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Davidson, Karen. "Medicare/Medicaid." Journal of Consumer Health On the Internet 10, no. 1 (April 19, 2006): 33–51. http://dx.doi.org/10.1300/j381v10n01_03.
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Green, Clare, Michael Polmear, John Dunn, Nata Parnes, and John Scanaliato. "Care of low-income patients with sports injuries disincentivized by government reimbursement." Journal of Orthopaedic Business 1, no. 1 (June 1, 2021): 4–7. http://dx.doi.org/10.55576/job.v1i1.3.
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Objectives: The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement for 10 commonly performed orthopaedic sports medicine procedures. Design: Database review. Setting: State Medicaid physician fee schedules and national Medicare fee schedule. Intervention: Medicaid and Medicare reimbursement for meniscus debridement (medial or lateral), meniscus repair (medial or lateral), anterior cruciate ligament (ACL) reconstruction, posterior cruciate ligament (PCL) reconstruction, anterior labral (Bankart) repair, rotator cuff repair, biceps tenodesis, femoral osteochondroplasty, acetabular osteoplasty, and acetabular labral repair. Main outcome measurement: Overall Medicaid to Medicare reimbursement ratio, dollar difference between Medicaid and Medicare reimbursement, dollar difference between Medicaid and Medicare per relative value unit (RVU), dispersion of reimbursement rates. Results and conclusions: Significant discrepancies were found between Medicaid and Medicare reimbursement for all 10 procedures, with Medicaid reimbursing on average 65.15% of the Medicare rate. Medicaid reimbursement also exhibited substantial variation between individual state programs. Financial incentives matter and between these two government programs, orthopaedic surgeons are incentivized to provide care to elderly patients over poorer patients. Level of Evidence: IV; Economic Analysis Keywords: Medicaid; Medicare; Reimbursement; RVU; Variation (J Ortho Business 2021; 1:4-6)
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&NA;. "MEDICARE, MEDICAID REIMBURSEMENT." American Journal of Nursing 97, no. 4 (April 1997): 16. http://dx.doi.org/10.1097/00000446-199704000-00009.
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SHEEHAN, KATHLEEN. "Medicare and Medicaid." Home Healthcare Nurse 30, no. 5 (May 2012): 319–20. http://dx.doi.org/10.1097/nhh.0b013e318252c288.
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TAN, S. Y. "Medicare/Medicaid Fraud." Internal Medicine News 44, no. 13 (August 2011): 81–83. http://dx.doi.org/10.1016/s1097-8690(11)70704-1.
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Williams, Kim Allan. "Medicare and Medicaid." Journal of the American College of Cardiology 66, no. 7 (August 2015): 861–63. http://dx.doi.org/10.1016/j.jacc.2015.06.1316.
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Eckhoff, Michael, and Joshua Tadlock. "Medicaid Reimbursement of Pediatric Surgeries." Journal of Orthopaedic Business 2, no. 1 (January 1, 2022): 1–3. http://dx.doi.org/10.55576/job.v2i1.10.
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Intro: Medicaid is an important means of health care insurance for millions of people in the United States and 49.5% of Medicaid patients are children. . Reimbursements in Medicaid have been shown to be a limiting factor in access to health care in pediatric patients. This study investigates the amount of difference in reimbursement between Medicaid and Medicare, as well as state to state variability.
Methods: Medicaid and Medicare fee reimbursements were collected from each state for 10 different common pediatric orthopedic procedures. The difference between and variability of reimbursement were calculated for both Medicaid and Medicare.
Results: There was an average difference of -22.2% ± 26.9 or -$184.14 ± $226.89 in Medicaid reimbursement compared to Medicare. New Jersey had the greatest difference at 72.7% less reimbursement with Medicaid, while Delaware had higher Medicaid reimbursement of 95.2% compared to Medicare. Only three states had higher reimbursement with Medicaid compared to Medicare for all 10 procedures. Additionally, there was statistically higher coefficient of variation with Medicaid reimbursement compared to Medicare (0.26 vs 0.46) among states.
Conclusion: Medicaid reimbursement is significantly lower compared to Medicare for several common pediatric orthopedic procedures across the United States. The lower Medicaid reimbursement fees may contribute as a barrier to care access for an at-risk population of children.
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Jones, Kelley A., Amy G. Clark, Melissa A. Greiner, Emma Sandoe, Abhigya Giri, Bradley G. Hammill, Courtney H. Van Houtven, Aparna Higgins, and Brystana Kaufman. "Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries." Medical Care 61, no. 12 (November 9, 2023): S131—S138. http://dx.doi.org/10.1097/mlr.0000000000001895.
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Background: Evaluation of Medicare-Medicaid integration models’ effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation. Objective: To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries. Research Design: We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data. Participants: North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017. Measures: We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS). Results: Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older. Conclusions: Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.
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Davidoff, Amy J., Lindsey Enewold, Courtney Williams, Manami Bhattacharya, and Janeth I. Sanchez. "Reliability of cancer registry primary payer information and implications for policy research." Journal of Clinical Oncology 40, no. 16_suppl (June 1, 2022): 1587. http://dx.doi.org/10.1200/jco.2022.40.16_suppl.1587.
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1587 Background: Researchers commonly use “Primary Payer at Diagnosis” measured in cancer registry data to assess the impact of health policy, such as the Affordable Care Act, on insurance, and the impact of insurance on cancer care and outcomes. Measurement error may bias estimated effect size and significance. Little is known about patterns of Medicaid or Medicare misreporting in registry databases commonly used for policy analysis. Methods: We used the National Cancer Institute’s Surveillance, Epidemiology and End Results registry data for adults aged 19-64 years at diagnosis with known cancer stage, linked to most recently available (2007-2011) CMS records on Medicaid and Medicare enrollment at diagnosis month. We recoded the registry Primary Payer variable into 6 categories: private/managed care, Medicare, Medicaid, other government, status unknown, uninsured. State-year policy data regarding Medicaid eligibility and managed care enrollment were also linked. We compared the registry data to Medicaid and/or Medicare enrollment data, and calculated underreporting rates by patient characteristics and state policy. Results: The linked sample (N = 896,031) was 68% non-Hispanic white, 49% male. Overall, the registry data reported 7.8% Medicare and 10.1% Medicaid, while enrollment was 5.5% Medicare, 10.4% Medicaid, and 3.4% dual Medicare-Medicaid. The registry data concordantly identified 61.4% and 57.7% of persons identified per enrollment data to be Medicaid-only and Medicare-only, respectively (Table). Most Medicaid-only enrollees without concordant registry information were reported to have private insurance or be uninsured. Medicaid underreporting (39% overall), was higher for males (43%) vs females (37%), in low (46%) vs high (38%) poverty areas, for Medicaid poverty expansion or waiver enrolled (50%) vs cash assistance related eligibility (33%), and in states with large managed care enrollment, all at p<.001. If Medicaid and Medicare enrollment data were used to edit the registry data, 8% of persons would switch insurance assignment. Conclusions: Primary Payer data reported by cancer registries are subject to measurement error and may result in biased estimates of insurance-related policy impacts. Enhancement with objective Medicaid and Medicare enrollment data will reduce measurement error and may result in unbiased estimates necessary to support policy assessment. [Table: see text]
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Nguyen, Kevin H., Yoojin Lee, Rebecca Thorsness, Maricruz Rivera-Hernandez, Daeho Kim, Shailender Swaminathan, Rajnish Mehrotra, and Amal N. Trivedi. "Medicaid Expansion and Medicare-Financed Hospitalizations Among Adult Patients With Incident Kidney Failure." JAMA Health Forum 3, no. 11 (November 4, 2022): e223878. http://dx.doi.org/10.1001/jamahealthforum.2022.3878.
