Showing papers in "Health Care Financing Review in 2000"

Understanding and addressing racial disparities in health care.

Abstract: Racial disparities in medical care should be understood within the context of racial inequities in societal institutions. Systematic discrimination is not the aberrant behavior of a few but is often supported by institutional policies and unconscious bias based on negative stereotypes. Effectively addressing disparities in the quality of care requires improved data systems, increased regulatory vigilance, and new initiatives to appropriately train medical professionals and recruit more providers from disadvantaged minority backgrounds. Identifying and implementing effective strategies to eliminate racial inequities in health status and medical care should be made a national priority.

Using Diagnoses to Describe Populations and Predict Costs

Abstract: The Diagnostic Cost Group Hierarchical Condition Category (DCG/HCC) payment models summarize the health care problems and predict the future health care costs of populations. These models use the diagnoses generated during patient encounters with the medical delivery system to infer which medical problems are present. Patient demographics and diagnostic profiles are, in turn, used to predict costs. We describe the logic, structure, coefficients and performance of DCG/HCC models, as developed and validated on three important data bases (privately insured, Medicaid, and Medicare) with more than 1 million people each.

Improving health-based payment for Medicaid beneficiaries: CDPS.

Abstract: This article describes the Chronic Illness and Disability Payment System (CDPS), a diagnostic classification system that Medicaid programs can use to make health-based capitated payments for TANF and disabled Medicaid beneficiaries. The authors describe the diversity of diagnoses and different burdens of illness among disabled and AFDC Medicaid beneficiaries. Claims from seven States are analyzed, and payment weights are provided that States can use when adjusting HMO payments. The authors also compare the taxonomy and statistical performance of CDPS to other leading diagnostic classification systems and find that the new model performs better in a number of respects.

HCFA's Racial and Ethnic Data: Current Accuracy and Recent Improvements

Abstract: Using linked data from the Medicare Current Beneficiary Survey (MCBS), the authors assessed the accuracy of racial/ethnic classifications in HCFA's enrollment data base (EDB) before and after the 1997 effort to update the EDB. After the update, the sensitivity of the EDB was 97 percent for white persons and 95 percent for black persons, but less than 60 percent for all other categories. The positive predictive value was above 96 percent for white, black, and Hispanic persons, but below 80 percent for all others. There was some improvement in accuracy for white persons and black persons from 1991-1997, and larger improvements for the non-black minorities from 1996-1997.

Principal inpatient diagnostic cost group model for Medicare risk adjustment.

Abstract: The Balanced Budget Act (BBA) of 1997 required HCFA to implement health-status-based risk adjustment for Medicare capitation payments for managed care plans by January 1, 2000. In support of this mandate, HCFA has been collecting inpatient encounter data from health plans since 1997. These data include diagnoses and other information that can be used to identify chronic medical problems that contribute to higher costs, so that health plans can be paid more when they care for sicker patients. In this article, the authors describe the risk-adjustment model HCFA is implementing in the year 2000, known as the Principal Inpatient Diagnostic Cost Group (PIPDCG) model.

Disparities in Medicare services: potential causes, plausible explanations, and recommendations.

Abstract: Race/ethnicity and socioeconomic status (SES) are associated with the use of M e d i c a re services. In this ar ticle, the author juxtaposes disparities in health outcome measures (including death rates for h e a rt disease, cancer, and stroke) with disparities in the use of elective services expected to improve health, and with disparities in the use of non-elective services associated with poor management of chronic disease. This approach is intended to provide information for judging (a) the re a s o n a b l e n e s s of the explanations of f e red for disparities in M e d i c a re utilization and (b) the re c o mmendations made to effect change.

Medicaid 1915(c) home and community-based services waivers across the states.

Abstract: This article provides State-level data on the Medicaid 1915(c) home and community-based services (HCBS) waivers program. Medicaid 1915(c) waiver participants were 32 percent of the Medicaid participants in institutional care in 1997. These data document wide interstate variation in organizational oversight and program policies for the waivers. Many structural barriers to HCBS waiver growth existed. Case management services, in some form, were normative for most HCBS waiver participants, but formal mechanisms to assess client satisfaction and service quality were less common. Substantial new growth in this program may require fundamental changes in HCBS waiver policies.

Racial and ethnic differences in hospitalization rates among aged Medicare beneficiaries, 1998.

