Total Medicare Expenditures Research Articles

Hematocrit levels and associated Medicare expenditures

Clinical studies and the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines suggest that a target hematocrit of 33% to less than 36% is appropriate for patient benefit. Previous studies have shown an association of lower risks for death and hospitalization when hematocrits were 33% to less than 36%. In this study, we assessed the relationship between hematocrit value and associated Medicare expenditures, analyzing incident Medicare hemodialysis patients from January 1, 1991, through June 30, 1995. All patients survived at least 90 days to normalize eligibility and an additional 6-month entry period to assess comorbidity and hematocrit values. All patients were followed up from July 1, 1991, through December 31, 1996. We assessed the association between hematocrit values in the 6-month entry period and the Medicare-allowable Part A and Part B per-member-per-month (PMPM) expenditures in the follow-up period, controlling for other variables, including patient demographic characteristics, comorbid conditions, and severity of disease. We found that hematocrits of 33% to less than 36% and 36% and higher were associated with lower Medicare-allowable payments in the follow-up period. Compared with reference patients with hematocrits of 30% to less than 33%, the Medicare-allowable PMPM expenditures were significantly greater for patients with hematocrits less than 27% and 27% to less than 30% (12.7% and 5.3%, respectively), and the Medicare-allowable PMPMs were significantly less for patients with hematocrits of 33% to less than 36% and 36% and higher (6.0% and 8.2%, respectively). Although these findings suggest that the treatment of anemia may be associated with significant savings in total patient Medicare expenditures, caution should be considered because these findings are associations and should not be deemed as showing causality.

EPIDEMIOLOGICAL TRENDS AND FINANCIAL OUTCOMES IN RADICAL PROSTATECTOMY AMONG MEDICARE BENEFICIARIES, 1991 TO 1993

Purpose We define epidemiological trends in radical prostatectomy among Medicare beneficiaries in the United States, describe related financial reimbursement to hospitals and physicians, and determine how many men received adjuvant therapy with androgen ablation or pelvic irradiation from 1991 to 1993. Materials and Methods We examined radical prostatectomy claims from a national 5% simple random sample (688,000 men) of 1991, 1992 and 1993 data on Medicare beneficiaries from the Health Care Financing Administration. We determined rates of radical prostatectomies among patients stratified by age, race and geographical region, and measured the fraction of men who had claims submitted for postoperative therapies for prostate cancer. We also collected financial information for Medicare parts A and B to estimate federal government economic burden from radical prostatectomy in this population. Results Among the 5,016 patients identified with Medicare claims for radical prostatectomy during 1991 to 1993 the rate peaked at 284/100,000 men in 1992 before declining the next year. For the youngest Medicare beneficiaries the rate increased 233% from 1991 to 1992 and 156% from 1992 to 1993. White men had a higher rate than nonwhite men in all 3 years but only in nonwhite men did the rate continue to rise during the study period. Geographical variations greater than 2-fold were noted. Total Medicare expenditures for radical prostatectomy were $194.2 million in 1991, $277.8 million in 1992 and $230.8 million in 1993. During 1991 to 1993 hospitals received more than three-fourths of total Medicare payments for radical prostatectomy, while physicians received less than one-fourth. More than 23% of men undergoing radical prostatectomy received subsequent therapy with gonadotropin releasing hormone agonists, bilateral orchiectomy and/or pelvic irradiation within 3 years of radical prostatectomy. Conclusions Radical prostatectomy represents a significant burden on the federal health care dollar and does not appear to be as definitively curative as expected.

State variations in Medicare expenditures.

This study examined variations in Medicare expenditures across states. 1992 data on average Medicare expenditures per enrollee, users of services per 1000 enrollees, service use per user, and payment per unit of service were compared across states for various services. Weighted least squares regression analysis was employed to examine total Medicare expenditures per enrollee by state. Variation in Medicare expenditures across states is driven more by average number of service users per 1000 enrollees and average service units per user than by average payment per service unit. Medicare expenditures per enrollee by state are primarily a function of Medicare HMO penetration rate (P = .000), urban area (P = .001), hospital bed supply (P = .005), elderly mortality rate (P = .012), Medicare physician assignment rate (P = .026), percentage of primary care practitioners (P = .042), and interactions between urban elderly and percentage of primary care physicians (P = .005) and Black elderly and nursing home bed supply (P = .012). Before sweeping Medicare cuts are undertaken or excessive reliance on managed care occurs, attention should be focused on the current disproportionate distribution of expenditures across states.

