State Medicaid Reimbursement Research Articles

Has the Medicare Prospective Payment System Led to Increased Nursing Home Efficiency?

To assess the impact of recent Medicare prospective payment system (PPS) changes on efficiency in skilled nursing homes. Medicare Cost Reports (MCR), On-line Survey Certification and Reporting System (OSCAR), Area Resource Files (ARF), a Centers for Medicare and Medicaid Services (CMS) hospital wage index website, a Consumer Price Index (CPI) database, and a survey of state Medicaid reimbursement rates. The sample was 8,361 nursing homes in the Medicare Cost Report databases from the years 1997 to 2003. Data-envelopment analyses (DEA) calculated efficiency scores for three separate DEA models: unadjusted, acuity-adjusted, and acuity-and-quality-adjusted efficiency. The efficiency scores from these models were regressed on the Medicare PPS changes (the Balanced Budget Act [BBA], the Balanced Budget Refinement Act [BBRA] and the Benefits Improvement and Protection Act) and other organizational and market explanatory variables using a panel-data truncated regression. Mean values for all efficiency measures decreased over time, the acuity-quality-adjusted efficiency measures decreasing the most. All policy variables were significantly negatively related to all efficiency measures. Higher nurse staffing was negatively related to efficiency in all but the acuity-quality-adjusted model. Other explanatory variables varied in their relationships to the efficiency variables. The results suggest that the reimbursement policy changes had a significantly negative impact on efficiency. Higher nurse staffing contributed to lower efficiency only when efficiency was not adjusted for quality. Various organizational and market factors also played significant roles in all efficiency models.

Study of Participating and Nonparticipating States' Telemedicine Medicaid Reimbursement Status: Its Impact on Idaho's Policymaking Process

Although Medicare currently reimburses for telemedicine services, advocates are struggling to increase state Medicaid reimbursement. This study provides data from a national study of Medicaid telemedicine reimbursement policies and examines Idaho as a case study for developing telemedicine reimbursement policies. Idahoans have actively advocated for Medicaid telemedicine reimbursement by forming a statewide network. Working with policymakers, Idaho Medicaid and telemedicine advocates established interpersonal connections, providing policymakers information and support. With developing academic, private, and legislative interest, a window of opportunity opened to allow for positive, albeit minimal, movement. To establish protocols for Idaho's use of telemedicine, a national electronic policy survey was conducted to evaluate the direction of telemedicine policy in state Medicaid agencies. Surveys to explore Medicaid reimbursement status were sent to states that were both participating and non-participating in telemedicine. Responses were received from 10 of the 25 states providing Medicaid telemedicine reimbursement and 17 of the 25 states and one U.S. territory not providing reimbursement. Issues common among participating states included provider and reimbursement complications, allowable services, and modification of reimbursement codes. Nonparticipating states indicated an interest in reimbursing for telemedicine and a need to enhance advocate and state Medicaid agency relationships. In addition, the survey results demonstrated the need to provide cost-benefit analysis on the viability of Medicaid reimbursement for telemedicine. Research outcomes were used to develop Idaho's Interactive Video Telemedicine Protocols. These address identified barriers and fears regarding Medicare reimbursement and state budgetary concerns--the additional major issue identified for state Medicaid agencies.

Nurse staffing levels and Medicaid reimbursement rates in nursing facilities.

To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates. Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources. Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix. RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors. To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours.

