Changes In Medicare Reimbursement Research Articles

The Impact of PPS on Hospital-Sponsored Post-Acute Services: A Case Study of Delaware Medicare Providers

Hospitals were the first providers to experience the change in Medicare reimbursement from a cost basis to the prospective payment system (PPS). In the 1980s, this switch was accomplished through the development of diagnosis-related groups, a unique formula for Medicare reimbursement of inpatient hospital services. During that time, the concern was that, with the anticipated reduced payments to hospitals, adverse impacts on Medicare beneficiaries were likely, including premature release of patients from hospital care resulting in medical complications, increased readmissions, prolonged episodes of recuperation, and preventable mortality. The Balanced Budget Act of 1997 (BBA) mandated the implementation of the PPS for Medicare providers of skilled nursing home care and home health care. This change from cost-based reimbursement to PPS raised concerns that these providers would react as hospitals had done-that is, skilled nursing homes might limit their admission of Medicare patients and home health agencies might cut back on visits. As a result of that, hospitals might be faced with providing care for these post-acute patients without receiving additional reimbursement, and these changes in utilization patterns would be of critical importance to both providers and Medicare beneficiaries. This article examines the decisions that providers made in response to the perceived impact of the BBA. Qualitative data were derived from provider interviews. The article concludes with a discussion of how changes in Medicare reimbursement policy have influenced providers of post-acute care services to alter their level of participation in Medicare and the impact this may have on the general public as well as on Medicare beneficiaries.

Medicare reimbursement, nurse staffing, and patient outcomes

There is widespread concern about the quality of health care in the US, and the effect of provider payments on the quality of care is an important and unsettled issue in this debate. The critical question is whether changes in provider payments affect health. To date there is relatively little research on this question. Here, we present evidence of the effect of plausibly exogenous changes in Medicare reimbursement – caused by geographical reclassification – on hospital staffing (nurses) and patient outcomes. We find that changes in Medicare reimbursement levels of approximately 10% have no meaningful effect on hospital use of resources or patient outcomes.

Study Finds ‘Oldest Old’ Are Shifting From NHs

Nursing home use by the “oldest old”—or those aged 85 and older—has declined sharply since 1984, according to the Lewin Group. The health care and human services consulting firm cites less disability, new alternatives to nursing homes, and changes in the pattern of nursing home care. But an Urban Institute expert says a change in definitions may also be a factor. In a study released in November, the Lewin Group found that if all older adults (ages 65 and older) had continued to use nursing homes as they did in 1985, 1.95 million older adults would reside in nursing homes today. Instead, just 1.32 million residents ages 65 and older lived in nursing homes in 2004. At the same time, “the total number of people age 85 and older nearly doubled over the period,” but the number of individuals age 85 and over in nursing homes “remained about the same,” wrote Lisa Alecxih, vice president of the Lewin Group and author of the report, “Nursing Home Use by ‘Oldest Old’ Sharply Declines.” Consequently, the use rate among the oldest old fell from 21.1% in 1985 to 13.9% in 2004, and is likely to drop further, the study found. The finding reflects a desire of many older adults to continue to live in the community, and also suggests continued change as the Baby Boom generation begins to need long-term care, Ms. Alecxih concluded in her report. Several factors likely contributed to the decline in use rate, she said. First, age-adjusted disability rates among the elderly declined from 1984 to 1999, although the decline was somewhat less among the oldest old. And, the poverty rate for individuals 85 and older dropped 28%, from 18.7% in 1985 to 13.4% in 2005. The poverty rate for all seniors also fell about 20%. Changes in Medicare reimbursement have led to more of a focus on post-acute stays and shorter custodial stays, resulting in a decline of average length of stay from 2.9 years in 1985 to 2.4 years in 2004, and in median length of stay from 1.7 years to about 1.3 years. At the same time, alternatives to traditional nursing homes, such as assisted living facilities, continued to develop. They now house approximately 1 million residents with an average age over 80, said Ms. Alecxih, who leads the group's Center for Long-Term Care. Separately, approximately 10% of all adults 65 and older now own a long-term care insurance policy, which provides a small group of policyholders with the resources to choose where they want to receive care. Many states have tried to reduce the number of Medicaid recipients in nursing homes by providing more home and community-based services, while implementing pre-admission screening or single entry point systems in order to divert people away from nursing homes, the report said. With the aging of the Baby Boom generation, the United States will see twice as many older adults in 2030 as there were in 2006. But if the demand for nursing homes continues to decline at just half the national average over the past 20 years, the use rate among adults age 65 and older would drop from a projected 3.2% to 2.5% in 2030, Ms. Alecxih said. That would mean an increase of just 320,000 older adults by 2030, Ms. Alecxih wrote in the report. The decline may be more related to how states define and regulate nursing homes, according to Brenda Spillman, Ph.D., a senior research associate with the Urban Institute's Health Policy Center. “States have begun licensing other types of long-term care settings and other supportive residential care settings, and some of the more marginal places changed licensure,” she said. That could mean some institutions now are classified as assisted-living facilities rather than as nursing homes, even though the care provided in them has not changed, Dr. Spillman explained. “They may not be nursing homes any longer, but Mrs. Jones may be sitting in the same bed in the same room. And, there may be less quality oversight,” said Dr. Spillman, who co-authored in January 2006 the Urban Institute study “Size and Characteristics of the Residential Care Population: Evidence from Three National Surveys.” Still, measuring and improving quality of care at all residential facilities—not just nursing homes—is becoming a bigger is-sue for regulators, Dr. Spillman said. And even though those 85 or older increasingly are choosing alternatives to nursing homes, she said, that doesn't mean they won't enter one eventually. “In assisted living settings, it is very likely you will reach a point where they won't keep you any more. I wonder if they aren't becoming a step between home and a nursing home.

