Expansion Of Medicare Research Articles

Market Competition and Anemia Management in the United States Following Dialysis Payment Reform.

Whether market competition influences health care provider responses to national reimbursement reforms is unknown. We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition. With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform. A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform. Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers. Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas. After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

Continuous Glucose Monitoring in Primary Care: Understanding and Supporting Clinicians' Use to Enhance Diabetes Care.

Diabetes affects approximately 34 million Americans and many do not achieve glycemic targets. Continuous glucose monitoring (CGM) is associated with improved health outcomes for patients with diabetes. Most adults with diabetes receive care for their diabetes in primary care practices, where uptake of CGM is unclear. We used a cross-sectional web-based survey to assess CGM prescribing behaviors and resource needs among primary care clinicians across the United States. We used descriptive statistics and multivariable regression to identify characteristics associated with prescribing behaviors, openness to prescribing CGM, and to understand resources needed to support use of CGM in primary care. Clinicians located more than 40 miles from the nearest endocrinologist's office were more likely to have prescribed CGM and reported greater likelihood to prescribe CGM in the future than those located within 10 miles of an endocrinologist. Clinicians who served more Medicare patients reported favorable attitudes toward future prescribing and higher confidence using CGM to manage diabetes than clinicians with lower Medicare patient volume. The most-needed resources to support CGM use in primary care were consultation on insurance issues and CGM training. Primary care clinicians are interested in using CGM for patients with diabetes, but many lack the resources to implement use of this diabetes technology. Use of CGM can be supported with education in the form of workshops and consultation on insurance issues targeted toward residents, recent graduates, and practices without a nearby endocrinologist. Continued expansion of Medicare and Medicaid coverage for CGM can also support CGM use in primary care.

A polling experiment on public opinion on the future expansion of Medicare and Medicaid.

To conduct a polling experiment to understand the possible framing effects that drive constituents' views around Medicare For All (MFA) and Medicaid Buy-In (MBI). Five thousand and fifty-one US adults aged 18 and older were recruited to participate in an online poll conducted between September 12, 2018, and September 26, 2018. Participants were randomized to receive one of four polls: (a) a poll measuring respondent approval for MFA, with the name of the proposal stated with a description; (b) a poll measuring approval for MFA, with only a description of the proposal; (c) a poll measuring approval for MBI, with the name stated with a description; or (d) a poll measuring approval for MBI, with only a description. Including the names "Medicare For All" and "Medicaid Buy-In" increases approval by 3.4 (from 32.7 percent to 36.1 percent) and 5.0 (from 50.1 percent to 55.1 percent) percentage points, respectively. Support varies by age, where MBI is most strongly supported by Millennials, while Baby Boomers and those older than 65 are more likely to support MFA. Constituents are more likely to support a proposal when given the names of the proposal. Approval is also higher for health policies that are framed as expansions of existing policies than as new programs.

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

The Affordable Care Act (ACA) introduced wide-ranging health care reforms but faces many challenges. This article reviews 6 key points for today’s nurse leader on the law’s 10th anniversary: a renewed legal battle is on its way to the Supreme Court; 27 million people still lack coverage, partly due to nonexpansion of Medicaid in 15 states; Medicaid waivers provide coverage for some low-income people but leave many people out; value-based purchasing has allocated billions of dollars in rewards and penalties; ACA Marketplace plans are not always affordable, but premiums are stabilizing; and the 2020 elections could result in dramatic consequences for health care reform.

Medicare Expansion as a Path as well as a Destination: Achieving Universal Insurance through a New Politics of Medicare

Growing interest in “Medicare for All” has revived hopes for universal health insurance. Yet serious disagreements remain over how to expand Medicare and how far to move toward a universal Medicare system. In this article, I consider these disagreements in light of what we know about “policy feedback”—the ways in which policies, once enacted, reshape public opinion, governing institutions, and political organizations. Rather than focusing on the “political feasibility” of proposals for Medicare expansion, I focus on their “policy sustainability”: whether proposals, once enacted, can be established in place, entrenched over time, and expanded and improved as circumstances change. Achieving these “three E’s,” I argue, requires a flexible approach that builds on the current system (and hence falls short of Medicare for All) but also contains a universal coverage guarantee and other provisions designed to create strong feedback effects conducive to the expansion of Medicare over time.

