Medicare Payment Policy

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References Agency for Healthcare Research and Quality, Department of Health and Human Services. 2011. National healthcare disparities report 2011. Rockville, MD: AHRQ. Anderson, G. 2010. Chronic care: Making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation. Anderson, G. F., P. S. Hussey, B. K. Frogner, et al. 2005. Health spending in the United States and the rest of the industrialized world. Health Affairs 24, no. 4 (July–August): 903–914. Anderson, G. F., U. E. Reinhardt, P. S. Hussey, et al. 2003. It’s the prices, stupid: Why the United States is so different from other countries. Health Affairs 22, no. 3 (May–June): 89–105. Anderson, G. F., and D. A. Squires. 2010. Measuring the U.S. health care system: A cross-national comparison. New York: The Commonwealth Fund. Auerbach, D. I., and A. L. Kellermann. 2011. A decade of health care cost growth has wiped out real income gains for an average US family. Health Affairs 30, no. 9 (September): 1630–1636. Bach, P. B., H. H. Pham, D. Schrag, et al. 2004. Primary care physicians who treat blacks and whites. New England Journal of Medicine 351, no 6 (August 5): 575–584. Baicker, K., and A. Chandra. 2011. Aspirin, angioplasty, and proton beam therapy: The economics of smarter health care spending. Cambridge, MA: National Bureau of Economic Research. Baicker, K., and A. Chandra. 2006. The labor market effects of rising health insurance premiums. Journal of Labor Economics 24, no. 3 (July): 609–634. Baicker, K., and A. Chandra. 2004. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs Web Exclusive. Berenson, R., P. B. Ginsburg, J. B. Christianson, et al. 2012. The growing power of some providers to win steep payment from insurers suggests policy remedies may be needed. Health Affairs 31, no. 5 (May): 973–981. Berenson, R., P. B. Ginsburg, and N. Kemper. 2010. Unchecked provider clout in California foreshadows challenges to health reform. Health Affairs 29, no. 4 (April): 699–705. 24 Context for Medicare payment policy 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. Bureau of Labor Statistics. 2008a. More seniors working full time. Washington, DC: Bureau of Labor Statistics. August 6. Bureau of Labor Statistics. 2008b. Projected growth in labor force participation of seniors, 2006–2016. Washington, DC: Bureau of Labor Statistics. July 31. Bureau of Labor Statistics. 2012. Labor force statistics from the current population survey. Washington, DC: Bureau of Labor Statistics. October. Centers for Disease Control and Prevention. 2012a. Multiple chronic conditions among adults aged 45 and over: Trends over the past 10 years. Atlanta, GA: CDC. Centers for Disease Control and Prevention. 2012b. Prevalence of obesity in the United States, 2010–2011. Atlanta, GA: CDC. Centers for Medicare & Medicaid Services, Department of Health and Human Services. 2012. Chronic conditions among Medicare beneficiaries. Chartbook: 2012 edition. Baltimore, MD: CMS. Chernew, M. 2010. Growth in health care spending: Can we avoid fiscal Armageddon? Inquiry 47, no. 4 (Winter): 285–295. Coakley, Martha. 2011. Examination of health care cost trends and cost drivers. Boston: Office of the Attorney General. Congressional Budget Office. 2012. The 2012 long-term budget outlook. Washington, DC: CBO. Cutler, D. M. 1995. Technology, health costs, and the NIH. National Institute of Health Economics Roundtable on Biomedical Research. Cambridge, MA: Harvard University and National Bureau of Economic Research. Cutler, D. M., and M. McClellan. 2001. Is technological change in medicine worth it? Health Affairs 20, no. 5 (September– October): 11–29. Cutler, D. M., A. B. Rosen, and S. Vijan. 2006. The value of medical spending in the United States, 1960–2000. New England Journal of Medicine 355, no. 9 (August 31): 920–927. DeNavas-Walt, C., B. D. Proctor, and J. C. Smith. 2012. Income, poverty, and health insurance coverage in the United States: 2012. Washington, DC: Census Bureau.
