Showing papers in "Health Care Financing Review in 1998"

Evaluating Alternative Risk Adjusters for Medicare

Abstract: In this study the authors use 3 years of the Medicare Current Beneficiary Survey (MCBS) to evaluate alternative demographic, survey, and claims-based risk adjusters for Medicare capitation payment. The survey health-status models have three to four times the predictive power of the demographic models. The risk-adjustment model derived from claims diagnoses has 75-percent greater predictive power than a comprehensive survey model. No single model predicts average expenditures well for all beneficiary subgroups of interest, suggesting a combined model may be appropriate. More data are needed to obtain stable estimates of model parameters. Advantages and disadvantages of alternative risk adjusters are discussed.

Impact of report cards on employees: a natural experiment.

Abstract: To determine the effect of survey-based, health plan report cards on employees as they selected their 1995 health plan, the authors surveyed two groups of Minnesota State employees, one of which received the report card and one that did not. Both groups were surveyed before and after their enrollment. The authors looked for report card effects on relative changes in the employees' knowledge of health plan benefits and their ratings of quality and cost attributes, as well as their plan choice, rates of switching plans, and willingness to pay higher premiums. The only report card effect found was an increase in perceived knowledge for employees with single coverage.

Profile of Medicare beneficiaries with AIDS: application of an AIDS casefinding algorithm.

Abstract: This profile of Medicare beneficiaries with acquired immunodeficiency syndrome (AIDS) was developed by applying a casefinding algorithm to virtually all Medicare claims from 1991-93. The algorithm identified more than 37,000 beneficiaries with AIDS, approximately 21,000 of whom were living at the end of 1993. These estimates suggest that as many as 12 percent of people living with AIDS at the end of 1993 were covered by Medicare. Medicare expenditures for these beneficiaries averaged more than $2,400 per month and totaled more than $500 million in 1993. These expenditures are likely to rise as more people with AIDS live long enough to qualify for Medicare coverage.

Impact of Medicaid Expansion on Early Prenatal Care and Health Outcomes.

Abstract: To assess the impact of Medicaid expansion for pregnant women in South Carolina and California, the authors compared change in rates of timely prenatal care, adverse infant and maternal health outcomes, and use of cesarean section for groups of pregnant women who were either uninsured or covered by Medicaid, versus women with private coverage. The results showed small and/or inconsistent changes. Provision of coverage may be the first logical step in improving health care for the uninsured, but outcomes may rely more on outreach, coordination of care, and non-medical interventions than on provision of insurance coverage per se.

Research Issues: Dually Eligible Medicare and Medicaid Beneficiaries, Challenges and Opportunities.

Abstract: This overview describes the Medicare and Medicaid dually eligible beneficiaries, and it summarizes challenges in obtaining information and designing health care and supportive systems across the continuum of their needs. Some of the challenges include: the complexities of Medicaid eligibility, key structural differences between Medicare and Medicaid, long-standing data limitations, and determining appropriate payment mechanisms and amounts. The overview discusses and highlights changes that are expected to improve the potential for research on dual eligible issues.

National health expenditures, 1997.

Abstract: In 1997 health spending in the United States increased just 4.8 percent to $1.1 trillion. As a share of gross domestic product (GDP), national health expenditures (NHE) absorbed 13.5 percent of the country's output in 1997--a share that has remained relatively constant for 5 years. Despite the relative stability in recent years, signs of changing trends are emerging.

Cost and Financing of Care for Persons With HIV Disease: An Overview.

Abstract: This article explores the impact of new combination drug therapies on the cost and financing of human immunodeficiency virus (HIV) disease. Evidence indicates that the proportion of costs attributable to drugs has increased significantly since the diffusion of new combination drug therapies, and that the proportion of costs attributable to hospital inpatient care has decreased. The absence of timely data is the major difficulty in analyzing the impact of recent changes. Only two studies have examined costs since the diffusion of new combination drug therapies, and there are no recent studies of the insurance status of persons with HIV disease.

MCBS Highlights: Dually Eligible Medicare Beneficiaries.

Abstract: The Medicare Current Beneficiary Survey (MCBS) is a powerful tool for analyzing the Medicare population. Based on a stratified random sample, we can derive information about the health care use, expenditure, and financing of Medicare's 37 million enrollees. We can also learn about those enrollees' health status, living arrangements, and access to and satisfaction with care. The MCBS allows for detailed analysis of the dually eligible population. The 1997 sample of dually eligible beneficiaries totaled about 3,500 respondents. In addition to Medicare expenditures the MCBS collects data on health expenditures paid for by Medicaid, by others, and by the beneficiaries themselves. Demographic data, and information on living arrangements, and health conditions are also collected. All of this information can be combined to offer a more complete profile of the dually eligible population than would be possible from Medicare administrative data alone.