Home Care: A Key to the Future of Family Medicine?

This essay is about my transition from family medicine residency into house call/home-based primary care practice. Though some aspects of making home visits have been difficult and uncomfortable, I have found a higher level of satisfaction and sense of purpose than I had as a resident in a traditional outpatient clinic. This enhanced satisfaction is, in part, due to my discovery that a lower-volume, time-intensive house call practice is a more appropriate way than the brief office visit to care for older patients who have multiple morbidities. In light of the aging population, advances in portable medical technology, and changes in Medicare reimbursement, home care could become a key to the future success and ongoing relevance of family medicine.

Documentation of Chemotherapy Infusion Preparation Costs in Academic- and Community-Based Oncology Practices

Significant changes in Medicare reimbursement for outpatient oncology services were proposed as part of the Medicare Modernization Act of 2003. The purpose of this study was to identify the "true cost" associated with drug-related handling for the preparation and delivery of chemotherapy doses to estimate the impact of changing reimbursement schema by Medicare. Two academic medical outpatient infusion centers and 2 community cancer centers provided data used to estimate all costs (excluding drug cost) associated with the preparation of chemotherapy doses. The data included both fixed costs (drug storage, space, equipment, and information resources) and variable costs (insurance management, inventory, waste management, pharmacy staff payroll, supplies, and shipping). The average cost for the preparation of chemotherapy doses across all sites was dollar 34.27 (range, dollar 32.08-dollar 41.23). A time-and-motion study was also performed to determine what tasks were conducted by pharmacy staff and how much time was spent in the preparation of the top 15 chemotherapeutic drugs and regimens used in the 4 sites. Data from the 4 centers was projected to show that if 3,990,495 million chemotherapy infusions were administered to a national Medicare population in 2003, when multiplied by the average cost of preparation for infusions determined by the current study (dollar 34.27), the estimated total annual cost to Medicare for chemotherapy preparation by pharmacists is dollar 136,754,263.65. The pharmacists spent most of their days (90% or more) performing tasks directly related to the preparation of these agents. These data provide scientific support for the consideration of appropriate reimbursement for chemotherapy services provided by pharmacists to Medicare beneficiaries.

The impact of Medicare reimbursement changes on staffing and the quality of care in nursing homes

This study assesses the impact of recent Medicare reimbursement changes on nurse staffing and quality of care in skilled nursing facilities. We utilise data from the Online Survey Certification and Reporting System and Area Resource Files for the years 1997–2003. The impacts of the reimbursement changes on licensed nurse hours per resident day and on a quality index were estimated, controlling for facility and market factors, and including interaction between payer mix and policy. We find that the 1997 Balanced Budget Act had a negative effect on staffing and quality while the 1999 Balanced Budget Reconciliation Act and the 2000 Benefits Improvement and Protection Act had positive effects on staffing and quality. The percentage of Medicaid patients was a strong contributor to lower staffing and quality, and moderated the effects of all three policies. The results should be useful for policy makers considering cuts in Medicare or Medicaid spending for nursing homes.