Abstract: Efforts to study racial variations in access to health care for minorities other than black persons have been hampered by a paucity of data. The Health Care Financing Administration (HCFA) has made efforts in the past few years to enhance the racial codes on the Medicare enrollment files to include Hispanic, Asian American, and Native American designations. This study examines hospitalization rates by these more detailed racial/ethnic groupings. The results show black, Hispanic, and Native American aged beneficiaries compared with white beneficiaries have higher hospitalization rates. Asian American beneficiaries have lower hospitalization rates. Rates of revascularization--coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA)--are lower for black, Hispanic, and Native American beneficiaries compared with white beneficiaries, while rates for Asian Americans are similar to rates for white beneficiaries.

Home and Community-Based Services Waivers

Abstract: The history and current status of the Medicaid Home and Community-Based Services Waiver Program are presented. The article discusses the States' role in developing and implementing creative alternatives to institutional care for individuals who are Medicaid eligible. Also described are services that may be provided under the waiver program and populations served.

Health-related quality of life predictors of survival and hospital utilization.

Abstract: The health-related quality of life (HRQOL) of 103 end-stage renal disease (ESRD) patients on hemodialysis was studied for prediction of 1-year survival and hospital days in the context of other predictors. Higher HRQOL physical functioning, higher provider-reported functional performance, fewer private religious activities, living with family, black race, and having a diagnosis of hypertension predicted survival. Lower HRQOL energy, higher pain, and not living with family predicted more hospital days. Patients living with family reported more social support and better HRQOL general health, emotional well-being, social health, and quality of social interactions than other patients.

Reforming the Medicaid disproportionate share hospital program.

Abstract: Since 1991, three Federal laws have sought to reform the Medicaid disproportionate share hospital (DSH) program, which is designed to help safety net hospitals This article provides findings from a 40-State survey about Medicaid DSH and supplemental payment programs in 1997 Results indicate that the overall size of the DSH program did not grow from 1993 to 1997, but the composition of DSH revenues and expenditures changed substantially: A much higher share of the DSH funds were being paid to local hospitals and relatively less was being retained by the States The study also revealed that large differences in States' use of DSH still persist

Medicaid and the HIV/AIDS Epidemic in the United States.

Abstract: This article explores the impact on Medicaid costs of new AIDS treatments and other technology advances. Available data on total projected Medicaid expenditures and actual expenditures for antiretroviral drugs are presented. The article further addresses Medicaid State agencies' efforts to assure that Medicaid-eligible persons with AIDS receive quality care, and reviews recent studies on utilization of services among persons with HIV disease.

Favorable selection in the Medicare+Choice program: new evidence.

Abstract: Historically, studying the Medicare managed care favorable-selection issue has been difficult because direct data on managed care enrollees have been unavailable. In this study, we analyzed the first year of Balanced Budget Act (BBA)-mandated inpatient encounter data. Based on this comparison of actual managed care and fee-for-service (FFS) beneficiaries, it appears that there are significant differences between these populations. The most striking differences are found in the comparison of average risk factors, indicating a clear bias in the managed care populations toward beneficiaries predicted to be less costly.

Medicare's End Stage Renal Disease Program.

Abstract: Perhaps no other Federal Government program can lay claim to have saved as many lives as the Medicare end stage renal disease (ESRD) program. Since its inception in 1973, as a result of the Social Security Amendments of 1972 (Public Law 92-603, section 299I), over 1 million persons have received life-saving renal replacement therapy under this program. Prior to the enactment of this legislation, treatment was limited to a very few patients due to its extremely high cost and the limited number of dialysis machines. In the 1960s, it was not uncommon for hospitals that had dialysis machines to appoint special committees to review applicants for dialysis and decide who should receive treatment, the others were left to die of renal failure. Public Law 92-603 removed this odious task from the nephrology community. A person with ESRD is entitled to Medicare if he/she is fully or currently insured for benefits under Social Security, or is a spouse or dependent of an insured person. Consequently, entitlement is less than universal, with 92 percent of all persons with ESRD qualifying for Medicare coverage.

Approaches to eliminating sociocultural disparities in health.

Abstract: The recent flurry of studies documenting the presence of racial, ethnic, and socioeconomic disparities in health care and health have outpaced articles that describe effective strategies to eliminate disparities. Through literature review and informal interviews with research, policy, and program experts, we developed a framework of programs that address disparities through targeting clinicians, patients and communities, and health systems. We found that the lack of technical expertise, resources, and sensitive tools are all common barriers to evaluating programs. To stimulate more effective programs and rigorous evaluations, we describe specialized implementation and evaluation techniques programs can use, and make recommendations for future efforts.