X. The cost effectiveness of alternative types of vascular access and the economic cost of ESRD

While total Medicare ESRD expenditures continue to increase in real terms, the growth is primarily due to growth in the number of treated ESRD patients. Growth in ESRD expenditures per patient has changed little during the last year and has only just matched the overall rate of inflation over the last five years. Understanding the reasons for growth in the patient population is the key to understanding recent growth in total Medicare expenditures for ESRD.

Medicare payments from diagnosis to death for elderly cancer patients by stage at diagnosis.

Although extensive resources go to cancer care, national population-based data on the costs of such care at the patient level have been unavailable. Medicare payments subsequent to diagnosis of cancer for elderly enrollees with five common cancers were estimated using tumor registry data from the Surveillance, Epidemiology, and End Results Program linked to Medicare claims from 1984 to 1990. The time between diagnosis and death was divided into four phases corresponding to the clinical course of solid tumors, average payments for each phase were estimated (including payments for services not related to cancer), then phase-specific payment data were aggregated. Average payments by phase varied among cancer sites, especially in the initial care phase, where payments were highest for lung and colorectal cancers ($17,500 in 1990 dollars) and lowest for female breast cancer ($8,913). Total Medicare payments from diagnosis to death were highest for persons with bladder cancer ($57,629) and lowest for those with lung cancer ($29,184). Low payments for persons with lung cancer corresponded to brief survival times. Persons diagnosed at earlier stages incurred higher total payments between diagnosis and death than those diagnosed at later stages, reflecting their longer survival. This implies that early detection may increase total Medicare expenditures by extending beneficiaries' lives. However, Medicare payments per year of survival were lower for earlier stages. Data on Medicare payments subsequent to diagnosis of cancer are useful for identifying the cost implications of differences in treatment patterns by demographic characteristics, geography, and delivery systems; comparing the financial impact of alternative therapies; evaluating the long-term cost impacts of screening and prevention programs; and risk-adjusting payments to health plans.

Disease Prevention Policy Under Medicare: A Historical and Political Analysis

I review the history and politics of Medicare disease prevention policy and identify factors associated with the success or failure of legislative initiatives to add preventive services benefits to Medicare. Between 1965 and 1990, 453 bills for Medicare preventive services were introduced in the U.S. Congress, but not until 1980, after 350 bills had failed, was the first preventive service added to the Medicare program. Medicare currently pays for only four of the 44 preventive services recommended for the elderly by the U.S. Preventive Services Task Force (pneumococcal and hepatitis B vaccinations, Pap smears, and mammography). In addition, Congress has funded demonstration programs for the influenza vaccine and comprehensive preventive services. The preventive services added to Medicare reflect the bias of the biomedical model toward screening and immunizations. Counseling services have received the least legislative attention. Factors associated with successful enactment include single-benefit bills, incorporation into budget-deficit reduction legislation, documented evidence of cost-effectiveness, public hearings, sponsorship by chairs of key congressional committees, and persistent congressional leadership. Factors associated with failure include lack of support from Medicare beneficiaries, lack of professional support, impact on total Medicare expenditures, disagreement over or failure to address payment and financing mechanisms, and competing congressional priorities.

Health Care Policies/Economics of the Geriatric Renal Population

The end-stage renal disease (ESRD) program is the only Medicare program for which entitlement is based on the presence of a medical diagnosis. In addition, entitlement is nearly universal. Over 90% of persons with ESRD receive Medicare benefits. Because of these unique characteristics, the ESRD program has been the subject of continuing debates about the role of the Federal government in the categorical funding of high-cost illnesses, reimbursement policies, and the ethical issues of treatment of terminal, or near terminal, patients. This report presents descriptive data from the Medicare ESRD Program Management and Medical Information System (PMMIS) concerning trends in program expenditures, incidence and prevalence of ESRD, and mortality. The purpose is to provide background material for informed discussions of these issues. Expenditures for the ESRD program have grown from $240 million in 1974 to $3.3 billion in 1987. During that same time, total Medicare expenditures increased at a comparable rate so that ESRD costs have remained a relatively constant proportion of Medicare costs for the last decade. The ESRD population is rapidly changing. Between 1978 and 1987, enrollment nearly tripled, from 44,000 to 124,000. Much of this change has occurred in the elderly population. Persons over 65 accounted for 20% of total enrollment in 1978 and 29% of total enrollment in 1987. Census projections show that the "graying" of the ESRD population will continue into the foreseeable future. Transplantation has had a marked effect on the ESRD population. Persons with a functioning kidney graft have increased from 11% of the total population in 1978 to 22% in 1987.(ABSTRACT TRUNCATED AT 250 WORDS)