Docteur, E., and R. Berenson. 2009. How does U.S. health care compare internationally? Washington, DC: Urban Institute. Finkelstein, A. 2007. The aggregate effects of health insurance: Evidence from the introduction of Medicare. Quarterly Journal of Economics 122, no. 1: 1–37. Finkelstein, A., S. Taubman, B. Wright, et al. 2010. The Oregon health insurance experiment: Evidence from the first year. Cambridge, MA: National Bureau of Economic Research. Fisher, E. S., D. E. Wennberg, T. A. Stukel, et al. 2003a. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Annals of Internal Medicine 138, no. 4 (February 18): 273–287. Fisher, E. S., D. E. Wennberg, T. A. Stukel, et al. 2003b. The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. Annals of Internal Medicine 138, no. 4 (February 18): 288–298. Flegal, K. F., M. D. Carroll, B. K. Kit, et al. 2012. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. Journal of the American Medical Association 307, no. 5 (February 1): 491–497. Garber, A., D. P. Goldman, and A. B. Jena. 2007. The promise of health care cost containment. Health Affairs 26, no. 6 (November–December): 1545–1547. Ginsburg, P. B. 2008. High and rising health care costs: Demystifying U.S. health care spending. Princeton, NJ: Robert Wood Johnson Foundation, The Synthesis Project. Goldman, D. P., N. Sood, and A. Leibowitz. 2005. Wage and benefit changes in response to rising health insurance. Forum for Health Economics & Policy: Frontiers in Health Policy Research 8, article 3. Hartman, M., A.B. Martin, J. Benson, et al. 2013. National health spending in 2011: Overall growth remains low, but some payers and services show signs of acceleration. Health Affairs 32, no. 1 (January): 87–99. Health Care Cost Institute. 2012a. Health care cost and utilization report: 2010. Washington, DC: Health Care Cost Institute. May. Health Care Cost Institute 2012b. Health care cost and utilization report: 2011. Washington, DC: Health Care Cost Institute. September. Hurd, M. D., and S. Rohwedder. 2010. Effects of the financial crisis and Great Recession on American households. National Bureau of Economic Research, no. 16407. Cambridge, MA: NBER. Jha, A. K., E. J. Orav, Z. Li, et al. 2007. Concentration and quality of hospitals that care for elderly black patients. Archives of Internal Medicine 167, no. 11 (June 11): 1177–1182. Kaiser Family Foundation. 2012. Health security watch. Washington DC: KFF. Kaiser Family Foundation. 2010. Medicare chartbook. 4th ed. Washington, DC: KFF. Kaiser Family Foundation and Health Research and Educational Trust. 2012. Employer health benefits: 2012 annual survey. Menlo Park, CA: KFF and HRET. Keehan, S. P., G. A. Cuckler, A. M. Sisko, et al. 2012. National health expenditure projections: Modest annual growth until coverage expands and economic growth accelerates. Health Affairs 31, no. 7 (July 31): 1600–1612. Kutner, M., E. Greenberg, Y. Jin, et al. 2006. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006–483. Washington, DC: Department of Education, National Center for Education Statistics. Laugesen, M. and S. A. Glied. 2011. Higher fees paid to US physicians drive higher spending for physician service compared to other countries. Health Affairs 30, no.9 (September): 1647– 1656. Leveille, S. G., C. C. Wee, and L. I. Iezzoni. 2009. Are baby boomers aging better than their predecessors? Trends in overweight, arthritis, and mobility difficulty. Cambridge, MA: National Bureau of Economic Research. Lowrey, A. 2012. In hopeful sign, health spending is flattening out. The New York Times. April 28. Martin, A. B., D. Lassman, B. Washington, et al. 2012. Growth in US health spending remained slow in 2010: Health share of gross domestic product was unchanged from 2009. Health Affairs 31, no. 1 (January): 208–219. McKinsey Global Institute. 2008. Accounting for the cost of U.S. health care: A new look at why Americans spend more. New York: McKinsey and Company. Medicaid and Children’s Health Insurance Program Payment and Access Commission. 2012. Medicaid and CHIP program statistics: March 2012 MACStats. Washington, DC: MACPAC. Medicare Payment Advisory Commission. 2012a. Report to the Congress: Medicare and the health care delivery system. Washington, DC: MedPAC. Report to the Congress: Medicare Payment Policy | March 2013 25
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 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
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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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C H A p t e R14 Medicare Advantage
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Medicare Advantage special needs pl
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integrating Medicaid benefits. We f
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tABLe 14-1 Distribution of snp enro
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previous Commission recommendations
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tABLe 14-4 Readmission rates by typ
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There has been recent movement in t
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of the quality measures that only S
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Separate appeals and grievances pro
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References Government Accountabilit
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status report on part D Chapter sum
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controlling growth in drug spending
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tABLe 15-2 and pharmacists who part
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Characteristics of Medicare benefic
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tABLe 15-6 Distribution of enrollme
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FIGURE FIguRe Percent of all Part D
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3). Most regions continue to have m
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tABLe 15-9 • Reinsurance—Medica
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tABLe 15-11 toward the OOP threshol
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tABLe 15-12 Cost-sharing amounts fo
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tABLe 15-14 enrollees—by about $9
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Drug price index equal to 1.0 at th
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Voluntary switchers Each year, Part
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endnotes 1 PPACA eliminates the cov
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References Boards of Trustees, Fede
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Commissioners’ voting on recommen
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Chapter 12: Hospice services The Co
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A p p e n D I X Moving forward from
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well as the cost of temporary repri
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payments rates be frozen at their c
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than primary care physicians (class
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achieving a total estimated 10-year
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would be costly, too, and they are
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payment accuracy. For example, such
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Final regulations on the ACO progra
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statemen nt of MedPAC’s position
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Cumulative percent change 70 7 60 6
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390 Moving forward from the sustain
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Note: The availability and scoring
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Acronyms AAgR average annual growth
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op outpatient opD hospital outpatie
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Commission members glenn M. Hackbar
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a state society of the National Med
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on the Advocate Physician Partners
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425 eye street, nW • suite 701
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