Inpatient Psychiatric Care of Medicare Beneficiaries With State Buy-In Coverage.

Abstract: Administrative data were used to compare lengths of stay, Medicare payment, total and average daily costs, discharge destinations, rehospitalizations, and emergency room (ER) use of dually eligible and non-dually eligible Medicare inpatients admitted for a psychiatric diagnosis. Regressions controlled for State buy-in coverage as a proxy for dual eligibility, hospital type, and beneficiary sociodemographic and clinical characteristics. Measures of severity within diagnostic category were limited to comorbidities. Among disabled beneficiaries, dually eligible beneficiaries had lower costs and shorter stays. Among elderly and disabled persons, dually eligible beneficiaries had higher rates of rehospitalization, post-discharge ER use without admission, and discharge to destinations other than self-care.

Does Health Status Explain Higher Medicare Costs of Medicaid Enrollees

Abstract: In this article, the authors present findings on differences in Medicare costs between elderly beneficiaries who are dually eligible for Medicare and Medicaid and other Medicare beneficiaries. Data from the Medicare Current Beneficiary Survey (MCBS) were used in the analysis. After controlling for health and functional-status differences, the higher Medicare costs of dually eligible persons, relative to other enrollees, was reduced from 282 percent to 45 percent.

Choice of health plan: implications for access and satisfaction.

Abstract: In this article, the authors examine why low-income persons choose a managed care plan and the effects of choice on access and satisfaction, using data from the 1995-96 Kaiser/Commonwealth Five-State Low-Income Survey. Two-thirds of those choosing a managed care plan cited costs or benefits as their primary reason. Logistic regressions indicate that choice of plan had a neutral or positive effect on access and satisfaction. Medicaid enrollees with choice were less likely than those without to have difficulty obtaining particular services, more likely to rate plan quality highly, and less likely to report major problems with plan rules.

Stability of disability among PACE enrollees: financial and programmatic implications.

Abstract: This article examines the experience of the first 11 Program of All-inclusive Care for the Elderly (PACE) programs. It investigates changes in functional status of participants in relation to length of enrollment in the program and individual risk characteristics. Our findings indicate that mature programs experience stable disability mix over time, supporting the rationale for the current PACE payment method. However, significant differences exist between programs, suggesting that payment rates could be more program specific. Analysis of the effect of patient characteristics at admission on the likelihood of improvement in functional status identified areas for quality improvement. The implications of this study have increasing importance in light of the expected expansion of PACE to approximately 100 sites by the year 2000.

Children's Use of Primary and Preventive Care Under Medicaid Managed Care

Abstract: The authors found that two mandatory Medicaid primary care case management (PCCM) programs were somewhat successful in improving access to primary care among children in the early 1990s. However, the Florida program, in which the PCCM benefit package included Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, did not meaningfully increase EPSDT screening visits among preschoolers. Further, the increase seen in New Mexico, where EPSDT was carved out of the PCCM benefit package, was evident for both program participants and non-participants and therefore could not be attributed to the PCCM program.

Health-Based Payment for HIV/AIDS in Medicaid Managed Care Programs.

Abstract: In recent years, State Medicaid programs have begun adopting health-based payment systems to help ensure quality care for people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and to ensure equity for the managed care organizations (MCOs) in which these people are enrolled. In this article, the authors discuss reasons why such payment systems are needed and describe AIDS-specific capitation rates that have been adopted in several State Medicaid waiver programs. The authors also examine comprehensive risk-adjustment systems both within Medicaid and outside the program. Several research questions needing further work are discussed.

Evolution of Medicaid Coverage of Medicare Cost Sharing.

Abstract: State Medicaid agencies are required to assist low-income Medicare beneficiaries to pay Medicare cost sharing, defined as premiums, deductibles, and coinsurance, as follows: all cost sharing for those below the Federal poverty level (FPL) and otherwise qualifying; Part B premiums for persons with incomes 100-120 percent of FPL; all or a portion Part B premiums for persons 120-175 percent of FPL, limited by funding availability; Part A premiums for persons with disabilities who have worked their way off Social Security and whose incomes are below 200 percent of FPL. States also have the option to extend additional protections or to cover additional Medicare beneficiaries beyond what is mandated by Federal law. Obviously, Federal changes in Medicare may have profound, if not always anticipated, implications for Medicaid. Understanding how current policy on dually eligible beneficiaries came into being may help shape what it will become.