Poor Relations: Connecting Waste, Need, And Health SpendingPoverty And The Myths Of Health Care Reform By Cooper Richard “Buz” Baltimore (MD) : Johns Hopkins University Press , 2016 304 pp., $35.00

Poor Relations: Connecting Waste, Need, And Health SpendingPoverty And The Myths Of Health Care Reform By Cooper Richard “Buz” Baltimore (MD) : Johns Hopkins University Press , 2016 304 pp., $35.00

Medicare Health Plan Choices of the Elderly: A Choice-With-Screening Model

With the expansion of Medicare, increasing attention has been paid to the behavior of elderly persons in choosing health insurance. This article investigates how the elderly use plan attributes to screen their Medicare health plans to simplify a complicated choice situation. The proposed model extends the conventional random utility models by considering a screening stage. Bayesian estimation is implemented, and the results based on Medicare data show that the elderly are likely to screen according to premium, prescription drug coverage, and vision coverage. These attributes have nonlinear effects on plan choice that cannot be captured by conventional models. This article has supplementary material online.

Medicare Health Plan Choices of the Elderly: A Choice-With-Screening Model

With the expansion of Medicare, increasing attention has been paid to the behavior of elderly persons in choosing health insurance. This article investigates how the elderly use plan attributes to screen their Medicare health plans to simplify a complicated choice situation. The proposed model extends the conventional random utility models by considering a screening stage. Bayesian estimation is implemented, and the results based on Medicare data show that the elderly are likely to screen according to premium, prescription drug coverage, and vision coverage. These attributes have nonlinear effects on plan choice that cannot be captured by conventional models. This article has supplementary material online.

Racial and ethnic disparities in colorectal cancer screening persisted despite expansion of Medicare's screening reimbursement.

We examined the effect of Medicare's expansion of colorectal cancer (CRC) screening test reimbursement on racial/ethnic disparities in CRC screening. CRC screening was ascertained for Medicare beneficiaries (n = 30,893), aged 70 to 89, who had no history of any tumor and resided in 16 Surveillance, Epidemiology and End Results regions of the United States from 1996 to 2005. CRC screening tests were identified in the 5% sample of Medicare claims. Age-gender-adjusted percentages and -adjusted odds of receiving any guideline-specific CRC screening [i.e., annual fecal occult blood test (FOBT), sigmoidoscopy every 5 years or colonoscopy every 10 years] by race/ethnicity and Medicare coverage expansion period (i.e., prior to FOBT coverage, FOBT coverage only, and post-colonoscopy coverage) were reported. CRC screening increased as Medicare coverage expanded for white and black Medicare beneficiaries. However, blacks were less likely than whites to receive screening prior to FOBT coverage (OR = 0.74, 95% CI: 0.61-0.90), during FOBT coverage only (OR = 0.66, 95% CI: 0.52-0.83) and after colonoscopy coverage (OR = 0.80, 95% CI: 0.68-0.95). Hispanics were less likely to receive screening after colonoscopy coverage (OR = 0.73, 95% CI: 0.54-0.99). Despite the expansion of Medicare coverage for CRC screening tests, racial/ethnic differences in CRC screening persisted over time in this universally insured population, especially for blacks and Hispanics. Future studies should explore other factors beyond health insurance that may contribute to screening disparities in this and younger populations. Although CRC screening rates increased over time, they were still low according to recommendations. More effort is needed to increase CRC screening among all Medicare beneficiaries.