Nurse and Client Perceptions of Home Health Wound Care Effectiveness After a Change in Medicare Reimbursement

The purpose of this study was to begin to explore client and nurse perceptions related to how a change in a Medicare reimbursement, Prospective Payment System (PPS), affects home health care. The target population included home health clients with stage III or greater decubitus ulcers, age 65 years or older. Six Virginia home health agencies were randomly selected. From those sites, all 39 charts that met population criteria were accessed and analyzed, and then 16 care recipients were purposely selected. In addition, 26 home health nurses with pre- and post-PPS experience were purposefully selected. Semistructured, audiotaped interviews were conducted, transcribed, and analyzed using thematic content analysis. Results demonstrated PPS adaptive behavior and an increase in use of education and family caregivers related to wound care. Themes that emerged included professional competence, caregiver as key, and sense of support. Perceptions emphasize the necessity for resource management, collaboration, and patient advocacy.

Did Recent Changes in Medicare Reimbursement Hit Teaching Hospitals Harder?

To inform the policy debate on Medicare reimbursement by examining the financial effects of the Balanced Budget Act of 1997 (BBA) and subsequent adjustments on major academic medical centers, minor teaching hospitals, and nonteaching hospitals. The authors simulated the impacts of BBA and subsequent BBA adjustments to predict the independent effects of changes in Medicare reimbursement on hospital revenues using 1997-2001 Medicare Cost Reports for all short-term acute-care hospitals in the United States. The authors also calculated actual (nonsimulated) operating and total margins among major teaching, minor teaching, and nonteaching hospitals to account for hospital response to the changes. The BBA and subsequent refinements reduced Medicare revenues to a greater degree in major teaching hospitals, but the fact that such hospitals had a smaller proportion of Medicare patients meant that the BBA reduced overall revenues by similar percentages across major, minor, and nonteaching hospitals. Consistently lower margins may have made teaching hospitals more vulnerable to cuts in Medicare support. Recent Medicare changes affected revenues at teaching and nonteaching hospitals more similarly than is commonly believed. However, the Medicare cuts under the BBA probably exacerbated preexisting financial strain on major teaching hospitals, and increased Medicare funding may not suffice to eliminate the strain. This report's findings are consistent with recent calls to support needed services of teaching hospitals through all-payer or general funds.

Uncertainty, Real Options, and Cost Behavior: Evidence from Washington State Hospitals

ABSTRACTThis study tests an implication of the real‐options theory of investment, that uncertainty leads firms to prefer technologies with low fixed and high variable costs. In 1983, a change in Medicare reimbursement increased the uncertainty of revenues for hospitals. Using a sample of 831 departments in 59 Washington State hospitals over the 1977–1994 period, we find that the ratio of variable to total costs increased after 1983. This increase is not attributable to a gradual increase in the ratio over time: We estimate a significant increase after 1983 even after controlling for a time trend. Further, we find a greater increase in the variable‐to‐total cost ratio for hospitals that had higher percentages of Medicare patients, increasing our confidence in the conclusion that the change in cost behavior is attributable to Medicare's change in reimbursement.

Changes in Medicare Reimbursement and Patient-Nephrologist Visits, Quality of Care, and Health-Related Quality of Life

Medicare's reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life. We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods. For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction. Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Experts Recommend Strategies for Strengthening the Use of Advanced Practice Nurses in Nursing Homes

In 2003, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University Division of Nursing, convened an expert panel to explore the potential for developing recommendations for the caseloads of advanced practice nurses (APNs) in nursing homes and to provide substantive and detailed strategies to strengthen the use of APNs in nursing homes. The panel, consisting of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care, developed six recommendations related to caseloads for APNs in nursing homes. The recommendations address educational preparation of APNs; average reimbursable APN visits per day; factors affecting APNs caseload parameters, including provider characteristics, practice models, resident acuity, and facility factors; changes in Medicare reimbursement to acknowledge nonbillable time spent in resident care; and technical assistance to promote a climate conducive to APN practice in nursing homes. Detailed research findings and clinical expertise underpin each recommendation. These recommendations provide practitioners, payers, regulators, and consumers with a rationale and details of current advanced practice nursing models and caseload parameters, preferred geriatric education, reimbursement strategies, and a range of technical assistance necessary to strengthen, enhance, and increase APNs' participation in the care of nursing home residents.

