Unbiased Analysis of Today's Healthcare Issues

Free Money for Amgen

The language buried in Section 632 of the [American Taxpayer Relief] law delays a set of Medicare price restraints on a class of drugs that includes Sensipar, a lucrative Amgen pill used by kidney dialysis patients. The provision gives Amgen an additional two years to sell Sensipar without government controls. The news was so welcome […]

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Timeline: Medicare Payment for Dialysis

Medicare spending for outpatient dialysis and injectable drugs administered during dialysis was about $9.2 billion in 2009 and is a predominant share of revenues for dialysis facilities. According to MedPAC, “Medicare covers two methods of dialysis—hemodialysis and peritoneal dialysis. In hemodialysis, a patient’s blood is cycled through a dialysis machine, which filters out body waste. […]

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Where is the Quality Incentive Program for End-Stage Renal Disease Facilities heading in 2013 and 2014?

Medicare payments for End Stage Renal Disease rely on a value-based purchasing (VBP) system known as the Quality Incentive Program (QIP). Today I review proposed changes to the QIP that will effect the payments for dialysis centers in 2013 and 2014. Payment Year 2013 Two measures have been adopted for the payment year (PY) 2013 […]

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Measuring Patient Case Mix in Medicare

How does Medicare measure patient case mix?  For the most part, Medicare uses the Hierarchical Condition Category (HCC) model.  A recent CMS presentation describes the HCC model in more detail.  Today I review where CMS applies the HCC model, provide an overview of the HCC methodology, briefly describe its performance, and give some background on […]

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Medicare payments for outpatient dialysis

Today I will review how Medicare treats patients with end-stage renal disease (ESRD), relying largely on data from MedPAC’s 2011 Report to Congress. In 2009, about 340,000 dialysis beneficiaries were covered by fee-for-service (FFS) Medicare. Compared with all Medicare beneficiaries, dialysis FFS beneficiaries are disproportionately younger and African American. Ninety two percent of there beneficiaries […]

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Investigative Journalism: Medicare’s ESRD Program

Today, I will review an excellent piece of investigative journalism on Medicare’s end-stage renal disease (ESRD) program.  The program provides free access to medical care for patients with kidney disease.  Some highlights of these ProPublica report include the following: Program Inception “…the new program would help about 11,000 Americans, just for starters. For a modest […]

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ESRD Quality Monitoring Initiative

All patients with end stage renal disease (ESRD) are eligible for Medicare regardless of their age.  In 1972, the Social Security Act extended all Medicare Part A and Part B benefits to individuals with ESRD (of any age) who are entitled to receive Social Security benefits. ESRD beneficiaries now account for 1% of Medicare enrollment. […]

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How to set Medicare reimbursement rates correctly

For many illnesses, Medicare pays physicians a lump sum for the entire episode of care.  This is known at the prospect payment system (PPS).  But how does Medicare determine the payment amount?  How should Medicare determine the payment amount? Medicare generally looks at 1) what treatments are generally used on average to treat a patient […]

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