Medicare Payment Policy

Recommendations

Info

334 Status report on Part D percent had no drug coverage or coverage less generous than Part D. Beneficiaries with no creditable coverage tended to be healthier, on average. More than half reported not joining Part D because they did not take enough medications to need such coverage. Among Part D plan enrollees, 10.8 million individuals (about 34 percent) received the low-income subsidy (LIS). Benefit offerings for 2013—The number of plan offerings remained stable between 2012 and 2013. Sponsors are offering slightly fewer stand-alone PDPs (a decrease of just under 1 percent) and 6 percent more MA–PDs than in 2012. Beneficiaries will continue to have between 23 and 38 PDPs to choose from, depending on where they live, along with many MA–PDs. MA–PDs continue to be more likely than PDPs to offer enhanced benefits that include some coverage in the gap. For 2013, slightly more premium-free PDPs are available to enrollees who receive the LIS; 331 plans qualify compared with 327 in 2012. In most regions, LIS enrollees will continue to have many premium-free plans available. In two regions, Florida and Nevada, only two plans qualified as premium free in each region. Part D spending—Between 2007 and 2011, Part D spending increased from $46.7 billion to $60 billion (an average annual growth of about 7 percent), and CMS expects it will have reached $62 billion in 2012. These expenditures include the direct monthly subsidy plans receive for their Part D enrollees, reinsurance paid for very-high-cost enrollees, premiums and cost sharing for LIS enrollees, and payments to employers that continue to provide drug coverage to their Medicare beneficiary retirees. In 2011, LIS payments continued to be the largest single component of Part D spending, while Medicare’s reinsurance payments were the fastest growing component. Changes made by the Patient Protection and Affordable Care Act of 2010 to gradually close the coverage gap likely contributed to the higher growth in reinsurance payments between 2010 and 2011. Change in Part D bids and premiums—While the average costs for basic Part D benefits are expected to remain stable (a growth of less than 1 percent) between 2012 and 2013, plan sponsors are expecting significant changes in costs for individual components: a decrease of over 9 percent for the direct subsidy and an increase of about 14 percent for the reinsurance component. In 2013, the base beneficiary premium is about the same as in 2012 ($31). It reflects the basic portion of the benefit and does not include premiums for enhanced, or supplemental, benefits. The actual premium paid depends on the beneficiary’s choice of plan. Role of competition in Part D—Part D uses a competitive design to give plan sponsors incentives to offer beneficiaries attractive prescription drug coverage while
controlling growth in drug spending. Plans that are able to manage drug spending and bid more competitively are supposed to be rewarded with higher enrollment than plans that do not. We find that a higher share of enrollees have switched plans voluntarily in recent years than was reported by CMS during the first few years of the program. ■ Report to the Congress: Medicare Payment Policy | March 2013 335
Page 1 and 2:
RepoRt to the CongRess Medicare Pay
Page 3:
RepoRt to tHe CongRess Medicare Pay
Page 6 and 7:
with the structure of the payment s
Page 9 and 10:
table of contents Acknowledgments .
Page 11:
executive summary