Medicaid Spending: A Brief History.

Abstract: Medicaid spending growth has varied greatly over time. This article uses financial and statistical data to trace the history of Medicaid spending in relation to some of the major factors that have influenced its growth over the years. Periods of varying growth are divided into eight "eras," ranging from program startup in 1966 through the post-welfare reform period. Average expenditure and enrollee growth for each era are presented and briefly discussed. Finally, some factors are mentioned that are likely to affect future growth in the Medicaid program.

Minority health status in adulthood: the middle years of life.

Abstract: The objective of this article is to describe the racial and ethnic differences in health status during the "middle years" of life. We use data from National Vital Statistics Reports (Hoyert, Kochanek, and Murphy, 1999) to estimate excess mortality among racial and ethnic minority groups for the leading causes of death among adults. Also discussed are the current state of scholarship in minority health and suggestions for future directions for research on racial and ethnic differences in health status.

Milestones in Medicare Managed Care.

Abstract: Medicare managed care has a long history, dating back to the beginning of the Medicare program. The role and prominence of managed care in Medicare have both changed over the years; though plan participation has waxed and waned, enrollment has grown steadily The greatest growth in Medicare managed care enrollment occurred in the middle to late 1990s, coinciding with the "managed care revolution." Enrollment growth has slowed in recent years, plan participation is declining, and the future of the program is not easy to predict.

Covering Uninsured Adults Through Medicaid: Lessons from the Oregon Health Plan.

Abstract: The Oregon Health Plan (OHP), Oregon's section 1115 Medicaid waiver program, expanded eligibility to all residents living below poverty. We use survey data, as well as OHP administrative data, to profile the expansion population and to provide lessons for other States considering such programs. OHP's eligibility expansion has proved a successful vehicle for covering large numbers of uninsured adults, although most beneficiaries enroll for only a brief period of time. The expansion population, particularly childless adults, is relatively sick and has high service use rates. Beneficiaries are also likely to enroll when they are in need of care.

An Overview: Eliminating Racial, Ethnic, and SES Disparities in Health Care

Abstract: The papers featured in this issue of the Health Care Financing Review were presented at "Eliminating Racial, Ethnic, and SES Disparities in Health Care: A Research Agenda for the New Millennium." This conference was held on October 15, 1999, in the Washington, DC., area and was co-sponsored by the Health Care Financing Administration (HCFA), the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research), and the Henry J. Kaiser Family Foundation. The conference was undertaken in response to the challenge posed by President Clinton's national goal of eliminating racial and ethnic disparities in six health domains by the year 2010.

Medicare risk-adjusted capitation payments: from research to implementation:

Abstract: In this issue of the Health Care Financing Review, we focus on risk adjustment. A now-popular part of current health care jargon, risk adjustment can actually refer to a number of interrelated concepts. For example, risk adjustment sometimes describes a way of accounting for differences in health status among various study populations; this is also referred to as case-mix adjustment. Risk adjustment can also be used for the purpose of measuring and/or predicting the health care expenditures of individuals or groups, and applied specifically as part of a payment system. It is this latter application of the term that is the focus of this issue. In part, this issue updates some of the research that was previously published in the 1996 issue of the Review Volume 17, Number 3 on risk adjustment. While much has changed regarding the policy applications of risk adjustment—risk-adjusted capitated payments are now a reality in the Medicare program, as well as in many State Medicaid programs—recent research on risk adjustment continues to focus on model development and improvement. However, because the real world of risk-adjusted payment systems are far more common than in 1996, some of the newest work in risk adjustment is related to policy applications. This issue presents articles that touch both on recent model development work and on policy applications.

Medicaid and the Health of Children

Abstract: The Medicaid program has evolved and expanded since its inception in 1965, providing health insurance coverage for ever-increasing numbers of children living in poverty. During the first 35 years of Medicaid, the program has expanded coverage to include preventive services for children, expanded eligibility criteria to include uninsured children not receiving welfare. The Medicaid program has encouraged innovation in the form of managed care and primary care case management. Most recently, the State Children's Health Insurance Program (SCHIP) has given States freedom in providing more children with coverage. Medicaid has had a powerful influence on the health of the Nation's children. Because of Medicaid coverage, fewer children die, and children have less severe illnesses, fewer hospitalizations, fewer emergency department visits, more preventive care, and more immunizations than they would have had they not been insured.

