Search results

This chapter assesses the doctrine of reasonable interchangeability through the lens of the US Department of Justice’s (DOJ’s) successful effort to enjoin the megamerger of two of the largest national insurance companies, Aetna and Humana. The DOJ focused its challenge on the companies’ Medicare Advantage business, arguing that it is a separate product market from original Medicare and the merger would substantially reduce competition in the market for Medicare Advantage in many geographic markets across the country. The case turned on whether there was reasonable interchangeability between original Medicare and Medicare Advantage in the eyes of consumers. The judge relied on both practical indicia of interchangeability, including evidence of how likely Medicare beneficiaries were to switch between Medicare Advantage and Original Medicare, along with econometric evidence. The decision provides a useful roadmap of how a knowledgeable judge reviewing a merger will consider both Brown Shoe factors and econometric evidence in assessing reasonable interchangeability.

As the size of the U.S. population age 65 and older continues to grow, racial disparities within this population persist despite near universal insurance coverage provided through Medicare. Reform of the government administered program in 2003 has the potential to influence racial disparities due to increased privatization. This study compares racial disparities in health service utilization between Medicare fee-for-service and managed care, the two drastically different ways Medicare administers health care. Data was analyzed from the National Health Interview Survey (NHIS), a nationally representative study of the U.S. civilian, noninstitutionalized, household population. Included in this study were African American and white respondents aged 65 and older who participated in the NHIS in any year from 2004 to 2008 (N=22,364). Small differences were found in regard to the number of medical office visits, with African Americans reporting fewer visits. However, these differences were significant in only 25% of the analyses conducted. Across both types of Medicare, significant differences between African Americans and whites regarding consultations with a medical specialist and having surgery were found in 75% of analyses. In all analyses, African Americans were less likely to have interacted with a specialist or have surgery. The greatest difference in racial disparity between fee-for-service and managed care for all three health service use indicators was observed among those who were chronically ill and poor, and the smallest difference was observed among those who were chronically ill and very poor. These racial disparities in health service use may be linked to earlier life disparities in access to health care, higher out-of-pocket costs in Medicare fee-for-service, and the for-profit structure of managed care plans.

Disparities in access to health services continue to exist among adults age 65 and older in the United States despite near-universal insurance coverage provided through Medicare. One potential barrier to health service utilization is knowledge of health insurance coverage. Medicare has been drastically restructured in the recent past, and as the program becomes increasingly privatized, Medicare enrollees are left with more choices, but also a more complicated system through which to navigate. This study examines the relationship between Medicare enrollee knowledge of their Medicare health insurance and sociodemographic factors, health status, and the use of health services. Data was analyzed from the National Health Interview Survey (NHIS), a nationally representative study of the U.S. civilian, non-institutionalized, household population. Included in this study were Black, Hispanic, and White respondents aged 65 and older who participated in the NHIS from 2004 to 2009 (N=30,002). The prevalence of a lack of Medicare knowledge appears to be low among Medicare enrollees, with 13% reporting they did not know the answer to one or more questions about their coverage. Age and chronic illness status were found to be related to Medicare plan knowledge, with older adults and those who were not chronically ill more likely to report they did not know some aspect about their Medicare plan. Respondents who reported not knowing at least one question about their Medicare plan reported significantly fewer medical office visits and more time since they last interacted with a doctor, were less likely to have talked with a medical specialist, and have had surgery over the past year. The findings from this study suggest that knowledge of health insurance coverage is an important correlate of health service utilization, which may be shaped by disparities in access to health insurance across the life course.

With expenditures totaling $227 billion in 2007, prescription drug purchases are a growing portion of the total medical expenditure, and as this industry continues to grow, prescription drugs will continue to be a critical part of the larger health care industry. This chapter presents a survey on the economics of the US pharmaceutical industry, with a focus on the role of R&D and marketing, the determinants (and complications) of prescription drug pricing, and various aspects of consumer behavior specific to this industry, such as prescription drug regulation, the patient's interaction with the physician, and insurance coverage. This chapter also provides background in areas not often considered in the economics literature, such as the role of pharmacy benefit managers in prescription drug prices and the differentiation between alternative measures of prescription drug prices.

GASB Statement No. 45 addresses how governmental units account for employees' other post-employment benefits (OPEB), requiring government employers to replace OPEB reporting on a pay-as-you-go basis with an accounting of the cost of current and future benefits. This requirement and the resulting OPEB liability may prompt government employers to reconsider key questions regarding their OPEB provision. The size of the OPEB liability depends on both the benefit promises made to employees and the assets to fund these promises. We propose a typology that defines four approaches for governments to respond to GASB 45 and their OPEB liabilities. These approaches represent different combinations of strategies involving OPEB promises and assets. We illustrate these strategies and responses using selected counties and nine mid-Atlantic cities.