Access to Orthopaedic Care for Children With Medicaid Versus Private Insurance

It has been documented that children insured by Medicaid in California have significantly less access to orthopedic care than children with private insurance. Low Medicaid physician reimbursement rates have been hypothesized to be a major factor. The first objective of this study was to examine whether children insured by Medicaid have limited access to orthopedic care in a national sample. The second objective was to determine if state variations in Medicaid physician reimbursement rates correlate with access to orthopedic care. Two-hundred fifty orthopedic surgeon's offices, 5 randomly chosen in each of 50 states, were telephoned. Each office called was asked to answer questions to an anonymous, disclosed survey. The survey asked whether the office accepted pediatric patients, whether they accepted children with Medicaid, and whether they limited the number of children that they accepted with Medicaid, and if so why. Each state sets its own rate of physician reimbursement rates that were collected from individual state Medicaid agencies for 3 different CPT codes. The relationship between acceptance of patients with Medicaid and the individual state's Medicaid reimbursement rate was examined. Children with Medicaid insurance had limited access to orthopedic care in 88 of 230 (38%) offices that treat children, and 18% (41/230) of offices would not see a child with Medicaid under any circumstances. Reimbursement rates for CPT codes widely varied by state: 99243 for an outpatient consultation (range, $20-$176.38), 99213 for an established follow-up outpatient visit (range, $6-$77.76), and 25560 for global treatment of a nondisplaced radius and ulna shaft fracture without manipulation (range, $50-$403.94). There was a statistically significant relationship between access to medical care for Medicaid patients and physician reimbursement rates for all 3 CPT codes. Children insured with Medicaid have limited access to orthopedic care in this nationwide sample. Medicaid physician reimbursement significantly correlates with patient access to medical care. These data may be of value in the ongoing efforts to improve access to medical care for children on Medicaid. The logical inference from this study is that increasing physician reimbursement rates will improve access. In the authors' opinion, reimbursement rates should be made higher than office overhead to effect meaningful change.

Psychiatrists' Acceptance of Medicaid Patients

Back to table of contents Previous article Next article LettersFull AccessPsychiatrists' Acceptance of Medicaid PatientsSelby C. Jacobs, M.D., M.P.H., Joshua E. Wilk, Ph.D., and Maritza Rubio-Stipec, Sc.D.Selby C. JacobsSearch for more papers by this author, M.D., M.P.H., Joshua E. WilkSearch for more papers by this author, Ph.D., and Maritza Rubio-StipecSearch for more papers by this author, Sc.D.Published Online:1 Nov 2005https://doi.org/10.1176/appi.ps.56.11.1461AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the April issue, Wilk and colleagues (1) raised concerns about Medicaid patients' access to psychiatrists and the low rate of acceptance of Medicaid patients by psychiatrists, a concern that has been raised by others (2). We examined the relationship between Medicaid reimbursement rates and psychiatrists' self-reported acceptance of Medicaid patients and found that low Medicaid reimbursement rates were associated with low participation by psychiatrists for service code 90807 (individual psychotherapy with medical evaluation for 45 minutes).On the basis of the assumption that psychiatrists' sensitivity to reimbursement rates might occur in the lower range of rates, we divided Medicaid reimbursement rates by a median split. We found a positive correlation (r=.52, p=.03) between rates for service code 90807 (median split=$64.10) and psychiatrists' self-reported acceptance of Medicaid patients for the lower half of the range of the reimbursement rate but not the upper half. We found no such relationship for codes 90801 (diagnostic interview exam) and 90862 (pharmacologic management), nor did we find simple, significant correlations between these three codes and the full distribution of reimbursement rates (r=-.03, .25, and .20, respectively). Details of multivariate analyses of variables that affect acceptance of Medicaid patients by psychiatrists are described elsewhere (1).As in the study by Wilk and colleagues, we used data from an item in the 2002 National Survey of Psychiatric Practice, which was conducted by the American Psychiatric Institute for Research and Education (3). A total of 1,189 psychiatrists responded to an item about acceptance of patients by payer. Because we were unable to find Medicaid reimbursement data for 2002, we used 2001 reimbursement rates by state for codes 90801, 90807, and 90862 from an American Academy of Pediatrics data set published on its Web site. There was substantial distribution in values for both psychiatrist acceptance rates and Medicaid reimbursement rates for code 90807.Our preliminary, suggestive observation warrants further study with better designs and more complex models. The period between 2001 and 2002 was one of significant change for Medicaid. States faced budget deficits and cut eligibility, benefits, and reimbursement. Therefore, the discrepancy in time between the 2001 reimbursement rates and the 2002 data on psychiatrists' acceptance of Medicaid patients is a weakness of these analyses. Also, many factors affect psychiatrists' decisions to accept Medicaid patients, including administrative burden and cross-cultural preferences, among others, and these factors were not included in the analyses.Another important consideration is the possibility of a more pronounced association between reimbursement levels and the volume of new Medicaid patients that psychiatrists can accept, whereas our analyses examined the association between accepting "any" new Medicaid patients and reimbursement. Furthermore, the relationship between reimbursement rates and acceptance may be reciprocal and complex and not simply positive—for example, when a low rate of psychiatrist participation spurs higher state Medicaid reimbursement rates. Such inverse correlations would be investigated best on a state-by-state basis, which was not possible with our data.The observation made in this letter is potentially important for child psychiatrists, clinic psychiatrists, international medical graduates, and early-career psychiatrists, who have caseloads with large proportions of patients whose care is covered by Medicaid (4).Dr. Jacobs is with the department of psychiatry at Yale University in New Haven, Connecticut. Dr. Wilk and Dr. Rubio-Stipec are with the American Psychiatric Institute for Research and Education of the American Psychiatric Association in Arlington, Virginia.

