including prenatal, postpartum and newborn care); the average expenditure per patient is $2,200. Tennessee reports the highest expenditure per patient ($3,500) and Louisiana the lowest ($1,300). Only the highest payments under Medicaid are close to charges for maternity care in the open market, a fact that results in a significant disincentive for physicians and hospitals to accept Medicaid patients. The $1.2 billion spent for Medicaid-subsidized maternity care compares with an estimated $11.5 billion spent for such care nationwide. Thus, Medicaid pays for about 10 percent of the nation's maternity care bill, although Medicaid subsidizes deliveries for 15 percent of all women who give birth. The figures for maternity care do not include Medicaid expenditures for neonatal intensive care, which, for the 17 states reporting data, average about $11,800 per infant. Although only about six percent of all newborns whose deliveries are subsidized by Medicaid require neonatal intensive care, such care is so expensive that it adds about 30 percent to all Medicaid expenditures for maternity care. Increased Medicaid payments for maternity care, including prenatal care, could have a positive impact on health outcomes for low-income mothers and their babies, and could reduce the necessity for massive and expensive medical treatment for newborns.     

New directions in Medicaid payment for hospital care

Medicaid now pays for 20 percent of all inpatient stays and plays an especially important role in funding obstetric, pediatric, and mental health care. In coming years, policy decisions on inpatient payment may be the most consequential since diagnosis-related groups (DRGs) were introduced two decades ago. This study describes Medicaid's growing role in purchasing inpatient care, reports Medicaid-specific results from an evaluation of three DRG algorithms, provides a case study of a new payment method designed in Mississippi, and summarizes recent developments in paying for quality.     

Evaluation of the impact of Medicare and Medicaid prospective payment on utilization of Philadelphia area hospitals.

The article evaluates the impact of Medicare and Medicaid DRG prospective payment on utilization in Philadelphia area hospitals. These hospitals began a combined Medicare-Medicaid DRG prospective payment at the same time after a common cost-based reimbursement history. Particular attention is paid to the hospital-driven as opposed to physician-driven explanations of declining inpatient utilization. The evaluation of the Tax Equity and Fiscal Responsibility Act (TEFRA) and Diagnosis-Related Group (DRG) interventions uses an ARIMA model that removes both seasonal and autoregressive effects. Both TEFRA and the DRG payment system produced significant reductions in average length of stay, total hospital days, and hospital occupancy rates. Neither, however, had a significant effect on admissions. Hospitals with a higher proportion of Medicare and Medicaid discharges reduced their average length of stay more than other facilities. Hospitals with a higher proportion of outpatient visits to inpatient admissions also reduced inpatient length of stay more. Hospitals with higher than expected overall admissions after the introduction of the DRG program tended to have lower than expected average lengths of stay. The results lend support to the "hospital-driven" interpretation of declines in average length of stay. They fail to support the contention that the DRG system will produce automatic counteracting increases in admissions in the system as a whole.     

Case-mix reimbursement for nursing homes: objectives and achievements

Six state Medicaid programs currently use case-mix reimbursement (CMR) systems to pay nursing homes. Quality of care is not decreased under these payment systems and may actually have increased in some instances, while access for heavy-care Medicaid patients appears to have improved. As for equity of payment, CMR methods when compared with others tend to redistribute funds more in accord with resident care needs. Not all of the six states have made cost containment an explicit objective, and program administration costs typically increase. Since CMR systems primarily affect relative payments, however, they can be shaped to achieve total program expenditure objectives.     

Medicaid patients increasingly concentrated among physicians

Despite increases in Medicaid payment rates and enrollment, the proportion of U.S. physicians accepting Medicaid patients has decreased slightly over the past decade, according to a national study by the Center for Studying Health System Change (HSC). In 2004-05, 14.6 percent of physicians reported that they received no revenue from Medicaid, an increase from 12.9 percent in 1996-97. There were also small increases in the percentage of physicians who were not accepting new Medicaid patients. A more striking trend is that care of Medicaid patients is becoming increasingly concentrated among a smaller proportion of physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. Relatively low payment rates and high administrative costs are likely contributing to decreased involvement with Medicaid among physicians in solo and small group practices.     

The Relationship of Medicaid Payment Rates, Bed Constraint Policies, and Risk-Adjusted Pressure Ulcers

Objective. To examine the effect of Medicaid reimbursement rates on nursing home quality in the presence of certificate-of-need (CON) and construction moratorium laws.
Data Sources/Study Setting. A single cross-section of Medicaid certified nursing homes in 1999 ( N =13,736).
Study Design. A multivariate regression model was used to examine the effect of Medicaid payment rates and other explanatory variables on risk-adjusted pressure ulcer incidence. The model is alternatively considered for all U.S. nursing home markets, those most restrictive markets, and those high-Medicaid homes to isolate potentially resource-poor environments.
Data Extraction Methods. A merged data file was constructed with resident-level information from the Minimum Data Set, facility-level information from the On-Line, Survey, Certification, and Reporting (OSCAR) system and market- and state-level information from various published sources.
Principal Findings. In the analysis of all U.S. markets, there was a positive relationship between the Medicaid payment rate and nursing home quality. The results from this analysis imply that a 10 percent increase in Medicaid payment was associated with a 1.5 percent decrease in the incidence of risk-adjusted pressure ulcers. However, there was a limited association between Medicaid payment rates and quality in the most restrictive markets. Finally, there was a strong relationship between Medicaid payment and quality in high-Medicaid homes providing strong evidence that the level of Medicaid payment is especially important within resource poor facilities.
Conclusions. These findings provide support for the idea that increased Medicaid reimbursement may be an effective means toward improving nursing home quality, although CON and moratorium laws may mitigate this relationship.     