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ImportanceAlthough Medicare provides health insurance coverage for most patients with kidney failure in the US, Medicare beneficiaries who initiate dialysis without supplemental coverage are exposed to substantial out-of-pocket costs. The availability of expanded Medicaid coverage under the Patient Protection and Affordable Care Act (ACA) for adults with kidney failure may improve access to care and reduce Medicare-financed hospitalizations after dialysis initiation.ObjectiveTo examine the implications of the ACA’s Medicaid expansion for Medicare-financed hospitalizations, health insurance coverage, and predialysis nephrology care among Medicare-covered adults aged 19 to 64 years with incident kidney failure in the first year after initiating dialysis.Design, Setting, and ParticipantsThis cross-sectional study used a difference-in-differences approach to assess Medicare-financed hospitalizations among adults aged 19 to 64 years who initiated dialysis between January 1, 2010, and December 31, 2018, while covered by Medicare Part A (up to 5 years postexpansion). Data on patients were obtained from the Renal Management Information System’s End Stage Renal Disease Medical Evidence Report, which includes data for all patients initiating outpatient maintenance dialysis regardless of health insurance coverage, treatment modality, or citizenship status, and these data were linked with claims data from the Medicare Provider Analysis and Review. Data were analyzed from January to August 2022.ExposureLiving in a Medicaid expansion state.Main Outcomes and MeasuresPrimary outcomes were number of Medicare-financed hospitalizations and hospital days in the first 3 months, 6 months, and 12 months after dialysis initiation. Secondary outcomes included dual Medicare and Medicaid coverage at 91 days after dialysis initiation and the presence of an arteriovenous fistula or graft at dialysis initiation for patients undergoing hemodialysis.ResultsThe study population included 188 671 adults, with 97 071 living in Medicaid expansion states (mean [SD] age, 53.4 [9.4] years; 58 329 men [60.1%]) and 91 600 living in nonexpansion states (mean [SD] age, 53.0 [9.6] years; 52 677 men [57.5%]). In the first 3 months after dialysis initiation, Medicaid expansion was associated with a significant decrease in Medicare-financed hospitalizations (−4.24 [95% CI, −6.70 to −1.78] admissions per 100 patient-years; P = .001) and hospital days (−0.73 [95% CI, −1.08 to −0.39] days per patient-year; P &lt; .001), relative reductions of 8% for both outcomes. Medicaid expansion was associated with a 2.58–percentage point (95% CI, 0.88-4.28 percentage points; P = .004) increase in dual Medicare and Medicaid coverage at 91 days after dialysis initiation and a 1.65–percentage point (95% CI, 0.31-3.00 percentage points; P = .02) increase in arteriovenous fistula or graft at initiation.Conclusions and RelevanceIn this cross-sectional study with a difference-in-differences analysis, the ACA’s Medicaid expansion was associated with decreases in Medicare-financed hospitalizations and hospital days and increases in dual Medicare and Medicaid coverage. These findings suggest favorable spillover outcomes of Medicaid expansion to Medicare-financed care, which is the primary payer for patients with kidney failure.
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Minarik, Pamela A. "Medicare and Medicaid Reimbursement." Clinical Nurse Specialist 12, no. 2 (March 1998): 83–84. http://dx.doi.org/10.1097/00002800-199803000-00012.
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Datto, Catherine J., Yiqun Hu, Eric Wittbrodt, and Perry G. Fine. "Cancer and non-cancer pain opioid utilization in Medicare and Medicaid populations." Journal of Clinical Oncology 36, no. 7_suppl (March 1, 2018): 139. http://dx.doi.org/10.1200/jco.2018.36.7_suppl.139.
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139 Background: Limited data exist comparing opioid use patterns in Medicare and Medicaid patients with cancer-related (CP) and non-cancer-related pain (NCP). Methods: A retrospective analysis of Medicare and Medicaid claims data (MarketScan Research Databases) investigated opioid use patterns in patients with CP and NCP. Adults (age ≥18 yr) with ≥1 pharmacy claim for an opioid (index date), continuous plan eligibility for 6 months pre- and 12 months post-index date, and duration of opioid use of ≥4 weeks were identified. CP patients were identified by medical claim for a cancer diagnosis within 30 days before index date. Results: A total of 4,009 Medicare and 551 Medicaid patients with CP and 98,631 Medicare and 25,163 Medicaid patients with NCP were analyzed. The most common cancer diagnoses were breast, lung, prostate, and colorectal. Medicare patients with CP and NCP had similar mean age; in the Medicaid cohort, patients with CP were older than those with NCP. In the Medicare cohort, NCP patients were more likely to be women; sex distribution was similar among Medicaid patients. Higher rates of comorbidity in the CP cohorts were observed in both datasets. Median index and post-index opioid doses were consistent between the CP and NCP cohorts. The post-index pattern of change in opioid dose was consistent between CP and NCP in both Medicare and Medicaid patients. The most common pattern observed was up to a doubling of index dose. Conclusions: Similar opioid utilization patterns in Medicare and Medicaid populations, including dose escalation, were observed regardless of pain etiology (cancer or non-cancer). [Table: see text]
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Vallabhajosyula, Saraschandra, Vinayak Kumar, Pranathi R. Sundaragiri, Wisit Cheungpasitporn, Malcolm R. Bell, Mandeep Singh, Allan S. Jaffe, and Gregory W. Barsness. "Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States." PLOS ONE 15, no. 12 (December 18, 2020): e0243810. http://dx.doi.org/10.1371/journal.pone.0243810.
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Background There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI). Objective To assess the influence of insurance status on STEMI outcomes. Methods Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000–2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition. Results Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home. Conclusions Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.
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Kim, Hyunjee, Christina J. Charlesworth, K. John McConnell, Jennifer B. Valentine, and David C. Grabowski. "Comparing Care for Dual-Eligibles Across Coverage Models: Empirical Evidence From Oregon." Medical Care Research and Review 76, no. 5 (November 15, 2017): 661–77. http://dx.doi.org/10.1177/1077558717740206.