Majority of Physicians Back Public Option in Health Reform

Back to table of contents Previous article Next article Government NewsFull AccessMajority of Physicians Back Public Option in Health ReformRich DalyRich DalySearch for more papers by this authorPublished Online:16 Oct 2009https://doi.org/10.1176/pn.44.20.0006A national survey of psychiatrists and other physicians found that most of them support inclusion of a government-funded option in any legislative effort to overhaul the existing health care system dominated by the private health insurance industry.The summer-long survey, to which 2,130 physicians responded, asked them which of three options for expanding health insurance coverage they supported the most: combining public and private options, expanding access to private options only, or covering everyone through a single public plan like Medicare does. A substantial majority of physicians (62.9 percent) said they supported a combination of public and private insurance plans. The survey was conducted by Salomeh Keyhani, M.D., M.P.H., an assistant professor of medicine at Mount Sinai School of Medicine, and Alex Federman, M.D., M.P.H., an assistant professor of general internal medicine also at Mount Sinai. The findings were published in the September 14 New England Journal of Medicine.While 27.3 percent of physicians said their first option was a system based on private insurance options, only 9.6 percent of respondents supported a reform plan that relied solely on a government-funded insurance, such as a nationwide expansion of Medicare. However, 58.3 percent of the physician respondents supported an expansion of Medicare to Americans as young as age 55.While the survey report did not disclose the number of psychiatrists who participated, the authors pointed out that responses were consistent across physician specialties, practice settings, and regions of the country.“Regardless of their preferred solution, the majority of APA members would want to see parity principles recognized, appropriate physician reimbursement, and voluntary participation in any reform plans that emerge from Congress,” said Irvin “Sam” Muszynski, J.D., director of APA's Office of Healthcare Systems and Financing.In September APA's Board of Trustees voted unanimously to support America's Affordable Health Choices Act (HR 3200) as the basis for health care reform (see Original article: APA Board Takes Stance on Health Reform Proposals). That bill—approved by three House of Representatives committees and previously endorsed by the AMA and other groups—includes the most aggressive government-funded insurance program, or public option, of the major health reform bills advancing through Congress.The APA Board's support was based in part on the bill's requirement that its proposed Health Insurance Exchange feature include the option of a public health insurance program. The bill clarifies that physician participation in a public plan would be voluntary and that no penalties may be levied against physicians who choose not to participate.The survey and the APA Board's actions came as the Obama administration and its allies explicitly called for physicians to help educate their patients about the need for a health system overhaul and how it could benefit them.“It's especially important that we have doctors speaking up in their communities for the change that our health system needs,” said Vivek Murthy, president of Doctors for America, a liberal advocacy group, during a September 17 White House conference call for physicians.Previous surveys on physicians' views of health reform proposals asked about somewhat different national health insurance questions and received varying answers. One survey of 1,650 physicians published in the November 2003 Annals of Internal Medicine found, for example, that 49 percent of physicians supported legislation to establish national health insurance, but only 26 percent supported a federally funded national health insurance plan. A majority of psychiatrists in that survey supported national health insurance, but less than 50 percent of them backed the federal government as the sole payer of national health insurance.“Doctors on Coverage—Physicians' Views of a New Public Insurance Option and Medicare Expansion” is posted at<http://healthcarereform.nejm.org/?p=1790>.▪ ISSUES NewArchived

U.S. Hospice Benefits

The remarkable growth of palliative care in the United States in the last 25 years has been fueled by the expansion of Medicare to include a hospice benefit. Medicare provides health insurance for qualified elderly individuals and Medicaid covers the poor. Hospice benefits are the same for both Medicare and Medicaid. Over one million elderly Americans make use of this benefit annually. Private insurers often mirror the Medicare benefit. Increasingly, hospice patients in the United States are patients with diagnoses other than cancer. Although national average length of service has increased to over two months, median length of service has declined to 20 days, with both more long- and short-term periods of service. U.S. hospice care is predominantly care delivered in the place the patient calls home (95.6%). Although the hospice benefit has provided palliative care for more patients and families than any other country, the requirements for use have been found to be self-limiting.

Ex Ante Policy Evaluation, Structural Estimation, and Model Selection

A number of major social policy interventions have been introduced recently in the United States. The new Temporary Assistance for Needy Families (TANF) program, introduced in 1996, was advertised changing the welfare system as we know it. The new Medicare prescription drug benefit, introduced in 2006, was the largest expansion of Medicare in its history. Developing countries are also fertile ground for innovative new policies. Mexico introduced a program in 1997 (Progresa) that provided subsidies to poor rural households contingent upon the school attendance of their children. The distinction between ex post and ex ante policy evaluation is important. Ex post policy evaluation occurs upon or after the policy has been implemented. It is ubiquitous in the social sciences. Such studies make use of existing policy variation. Examples include the study of minimum wage effects on labor market outcomes, the study of the impact of welfare benefits on labor market and demographic outcomes, and the study of how divorce laws affect marital stability. The development of methodological approaches to ex post program evaluation using nonexperimental methods is an active area of research (Petra Todd 2006). There is little methodological or applied research explicitly concerned with ex ante policy evaluation using nonexperimental methods, which is perhaps surprising given its potential value. Interventions that require ex ante evaluation are those that are outside the historical experience. These include a large change in the parameters of existing programs such doubling the (real) minimum wage, adding new features to an existing program such the Medicare drug benefit program, or introducing a completely new program such Progresa. The nonexperimental approach to ex ante policy evaluation must be an extrapolation from existing policy or policy-relevant variation.' Because of that, and unlike ex post evaluation, ex ante valuation must rely on parametric and/or behavioral assumptions (theory).