美国卫生费用持续上涨的原因及控制措施

目前美国的卫生费用基数庞大,1998年占GDP的14%,造成卫生经费持续上涨的原因除通货膨胀外,还与以下因素有关;第三方付费的方式、不完善的市场、新技术的应用、人口老龄化,卫生保健模式、多方付费系统,庞大的管理费用、防卫性医疗、浪费等,在美国控制医疗费用的措施包括政府行为和市场竞争机制两方面,比如;资源配置许可制度、对外国医科毕业生的限制政策、采用DRG付费方式、管理型保健医疗等。     

Mounting pressures: physicians serving Medicaid patients and the uninsured, 1997-2001

The proportion of doctors providing any charity care decreased from 76.3 percent in 1997 to 71.5 percent in 2001, according to a new study by the Center for Studying Health System Change (HSC). The proportion of physicians serving Medicaid patients also decreased from 87.1 percent in 1997 to 85.4 percent in 2001. The small decrease in physicians serving Medicaid patients does not appear to have had any negative effects on access to physicians among Medicaid beneficiaries. On the other hand, the more sizable decrease in physicians providing charity care is consistent with other evidence showing decreased access to physicians by uninsured persons. New budget pressures could lead states to freeze or cut Medicaid provider payment rates, which could then trigger access problems.     

A study of the relationship between severity of illness and hospital cost in New Jersey hospitals.

In response to concerns over the equity of diagnosis-related group (DRG)-based prospective payment, the New Jersey Department of Health conducted a Severity of Illness evaluation study in which severity of illness, DRG, and uniform cost information were collected for 76,798 patients in 25 hospitals. Severity of illness was measured using the Computerized Severity Index (CSI) and was found to be a significant determinant of hospital cost in 76 DRGs that accounted for 41.4 percent of the total direct hospital patient care costs and 27 percent of the patients. The addition of CSI severity levels to the 76 DRGs reduced the coefficient of variation of cost in these DRGs by 17.4 percent and improved the overall reduction in variance of cost within the 76 DRGs by 38.2 percent. The change in total hospital payments due to the addition of severity for the 76 DRGs varied from a positive 5.71 percent to a negative 5.48 percent. These results demonstrate that a severity adjustment to this subset of DRGs would result in a more equitable DRG-based prospective payment system.     

An evaluation of diagnosis-related group severity and complexity refinement

In 1988, an ambitious and extensive project was undertaken in New Jersey to evaluate severity class adjustment of the all-payer prospective payment system. Another project objective was to evaluate alternative strategies for refining diagnosis-related groups (DRGs). The evaluation presented here includes a comparison of DRG refinement using Computerized Severity Index classes and Yale University complexity classes. Statistical methods and payment simulations are used to assess the impact of DRG refinement and consequent revenue changes. When a high volume subset of DRGs is refined, simulated payment shifts between hospitals on the order of 5 percent of total hospital costs are indicated by this analysis.     

Methadone Maintenance and State Medicaid Managed Care Programs

Coverage for methadone services in state Medicaid plans may facilitate access to the most effective therapy for heroin dependence. State Medicaid plans were reviewed to assess coverage for methadone services, methadone benefits in managed care, and limitations on methadone treatment. Medicaid does not cover methadone maintenance medication in 25 states (59 percent). Only 12 states (24percent) include methadone services in Medicaid managed care plans. Moreover, two of the 12 states limit coverage for counseling or medication and others permit health plans to set limits. State authorities for Medicaid and substance abuse can collaborate to ensure that appropriate medication and treatment services are available for Medicaid recipients who are dependent on opioids andto construct payment mechanisms that minimize incentives that discourage enrollment among heroin-dependent individuals.     

Medicaid policies for AIDS-related hospital care

With hospital services comprising an important part of care related to acquired immunodeficiency syndrome (AIDS), and all Medicaid programs becoming major payers of these services, Medicaid policies affect the care that Medicaid recipients with AIDS receive. Many States pay hospitals on the basis of prospective payments that do not vary with patient diagnosis. In contrast, Medicaid programs using diagnosis-related group (DRG) payment methods adjust payments to reflect the greater cost of AIDS care. At least 12 Medicaid programs limited the number of paid inpatient hospital days during 1992; Medicaid recipients with AIDS could easily exceed such limits.     