Page 14 and 15:
of services—and pressure on feder
Page 16 and 17:
current Medicare payments are adequ
Page 18 and 19:
outpatient dialysis services Outpat
Page 20 and 21:
some facilities are willing to acce
Page 22 and 23:
coverage for conventional treatment
Page 24 and 25:
of care for these conditions should
Page 27:
Context for Medicare payment policy
Page 30 and 31:
4 Context for Medicare payment poli
Page 32 and 33:
FIguRe FIGURE 1-2 1-2 12% Out of po
Page 34 and 35:
the level of health care spending a
Page 36 and 37:
1-4 FIguRe 1-4 140 120 100 80 60 Do
Page 38 and 39:
FIguRe 1-6 1-6 Growth rate (in perc
Page 40 and 41:
FIGURE FIguRe Share of GDP (in perc
Page 42 and 43:
Share of GDP (in percent) FIGURE 1-
Page 44 and 45:
FIGURE FIguRe 1-10 1-10 8% African
Page 46 and 47:
FIguRe 1-12 1-11 1800 1600 1400 120
Page 48 and 49:
Americans than for other racial and
Page 50 and 51:
References Agency for Healthcare Re
Page 52 and 53:
Medicare Payment Advisory Commissio
Page 55 and 56:
Assessing payment adequacy and upda
Page 57 and 58:
The goal of Medicare payment policy
Page 59 and 60:
may go up when payment rates go dow
Page 61 and 62:
hospitals and that hospitals shift
Page 63 and 64:
individual payment systems but also
Page 65 and 66:
Hospital inpatient and outpatient s
Page 67 and 68:
Hospital inpatient and outpatient s
Page 69:
covered the fully allocated costs o
Page 72 and 73:
3-1 3-1 FIguRe 100 80 60 40 Number
Page 74 and 75:
Visits or claims per 1,000 benefici
Page 76 and 77:
3-4 3-4 FIguRe 2012 dollars (in bil
Page 78 and 79:
of physicians employed directly by
Page 80 and 81:
FIguRe FIGURE Annual percent change
Page 82 and 83:
FIGURE FIguRe Margin (in percent) 3
Page 84 and 85:
FIGURE FIguRe Margin (in percent) 3
Page 86 and 87:
tABLe 3-5 performance of efficient
Page 88 and 89:
Act, the EHR Incentive Program also
Page 90 and 91:
as Medicaid expands, the new insura
Page 92 and 93:
ates for separately paid drugs resu
Page 94 and 95:
endnotes 1 From 2002 to 2011, 479 h
Page 96 and 97:
References Agency for Healthcare Re
Page 99 and 100:
C H A p t e R4 physician and other
Page 101 and 102:
physician and other health professi
Page 103:
from the SGR system in its October
Page 106 and 107:
4-1 4-1 FIguRe 40 35 30 25 20 15 10
Page 108 and 109:
tABLe 4-1 Most aged Medicare benefi
Page 110 and 111:
tABLe 4-2 Medicare beneficiaries ha
Page 112 and 113:
payment adjustments for health prof
Page 114 and 115:
tABLe 4-3 Year physicians primary c
Page 116 and 117:
provider’s characteristics, geogr
Page 118 and 119:
tABLe 4-4 type of service Change in
Page 120 and 121:
tABLe 4-5 type of imaging Change in
Page 122 and 123:
the patient-centered medical home T
Page 124 and 125:
FIguRe FIGURE Cumulative percent ch
Page 126 and 127:
References ABIM Foundation. 2012. C
Page 129 and 130:
Ambulatory surgical center services
Page 131 and 132:
Ambulatory surgical center services
Page 133 and 134:
Background An ambulatory surgical c
Page 135 and 136:
Differences in types of patients tr
Page 137 and 138:
Differences in types of patients tr
Page 139 and 140:
number of services grew from 2006 t
Page 141 and 142:
tABLe 5-7 rapidly than nonowning ph
Page 143 and 144:
Creating a value-based purchasing p
Page 145 and 146:
Revisiting the ambulatory surgical
Page 147 and 148:
endnotes 1 Because CMS updates paym
Page 149:
Medicare Payment Advisory Commissio
Page 152 and 153:
R e C o M M e n D A t I o n 6 The C
Page 154 and 155:
128 Outpatient dialysis services: A