Urban Health Care in Transition: Challenges Facing Los Angeles County

Abstract: The authors examine the Medicaid Section 1115 Demonstration Project currently underway in Los Angeles County. The waiver was designed as part of a response to a financial crisis the Los Angeles County Department of Health Services (LACDHS) faced in 1995. It provides financial relief to give the county time to restructure its system for serving the medically indigent population. Los Angeles County's goal is to reduce its traditional emphasis on emergency room and hospital care by building an integrated system of community-based primary, specialty, and public health care. This case study describes activities completed through the spring of 1997, approximately 1 year after the waiver was approved.

Linked Data Analysis of Dually Eligible Beneficiaries in New England.

Abstract: Analysis of linked Medicare/Medicaid data files from four New England States (Connecticut, Maine, Massachusetts, and New Hampshire) confirm that dually eligible beneficiaries used a disproportionate amount of both Medicare and Medicaid resources in 1995, driven largely by the significant subset of the population that used institutional long-term care (LTC). If States and the Federal Government are successful in developing approaches to dually eligible beneficiaries that reduce the use of institutional LTC, overall public costs per person could decline while Federal costs remained constant, and beneficiaries could have a greater selection of community-based options and experience greater satisfaction.

Risk Adjustment for Dually Eligible Beneficiaries Using Long-Term Care

Abstract: This study explores use of the principal inpatient diagnostic cost groups (PIPDCG) and hierarchical coexisting conditions (HCC) risk-adjustment methodologies for a population of dually eligible beneficiaries receiving chronic long-term care (LTC). Measures of individual predictive accuracy for this population compared with the total Medicare population were similar for the PIPDCG models but somewhat smaller for the HCC models. Incorporating measures of functional status increased the R2 values by only a small amount for Medicare expenditures but by a somewhat larger amount for total expenditures. Addition of other variables, especially placement, further improved the predictive power.

Hospitalizations for Injury Among Medicaid Children: California, 1992.

Abstract: Little is known about the incidence and cost of injuries for Medicaid children. This article provides data on hospital utilization and payments for injuries among Medicaid children, using the Health Care Financing Administration's (HCFA) State Medicaid Research Files. During 1992, there were nearly 17,000 injury hospitalizations for California's Medicaid children (758 per 100,000 enrollees), representing over $93 million in program payments. The most frequent injury hospitalizations were fractures and dislocations. Disabled children and 18- to 20-year-old males experienced the highest hospital utilization rates. These findings will assist Medicaid policymakers in targeting prevention efforts to reduce incidence and program payments for children's injuries.

Duration in and Pattern of Utilization Under Children's Health Insurance Programs

Abstract: This article provides information on duration of enrollment and utilization under children's health insurance programs for States planning to expand such programs in response to the Balanced Budget Act of 1997. Using data from children's health insurance programs in Pennsylvania, we find that there is a significant turnover among enrollees and the pattern of use following enrollment suggests considerable pent-up demand for medical services. The annual payment per child for services with a comprehensive benefit package in 1994-95 was estimated to range from $500 to $600 depending on turnover, which is a slight underestimation because some hospitalized children were shifted to Medicaid.

Managed Care's Impact on Medicaid Financing for Early Intervention Services

Abstract: Medicaid has been a major source of financing for early intervention services since the inception of the Infants and Toddlers with Disabilities Program in 1986. In this article, the authors analyze Medicaid financing of early intervention services in 39 States before and after the introduction of managed care. The association between level of Medicaid financing and program characteristics, provider arrangements, managed care carve-out policies, and managed care contract requirements is assessed. The authors discuss the reduction of Medicaid financing after managed care and its implications for State Infants and Toddlers with Disabilities Programs, State Medicaid agencies, and managed care organizations.

Serving rural Medicare risk enrollees: HMOs' decisions, experiences, and future plans.

Abstract: This article identifies factors that influence health maintenance organizations' (HMOs) decisions about offering a Medicare risk product in rural areas; describes HMOs' recent experiences serving rural Medicare risk enrollees; and assesses the potential impact of Medicare program changes on the future willingness of HMOs to offer a Medicare risk product in rural areas Data for the analysis were collected through interviews with a national sample of 27 HMOs The results underscore the importance of adjusted average per capita cost (AAPCC) rates in HMOs' decisions to offer Medicare risk products in rural areas, but also indicate that other factors influence these decisions

State Implementation of the AIDS Drug Assistance Programs.

Abstract: Acquired immunodeficiency syndrome (AIDS) drug assistance programs (ADAPs) provide access to medications for people who lack other health coverage. In this article, the authors present the results of a 1997 survey identifying how 48 States implemented ADAPs, focusing on the number of beneficiaries, medical and financial eligibility criteria, the administration of waiting lists, and the coverage of drugs including protease inhibitors. Increased funding for ADAPs is necessary to maintain this important part of the public sector safety net for human immunodeficiency virus (HIV) care.