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Dual-eligible beneficiaries or “duals” are individuals enrolled in both the Medicare and Medicaid programs. For both Medicare and Medicaid, they may be enrolled in fee-for-service or managed care, creating a mix of possible coverage models. Understanding these different models is essential to improving care for duals. Using All-Payer All-Claims data, we empirically described health service use and quality of care for Oregon duals across five coverage models with different combinations of fee-for-service, managed care, and plan alignment status across Medicare and Medicaid. We found substantial heterogeneity in care across these five coverage models. We also found that duals in plans with aligned financial incentives for Medicare and Medicaid experienced more improvement in their care relative to those with nonaligned Medicare Advantage and Medicaid managed care plans. These results highlight the importance of developing policies that account for the heterogeneity of the dual population and their coverage options.
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Mack, Jennifer W., Kun Chen, Francis P. Boscoe, Foster C. Gesten, Patrick J. Roohan, Jane C. Weeks, Maria J. Schymura, and Deborah Schrag. "Underuse of Hospice Care by Medicaid-Insured Patients With Stage IV Lung Cancer in New York and California." Journal of Clinical Oncology 31, no. 20 (July 10, 2013): 2569–79. http://dx.doi.org/10.1200/jco.2012.45.9271.
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Purpose Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare. Patients and Methods Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results–Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use. Results Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients. Conclusion Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.
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Lin, Eugene, Matthew W. Mell, Wolfgang C. Winkelmayer, and Kevin F. Erickson. "Health Insurance in the First 3 Months of Hemodialysis and Early Vascular Access." Clinical Journal of the American Society of Nephrology 13, no. 12 (November 1, 2018): 1866–75. http://dx.doi.org/10.2215/cjn.06660518.
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Background and objectivesPatients without Medicare who develop ESKD in the United States become Medicare eligible by their fourth dialysis month. Patients without insurance may experience delays in obtaining arteriovenous fistulas or grafts before obtaining Medicare coverage.Design, setting, participants, & measurementsIn this retrospective cohort study, we used a national registry to compare uninsured patients starting in-center hemodialysis with a central venous catheter between 2010 and 2013 with similar patients with Medicare or Medicaid. We evaluated whether insurance status at dialysis start influenced the likelihoods of switching to dialysis through an arteriovenous fistula or graft and hospitalizations involving a vascular access infection. We used multivariable logistic and Cox regression models and transformed odds ratios to relative risks using marginal effects.ResultsPatients with Medicare or Medicaid were more likely to switch to an arteriovenous fistula or graft by their fourth dialysis month versus uninsured patients (Medicare hazard ratio, 1.63; 95% confidence interval, 1.14 to 2.43; Medicaid hazard ratio, 1.23; 95% confidence interval, 1.12 to 1.38). There were no differences in rates of switching to arteriovenous fistulas or grafts after all patients obtained Medicare in their fourth dialysis month (Medicare hazard ratio, 1.17; 95% confidence interval, 0.97 to 1.42; Medicaid hazard ratio, 1.01; 95% confidence interval, 0.96 to 1.06). Patients with Medicare at dialysis start had fewer hospitalizations involving vascular access infection in dialysis months 4–12 (hazard ratio, 0.60; 95% confidence interval, 0.37 to 0.97).ConclusionsInsurance-related disparities in the use of arteriovenous fistulas and grafts persist through the fourth month of dialysis, may not fully correct after all patients obtain Medicare coverage, and may lead to more frequent vascular access infections.
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McInerney, Melissa, Jennifer M. Mellor, and Lindsay M. Sabik. "The Effects of State Medicaid Expansions for Working-Age Adults on Senior Medicare Beneficiaries." American Economic Journal: Economic Policy 9, no. 3 (August 1, 2017): 408–38. http://dx.doi.org/10.1257/pol.20150402.
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Do Medicaid expansions to working-age adults affect healthcare spending and utilization among older Medicare beneficiaries? Although economic theory provides conflicting predictions about the presence and direction of such spillover effects, it does identify circumstances when spillovers can reduce Medicare spending. Using data on Medicaid expansions during the 2000s and microdata from the Medicare Current Beneficiary Survey, we find that a 1 percentage point rise in the share of working-age adults eligible for Medicaid has modest effects on the average Medicare beneficiary's spending, but reduces average spending by $477 among dual eligibles. Importantly, we find no evidence of adverse health effects. (JEL G22, H75, I12, I13, I18, I38, J14)
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Kaufman, Brystana G., Kelley A. Jones, Melissa A. Greiner, Abhigya Giri, Lucas Stewart, Amanda He, Amy G. Clark, et al. "Health Care Use and Spending Among Need-Based Subgroups of Medicare Beneficiaries With Full Medicaid Benefits." JAMA Health Forum 4, no. 5 (May 12, 2023): e230973. http://dx.doi.org/10.1001/jamahealthforum.2023.0973.
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ImportanceBeneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes.ObjectiveTo inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina’s full benefit, dual-eligible population.Design, Setting, and ParticipantsThis cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022.ExposureNeed-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users.MeasuresMedicare and Medicaid utilization and spending per person-year (PPY).ResultsThe cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users’ combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012).Conclusions and relevanceFederal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.
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Hershman, Dawn L., Riha Vaidya, Cathee Till, William E. Barlow, Mike LeBlanc, and Joseph M. Unger. "Abstract PD6-04: PD6-04 Baseline Insurance and Unplanned Emergency Room Use and Hospitalizations Among Elderly Breast Cancer Patients Participating in Clinical Trials." Cancer Research 83, no. 5_Supplement (March 1, 2023): PD6–04—PD6–04. http://dx.doi.org/10.1158/1538-7445.sabcs22-pd6-04.