Page 156 and 157:
tABLe 6-1 Characteristics of FFs di
Page 158 and 159:
Physicians Association has publishe
Page 160 and 161:
tABLe 6-3 Increasing number and cap
Page 162 and 163:
Number of FFS dialysis beneficiarie
Page 164 and 165:
FIguRe 6-3 Percent of dialysis bene
Page 166 and 167:
and 2011, the proportion of adult h
Page 168 and 169:
anticipated under the modernized pa
Page 170 and 171:
endnotes 1 In this chapter, we use
Page 172 and 173:
References ABIM Foundation. 2012. C
Page 175:
C H A p t e R7 post-acute care prov
Page 178 and 179:
encourages more 60-day episodes. Fu
Page 181 and 182:
C H A p t e R8 skilled nursing faci
Page 183 and 184:
skilled nursing facility services C
Page 185:
adjust for differences in patients
Page 188 and 189:
Description of beneficiaries who us
Page 190 and 191:
snF prospective payment system and
Page 192 and 193:
Number of SNFs FIguRe FIGURE 8-1 7-
Page 194 and 195:
FIGURE FIguRe Percent 7-2 8-2 30 25
Page 196 and 197:
and other SNF users were essentiall
Page 198 and 199:
FIguRe FIGURE Program spending (in
Page 200 and 201:
7-8 8-6 FIguRe 30 25 20 15 10 Medic
Page 202 and 203:
(e.g., whether there is a requireme
Page 204 and 205:
the Commission’s 2012 update reco
Page 206 and 207:
tABLe 8-9 non-Medicare margins were
Page 208 and 209:
found to be associated with one or
Page 210 and 211:
Smith, V. K., K. Gifford, E. Ellis,
Page 212 and 213:
R e C o M M e n D A t I o n s (The
Page 214 and 215:
188 Home health care services: Asse
Page 216 and 217:
tABLe 9-1 use and growth of home he
Page 218 and 219:
FIGURE FIguRe Number of new agencie
Page 220 and 221:
tABLe 9-2 of services. The review a
Page 222 and 223:
tABLe 9-4 Community-admitted home h
Page 224 and 225:
tABLe 9-5 type of county Claims dat
Page 226 and 227:
tABLe 9-6 state County are collecte
Page 228 and 229:
tABLe 9-8 Medicare margins for free
Page 230 and 231:
tABLe 9-11 provider characteristics
Page 232 and 233:
tABLe 9-12 Medicare visits per full
Page 234 and 235:
strengthening incentives for effect
Page 236 and 237:
endnotes 1 The exceptions pertain t
Page 239 and 240:
C H A p t e R10 Inpatient rehabilit
Page 241 and 242:
Inpatient rehabilitation facility s
Page 243 and 244:
FIguRe FIGURE 10-1 9-1 Note: IRF (i
Page 245 and 246:
Medicare IRF classification require
Page 247 and 248:
tABLe 10-2 type of IRF 2004 2005 20
Page 249 and 250:
tABLe 10-4 number of IRF beds decre
Page 251 and 252:
weight for compliant cases was 1.39
Page 253 and 254:
unobserved factors regarding patien
Page 255 and 256:
freestanding IRFs were about $4,340
Page 257 and 258:
increase for changes in the outlier
Page 259:
References Centers for Medicare & M
Page 262 and 263:
R e C o M M e n D A t I o n 11 The
Page 264 and 265:
Quality of care—LTCHs only recent
Page 266 and 267:
FIguRe FIGURE 11-1 10-1 Source: Med
Page 268 and 269:
short-stay outlier cases in long-te
Page 270 and 271:
tABLe 11-1 growth in the number of
Page 272 and 273:
Chronically critically ill benefici
Page 274 and 275:
Quality measures for long-term care
Page 276 and 277:
tABLe 11-4 type of LtCH per case pa
Page 278 and 279:
temporary legislative relief from s
Page 280 and 281:
16 We observed growth over time in
Page 282 and 283:
Durairaj, L., J. C. Torner, E. A. C
Page 285 and 286:
Hospice services C H A p t e R12
Page 287 and 288:
Hospice services Chapter summary Th
Page 289 and 290:
Background Medicare began offering
Page 291 and 292:
March 2009 Commission recommendatio
Page 293 and 294:
March 2009 Commission recommendatio
Page 295 and 296:
number peaking in 2009). With rapid
Page 297 and 298:
tABLe 12-4 Hospice use has increase
Page 299 and 300:
tABLe 12-5 Characteristic insurers
Page 301 and 302:
three settings, respectively) (Tabl
Page 303 and 304:
measures, it is likely that the vas
Page 305 and 306:
tABLe 12-10 Category percentage poi
Page 307 and 308:
• additional wage index changes,
Page 309 and 310: elieve the cost report data provide
Page 311: C H A p t e R13 the Medicare Advant
Page 314 and 315: 288 The Medicare Advantage program:
Page 317 and 318: The Medicare Advantage (MA) program
Page 319 and 320: enchmark. If a plan’s bid is abov
Page 321 and 322: tABLe 13-3 projected payments excee
Page 323 and 324: We broke the fourth quartile into t
Page 325 and 326: tABLe 13-5 Distribution of enrollme
Page 327 and 328: tABLe 13-6 examples of measures inc
Page 329 and 330: tABLe 13-7 Between 2011 and 2012, l
Page 331 and 332: tABLe 13-9 admission-weighted ratio
Page 333 and 334: ecommended that payments be brought
Page 335 and 336: eport HEDIS measures based on admin
Page 337 and 338: C H A p t e R14 Medicare Advantage
Page 339 and 340: Medicare Advantage special needs pl
Page 341: integrating Medicaid benefits. We f
Page 344 and 345: tABLe 14-1 Distribution of snp enro
Page 346 and 347: previous Commission recommendations
Page 348 and 349: tABLe 14-4 Readmission rates by typ
Page 350 and 351: There has been recent movement in t
Page 352 and 353: of the quality measures that only S
Page 354 and 355: Separate appeals and grievances pro
Page 356 and 357: References Government Accountabilit
Page 359: status report on part D Chapter sum
Page 364 and 365: tABLe 15-2 and pharmacists who part
Page 366 and 367: Characteristics of Medicare benefic
Page 368 and 369: tABLe 15-6 Distribution of enrollme
Page 370 and 371: FIGURE FIguRe Percent of all Part D
Page 372 and 373: 3). Most regions continue to have m
Page 374 and 375: tABLe 15-9 • Reinsurance—Medica
Page 376 and 377: tABLe 15-11 toward the OOP threshol
Page 378 and 379: tABLe 15-12 Cost-sharing amounts fo
Page 380 and 381: tABLe 15-14 enrollees—by about $9
Page 382 and 383: Drug price index equal to 1.0 at th
Page 384 and 385: Voluntary switchers Each year, Part
Page 386 and 387: endnotes 1 PPACA eliminates the cov
Page 388 and 389: References Boards of Trustees, Fede
Page 391 and 392: Commissioners’ voting on recommen
Page 393 and 394: Chapter 12: Hospice services The Co
Page 395: A p p e n D I X Moving forward from
Page 398 and 399: well as the cost of temporary repri
Page 400 and 401: payments rates be frozen at their c
Page 402 and 403: than primary care physicians (class
Page 404 and 405: achieving a total estimated 10-year
Page 406 and 407: would be costly, too, and they are
Page 408 and 409: payment accuracy. For example, such
Page 410 and 411:
Final regulations on the ACO progra
Page 412 and 413:
statemen nt of MedPAC’s position
Page 414 and 415:
Cumulative percent change 70 7 60 6
Page 416 and 417:
390 Moving forward from the sustain
Page 418 and 419:
Note: The availability and scoring
Page 421 and 422:
Acronyms AAgR average annual growth
Page 423:
op outpatient opD hospital outpatie
Page 427:
Commission members glenn M. Hackbar
Page 430 and 431:
a state society of the National Med
Page 432 and 433:
on the Advocate Physician Partners
Page 435:
425 eye street, nW • suite 701
show all

Medicare Payment Policy

Create successful ePaper yourself

Delete template?

Save as template?