Risk adjustment for health plans disproportionately enrolling frail Medicare beneficiaries.

Abstract: There is concern about the adequacy of diagnosis-based risk adjusters for paying health plans that disproportionately enroll frail Medicare beneficiaries The Medicare Current Beneficiary Survey (MCBS) was used to examine the ability of two risk-adjustment models to predict Medicare costs for groups defined by institutional status and difficulty with activities of daily living (ADLs) Both models underpredicted average costs for non-institutionalized frail beneficiaries; however, the models slightly overpredicted expenses for most frail individuals and severely underpredicted for a minority Further refinements are needed if diagnosis-based models are used to pay plans that disproportionately enroll frail beneficiaries

A clinically detailed risk information system for cost.

Abstract: The authors discuss a system that describes the resources needed to treat different subgroups of the population under age 65, based on burden of disease. It is based on 173 conditions, each with up to 3 severity levels, and contains models that combine prospective diagnoses with retrospectively determined elements. We used data from four different payers and standardized the cost of most services. Analyses showed that the models are replicable, are reasonably accurate, explain costs across payers, and reduce rewards for biased selection. A prospective model with additional payments for birth episodes and for serious problems in newborns would be an effective risk adjuster for Medicaid programs.

Medicaid reform in the 1990s.

Abstract: The 1990s saw considerable change in the Medicaid program. At the beginning of the decade, Medicaid was still primarily a program that provided health care coverage to persons receiving cash assistance under the Aid to Families with Disabled Children (AFDC) or Supplemental Security Income (SSI) programs, although expansions of eligibility for low income pregnant women and children had already begun shifting the focus of coverage away from cash recipients. Health care providers were reimbursed directly for services rendered, and little was offered in the way of care management. While fee-for-service (FFS) reimbursement remains important, by the end of the decade State Medicaid programs had taken on a new role as purchasers of managed health care and case management services. At the same time, many States relaxed eligibility standards for Medicaid, extending coverage to higher income pregnant women and children or, in some cases, to the general low income uninsured population. In these States, Medicaid reform was a component of a broader effort to increase access to health insurance generally, and to encourage the development of managed care. The States were not the only actors in the Medicaid reform arena. Congress enacted a number of reforms at the national level, including changes in the laws governing Medicaid payments to disproportionate share hospitals (DSH), welfare reform, repeal of the Boren Amendment and enactment of the State Children's Health Insurance Program (SCHIP). As we enter the first decade of the 21st Century, these various reform movements continue to develop, and their full implications are not yet clear. One thing that is certain, however, is that Medicaid reform has thrown into relief the program's broad reach and its relationships to multiple constituencies. It has also highlighted the administrative, logistical, and political challenges inherent in any attempt to reform a large public program such as Medicaid. This special issue of the Health Care Financing Review features eight articles that examine various aspects of Medicaid reform, their impact and possible future directions for the reform movement. Together they provide an overall view of the impact, successes, and challenges of Medicaid reform, and the prospects for the future.

A physician's perspective on minority health.

Abstract: In this article, the author discusses her many and varied experiences with health care provision. Her insights into the many dimensions of disparity in health care lead to a set of recommendations for further research.

Trends in Medicare Expenditures and Financial Status, 1966-2000.

Abstract: In this article, the author reviews expenditure growth trends over Medicare's 35-year history and comments on how the program's long-range financial outlook has changed over time. The author focuses on the various legislative, economic, and demographic factors that have affected expenditure growth and financial status. In addition, Medicare's share of total U.S. health costs is briefly reviewed. In an appended comment, the author considers whether the impact of the Balanced Budget Act of 1997 (BBA) was greater than intended by Congress and the Administration. The author concludes with a plea for greater attention to correcting the projected long-range deficits for the Hospital Insurance (HI) Trust Fund.

Implementation of risk adjustment for Medicare.

Abstract: The Health Care Financing Administration (HCFA) implemented risk adjustment for Medicare capitated organizations January 2000. The risk adjustment system used, the Principal Inpatient Diagnostic Cost Group (PIPDCG) method, had to be incorporated into the payment structure mandated by the Balanced Budget Act of 1997 (BBA). This article describes how risk adjustment was integrated into the payment system within the rules of the BBA, and how fee-for-service (FFS) and health maintenance organization (HMO) data are collected and used in the determination of payment.