The purpose of this paper is to determine the association between patients who talked to their doctor about their risk of falling, or occurrence of balance problem. This study analyzed a secondary data set based on the Medicare Health Outcomes Survey (HOS) for the Medicare Advantage patients of 65 years and older. This study guided by two hypotheses that: patients who talked to their doctor about falling or balance problem are more likely to have fallen in the past than those who did not talk to their doctor about their fall risk; and patients talking to their doctor about a fall or balance problem are more likely to receive an early intervention such as patient education to prevent a future fall.

This study utilized a secondary data set to test its hypotheses. The Centers for Medicare and Medicaid Services (CMS) is dedicated to monitoring the quality of care provided to Medicare population in a managed care setting. Inter-University Consortium for Political and Social Research conducts the HOS to measure outcomes of quality improvement interventions developed by CMS in collaboration with the National Committee for Quality Assurance for Medicare Advantage Organizations (MAOs). The measures are focused on assessing the physical functioning and mental health being of Medicare beneficiaries and are aligned with reporting evidence of standards of care. Medicare HOS is administered in each Spring surveying a random sample of Medicare beneficiaries from MAOs that have a minimum of 500 enrollees; the cohort is surveyed again two years later as a follow-up measurement.

Reporting of a fall or balance problem is a critical component in fall prevention strategies. This study analyzed the distribution of beneficiaries who talked with their doctor about a fall or balance problem to understand if personal disposition (i.e. social class – educational level, gender, and race) would have been a factor in patients communicating with their doctor about their risk factors. The study found that 67.77 percent of patients who talked with their doctor about a fall or balance problem have at least a high school education compared with 32.23 percent who have less than a high school education or GED.

All patients who responded to the survey and fulfilled the inclusion criteria were included in the study. Therefore, the data presented a limitation due to a self-report of no doctor visits, which could indicate inopportunity for provider-patient communication to take place. Additionally, such an information on fall or balance problem, including actual fall occurrence in the past 12 months, was based on self-report that could present inaccuracy since the elderly population tend to have diminished or poor memory, which may also be problematic.

Although this specific interaction starts with patient reporting of a health problem such as a fall or balance problem, provider must take a proactive approach in deploying prevention strategies, such as to conduct a comprehensive fall-risk assessment regardless of a report of a fall history by the patient. Further investigation of this study is recommended to ascertain pre-dispositional factors that affect patient communication, in order to address any barriers that could impede patient-provider collaboration. Nonetheless, enhancing patient-provider communication is fundamental to any quality intervention strategies such as fall prevention.

Another key finding in this study is that patient communication facilitates fall prevention. Patients who talked to their doctor about their fall or gait problem were provided with patient education on how to prevent falls by their doctor. The provider is informed on patient’s balance problem, which leads to further evaluation of patient health status in order to identify other related factors since a comprehensive fall-risk assessment would have been likely conducted providing adequate information beyond the fall occurrence. This affirms the need for provider-patient communication to serve as catapult for effective care coordination, which is effectual in any intervention strategies.

Fall prevention is increasingly drawing attention and gaining momentum among healthcare organizations (including non-managed care) since falls and fall-related injuries are easily preventable (Lach et al., 2011). Efforts that can identify and accurately analyze patient health status, including intrinsic and extrinsic risk factors, promote effective interaction between patient and provider. This study has shown the positive effect of patient communication in order to allow doctors to effectively intervene (i.e. prevent a future fall) through the provision of patient education.

People with severe persistent mental illness pose a significant challenge to managed care organizations and society in general. The financial costs are staggering as is the community impact including homelessness and incarceration. This population also has a high incident of chronic comorbid disorders that not only drives up healthcare costs but also significantly shortens longevity. Traditional case management approaches are not always able to provide the intense and direct interventions required to adequately address the psychiatric, medical and social needs of this unique population. This article describes a Medicare Advantage Chronic Special Needs Program that provides a Medical Home, Active Community Treatment, and Integrated Care. A comparison of utilization and patient outcome measures of this program with fee for service Medicare found significant reduction in utilization and costs, as well as increased adherence to the management of chronic medical conditions and preventative services.

Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway.

We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models.

The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners.

While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization.

Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices.

Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats.

This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.