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Provides a review and analysis of Medicare health maintenance organizations in the USA. The Porter model of industry structure is used. Discusses the issues of suppliers…
Provides a review and analysis of Medicare health maintenance organizations in the USA. The Porter model of industry structure is used. Discusses the issues of suppliers, buyers, market entry and substitutes. Indicates there is currently no intense rivalry among Medicare risk‐based HMOs. However, the Porter model reveals crucial information regarding the forces which drive industry competition. Trends in the field of managed care and Medicare financing continue to be a real challenge regarding future research.
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…
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.
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…
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.
This chapter assessed internal and external environmental factors that affect variations in rural hospital profitability with a focus on the impact of the Patient…
This chapter assessed internal and external environmental factors that affect variations in rural hospital profitability with a focus on the impact of the Patient Protection and Affordable Care Act regulations that resulted in the expansion of Medicaid eligibility, as well as four Medicare programs that target rural hospitals. A cross section of 2,114 rural US hospitals operating during 2015 was used. The primary source of data was Medicare Hospital Cost Reports. Ordinary least squares regression with correction for serial correlation, using total margin and operating margin as dependent variables, was employed to ascertain the association between profitability and its correlates.
The mean values for operating margin and total margin were −0.0652 and 0.0259, respectively. Hospital profitability was positively associated with location in a Medicaid expansion state, classification by Medicare as a Critical Access Hospital or Rural Referral Center (total margin only), hospital size, system membership, and occupancy rate. Profitability was negatively associated with average length of stay, government ownership, Medicare and Medicaid share of admissions, teaching status, and unemployment rate.
This chapter found that the Medicaid expansions provided modest help for the financial condition of rural hospitals. However, the estimates for the four targeted Medicare Programs (i.e., Critical Access Hospital, Medicare Dependent, Sole Community Critical Access Hospital, and Rural Referral Center) were either small or not significant (p > 0.10). Therefore, these specially targeted federal programs may have failed to achieve their goals of preserving the financial viability of rural hospitals. This chapter concludes with implications for practice.
Purpose – This study analyzed individual factors of race and dual eligibility on emergency room (ER) utilization of older adult Medicare patients treated by RHCs in CMS…
Purpose – This study analyzed individual factors of race and dual eligibility on emergency room (ER) utilization of older adult Medicare patients treated by RHCs in CMS Region 4.
Methodology/approach – A prospective, longitudinal design was employed to analyze health disparities that potentially exist among RHC Medicare beneficiary patients (+65) in terms of ER use. The years of investigation were 2010 through 2012, using mixed multilevel, binary logistic regression.
Findings – This study found that dual eligible RHC patients utilized ER services at higher rates than nondual eligible, Medicare only RHC patients at: 77%, 80%, and 66%, in 2010, 2011, and 2012, respectively; and above the White reference group, Black RHC Medicare patients utilized ER services at higher rates of: 18%, 20%, and 34%, in 2010, 2011, and 2012, respectively.
Research limitations/implications – Regarding limitations, cohort data observations within the window of 3 years were only analyzed; regarding generalizability, in different CMS regions, results will likely vary; and linking other variables together in the study was limited by the accessible data. Future research should consider these limitations, and attempt to refine. The findings support that dual Medicare and Medicaid eligibility, as a proxy measure of socioeconomic status, and race continue to influence higher rates of ER utilization in CMS Region 4.
Originality/value – In terms of ER utilization disparities, persistently, as recent as 2012, Black, dual eligible RHC Medicare beneficiary patients age 65 years and over may be twice as likely to utilize ER services for care than their counterparts in the Southeastern United States.
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…
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.
Purpose – To evaluate the efficiency consequences of the Medicare Part D program.Methods – We develop and empirically calibrate a simple theoretical model to examine the…
Purpose – To evaluate the efficiency consequences of the Medicare Part D program.
Methods – We develop and empirically calibrate a simple theoretical model to examine the static and the dynamic welfare effects of Medicare Part D.
Findings – We show that Medicare Part D can simultaneously reduce static deadweight loss from monopoly pricing of drugs and improve incentives for innovation. We estimate that even after excluding the insurance value of the program, the welfare gain of Medicare Part D roughly equals its social costs. The program generates $5.11 billion of annual static deadweight loss reduction and at least $3.0 billion of annual value from extra innovation.