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Abstract Background Reducing acute care use is an important strategy for improving value in cancer care. Patients with cancer are at risk for unplanned Emergency Room (ER) visits and hospitalizations during treatment which can increase the cost of care. Patients enrolled in clinical trials have equal access to supportive care and are treated uniformly according to protocol. While demographic factors such as age, race and number of comorbidities have been associated with increased healthcare utilization, less is known about insurance status, which may be a proxy for structural barriers to outpatient quality care, especially since many unplanned ER visits and hospitalizations are preventable. Methods We conducted a retrospective analysis among breast cancer patients over the age of 65 treated on SWOG clinical trials from 2001 to 2019 with trial data linked to Medicare claims. Patients were included if they were enrolled in Medicare for at least 12 continuous months after trial registration. Type of insurance at trial enrollment was classified as Medicare alone, Medicare + Commercial or Medicare + Medicaid. The outcomes – derived from Medicare claims – were healthcare utilization ER visits, hospital stays, and healthcare costs in the first year. Demographic, clinical, and prognostic factors were captured from clinical trial records. Logistic regression was used to examine utilization outcomes and linear regression was used to examine healthcare costs. Regression models were adjusted for age, race, and a study-specific prognostic risk score, and stratified by study and treatment. Costs were analyzed in 2021 US dollars. Results In total, N = 1,067 patients were analyzed. Median age was 70 years, 32% of patients had Medicare alone, 64% had Medicare + Commercial, and 4% had Medicare + Medicaid. Overall 29% had one or more ER visits and 22% had one or more hospital stays. There were no differences in outcomes between patients with Medicare alone vs. Medicare + Commercial; these groups were combined. In adjusted analyses, patients on Medicare + Medicaid were statistically significantly more likely to have a hospital stay or ER visit (combined outcome) within 12 months of trial registration (58% vs 34%; OR [95% CI], 2.13 [1.05-4.31], p=.04). Separately, patients on Medicare + Medicaid were statistically significantly more likely to have ER visits (51% vs 27.7%, OR [95% CI], 2.09 [1.05-4.19], p=.04), but not hospitalizations (34.9% vs 20.7%, OR [95% CI], 1.55 [0.74-3.24], p=.25) compared to the others combined. Mean costs were higher for patients who had Medicare + Medicaid compared to the others combined, but the differences were not statistically significant ($43,150 vs. $37,259, p = 0.55), possibly due to the small Medicare + Medicaid sample size. Conclusion Despite participation in a BC clinical trial, patients with Medicare + Medicaid had a two-fold increased risk of unplanned ER visits despite controlling for clinical, demographic and prognostic factors. These findings suggest that access and structural factors may adversely influence utilization outcomes for socioeconomically vulnerable older patients with breast cancer. In conjunction with reducing insurance related barriers to clinical trials, efforts are needed to ensure adequate clinical resources to prevent unplanned use of acute care. Citation Format: Dawn L. Hershman, Riha Vaidya, Cathee Till, William E. Barlow, Mike LeBlanc, Joseph M. Unger. PD6-04 Baseline Insurance and Unplanned Emergency Room Use and Hospitalizations Among Elderly Breast Cancer Patients Participating in Clinical Trials [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD6-04.
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Bishop, Christine E. "INTEREST GROUP SESSION—ECONOMICS OF AGING: EVOLVING CARE SYSTEMS FOR OLDER ADULTS: UTILIZATION IMPACTS OF MEDICARE AND MEDICAID PAYMENT TRENDS." Innovation in Aging 3, Supplement_1 (November 2019): S547. http://dx.doi.org/10.1093/geroni/igz038.2015.
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Abstract With the promise of better care coordination, better member outcomes, and lower costs, Medicare and state Medicaid programs are implementing population-based payment systems for older adults. Medicare Advantage (MA) plans are responsible for Medicare services for their members, Medicaid managed long-term services and supports (MLTSS) programs cover a broad span of Medicaid benefits, and some state initiatives enroll beneficiaries dually eligible for both Medicaid and Medicare and integrate benefits from the two programs. Simultaneously, Medicaid programs are attempting to shift LTSS utilization away from nursing homes and toward home and community based services (HCBS). The presentations for this symposium address aspects of this changing landscape using Medicare and Medicaid claims and other data and causal econometric models. The first paper considers the effect of MA utilization on SNF staffing, quality, and financial health. The second paper compares medical care utilization outcomes, specifically risk of hospitalization, for Medicaid nursing home residents to outcomes for similar Medicaid members receiving HCBS. The third paper presents an MLTSS initiative in one state in the context of national developments and considers the challenges of evaluating its impact. The fourth paper compares hospitalization rates for MLTSS populations to rates for dually eligible-beneficiaries not enrolled in MLTSS. The discussion will bring findings together to assess early gains and costs as these systems of care evolve.
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Doll, Kemi Morenikeji, Ke Meng, Ethan M. Basch, Paola A. Gehrig, Wendy R. Brewster, and Anne-Marie Meyer. "Gynecologic cancer outcomes of Medicare's elderly poor: A population-based study of North Carolina." Journal of Clinical Oncology 32, no. 30_suppl (October 20, 2014): 290. http://dx.doi.org/10.1200/jco.2014.32.30_suppl.290.
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290 Background: Women ≥ 65 years dually enrolled in Medicare and Medicaid (‘Duals’) represent an at-risk group in cancer care, yet their outcomes across the spectrum of gynecologic cancers have not been studied. Our goal was to compare the association of insurance type to stage at diagnosis and mortality of older women after a gynecologic cancer diagnosis. Methods: Population-based, retrospective cohort study of women ≥ 65 years, diagnosed with gynecologic cancers from 2003 – 2009 in North Carolina Central Cancer Registry files. Medicare, Medicaid, and claims from privately insured health plans were linked with census data. Multiple logistic regression, Cox proportional hazard models, and Kaplan Meier survival curves were constructed comparing Medicare, Medicare HMO, and Medicare/Medicaid populations. Results: Among 4,554 patients in the cohort, 3,403 (74%) Medicare+/- supplemental private, 531(11%) Medicare HMO, and 620 (14%) Medicare + Medicaid (Dual). There were 2,215(49%) cases of early stage disease and 1,447(32%) deaths. Dual enrollees had increased mortality rates vs. Medicare overall (HR 1.61, 95%CI:1.4–1.8), and within each cancer site: uterine HR 1.50 (95%CI:1.2-1.9); ovarian HR 1.46 (95%CI:1.1-1.9); cervical HR 1.54 (95%CI:1.0–2.3); and vulvar/vaginal HR 2.84 (95%CI:1.9–4.2). Duals also had increased odds of advanced stage diagnosis in uterine cancer (OR 1.48, 95%CI:1.1–2.0). Stratified survival curves demonstrate the largest disparities amongst women with early stage uterine, advanced stage ovarian, and early stage vulvar/vaginal cancers. Conclusions: Dually enrolled gynecologic cancer patients have a 60% increased mortality rate compared to non-duals despite equivalent stage distribution at the time of diagnosis. Specific site/stage subgroups drive these results and should be the focus of future studies elucidating mediators of these disparate outcomes, including barriers in access to specialty surgical care.
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Ackley, Calvin, Abe Dunn, Eli Liebman, and Adam Hale Shapiro. "Are Medicaid and Medicare Patients Treated Equally?" Federal Reserve Bank of San Francisco, Working Paper Series 2024, no. 14 (April 16, 2024): 01–75. http://dx.doi.org/10.24148/wp2024-14.
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We examine whether Medicaid recipients receive the same health care services as those on Medicare. We track the services provided to the same individual as they age into Medicare from Medicaid at age 65, becoming dual enrolled. Cost sharing remains negligible across the insurance switch, implying that observed changes in service provision reflect supply-side factors. Service provision increases by about 20 percent upon switching to Medicare, across a range of categories and treatments including high-value care. We find that 60 to 90 percent of the increase in office visits is explained by physicians averse to accepting new Medicaid patients. Geographic variation in our estimates shows that the average increase in utilization is larger in those states with lower Medicaid acceptance rates and higher Medicare acceptance rates. By contrast, we find relatively small increases in care from existing Medicaid providers. This analysis indicates that Medicaid’s smaller provider network plays a large role in limiting service provision.