Effect of Low-Income Elderly Insurance Copayment Subsidies

Abstract: The authors use a two-part model of demand to model the impact of qualified Medicare beneficiary (QMB) enrollment on medical care use. Assuming QMB enrollment to be exogenous, they find Medicare Part B utilization to be 12 percent higher and Part B expenditures 44 percent greater among QMBs than among eligible non-enrollees. There is no difference between these two groups in overall Part A expenditures. Modeling the possibility that QMB enrollment is endogenous, the authors find qualitatively similar results, but the estimates are not precisely estimated.

Preventive Services for Children Under Medicaid, 1989 and 1992.

Abstract: Receipt of key preventive services among Medicaid children in four States is examined. Between 1989 and 1992, small-to-moderate improvements in well-child visit and immunization rates were observed. Age, eligibility group, and statewide factors affected these rates. Uniformly low use of preventive dental care was found. These rates were generally higher among children with well-child visits. To understand the full extent of preventive care for children, all Medicaid-financed well-child services should be considered, not just those provided under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services program. Nonetheless, EPSDT is a critical vehicle for outreach and case management.

Children's Preventive Care Use Under Two Mature Medicaid Managed Care Plans in California

Abstract: We investigated the extent to which children continuously enrolled in two mature county-organized Medicaid managed care plans for 6, 12, and 24 months received recommended well-child visits and immunizations. We also investigated whether any improvements in compliance were evident during the period 1989-92. Compliance was low for well-child visits and immunizations at the recommended ages regardless of eligibility group. Although slight improvements in immunizations were made over time, little progress was made in compliance with well-child visits. Continued vigilance is required to achieve the government's goal of 90 percent immunization compliance among 2-year-olds.

Medicaid Providers of Children's Preventive and EPSDT Services, 1989 and 1992

Abstract: In this study, the authors use 1989 and 1992 Medicaid Tape-to-Tape data from California, Georgia, Michigan, and Tennessee to examine changes in provider systems before and after enactment of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89). Although all four study States' preventive and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services provider system grew, Michigan's growth was markedly higher. Growth occurred in the number of both office-based and clinic-based providers. However, this growth was outpaced by growth in enrollment, so that child/provider ratios were generally higher at the end of the study period.

Previous Medicaid Status of Children Newly Enrolled in Supplemental Security Income.

Abstract: The Supplemental Security Income (SSI) program for children and adolescents has experienced a fourfold enrollment growth since 1989. Most SSI recipients also receive Medicaid, and SSI growth could therefore lead to major new Medicaid expenditures if new SSI recipients were not previous Medicaid enrollees. Using Medicaid claims for 1989-92, we determined whether SSI expansions included many children new to Medicaid as well as whether children with certain disabilities were more likely to have had Medicaid prior to SSI enrollment. Rates of new SSI enrollees without previous Medicaid coverage decreased from 53 percent in 1989 to 39 percent by 1992.

MCBS Highlights: Barriers to Physician Care for Medicare Beneficiaries.

Abstract: The 1989 Omnibus Budget Reconciliation Act (OBRA 89) included physician payment reform, part of which was a limit on balanced billing. The provision limiting charges was implemented in 1991. Under this reform, physicians who did not accept Medicare assignment were prohibited from billing Medicare beneficiaries more than 140 percent of the prevailing charge for evaluation and management services, and 125 percent of the prevailing charge for all other services. With the implementation of the physician fee schedule in 1992, the limits on balanced billing became more stringent. Physicians who did not participate in Medicare were allowed 95 percent of the physician fee schedule amount for covered services from Medicare and could charge beneficiaries up to 120 percent of the fee schedule amount in 1992 and 115 percent of the fee schedule amount in 1993. In 1993, then, the actual amount that physicians could charge Medicare beneficiaries for covered services equaled 115 percent of the 95 percent allowed fee schedule amount—or 9.25 percent over the fee schedule rate. This limit has been in effect since 1993. Before the OBRA 89 reforms, limits on the amount physicians could charge beneficiaries for Medicare covered services were much higher. At the time these limits were implemented there was speculation from special interest groups that many physicians would stop treating Medicare patients, causing beneficiaries to have difficulty receiving medical care, even though at the time roughly 80 percent of physicians accepted assignment. Proposed legislation in the Senate (S 1194) and the House of Representatives (HR 2497) would allow physicians to enter into private contracts with Medicare beneficiaries for covered services that effectively circumvent the balanced billing limits. The proposed legislation would allow physicians to accept Medicare payment for covered services from some patients while entering into private contracts for the same services with other patients. The physician, then, would determine the amount charged to the beneficiary for services provided under private contracts and Medicare would pay for no portion of those services. The legislation is designed to allow better access to care for Medicare beneficiaries in response to anecdotal reports from beneficiaries that their physicians are unwilling to take them as Medicare patients.