Costs and reimbursement of long-term ventilation.

Patients receiving long-term mechanical ventilation present a serious financial challenge to hospitals. Depending on the case mix in a particular hospital of Medicare, Medicaid, managed-care contract, and fully insured patients, the financial picture in most hospitals is bleak. Depending on the level of state Medicaid reimbursement, Medicaid losses on these patients vary. Because acute care hospitals cannot be reimbursed for chronic ventilator units, hospitals have resorted to leasing space to separate entities, which, when separately incorporated, accredited, and staffed, can secure waivered status from the PPS and can be paid at a per diem rate based on their costs. Hospital patients who are ventilator dependent can be transferred to these PPS-waived units. There are states where no chronic ventilator facilities exist and where nursing homes do not accept ventilator-dependent patients. This situation is serious for the hospital if the patient does not have caregivers at home who are capable of caring for a ventilator-dependent patient. The problem of the large numbers of patients who are ventilated mechanically with endotracheal tubes but who do not fall into MDC 4 needs to be addressed by Medicare. Medicare needs to evaluate the cost and use of NIV in ICU practice and develop a system to reimburse for this modality at a reasonable level under Part A.

A Multi-Part Model Approach to Examining Medicaid Payment Methods and Nursing Home Quality

The incentive to provide nursing home quality depends, in part, on whether the state Medicaid reimbursement system is prospective or retrospective in nature. This paper examines the effect of state-level Medicaid reimbursement methods on the provision of quality in the context of bed constraint regulations that may influence market tightness. A three-part estimation strategy is constructed around the idea that a change in the Medicaid reimbursement method may affect both a facility's payer mix and the provision of quality. Across a range of quality measures, this multi-part model did not show nursing home quality to be significantly higher under a retrospective reimbursement system as compared with a prospective-based system of reimbursement. This finding holds regardless of whether the analysis was isolated to those markets with the tightest supply of beds or those homes that care for predominantly Medicaid residents.

Medicaid nursing facility reimbursement methods: 1979-1997.

This article describes state Medicaid nursing facility reimbursement methods and rates in 1979-1997, using data derived from telephone surveys of state Medicaid reimbursement. The 1980s saw shifts toward prospective methodology. The late 1980s and early 1990s were characterized by adoption of casemix methods. The early 1990s also saw fewer changes in methodology with a hiatus in the mid-1990s followed recently by renewed changes to methodology. Medicaid per diem rates have increased faster than inflation but less rapidly than general health costs. The repeal of the Boren Amendment may now allow states to institute greater cost controls or moratoria on rate increases. Despite states' tendencies to follow one another's examples, Medicaid reimbursement remains diverse nationally, with wide differences in policies and rates.

Hospice and nursing homes.

In this article a descriptive analysis of nursing homes with special care hospice units is provided. These are compared to nursing homes with other special care units and to nursing homes without any special care units. An analysis of the determinants of nursing homes with special care hospice units is also provided. Factors such as ownership, staffing levels, having other special care units, case-mix intensity, competitiveness of the nursing home market, and the state Medicaid reimbursement rate structure are examined. Finally, the influence of policies on hospice care in nursing homes is discussed.

Variation in psychotropic drug use in nursing homes.

Numerous studies of health service use reveal considerable variation in the degree of services provided. In this article the variation in psychotropic drug use in nursing homes is examined. First, a descriptive analysis of nursing homes with and without high levels of psychotropic drug use is provided. Second, an analysis of the determinants of high levels of psychotropic drug use in nursing homes is provided. Factors such as ownership, staffing levels, having special care units, case-mix intensity, competitiveness of the nursing home market, and the state Medicaid reimbursement rate structure are examined. The results of these analyses are discussed in terms of their policy issues.