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Cabin, William D. "HOME CARE EXECUTIVES SAY MEDICARE HOME HEALTH PAYMENT SYSTEM ENCOURAGES LESS-IS-BETTER PRACTICE." Innovation in Aging 3, Supplement_1 (November 2019): S301. http://dx.doi.org/10.1093/geroni/igz038.1104.
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Abstract There has been an increasing trend for Congress and the Centers for Medicare and Medicaid Services (CMS) to add non-skilled services to coverage under Medicare Advantage and Medicaid inpatient hospital. At the same time there has been a 75% decline in home health aide visits, the only Medicare home health non-skilled service, as a percentage of all Medicare home health visits from 2000-2016. A literature review indicates no studies addressing the potential factors accounting from these seemingly contradictory trends. The present study is based on interviews of five Chief Executive Officers (CEOs), five Chief Financial Officers (CFOs), and eight Chief Nursing Officers (CNOs) from Medicare-certified home health agencies between October 2017-July 2018. Results indicated agreement among interviewees on three themes: the Medicare home health relies on a medical model which focuses on intermittent skilled care; the Medicare home health prospective payment system (PPS) exacerbated the focus on skilled care by rewarding higher reimbursement for skilled care based episodes; and a synergy has evolved of “less is better” regarding utilization of home health aide services and reimbursement. Policymakers are urged to consider adding coverage of non-skilled services under Medicare home health, similar to Medicare Advantage, by funding demonstration projects with appropriate changes in reimbursement.
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Conduff, Joseph H., and Daniel H. Coelho. "Equity in Medicaid Reimbursement for Otolaryngologists." Otolaryngology–Head and Neck Surgery 157, no. 6 (August 22, 2017): 1005–12. http://dx.doi.org/10.1177/0194599817725714.
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Objective To study state Medicaid reimbursement rates for inpatient and outpatient otolaryngology services and to compare with federal Medicare benchmarks. Study Design State and federal database query. Setting Not applicable. Methods Based on Medicare claims data, 26 of the most common Current Procedural Terminology codes reimbursed to otolaryngologists were selected and the payments recorded. These were further divided into outpatient and operative services. Medicaid payment schemes were queried for the same services in 49 states and Washington, DC. The difference in Medicaid and Medicare payment in dollars and percentage was determined and the reimbursement per relative value unit calculated. Medicaid reimbursement differences (by dollar amount and by percentage) were qualified as a shortfall or excess as compared with the Medicare benchmark. Results Marked differences in Medicaid and Medicare reimbursement exist for all services provided by otolaryngologists, most commonly as a substantial shortfall. The Medicaid shortfall varied in amount among states, and great variability in reimbursement exists within and between operative and outpatient services. Operative services were more likely than outpatient services to have a greater Medicaid shortfall. Shortfalls and excesses were not consistent among procedures or states. Conclusions The variation in Medicaid payment models reflects marked differences in the value of the same work provided by otolaryngologists—in many cases, far less than federal benchmarks. These results question the fairness of the Medicaid reimbursement scheme in otolaryngology, with potential serious implications on access to care for this underserved patient population.
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Acebo, Joshua, Kenrick Lam, Shamis Khan, Rishabh Jain, and Vinod Panchbhavi. "Opioid Consumption after Foot and Ankle Surgery: The Influence of Payer Status." Foot & Ankle Orthopaedics 4, no. 4 (October 1, 2019): 2473011419S0008. http://dx.doi.org/10.1177/2473011419s00085.
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Category: Ankle, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Opioid utilization after foot and ankle surgery has received more attention recently with several papers publishing guidelines on the number of opioids to prescribe following surgery. To our knowledge the patient populations that have been studied in all of these papers are all private payer mixes, with a low amount of indigent patients. Social factors often have a large influence over surgical outcomes and therefore we aimed to see if this held true for post-operative opioid utilization as well. In this study we investigated differences in opioid utilization among patients with either Medicaid, Medicare or commercial insurance. Methods: All bony foot and ankle procedures performed by a single foot and ankle surgeon were reviewed between the dates of 7/1/2017 - 6/30/2018. Inclusion criteria were age over 18, did not have a history of chronic pain, and not incarcerated. Bony procedures included any osteotomy, fracture fixation, or arthrodesis. The number of narcotic prescriptions filled by the patient within 6 months following surgery was retrieved via the Texas Prescription Monitoring Program Database. Patients were also called and surveyed about their post-operative pain. The patients were then divided into 3 groups by payer status: commercial insurance including workman’s compensation, Medicaid including county insurance and self pay patients, and Medicare. Results: 92 patients met inclusion criteria, 22 Medicare, 26 Medicaid, and 44 commercial. Medicaid patients filled more narcotic prescriptions than commercial and medicare patients (870 mg morphine equivalent vs 781 mg morphine equivalent for commercial and 649 mg morphine equivalent for medicare) however this difference was not statistically significant (Medicaid vs Medicare p = 0.07). Medicaid patients also needed a greater number of refills per patient (0.27 for Medicaid vs 0.20 and 0.09 for commercial and Medicare, p = 0.22) and had a larger number of telephone encounters for pain (p = 0.02) than the other payer types. Conclusion: Although not statistically significant, there was a trend toward greater opioid utilization within the Medicaid and county insured patient population.
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Weech-Maldonado, Robert, Justin Lord, Rohit Pradhan, Ganisher Davlyatov, Neeraj Dayama, Shivani Gupta, and Larry Hearld. "High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance." INQUIRY: The Journal of Health Care Organization, Provision, and Financing 56 (January 2019): 004695801882506. http://dx.doi.org/10.1177/0046958018825061.
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High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services’ (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.
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SCHNEIDER, MARY ELLEN. "Bush's Proposal Trims Medicare, Medicaid." Family Practice News 37, no. 4 (February 2007): 41. http://dx.doi.org/10.1016/s0300-7073(07)70246-3.
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SCHNEIDER, MARY ELLEN. "President's Budget Targets Medicare, Medicaid." Family Practice News 42, no. 4 (March 2012): 16. http://dx.doi.org/10.1016/s0300-7073(12)70184-6.
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FRIEDEN, JOYCE. "For HIT, Medicaid Outpays Medicare." Caring for the Ages 10, no. 8 (August 2009): 18. http://dx.doi.org/10.1016/s1526-4114(09)60215-8.
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Green, Daniel, Rebekah E. Gee, and Patrick H. Conway. "Medicare and Medicaid Quality Programs." Obstetrics & Gynecology 121, no. 4 (April 2013): 705–8. http://dx.doi.org/10.1097/aog.0b013e3182883cdc.