Growing a State Society: The Michigan Model

The Michigan Society of Hematology and Oncology (MSHO) was formed in 1985 in response to unfavorable changes in Medicare reimbursement and inconsistent coverage issues with Michigan's private payers that jeopardized specialists' ability to deliver quality care. In 1989, MSHO became actively involved in the first state legislation mandating oncology drug coverage. This law was expanded to include off-label indications. This landmark legislation led to development of an Off-Label Oncology Panel review process that is still viable and has been emulated throughout the country. MSHO was invited to deliver Congressional testimony on Michigan's law as Congress formulated the Omnibus Reconciliation Act of 1993, which included provisions requiring Medicare coverage of off-label indications when included in certain drug compendia and peer-reviewed journals. Throughout its twenty-year history, MSHO has paid careful attention to membership recruitment and retention. Regional policymakers and regulators have given MSHO access because they understand that we represent 90% of the state's cancer specialists. As of today, the Michigan Society of Hematology and Oncology includes 313 physicians from private practice and academic medical center settings. Our organization provides educational, reimbursement, legislative advocacy and networking services to physician members as well as their nurse practitioners, physician assistants, oncology nurses, practice managers and billing staff members. Surveying and targeting the unique, local needs of our practices and clinics and employing a variety of communication vehicles keeps the Society relevant and valuable to its members. MSHO recognizes the importance of actively involving the practice administrators in all we do. This specific group can readily identify issues, encourage staff participation in Society initiatives and make sure the physicians maintain their membership. The alliance of the physicians and their administrators is something unique to the Michigan Society of Hematology and Oncology and crucial to our continued success. As an additional benefit, MSHO offers an active Group Purchasing Organization with contracts and partnerships accessible to both large and small practices. Since the founding of the Society, strong physician leadership and vision have driven MSHO's achievements. Our Board of Directors currently numbers 22 oncologists/hematologists representing all geographic areas of Michigan. The composition of the Board is well balanced. Physicians from large practices, solo practitioners and representatives from all of Michigan's academic medical centers are active Board members. Many Board members hold positions in national clinical and professional advocacy organizations. The talent and expertise that each of these overscheduled specialists bring to our Society is impressive. Being an MSHO Board member requires regular attendance at meetings and participation in subcommittees. With labor divided among so many competent and devoted members, burnout is low. As a group there is a great mutual respect and dedication to our core mission. Our members are connected with statewide and national stakeholders in cancer care. MSHO participates in the Michigan Cancer Consortium, facilitates the Michigan Working Group to Improve Cancer Outcomes and has ties to many local and national patient advocacy groups. The Society appoints the Hematology and Oncology Carrier Advisory Committee Members to our Medicare carrier, Wisconsin Physician Services. We have quarterly meetings with the medical policy team at our state's largest private payer, Blue Cross and Blue Shield of Michigan. We also work closely with the Michigan Department of Community Health, the Michigan Association of Health Plans, and individual payers. Education, networking and communication build strong allegiance to MSHO. Rather than being separate functions of the Society, the integration of these services promotes our mission and creates member ownership of our organization. Our CME program faculty is traditionally recruited from Michigan academic medical centers. We offer yearly ASH and ASCO Updates and an Annual Meeting Symposium that reviews the current information on specific tumors. This is an opportunity for community oncologists to recognize those who are the local thought leaders on specific topics. We offer a yearly Oncology Fellows Board Review that confirms our educational mission and dedication to the future of oncology care in the state. OCN pre-test trainings, clinical research workshops, and the Annual Oncology Nurse Network Retreat and dinner meetings advance professional growth and offer nurses an opportunity to meet and share with others in like and different practice settings. Oncology manager roundtables, hospital-based oncology economic updates and quarterly reimbursement meetings address the challenges of the business of oncology. In 2004, MSHO implemented an intensive, week-long academic oncology managers certification course focusing on health care finance, risk management, e-systems, contracting, outcomes measurement, and employment practices. All educational meetings are carefully designed to offer a setting conducive to networking and disseminating information about all MSHO initiatives. Quarterly newsletters, monthly fax-blasts, the MSHO Web site and direct mailings support education opportunities. The Society provides the services of a full-time reimbursement specialist to support practices. Figure 2

