Medicare Payment Policy

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References Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 2012. 2012 annual report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Insurance Trust Funds. Washington, DC: Boards of Trustees. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012a. 2013 Part C and D plan ratings. Fact sheet. Baltimore, MD: CMS. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012b. Email communication with CMS staff, October 25. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012c. Medicare health & drug plan quality and performance ratings 2013 Part C & Part D technical notes. Baltimore, MD: CMS. Updated October 10. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2011. Prescription Drug Benefit Manual. Chapter 5: Benefits and beneficiary protections. Baltimore, MD: CMS. http://www.cms.gov/Medicare/Prescription- Drug-Coverage/PrescriptionDrugCovContra/Downloads/ MemoPDBManualChapter5_093011.pdf. Congressional Budget Office. 2010. Effects of using generic drugs on Medicare’s prescription drug spending. Washington, DC: CBO. Department of Health and Human Services. 2010. Prescription drug cost relief to more than 750,000 Medicare beneficiaries. News release. http://www.hhs.gov/news/ press/2010pres/08/20100810a.html. August 10. Hargrave, E., L. Summer, D. Liffmann, et al. 2012. Findings from focus groups with beneficiaries and physicians and site visits with physicians, care coordinators, and other staff. Report prepared by staff from NORC at the University of Chicago for MedPAC. Washington, DC: MedPAC. Hoadley, J., J. Cubanski, E. Hargrave, et al. 2012. Medicare Part D: A first look at Part D plan offerings in 2013. Data spotlight. Menlo Park, CA: Kaiser Family Foundation. Keenan, T. A. 2007. Prescription drugs and Medicare Part D: A report on access, satisfaction, and cost. Washington, DC: AARP. McWilliams, J. M., A. M. Zaslavsky, and H. A. Huskamp. 2011. Implementation of Medicare Part D and nondrug medical spending for elderly adults with limited prior drug coverage. Journal of the American Medical Association 306, no. 4 (July 27): 402–409. 362 Status report on Part D Medical News Today. 2009. Medicare Part D continues to earn strong marks from America’s seniors. http://www. medicalnewstoday.com/releases/170820.php. Medicare Payment Advisory Commission. 2012a. Payment basics: Part D payment system. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2012b. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. 2008. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC. Office of Inspector General, Department of Health and Human Services. 2007. Generic drug utilization in the Medicare Part D program. No. OEI–05–07–00130. Washington, DC: OIG. PRNewswire. 2010. Medicare Part D continues to earn strong marks from America’s seniors. http://www.prnewswire.com/ news-releases/medicare-part-d-continues-to-earn-strong-marksfrom-americas-seniors-69867642.html. Stuart, B., J. S. Shoemaker, M. Dai, et al. 2013. Regions with higher Medicare Part D spending show better drug adherence, but not lower Medicare costs for two diseases. Health Affairs 32, no. 1 (January): 120–126. Suzuki, S., and D. Zabinski. 2010. Regional variation in Medicare service use and prescription drug use. Presentation at the Medicare Payment Advisory Commission’s public meeting. October 8. Weems, K. 2008. The Medicare drug benefit: Are private insurers getting good discounts for the taxpayer? Statement by Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services, before the Committee on Oversight and Government Reform, House of Representatives. 110th Congress, 2nd sess. July 24. Zhang, Y., J. M. Donohue, J. R. Lave, et al. 2009. The effect of Medicare Part D on drug and medical spending. New England Journal of Medicine 361, no. 1 (July 2): 52–61.
A p p e n D I X Commissioners' voting on recommendations A
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RepoRt to the CongRess Medicare Pay
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RepoRt to tHe CongRess Medicare Pay
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with the structure of the payment s
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table of contents Acknowledgments .