Chronic politics: health care security from FDR to George W. Bush

Few domestic issues dominate today's headlines as much as the high cost of health care. Despite this media attention and a litany of election-year debates over health care funding, some 45 million Americans remain without adequate health insurance. Philip Funigiello chronicles the contentious political history behind this state of affairs, from the New Deal to the present. Funigiello unlocks the puzzle of why the United States has never guaranteed its citizens health security comparable to that enjoyed by people of other first-world nations - and he tells what needs to happen for policy reform to take place. Examining specific episodes in the history of health care financing, he highlights the importance of key individuals in the legislative process, the political haggling involved in shaping a bill, the clash of personalities and agendas that determine its fate, and the extent to which American ideas about fairness are reflected in the result. Beginning with the National Health Survey of the 1930s, Funigiello traces the long struggle to enact Medicare and explains how medical inflation adversely affected both public and private employment-based insurance systems. He then recounts how Medicare became a target in the Republicans' war on spending, assesses the ill-fated Clinton health plan, and brings everything up to date with the Bush administration's expansion of Medicare to include prescription drug coverage. Throughout this history, Funigiello shows that both liberals and conservatives, Democrats and Republicans, share the blame for not providing every American with health security as a right of citizenship. He argues that ideological values such as rugged individualism and laissez-faire capitalism have continually overshadowed the spirit of pragmatism, cooperation, and community ethos that health security requires. As the swelling ranks of the uninsured threaten to destabilize the entire health care system for those who can still afford it, this country is faced with growing health insecurity unless we learn to rise above political differences. Chronic Politics is an incisive look at how history has affected current policy and is required reading for all concerned with the politics of financing health care in America.

The use of disease-modifying agents among multiple sclerosis patients enrolled in medicare from 1995 to 2002 and the impact of medicare part D: Analysis of claims data from the medicare current beneficiary survey

Objectives: The goals of this analysis were as follows:(1) identify the prevalence of access barriers to disease-modifying agents (DMAs) used in the United States for the treatment of multiple sclerosis (MS), (2) identify the relationship between patient characteristics and use of DMAs, and (3) interpret the results in the context of Medicare Part D. Methods: Using claims data from the Medicare Current Beneficiary Survey (MCBS) 1992 to 2001, we identified beneficiaries with a diagnosis of MS on ⩾4 claims. To adapt for the bimodality of the claims distribution and to capture the majority of MS claims, ⩾4 claims were used. We estimated the mean out-of-pocket price of prescription medications and prevalence of perceived economic barriers to address the hypothesis that the expansion of Medicare to include an out-patient drug benefit will decrease beneficiaries' burden of MS. Results: A total of 416 patients with MS were identified with the MCBS claims data. Furthermore, data for 3 DMAs used to manage MS were available: interferon β-1b, interferon β-1a, and glatiramer acetate. Data were available for interferon β-1b for the years 1995 to 2002, and for interferon β-1a and glatiramer acetate for the years 1999 to 2002. The mean out-of-pocket price per prescribing event (typically 30 days) for interferon β-1b was US $44.40 from 1995 to 1998 and US $15.08 from 1999 to 2002. Between 1999 and 2002, the mean out-of-pocket price per prescribing event for interferon β-1a was US $84.74; for glatiramer acetate during the same period, it was US $114.90. Assuming complete compliance for the year, the mean out-of-pocket burden per patient for each medication using the 1999-to-2002 numbers would be US $1016.88 for interferon β-1a, US $548.91 for interferon β-1b, and US $1378.80 for glatiramer acetate. The annual prevalence of use of any DMA increased from 6.5% during the years 1995 to 1998 to 21.2% during the years 1999 to 2002. Conclusions: Our findings suggest that these MSpatients, who were Medicare beneficiaries, faced considerable economic barriers to necessary health care, particularly prescription medications. Substantial differences existed in the out-of-pocket prices of DMAs between the 2 time periods analyzed. These differences could be expected to be attenuated by the expansion of Medicare to include a drug benefit (Part D), which will increase insurance coverage for DMAs and reduce the out-of-pocket burden of MS therapies.

Evidence-based medicine: Ready for prime time?