Challenges of Providing Nutrition Support in the Outpatient Dialysis Setting

Malnutrition is prevalent in maintenance hemodialysis (MHD) patients and has been strongly associated with increased morbidity and mortality. There are numerous contributors to the development, occurrence, and persistence of malnutrition in the MHD patient. Intensive diet counseling and use of enteral supplements may not be effective interventions for patients exhibiting high nutrition risk. More aggressive nutrition options such as enteral and parenteral support are less often used and have associated risks. Intradialytic parenteral nutrition (IDPN) as a form of PN delivered during the dialysis procedure is a convenient and attractive convention that is underused because of its history and controversy. There is a lack of randomized controlled trials demonstrating improved morbidity and mortality with all nutrition support interventions in MHD patients. This research is particularly crucial for IDPN in order to render change in Medicare reimbursement. Qualification of patients for this therapy is difficult because of the very strict coverage criteria. For those patients who do qualify for IDPN, clinician nutrition support knowledge is essential for safe administration of solutions and effective physical, metabolic, and nutrition management of the patient. Attention to other factors that contribute to malnutrition in MHD such as treatment adequacy and comorbid conditions is important; however, the early detection of malnutrition in the MHD patient with appropriate level of nutrition intervention is critical. Future improved understanding of the malnutrition of uremia will allow for development and investigation of other strategies that are anti-catabolic or anabolic.

The Influence of a Change in Medicare Reimbursement on the Effectiveness of Stage III or Greater Decubitus Ulcer Home Health Nursing Care

This study was designed to describe and evaluate the influence of a change in a Medicare reimbursement on the effectiveness of home health nursing care for stage III or greater decubitus ulcer patients. This health policy originated from the Balanced Budget Act (BBA) of 1997 and took its full effect with initiation of the Prospective Payment System (PPS) on October 1, 2000. A quantitative quasi-experimental design used OASIS data from the state of Virginia to evaluate 555 stage III or greater decubitus ulcer patients, age 65 or older. Comparisons were investigated between pre-PPS, 2000, and post-PPS, 2001, outcomes related to reported ulcer healing, lengths of stay, and discharge disposition. Results demonstrated significant differences for the outcomes studied. In addition, sanitation, ulcer healing, and discharge disposition were linked as predictors for length of stay. Results demonstrated that PPS has affected nursing care effectiveness for stage III or greater decubitus ulcer home health patients.

AAC in the Schools Moving Students Along a Communication Continuum

AAC in the Schools Moving Students Along a Communication Continuum

Social Work Licensing and the Evolving Home Care Setting

The home health care industry has recently undergone dramatic changes in Medicare reimbursement and the delivery of patient care services to the chronically ill elderly. One of the primary differences in the funding structure is that medical social services are no longer directly billable within the Medicare home health system. Many authors support the contention that social work field-educational experiences in health care are crucial in order to have a more prepared work force. Unfortunately, field practicum opportunities for social work students have been rare in the home health care industry because of the converging problems of licensing regulations and Medicare reimbursement. Although students must be supervised and monitored by a licensed social worker, there are many functions that they can perform in the home health care setting.

Health Spending Rebound Continues In 2002

U.S. health care spending climbed to dollars 1.6 trillion in 2002, or dollars 5,440 per person. Health spending rose 8.5 percent in 2001 and 9.3 percent in 2002, contributing to a spike of 1.6 percentage points in the health share of gross domestic product (GDP) since 2000. Hospital spending accounted for nearly a third of the aggregate increase. During the past three decades, per enrollee spending for a common benefit package has grown at a slightly slower average annual rate for Medicare than for private health insurance, with more pronounced growth differences recently reflecting legislated Medicare reimbursement changes and consumers' calls for more loosely managed care.

Volume and yield of screening colonoscopy at a tertiary medical center after change in medicare reimbursement.