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CORREA, FRANCES. "Congress Addresses Medicare, Medicaid Fraud." Clinical Endocrinology News 6, no. 4 (April 2011): 50. http://dx.doi.org/10.1016/s1558-0164(11)70205-x.
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Cubanski, Juliette, Barbara Lyons, Tricia Neuman, Laura Snyder, Anne Jankiewicz, and David Rousseau. "Medicaid and Medicare at 50." JAMA 314, no. 4 (July 28, 2015): 328. http://dx.doi.org/10.1001/jama.2015.8129.
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Vladeck, Bruce C. "Medicare, Medicaid Fraud and Abuse." JAMA: The Journal of the American Medical Association 273, no. 10 (March 8, 1995): 766. http://dx.doi.org/10.1001/jama.1995.03520340018007.
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Benevides, Teal W., Henry J. Carretta, George Rust, and Lindsay Shea. "Racial and ethnic disparities in benefits eligibility and spending among adults on the autism spectrum: A cohort study using the Medicare Medicaid Linked Enrollees Analytic Data Source." PLOS ONE 16, no. 5 (May 25, 2021): e0251353. http://dx.doi.org/10.1371/journal.pone.0251353.
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Background Research on children and youth on the autism spectrum reveal racial and ethnic disparities in access to healthcare and utilization, but there is less research to understand how disparities persist as autistic adults age. We need to understand racial-ethnic inequities in obtaining eligibility for Medicare and/or Medicaid coverage, as well as inequities in spending for autistic enrollees under these public programs. Methods We conducted a cross-sectional cohort study of U.S. publicly-insured adults on the autism spectrum using 2012 Medicare-Medicaid Linked Enrollee Analytic Data Source (n = 172,071). We evaluated differences in race-ethnicity by eligibility (Medicare-only, Medicaid-only, Dual-Eligible) and spending. Findings The majority of white adults (49.87%) were full-dual eligible for both Medicare and Medicaid. In contrast, only 37.53% of Black, 34.65% Asian/Pacific Islander, and 35.94% of Hispanic beneficiaries were full-dual eligible for Medicare and Medicare, with most only eligible for state-funded Medicaid. Adjusted logistic models controlling for gender, intellectual disability status, costly chronic condition, rural status, county median income, and geographic region of residence revealed that Black beneficiaries were significantly less likely than white beneficiaries to be dual-eligible across all ages. Across these three beneficiary types, total spending exceeded $10 billion. Annual total expenditures median expenditures for full-dual and Medicaid-only eligible beneficiaries were higher among white beneficiaries as compared with Black beneficiaries. Conclusions Public health insurance in the U.S. including Medicare and Medicaid aim to reduce inequities in access to healthcare that might exist due to disability, income, or old age. In contrast to these ideals, our study reveals that racial-ethnic minority autistic adults who were eligible for public insurance across all U.S. states in 2012 experience disparities in eligibility for specific programs and spending. We call for further evaluation of system supports that promote clear pathways to disability and public health insurance among those with lifelong developmental disabilities.
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Rahman, Abu Ahmed Zahidur, Nusrat Mujib, Marjan Mujib, and Tariq Nazir. "Primary payer status and outcomes after autologous hematopoietic stem cell transplant: A national perspective." Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): 7042. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.7042.
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7042 Background: With healthcare cost in rise, it is of interest to explore variation in healthcare delivery outcome with different payment source. This study was aimed to analyze relationship between payment source and outcome following autologous hematopoietic stem cell transplant (AutoHSCT) in a national database. Methods: We identified all hospitalizations with AutoHSCT (n=1,673) from Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality 2010 database using the ICD 9 procedure codes 41.04 and 41.07. Based on sample weights an estimated 8,444 AutoHSCT procedures were performed nationwide in 2010. Patients were stratified on the basis of payer status: Medicare (27%), Medicaid (12%), private insurance (60%), and uninsured (0.8%). Multivariable logistic regression models were used to determine the association of primary payer status and outcomes. Results: Patients had a mean age of 54 (±13) years, 39% were women and 69% were whites. In-hospital mortality occurred in 1.1%, 2.9% and 3.3% of AutoHSCT patients with primary payer status of private insurance, Medicaid and Medicare respectively. AutoHSCT patients with primary payer status of Medicaid and Medicare had a statistically significant higher chance of in-hospital mortality compared to patients with private insurance (adjusted odds ratios and 95% confidence intervals, 2.68; 1.54-4.65; P <0.001 and 1.90; 1.21-2.99; P=0.005 respectively). Length of stay was longer for Medicare patients (20 ± 11 days) and Medicaid patients (20 ± 12 days) compared to private insurance (18 ± 8 days; P <0.001). Medicare and Medicaid patients also accrued higher hospital charges (USD 175,221 and USD 166,453), compared to private insurance patients (USD 157,120; P <0.001). Conclusions: In this national study Medicaid and Medicare patients had an independent risk for in-hospital mortality compared to private insurance patients. Medicaid and Medicare patients also had longer length of hospital stays and accrued higher hospital charges. This may mandate a closer look into the current resource utilization strategies to reduce such disparities among patients undergoing AutoHSCT.
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Matthew, Dayna Bowen. "An Economic Model to Analyze the Impact of False Claims Act Cases on Access to Healthcare for the Elderly, Disabled, Rural and Inner-City Poor." American Journal of Law & Medicine 27, no. 4 (2001): 439–67. http://dx.doi.org/10.1017/s0098858800008212.
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In 1964 President Lyndon B. Johnson declared a “War on Poverty.” By 1965 Congress had enacted several key weapons in that war, including two massive revisions to the Social Security Act designed to provide broad access to healthcare for if. the elderly, the disabled and poor, uninsured pregnant women and infants. The current Medicare and Medicaid health insurance programs, along with the State Children's Health Insurance Program, provide health insurance and thus, access to healthcare, for 60% of people living in poverty. Medicaid alone pays for half of all nursing home care in this country. Medicare pays for hospital care for over 32.4 million elderly Americans, and for 3.7 million disabled Americans. Medicare and Medicaid have been called the “lynch pin” in the nation's strategy to assure access to healthcare for low income Americans. In short, the War on Poverty is not effective without the access to healthcare Medicare and Medicaid afford to the poor, elderly and disabled.
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Degenholtz, Howard. "PROJECTION OF MEDICAID SPENDING ON PEOPLE WITH ALZHEIMER’S DISEASE AND OTHER RELATED DEMENTIAS." Innovation in Aging 7, Supplement_1 (December 1, 2023): 879–80. http://dx.doi.org/10.1093/geroni/igad104.2831.