Implications – Medicare Part D and other public prescription drug programs can be welfare-improving, even for risk-neutral and purely self-interested consumers. Furthermore, negotiation for lower branded drug prices may further increase the social return to the program.
Originality – This study demonstrates that pure efficiency motives, which do not even surface in the policy debate over Medicare Part D, can nearly justify the program on their own merits.
The purpose of this research is to identify audience segments of Medicare beneficiaries, for the development of targeted and tailored communication activities to promote…
The purpose of this research is to identify audience segments of Medicare beneficiaries, for the development of targeted and tailored communication activities to promote informed health care decision making.
Secondary analysis was conducted on data from the 2001 Medicare Current Beneficiary Survey. The 9,520 Medicare beneficiaries who had complete data on key variables constituted the analytic sample.
Cluster analysis identified four audience segments that varied separately with regard to health care decision‐making skills and motivation. Those in the active segment are skilled and motivated. Those in the passive segment are unskilled and unmotivated. Those in the high effort segment are motivated, but unskilled. And those in the complacent segment are skilled, but unmotivated. Additional analyses showed that the segments also varied on several additional variables of interest, such as knowledge, income, education, health behavior, health status, and preferred information sources. And finally, the segmentation screening tool was developed and shown to function adequately as a simple method to conduct segmentation in the field.
Future research should further examine the reliability and validity of the segmentation scheme.
This research identified four segments of Medicare beneficiaries that vary with regard to health care decision‐making skills and motivation, and developed a simple tool to conduct segmentation.
Although the United States Congress has attempted to ameliorate some of the adverse impacts of the Balanced Budget Act through the 1999 Balanced Budget Refinement Act, the…
Although the United States Congress has attempted to ameliorate some of the adverse impacts of the Balanced Budget Act through the 1999 Balanced Budget Refinement Act, the final results of the reforms to Medicare remain to be seen. This article provides an update and examines the impacts of the Balanced Budget Act on health providers and medical education. The authors also discuss the implications of these impacts for further policy adjustment.
Criminal Medicare and/or Medicaid fraud costs taxpayers $60‐250 billion annually. This paper aims to outline the characteristics of physicians who have been convicted of…
Criminal Medicare and/or Medicaid fraud costs taxpayers $60‐250 billion annually. This paper aims to outline the characteristics of physicians who have been convicted of such fraud.
The names of convicted physicians were first gathered from public databases (primarily, the OIG exclusion list). The names were further cross‐checked and verified with other public records. Details regarding demographics and the particulars of the fraud were obtained by searching court documents, media reports, the internet, and records maintained by the American Medical Association and state medical licensing boards. The paper categorizes these doctors by: age, gender, geographic location, medical school attended, and medical specialty, and compares these demographics to those of the medical profession as a whole. The paper then identifies: the specific Medicare fraud these physicians were charged with; length of prison sentence and/or probation imposed; amount of fines assessed and/or restitution ordered; and professional sanctions imposed.
Physicians convicted of criminal Medicare and/or Medicaid fraud tend to be male (87 percent), older (average age of 58), and international medical graduates (59 percent). Family practitioners and psychiatrists are overrepresented. The amount of fraud averaged $1.4 million per convicted physician. Surprisingly, despite the fact that 40 percent of such fraud compromised patient care and safety, 37 percent of physicians convicted of felony fraud served no jail time, 38 percent of physicians with fraud convictions continue to practice medicine, and 21 percent were not suspended from medical practice for a single day despite their fraud convictions.
The paper makes several practical recommendations including: running as many claims as possible through predictive modeling software to detect fraud before claims are paid; developing metrics on the average rate of diagnoses and procedures by specialty to be used in the predictive modeling software; incorporating the basics of ethical billing and the consequences of fraud convictions into the medical school curriculum and testing this knowledge on the USMLE; and encouraging and/or pressuring state medical boards to hold physicians more accountable for fraud.
The paper categorizes doctors convicted of Medicare and/or Medicaid fraud and makes specific recommendations regarding physician training, licensing and discipline, to reduce the amount of Medicare fraud perpetrated by doctors in the future.