Starting July 1, 2001, Medicare began to reimburse for screening colonoscopy in asymptomatic adults older than 50 yr with no risk factors for colorectal cancer. We sought to determine the short-term impact of the change in Medicare reimbursement on the demand for and yield of screening colonoscopy at our tertiary institution. Asymptomatic patients older than 50 referred for first screening colonoscopy after the change in Medicare reimbursement from July 1, 2001 to December 31, 2001 were compared with a similar cohort screened before Medicare coverage for a family history of cancer or polyps during the same months the previous year (July 1, 2000 to December 31, 2000). Patient demographics, number, size, location, and histology of polyps/cancers for these screening colonoscopies were collected. A total of 1282 colonoscopies were performed in our institution from July 1, 2001 to December 31, 2001, 257 (20%) for screening. During the same months in the previous year, 121 of 938 colonoscopies (12.9%) were for screening (p < 0.01). This was a 55% increase in the percentage of colonoscopies performed for screening, and a 112% increase in the number of screening colonoscopies. Patients screened after the change in Medicare reimbursement were on average 5 yr older compared with patients of the previous year (62 +/- 10 [mean +/- SD] vs 56 +/- 9 yr; p < 0.01). A total of 61 screening colonoscopies (24%) performed after the change in Medicare reimbursement had adenomatous lesions, compared with 25 (21%) screened for family history (p = ns). The number of adenomas 10 mm or larger or cancers did not differ significantly between the two groups (17 in 2001 vs 12 in 2000; p = ns). Age of 65 or older was associated with detection of adenomatous lesions (OR = 1.7; 95% CI = 1.01-2.9013). Since the change in Medicare reimbursement, there has been a significant increase in the number and proportion of colonoscopies performed for screening at our institution. Patients screened since this change are older, and the detection rate of neoplastic lesions is similar to those previously screened for a family history of colorectal cancer or polyps.

Volume and yield of screening colonoscopy at a tertiary medical center after change in medicare reimbursement

Objective Starting July 1, 2001, Medicare began to reimburse for screening colonoscopy in asymptomatic adults older than 50 yr with no risk factors for colorectal cancer. We sought to determine the short-term impact of the change in Medicare reimbursement on the demand for and yield of screening colonoscopy at our tertiary institution. Methods Asymptomatic patients older than 50 referred for first screening colonoscopy after the change in Medicare reimbursement from July 1, 2001 to December 31, 2001 were compared with a similar cohort screened before Medicare coverage for a family history of cancer or polyps during the same months the previous year (July 1, 2000 to December 31, 2000). Patient demographics, number, size, location, and histology of polyps/cancers for these screening colonoscopies were collected. Results A total of 1282 colonoscopies were performed in our institution from July 1, 2001 to December 31, 2001, 257 (20%) for screening. During the same months in the previous year, 121 of 938 colonoscopies (12.9%) were for screening ( p < 0.01). This was a 55% increase in the percentage of colonoscopies performed for screening, and a 112% increase in the number of screening colonoscopies. Patients screened after the change in Medicare reimbursement were on average 5 yr older compared with patients of the previous year (62 ± 10 [mean ± SD] vs 56 ± 9 yr; p < 0.01). A total of 61 screening colonoscopies (24%) performed after the change in Medicare reimbursement had adenomatous lesions, compared with 25 (21%) screened for family history ( p = ns). The number of adenomas 10 mm or larger or cancers did not differ significantly between the two groups (17 in 2001 vs 12 in 2000; p = ns). Age of 65 or older was associated with detection of adenomatous lesions (OR = 1.7; 95% CI = 1.01–2.9013). Conclusions Since the change in Medicare reimbursement, there has been a significant increase in the number and proportion of colonoscopies performed for screening at our institution. Patients screened since this change are older, and the detection rate of neoplastic lesions is similar to those previously screened for a family history of colorectal cancer or polyps.

Changes in medicare reimbursement: impact on therapy for benign prostatic hyperplasia.

Medicare spending accounts for 17% of all health spending and therefore exerts a significant influence on health care spending policies. Medicare policies such as Diagnostic Related Groups and the Resource Based Relative Value System have resulted in profound changes in health care delivery in the United States. These resource-allocation methods are one of the major sources of controversies between managers, doctors, politicians, and social scientists. Financial disincentives associated with these resource-allocation policies have effectively rationed select therapies, particularly transurethral resection of the prostate (TURP). As a consequence, TURP, once the second most common surgical procedure billed to Medicare and comprising 38% of major surgical procedures performed by urologists, is increasingly challenged by medical therapy and minimally invasive surgical therapies that may be associated with lower efficacy and durability. This article examines the history of Medicare policies and their influence on TURP.