N b a e M s T T a s v M v c t F nce again, storm clouds are gathring over American medicine. Ination in health care costs, tamed y managed care in the mid-1990s, as reared its head again. The specer of uneven quality and medical istakes, estimated to cost as many s 98,000 lives annually, hangs over he country. And always there is the nrelenting national shame of 43 illion Americans without health nsurance. Some of these same issues suraced in the early 1990s and powred the debate over health care uring the Clinton administration. ven after the demise of the Clinon health plan, economists, busiess leaders, and health policy anaysts thought that they had the nswer: managed care. Managed are would bring market forces to ear in medicine, rationalize medial decision making, and empower onsumers. Of course, for the most art, managed care failed to deliver n these promises, thus bringing us o today’s quandary. So now where do we go? There’s ot much appetite in Washington or a massive federal program such s an expansion of Medicare or edicaid. Market forces may have place at the edges of health care, articularly in controlling costs, ut there is little optimism regardng their role in quality improveent or access. Large employers ave banded together to demand ower costs and better quality. But owadays, providers push back retty hard when pressured on osts, and there remains a stubborn ack of consensus on how to meaure quality, much less improve it. i

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (PL 108–73; MMA), signed into law in December 2003, represents the biggest expansion of Medicare in the program’s history. In addition to adding outpatient prescription drug coverage, the bill contains scores of other changes affecting the nation’s 40 million older and disabled Americans and the providers who care for them. Responsibility for implementing the complex law and educating beneficiaries about their new options falls to the Centers for Medicare and Medicaid Services (CMS), which is in the process of issuing regulations and preparing outreach materials for seniors to meet the deadlines mandated by Congress. During last year’s debate on the Medicare bill, the American Geriatrics Society (AGS) actively lobbied for a number of provisions in the legislation, including improvements in the physician fee schedule, and enactment of the Geriatric Care Act (GCA). We are pleased to report that the MMA replaces a scheduled 4.5% decrease in reimbursement fees paid to geriatric health providers with an increase of 1.5% in 2004 and 2005 and incorporates two provisions based on the GCA, which are summarized below. In 2004 AGS is committed to educating its members about how the legislation will affect geriatric providers and their patients while pursuing other elements of its legislative agenda. Below is a summary of some of the major provisions of the MMA. Readers are also encouraged to consult the AGS Web page devoted exclusively to the law, located at http:// www.americangeriatrics.org/policy/medicare_info.shtml.

Prescription drug prices: why do some pay more than others do?

The fact that sick elderly people without prescription drug coverage pay far more for drugs than do people with private health insurance has created a call for state and federal governments to take action. Antitrust cases have been launched, state price control legislation has been enacted, and proposals for expansion of Medicare have been offered in response to price and spending levels for prescription drugs. This paper offers an analysis aimed at understanding pricing patterns of brand-name prescription drugs. I focus on the basic economic forces that enable differential pricing of products to exist and show how features of the prescription drug market promote such phenomena. The analysis directs policy attention toward how purchasing practices can be changed to better represent groups that pay the most and are most disadvantaged.

Money Isn't Everything

WHETHER they take the form of managed competition, single-payer systems, regulated multipayer approaches, or expansion of Medicare and/or Medicaid, virtually all health care reform proposals share an underlying principle: that provision of coverage to the uninsured will ensure their access to care. (An exception is direct subsidy of hospital indigent care, which does not encourage structural change or make physician-based primary care available to the uninsured.) Unfortunately, the track record of American health care, especially in recent times, does not support the belief that coverage is equivalent to access. In the first place, all coverage is not created equal. For some theoretically insured groups, especially the Medicaid population, the availability of physician care is constrained,^1-3and differences have been found in treatment patterns among patients with Medicare alone, Medicare and private supplemental coverage, and Medicare and Medicaid together.⁴ Physicians' concerns about their financial viability following the introduction of

Money isn't everything. Nonfinancial barriers to access

WHETHER they take the form of managed competition, single-payer systems, regulated multipayer approaches, or expansion of Medicare and/or Medicaid, virtually all health care reform proposals share an underlying principle: that provision of coverage to the uninsured will ensure their access to care. (An exception is direct subsidy of hospital indigent care, which does not encourage structural change or make physician-based primary care available to the uninsured.) Unfortunately, the track record of American health care, especially in recent times, does not support the belief that coverage is equivalent to access. In the first place, all coverage is not created equal. For some theoretically insured groups, especially the Medicaid population, the availability of physician care is constrained,^1-3and differences have been found in treatment patterns among patients with Medicare alone, Medicare and private supplemental coverage, and Medicare and Medicaid together.⁴ Physicians' concerns about their financial viability following the introduction of

Universal coverage: building on Medicare and employer financing.

Universal coverage requires a strategy to sever the link between insurance coverage and employment in order to build a more stable insurance base. Universality also will require subsidies to make coverage affordable. Given these realities, the authors evaluate different financing proposals--employer and individual premium mandates and taxes--in terms of equity, affordability, and administrative and political criteria. An expansion of Medicare offers an insurance alternative that takes advantage of existing administrative structures of national scope.