Unbiased Analysis of Today's Healthcare Issues

Fixing the “Observation Status Loophole”

In order for Medicare to reimburse post-acute care in a skilled nursing facility (SNF), Medicare beneficiaries must have a 3-day hospital stay. Some hospital stays, however, are not counted as hospital stays; rather, they may be defined as “observation status” care that do not merit an inpatient admission. Patients may stay overnight at the hospital […]

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A drop in the bucket…

Every year, the Centers for Medicare and Medicaid Services (CMS) conducts a recovery audit. In a recent report, Medicare collected over $797 million in Medicare overpayments in 2011. Where do these overpayments come from? Inpatient: $677m Durable Medical Equipment & Other: $35m Physician: $33m Outpatient: $17m Skilled Nursing Facilities: $0.2m Recovery Audit Contractors returned $488 […]

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Medicare Part D Prescription Drug Enrollment Trends in 2013

According to research from Avalere, Medicare beneficiaries are overwhelmingly choosing low-cost Part D prescription drug plans . In 2013, more than 500,000 beneficiaries enrolled in the brand new AARP Saver Plus plan—catapulting it to a position in the top 10 list of plans in its first year. With the addition of Humana/Walmart and First Health Part D Value Plus, nearly 3 million beneficiaries are choosing low-premium plans with preferred […]

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Regional Variation in Medicare Spending and Utilization: 1974-2003

A paper by Cutler and Sheiner claim that if all areas in the United States had the level of spending prevailing at the 10th percentile from a ranking of 315 metropolitan statistical areas (MSAs) by Medicare spending, Medicare spending would fall by almost 30%. However, this may only be true in a static sense. If the high-cost […]

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Variation in Healthcare Spending: Medicare vs. Private Insurance

Is regional variation in health care spending larger for Medicare beneficiaries or those enrolled in private health plans? Before answering that question, one should better understand the sources of this variation.  Regional variation in spending can be due to variation in the utilization, variation in prices, or both.  A paper by Philipson et al. (2010) […]

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Medicare pays $5.1 billion for Poor Quality Skilled Nursing Facility Care

The Office of the Inspector General found substandard care at a number of skilled nursing facilities. Their investigation found the following: For 37 percent of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. For 31 percent of stays, SNFs did not meet discharge […]

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Medicare Reimbursement for Ambulance Servcies

In 2011, Medicare spent $5.3 billion on ambulance services. According to MedPAC, In 2011, 5.2 million Medicare beneficiaries (15 percent of fee-for-service (FFS) Medicare used an ambulance service. Medicare Part B covers 80 percent of the Medicare-approved amount of the ambulance trip. How does Medicare reimburse ambulance services?  A 2007 GAO report describes services for ambulance Medicare ambulance […]

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The Sequester hits Medicare

If you are a physician, hospital, or other provider that treats Medicare patients, how will the sequester effect you?  In March 2013, not at all.  Starting April 1, 2013, however, get ready for a bit of a haircut. A Centers for Medicare and Medicaid Services (CMS) memorandum states the following: Medicare FFS claims with dates-of-service […]

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Are Medicare Benefits Determined Nationally? If so, what are Local Coverage Determinations?

For most categories of services covered, Medicare pays for “reasonable and necessary” services.  This definitions, however, is fairly vague.  CMS does issue about 20 national coverage determinations (NCDs) each year to clarify which services are permitted.  [Here is a list of the CMS's pending national coverage analyses]. Foote et al. (2008) elaborate on how NCDs are implemented. CMS can […]

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Multiple Chronic Conditions

Patients with multiple chronic conditions are difficult to treat. As people continue to live longer, the number of chronic conditions they must cope with often increases. A Robert Wood Johnson report on chronic conditions reaches the following conclusions. The number of people with chronic conditions is rapidly rising. Between 2000 and 2030, the number of […]

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