Dually eligible enrollees: 2002

Individuals eligible in both Medicaid and Medicare, the dually eligible enrollees, account for a disproportionate share of Medicaid utilization and payments. While comprising 14.7 percent of the Medicaid population, they accounted for 40.5 percent of Medicaid payments in 2002. Mean reimbursement for the dually eligible enrollees was nearly four times that of non-dually eligible Medicaid enrollees. This highlight examines utilization and payment data for the dually eligible enrollees in 2002.     

Policy issues related to prospective payment for pediatric hospitalization.

Children's hospitals have been excluded from the Medicare prospective payment system (PPS) because of concerns over the applicability of the DRG case-mix system and PPS payment weights to pediatric hospitalization. Nevertheless, DRG-based payment systems are being adopted by State Medicaid agencies and private third-party payers, and the Health Care Financing Administration has been mandated to report to Congress on the feasibility of including children's hospitals in the Federal PPS. This article summarizes policy research on this issue and discusses options in the design of prospective payment systems for pediatric hospitalization.     

Trauma case mix and hospital payment: the potential for refining DRGs.

Uniform hospital discharge abstract data from Maryland were used to examine the homogeneity of trauma-related DRGs with respect to a well-established measure of injury severity, the Injury Severity Score (ISS). Thirty DRGs were identified as including trauma cases with a wide range of severity; for each of these DRGs, ISS explains a significant amount of variation in length of stay. By applying statistical techniques similar to those used to create the original DRG groupings, these 30 DRGs were subdivided by severity and age categories to create a new set of severity-modified DRGs. The potential effects of using DRGs and modified DRGs to pay for inpatient care within the Maryland state regionalized system of trauma care were examined. Payments based on regional averages per DRG and per modified DRG were compared to actual hospital charges regulated by the state's Health Services Cost Review Commission. Using average charges per DRG as a basis of payment, approximately !1.4 million (11 percent of total hospital charges) would be shifted from trauma centers to nontrauma centers. This shift represents an 18 percent loss in revenues to trauma centers and a 30 percent gain in revenues to nontrauma centers. Using a payment system based on severity-modified DRGs, trauma centers would still experience a net loss in revenues and the nontrauma centers a net gain, but the total amount of the shift would be reduced from $11.4 million to $9.8 million. The results argue for the need to explore alternative payment systems not strictly based on current DRGs. Because of DRGs do not adequately reflect severity differences, using them to pay hospitals will create financial incentives that discourage regionalization of trauma care.     

Why did the SSI-disabled program grow so much? Disentangling the effect of Medicaid

The number of participants in the SSI program grew by 1.1 million from 1987 to 1993. This paper examines the role of Medicaid on the SSI participation decision. I use the rapid growth in average Medicaid expenditure as a proxy for its value. OLS estimates of Medicaid's effect may be biased because of omitted variables bias and measurement error. I therefore apply two-stage least squares to estimate Medicaid's effect, using average Medicaid expenditure for blind SSI recipients as an instrument. These estimates show that rising Medicaid expenditure significantly increased SSI participation among adults with low permanent incomes, explaining 20% of the growth.     

Factors affecting conversion rates to Medicaid among new admissions to nursing homes.

OBJECTIVE. This study examines conversion to Medicaid as a payment source among a cohort of newly admitted nursing home residents. DATA SOURCE. The longitudinal data used came from regular assessments of residents in the National Health Corporation's 43 for-profit nursing homes in Missouri, Kentucky, South Carolina, and Tennessee. This information system tracked all residents who were discharged, providing a comprehensive record that may have spanned multiple admissions. STUDY DESIGN. Using survival analysis methods, Cox regression, and survival trees, we contrasted the effect of state, initial payment source, education, age, and functional status on the rate of spend-down to Medicaid. DATA EXTRACTION METHODS. New-admission cohorts were created by linking an admission record for a newly admitted resident with all subsequent assessments and follow-up records to ascertain the precise dates of any payment source changes and other discharge transitions. PRINCIPAL FINDINGS. For the 1,849 individuals who were admitted as self-payers and who were still in the nursing home at the end of one year, there is a 19 percent probability of converting to Medicaid. All analytic methods revealed that education, age, and state of residence were predictive of spend-down among residents who were admitted as self-payers. CONCLUSIONS. Our results confirm the effect of education as an SES indicator and state as a proxy for Medicaid policy on spend-down. Future research should model the effects and duration of intervening hospitalizations and other transitions on Medicaid spend-down among new admissions.     

In 2011 nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help

When fully implemented, the Affordable Care Act will expand the number of people with health insurance. This raises questions about the capacity of the health care workforce to meet increased demand. I used data on office-based physicians from the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement to summarize the percentage of physicians currently accepting any new patients. Although 96?percent of physicians accepted new patients in 2011, rates varied by payment source: 31?percent of physicians were unwilling to accept any new Medicaid patients; 17?percent would not accept new Medicare patients; and 18?percent of physicians would not accept new privately insured patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Higher state Medicaid-to-Medicare fee ratios were correlated with greater acceptance of new Medicaid patients. The findings serve as a useful baseline from which to measure the anticipated impact of Affordable Care Act provisions that could boost Medicaid payment rates to primary care physicians in some states while increasing the number of people with health care coverage.