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Abstract As the US population is aging, the number of people with Alzheimer’s Disease and Other Related Dementias (ADRD) is increasing. People with ADRD have high expenditures on medical care and long-term services and supports (LTSS). Medicaid is the largest single payor for LTSS, however, the literature on the demographic trends and epidemiology of people with ADRD does not offer projections of Medicaid spending. The goal of this study was to develop an estimate for future Medicaid spending for people with ADRD for the state of Pennsylvania. The approach taken was to develop a demographic projection of the size of the older population, then estimate the fraction of people with ADRD who are eligible for Medicaid. Next, we used estimates of current spending trends to project future spending through 2025. Nearly all Medicaid participants with ADRD are dually eligible for both Medicaid and Medicare, however, Medicare managed care encounter data were not available for analysis. Thus, the prevalence of ADRD was constructed using Medicaid and Medicare fee-for-service (FFS) claims data. Two alternate estimates of the prevalence of ADRD among Medicare managed care enrollees were used (same as Medicare FFS, or slightly lower). Estimates were generated under several growth rates in per person spending on home and community-based services (HCBS). The results shows that growth in HCBS spending is the largest factor in predicting spending, leading to estimates ranging from $2.8 billion to $3.5 billion. Future research will extend the model to additional years.
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Lichtman, Judith H., Erica C. Leifheit-Limson, and Larry B. Goldstein. "Centers for Medicare and Medicaid Services Medicare Data and Stroke Research." Stroke 46, no. 2 (February 2015): 598–604. http://dx.doi.org/10.1161/strokeaha.114.003255.
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Bean, James R. "Valuing neurosurgery services: Part II. The interdependence of Current Procedural Terminology and federal Medicare payment policy." Neurosurgical Focus 12, no. 4 (April 2002): 1–4. http://dx.doi.org/10.3171/foc.2002.12.4.3.
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Current Procedural Terminology (CPT) policies for coding of medical procedures and services are adopted by the American Medical Association CPT editorial panel. Since institution of the Medicare Fee Schedule in 1992, the Medicare budget neutrality rule has strongly influenced CPT policies for the coding of additions or modifications. The Centers for Medicare and Medicaid Services Medicare program policies, particularly payment limits, influence code modification strategies and CPT editorial panel processes.
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Konetzka, R. Tamara, and Sijiu Wang. "THE ROLE OF MEDICAID HOME- AND COMMUNITY-BASED SERVICES IN USE OF MEDICARE POST–ACUTE CARE." Innovation in Aging 7, Supplement_1 (December 1, 2023): 456. http://dx.doi.org/10.1093/geroni/igad104.1500.
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Abstract Medicaid-funded long-term services and supports are increasingly provided through home and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aims to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled. Using national Medicare claims, Medicaid claims (TAF), MDS, and OASIS data from 2014 to 2017, we estimated the relationship between prior Medicaid HCBS use and PAC utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups and tested for interactions between HCBS use and three measures of states’ HCBS generosity. We found HCBS use was associated with a 5.2 percentage-point increase in use of any Medicare-funded PAC, a 7.2 percentage-point increase in home health use, a 2.1 percentage-point decrease in institutional PAC, and a 1.95-day reduction of skilled nursing facility length of stay. In other words, use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings. These findings were stronger in states with more generous HCBS funding. As we found that use of Medicaid-funded HCBS may alter choices about Medicare-funded PAC use, this synergy with HCBS should be considered by policymakers when contemplating further HCBS expansions.
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Riley, Gerald F., James D. Lubitz, and Nancy Zhang. "Patterns of Health Care and Disability for Medicare Beneficiaries under 65." INQUIRY: The Journal of Health Care Organization, Provision, and Financing 40, no. 1 (February 2003): 71–83. http://dx.doi.org/10.5034/inquiryjrnl_40.1.71.
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Disabled people under age 65 are a vulnerable and growing segment of the Medicare population, yet Medicare reform has focused on the needs of the aged. This study linked the Medicare Current Beneficiary Survey to Social Security Administration records to analyze patterns of health care for disabled beneficiaries by reason for disability. We found substantial variation in average health care costs by type of service, including prescription drugs, and in sources of payment. Rates of institutionalization were high among some disability categories and there was heavy reliance on Medicaid and other public programs for payment. It is essential that the special needs of the disabled not be overlooked as policymakers consider fundamental modifications to Medicare and Medicaid.
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Rotenstein, Aliza, Sheldon Epstein, and Yonah Wilamowsky. "Auditing The Auditors In Medicare And Medicaid." Journal of Business Case Studies (JBCS) 8, no. 1 (December 22, 2011): 67–72. http://dx.doi.org/10.19030/jbcs.v8i1.6739.
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Baker Surgical Supplies, a small company, went bankrupt after it could not repay a significant overpayment charge demanded by Medicare based on a statistical extrapolation of claims of overpayment. The case centered on whether the extrapolation process was justifiable and whether it was properly implemented. This paper provides a description of the extrapolation process used by Medicare and Medicaid and presents the data and sampling procedure offered by Medicare and the statistical arguments offered by Baker. The case demonstrates some potential misuses of statistics in the auditing process. In shedding light on this issue, the analysis in this paper could prove to be instrumental in prompting significant improvements to the auditing process of Medicare and Medicaid.
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Meyers, David J., Kendra Offiaeli, Amal N. Trivedi, and Eric T. Roberts. "Medicare and Medicaid Dual-Eligible Special Needs Plan Enrollment and Beneficiary-Reported Experiences With Care." JAMA Health Forum 4, no. 9 (September 8, 2023): e232957. http://dx.doi.org/10.1001/jamahealthforum.2023.2957.
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Fang, Hanming, and Qing Gong. "Detecting Potential Overbilling in Medicare Reimbursement via Hours Worked." American Economic Review 107, no. 2 (February 1, 2017): 562–91. http://dx.doi.org/10.1257/aer.20160349.
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We propose a novel and easy-to-implement approach to detect potential overbilling based on the hours worked implied by the service codes which physicians submit to Medicare. Using the Medicare Part B Fee-for-Service (FFS) Physician Utilization and Payment Data in 2012 and 2013 released by the Centers for Medicare and Medicaid Services, we construct estimates for physicians' hours spent on Medicare beneficiaries. We find that about 2,300 physicians, representing about 3 percent of those with 20 or more hours of Medicare Part B FFS services, have billed Medicare over 100 hours per week. We consider these implausibly long hours. (JEL H51, I13, I18, J22)
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Brin, Lauren, Apar Kishor Ganti, Xiang Fang, Mary Warlaumont, Timothy Fuller, Naomi Whittaker, and Peter T. Silberstein. "Surgery and chemoradiotherapy in stage II and III esophageal cancer: A retrospective analysis of first-course treatment across different insurances using the NCDB." Journal of Clinical Oncology 30, no. 34_suppl (December 1, 2012): 29. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.29.