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executive summary
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of services—and pressure on feder
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current Medicare payments are adequ
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outpatient dialysis services Outpat
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some facilities are willing to acce
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coverage for conventional treatment
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of care for these conditions should
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Context for Medicare payment policy
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4 Context for Medicare payment poli
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FIguRe FIGURE 1-2 1-2 12% Out of po
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the level of health care spending a
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1-4 FIguRe 1-4 140 120 100 80 60 Do
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FIguRe 1-6 1-6 Growth rate (in perc
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FIGURE FIguRe Share of GDP (in perc
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Share of GDP (in percent) FIGURE 1-
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FIGURE FIguRe 1-10 1-10 8% African
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FIguRe 1-12 1-11 1800 1600 1400 120
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Americans than for other racial and
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References Agency for Healthcare Re
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Medicare Payment Advisory Commissio
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Assessing payment adequacy and upda
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The goal of Medicare payment policy
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may go up when payment rates go dow
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hospitals and that hospitals shift
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individual payment systems but also
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Hospital inpatient and outpatient s
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Hospital inpatient and outpatient s
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covered the fully allocated costs o
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3-1 3-1 FIguRe 100 80 60 40 Number
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Visits or claims per 1,000 benefici
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3-4 3-4 FIguRe 2012 dollars (in bil
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of physicians employed directly by
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FIguRe FIGURE Annual percent change
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FIGURE FIguRe Margin (in percent) 3
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FIGURE FIguRe Margin (in percent) 3
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tABLe 3-5 performance of efficient
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Act, the EHR Incentive Program also
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as Medicaid expands, the new insura
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ates for separately paid drugs resu
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endnotes 1 From 2002 to 2011, 479 h
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References Agency for Healthcare Re
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C H A p t e R4 physician and other
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physician and other health professi
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from the SGR system in its October
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4-1 4-1 FIguRe 40 35 30 25 20 15 10
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tABLe 4-1 Most aged Medicare benefi
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tABLe 4-2 Medicare beneficiaries ha
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payment adjustments for health prof
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tABLe 4-3 Year physicians primary c
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provider’s characteristics, geogr
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tABLe 4-4 type of service Change in
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tABLe 4-5 type of imaging Change in
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the patient-centered medical home T
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FIguRe FIGURE Cumulative percent ch
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References ABIM Foundation. 2012. C
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Ambulatory surgical center services
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Ambulatory surgical center services
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Background An ambulatory surgical c
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Differences in types of patients tr
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Differences in types of patients tr
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number of services grew from 2006 t
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tABLe 5-7 rapidly than nonowning ph
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Creating a value-based purchasing p
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Revisiting the ambulatory surgical
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endnotes 1 Because CMS updates paym
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Medicare Payment Advisory Commissio
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R e C o M M e n D A t I o n 6 The C
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128 Outpatient dialysis services: A
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tABLe 6-1 Characteristics of FFs di
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Physicians Association has publishe
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tABLe 6-3 Increasing number and cap
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Number of FFS dialysis beneficiarie
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FIguRe 6-3 Percent of dialysis bene
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and 2011, the proportion of adult h
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anticipated under the modernized pa
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endnotes 1 In this chapter, we use
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References ABIM Foundation. 2012. C
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C H A p t e R7 post-acute care prov
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encourages more 60-day episodes. Fu
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C H A p t e R8 skilled nursing faci
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skilled nursing facility services C
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adjust for differences in patients
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Description of beneficiaries who us
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snF prospective payment system and
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Number of SNFs FIguRe FIGURE 8-1 7-
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FIGURE FIguRe Percent 7-2 8-2 30 25
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and other SNF users were essentiall
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FIguRe FIGURE Program spending (in
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7-8 8-6 FIguRe 30 25 20 15 10 Medic
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(e.g., whether there is a requireme
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the Commission’s 2012 update reco
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tABLe 8-9 non-Medicare margins were
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found to be associated with one or
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Smith, V. K., K. Gifford, E. Ellis,
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R e C o M M e n D A t I o n s (The
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188 Home health care services: Asse
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tABLe 9-1 use and growth of home he
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FIGURE FIguRe Number of new agencie
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tABLe 9-2 of services. The review a
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tABLe 9-4 Community-admitted home h
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tABLe 9-5 type of county Claims dat
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tABLe 9-6 state County are collecte
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tABLe 9-8 Medicare margins for free
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tABLe 9-11 provider characteristics
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tABLe 9-12 Medicare visits per full
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strengthening incentives for effect
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endnotes 1 The exceptions pertain t
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C H A p t e R10 Inpatient rehabilit
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Inpatient rehabilitation facility s
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FIguRe FIGURE 10-1 9-1 Note: IRF (i
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Medicare IRF classification require
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tABLe 10-2 type of IRF 2004 2005 20
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tABLe 10-4 number of IRF beds decre
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weight for compliant cases was 1.39
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unobserved factors regarding patien
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freestanding IRFs were about $4,340
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increase for changes in the outlier
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References Centers for Medicare & M
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R e C o M M e n D A t I o n 11 The
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Quality of care—LTCHs only recent
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FIguRe FIGURE 11-1 10-1 Source: Med
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short-stay outlier cases in long-te
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tABLe 11-1 growth in the number of
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Chronically critically ill benefici
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Quality measures for long-term care
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tABLe 11-4 type of LtCH per case pa
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temporary legislative relief from s
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16 We observed growth over time in
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Durairaj, L., J. C. Torner, E. A. C
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Hospice services C H A p t e R12
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Hospice services Chapter summary Th
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Background Medicare began offering
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March 2009 Commission recommendatio
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March 2009 Commission recommendatio
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number peaking in 2009). With rapid
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tABLe 12-4 Hospice use has increase
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tABLe 12-5 Characteristic insurers
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three settings, respectively) (Tabl
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measures, it is likely that the vas
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tABLe 12-10 Category percentage poi
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• additional wage index changes,
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elieve the cost report data provide
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C H A p t e R13 the Medicare Advant
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288 The Medicare Advantage program:
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The Medicare Advantage (MA) program
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enchmark. If a plan’s bid is abov
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tABLe 13-3 projected payments excee
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We broke the fourth quartile into t
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tABLe 13-5 Distribution of enrollme
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tABLe 13-6 examples of measures inc
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tABLe 13-7 Between 2011 and 2012, l
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tABLe 13-9 admission-weighted ratio
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ecommended that payments be brought
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eport HEDIS measures based on admin
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Page 341: integrating Medicaid benefits. We f
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Page 386 and 387: endnotes 1 PPACA eliminates the cov
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Page 395: A p p e n D I X Moving forward from
Page 398 and 399: well as the cost of temporary repri
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Page 427: Commission members glenn M. Hackbar
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Medicare Payment Policy

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