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29 Background: The current standard of care for stage II/III esophageal carcinoma for patients who can withstand aggressive therapy is chemotherapy, radiotherapy and surgery (tri-modality therapy). This is the largest study of its kind to date. Methods: Using the National Cancer Database (NCDB) 46,758 patients diagnosed with stage II/III esophageal carcinoma between 2000 and 2009 were identified. The NCDB database includes data from 70% of cancer patients in the US. Results: In stage II/III esophageal cancer private insurance holders received more tri-modality therapy (39%) than VA insurance (18%), Medicaid (22%), Medicare (18%), and the uninsured (19%) (p<0.0001). There was no statistically significant difference in the amount of tri-modality therapy received in patients with VA, Medicare, or no insurance. Medicaid patients received more tri-modality therapy than Medicare, uninsured, and VA patients (p<0.05). VA and uninsured patients received no treatment more frequently (13%) than those with private insurance (5%), Medicare (10%), and Medicaid (9%) (p<0.0003). Patients over 70 less frequently underwent tri-modality therapy (13%) as compared to those under 70 (34%, p<0.0001). Conclusions: Although VA, Medicare, and the uninsured patients received similar rates of tri-modality therapy (18-19%), it was much less than private insurance holders (39%). Medicaid patients received less tri-modality therapy than private insurance holders despite similar ages. Uninsured patients received a similar amount of tri-modality therapy as those with VA and Medicare. [Table: see text]
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Zhu, Jane M., Kranti C. Rumalla, and Daniel Polsky. "New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards." JAMA Health Forum 4, no. 10 (October 6, 2023): e233194. http://dx.doi.org/10.1001/jamahealthforum.2023.3194.
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Archer, David L. "Will Catholic Hospitals Survive without Government Reimbursements?" Linacre Quarterly 84, no. 1 (February 2017): 23–28. http://dx.doi.org/10.1080/00243639.2017.1278998.
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This brief essay will begin to address the feasibility of operating a Catholic healthcare system without reimbursement from government healthcare programs such as Medicare and Medicaid. This question stems from the recent ACA/HHS “Nondiscrimination in Health Programs and Activities” final rule. Summary The average hospital in the United States receives 40-50 percent of its net revenues from governmental sources. Participation in Medicare is contingent upon the hospital having a Medicare provider agreement. Participation in other governmental programs (Medicaid) as well as most commercial insurance is also contingent upon that agreement. Hospitals, including “Catholic” hospitals, cannot survive without a Medicare provider agreement. That agreement may be terminated for non-compliance with Medicare and other governmental regulations such as the recent ACA/HHS “Nondiscrimination in Health Programs and Activities” final rule, which could require “Catholic” hospitals to provide services which violate moral principals of the Church.
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Warren, Joan L., Eboneé N. Butler, Jennifer Stevens, Christopher S. Lathan, Anne-Michelle Noone, Kevin C. Ward, and Linda C. Harlan. "Receipt of Chemotherapy Among Medicare Patients With Cancer by Type of Supplemental Insurance." Journal of Clinical Oncology 33, no. 4 (February 1, 2015): 312–18. http://dx.doi.org/10.1200/jco.2014.55.3107.
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Purpose Medicare beneficiaries with cancer bear a greater portion of their health care costs, because cancer treatment costs have increased. Beneficiaries have supplemental insurance to reduce out-of-pocket costs; those without supplemental insurance may face barriers to care. This study examines the association between type of supplemental insurance coverage and receipt of chemotherapy among Medicare patients with cancer who, per National Comprehensive Cancer Network treatment guidelines, should generally receive chemotherapy. Patients and Methods This retrospective, observational study included 1,200 Medicare patients diagnosed with incident cancer of the breast (stage IIB to III), colon (stage III), rectum (stage II to III), lung (stage II to IV), or ovary (stage II to IV) from 2000 to 2005. Using the National Cancer Institute Patterns of Care Studies and linked SEER-Medicare data, we determined each Medicare patient's supplemental insurance status (private insurance, dual eligible [ie, Medicare with Medicaid], or no supplemental insurance), consultation with an oncologist, and receipt of chemotherapy. Using adjusted logistic regression, we evaluated the association of type of supplemental insurance with oncologist consultation and receipt of chemotherapy. Results Dual-eligible patients were significantly less likely to receive chemotherapy than were Medicare patients with private insurance. Patients with Medicare only who saw an oncologist had comparable rates of chemotherapy compared with Medicare patients with private insurance. Conclusion Dual-eligible Medicare beneficiaries received recommended cancer chemotherapy less frequently than other Medicare beneficiaries. With the increasing number of Medicaid patients under the Affordable Care Act, there will be a need for patient navigators and sufficient physician reimbursement so that low-income patients with cancer will have access to oncologists and needed treatment.
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Canady, Valerie A. "CMS to test innovative behavioral health model to promote integrated care." Mental Health Weekly 34, no. 5 (January 27, 2024): 1–3. http://dx.doi.org/10.1002/mhw.33926.
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The Centers for Medicare & Medicaid Services (CMS) earlier this month announced a new model that would advance integrated care and health‐related social needs for Medicaid and Medicare beneficiaries. According to CMS, the model supports community‐based behavioral health practices to provide person‐centered care in behavioral health settings.
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Zhu, Carolyn W., Katherine A. Ornstein, Stephanie Cosentino, Yian Gu, Howard Andrews, and Yaakov Stern. "Medicaid Contributes Substantial Costs to Dementia Care in an Ethnically Diverse Community." Journals of Gerontology: Series B 75, no. 7 (August 19, 2019): 1527–37. http://dx.doi.org/10.1093/geronb/gbz108.
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Abstract Objectives The main objective of this study was to estimate effects of dementia on Medicaid expenditures in an ethnically diverse community. Methods The sample included 1,211 Medicare beneficiaries who did not have any Medicaid coverage and 568 who additionally had full Medicaid coverage enrolled in the Washington Heights-Inwood Columbia Aging Project (WHICAP), a multiethnic, population-based, prospective study of cognitive aging in northern Manhattan (1999–2010). Individuals’ dementia status was determined using a rigorous clinical protocol. Relationship between dementia and Medicaid coverage and expenditures were estimated using a two-part model. Results In participants who had full Medicaid coverage, average annual Medicaid expenditures were substantially higher for those with dementia than those without dementia ($50,270 vs. $21,966, p < .001), but Medicare expenditures did not differ by dementia status ($8,458 vs. $9,324, p = .19). In participants who did not have any Medicaid coverage, average annual Medicare expenditures were substantially higher for those with dementia than those without dementia ($12,408 vs. $8,113, p = .02). In adjusted models, dementia was associated with a $6,278 increase in annual Medicaid spending per person after controlling for other characteristics. Discussion Results highlight Medicaid’s contribution to covering the cost of dementia care in addition to Medicare. Studies that do not include Medicaid are unlikely to accurately reflect the true cost of dementia.