Issue brief (George Washington University. National Health Policy Forum : 2005)最新文献

With nearly 30 percent of Medicare beneficiaries opting to enroll in Medicare Advantage (MA) plans instead of fee-for-service Medicare, it's safe to say the MA program is quite popular. The Centers for Medicare & Medicaid Services (CMS) administers a Star Ratings program for MA plans, which offers measures of quality and service among the plans that are used not only to help beneficiaries choose plans but also to award additional payments to plans that meet high standards. These additional payments, in turn, are used by plans to provide additional benefits to beneficiaries or to reduce cost sharing--added features that are likely to factor into beneficiaries' choice of MA plans. The Star Ratings program is also meant to drive improvements in the quality of plans, and this secondary effort seems to have been successful. Despite this success, issues with the Star Ratings system remain, including: how performance metrics are developed, chosen, and maintained; how differences among beneficiary populations (particularly with regard to the dually eligible and those receiving low-income subsidies) should be recognized; and the extent to which health plans can control the variables on which they are being measured. Because the Star Ratings approach has been extended to providers of health care as well--hospitals, nursing homes, and dialysis facilities--these issues are worth exploring as CMS fine-tunes its methods of measurement.

Teleheath, and its subset telemedicine, extend across a range of technologies allowing patients to seek diagnosis, treatment, and other services from clinicians by electronic means. Telephone, videoconferencing, iPads, and apps are all employed. In its most established form, hospitals and medical centers use telehealth to reach patients in underserved rural areas. Proponents of telehealth suggest it can relieve medical workforce shortages; save patients time, money, and travel; reduce unnecessary hospital visits; improve the management of chronic conditions; and improve continuing medical education. But telehealth also faces ongoing challenges. States require physicians to be licensed in each state where they treat patients, even if from a distance. Most clinicians have not been trained in telehealth. Security concerns linger. Who should have access to telehealth and how it should be reimbursed are questions without fixed answers. This issue brief looks at telehealth's promise and its challenges and considers opportunities for policymakers to help in charting its future course.

The Medicare program, despite its reputation of being a bill payer with little regard to the worth of the services it buys, has begun to put in place a range of programs aimed at assessing quality and value, with more to come. Attention to resource use and cost is nascent. The issues are complex, and it is no surprise that there is a level of contention between providers and regulators, even though both profess commitment to improved quality. This paper summarizes the quality and value programs that apply to physicians and other clinical professionals, as well as programs designed to encourage the adoption of technology to support quality improvement. Participation in all is voluntary. However, a decision not to participate increasingly carries a financial penalty, as Congress (and, by extension, the U.S. Department of Health and Human Services, or HHS) tries to encourage behavior it cannot force.

As population growth and the aging of the overall population increase demand for health care, policymakers and analysts posit whether sufficient health care providers will be able to meet that demand. Some argue there are too few providers already; others say our current supply-demand problems lie with efficiency. But suppose both are correct? Perhaps the real challenge is to understand how physician practices are changing in response to market forces such as payment changes, provider distributions, and technology innovations. This issue brief reviews what is known about evolving practice organizations, professional mixes, information technology support, and the implications of these and other factors for public workforce policies.

In 2012, the Medicare program paid private health plans $136 billion to cover about 13 million beneficiaries who received Part A and B benefits through the Medicare Advantage (MA) program rather than traditional fee-for-service (FFS) Medicare. Private plans have been a part of the program since the 1970s. Debate about the policy goals--Should they cost less per beneficiary than FFS Medicare? Should they be available to all beneficiaries? Should they be able to offer additional benefits?--has long accompanied Medicare's private plan option.This debate is reflected in the history of Medicare payment policy,and policy decisions over the years have affected plans' willingness to participate and beneficiaries' enrollment at different periods of the program. Recently, evidence that the Medicare program was paying more per beneficiary in MA relative to what would have been spent under FFS Medicare prompted policymakers to reduce MA payments in the Patient Protection and Affordable Care Act of 2010 (ACA). So far, plans continue to participate in MA and enrollment continues to grow, but payment reductions in 2012 through 2014 have been partially offset by payments made to plans through the quality bonus payment demonstration.This brief contains recent data on plan enrollment, availability, and benefits and discusses MA plan payment policy, including changes to MA payment made in the ACA and their actual and projected effects.

State Medicaid programs make Medicaid disproportionate share hospital (DSH) payments to hospitals to help offset costs of uncompensated care for Medicaid and uninsured patients. Unlike most Medicaid spending, annual DSH allotments for each state are capped. Under the Patient Protection and Affordable Care Act of 2010 (ACA), DSH payments will decrease starting in fiscal year (FY) 2014 and continuing through FY 2020. This paper describes the proposed rule for reducing these federal allotments, which was released on May 15, 2013, by the Centers for Medicare & Medicaid Services (CMS). Comments on the proposed rule are due July 12, 2013.

The Patient Protection and Affordable Care Act of 2010 and the Supreme Court's related decision have significantly shifted the health care landscape for safety net providers. Federally qualified health centers (FQHCs) are a mainstay of primary care for the uninsured and those with limited access to care. This paper focuses on the impact of health reform on FQHCs given the significant federal investment in them through grants, Medicaid, and Medicare reimbursement. Where noteworthy, the effect on non-FQHC community clinics is also discussed. The implications of Medicaid coverage expansions (or lack thereof in states that choose not to expand), Medicaid disproportionate share hospital program cuts, discretionary budgets and sequestration, Medicare payment changes, contracting with qualified health plans in state health insurance exchanges, and delivery system reforms are explored.

Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.

Among the potential changes invoked in discussions on health system transformation, a need to revitalize primary care remains paramount. One way of doing this, most agree, is to move more in the direction of team-based care. Professionals such as physician assistants and nurse practitioners may be able to ease some of the physician's clinical care load, but some populations also need help accessing services and basic health education in a familiar setting. Enter the community health worker (CHW), known by many titles and playing a variety of roles, who comes from the community he or she is serving and therefore can interact with and effectively motivate clients. This paper examines what CHWs do, how they are trained, and the outlook for their incorporation into mainstream health care, as well as the challenges for developing the profession further.

As policymakers look for savings from the Medicare program, some have proposed eliminating or discouraging "first-dollar coverage" available through privately purchased Medigap policies. Medigap coverage, which beneficiaries obtain to protect themselves from Medicare's cost-sharing requirements and its lack of a cap on out-of-pocket spending, may discourage the judicious use of medical services by reducing or eliminating beneficiary cost sharing. It is estimated that eliminating such coverage, which has been shown to be associated with higher Medicare spending, and requiring some cost sharing would encourage beneficiaries to reduce their service use and thus reduce pro­gram spending. However, eliminating first-dollar coverage could cause some beneficiaries to incur higher spending or forego necessary services. Some policy proposals to eliminate first-dollar coverage would also modify Medicare's cost sharing and add an out-of-pocket spending cap for fee-for-service Medicare. This paper discusses Medicare's current cost-sharing requirements, Medigap insurance, and proposals to modify Medicare's cost sharing and eliminate first-dollar coverage in Medigap plans. It reviews the evidence on the effects of first-dollar coverage on spending, some objections to eliminating first-dollar coverage, and results of research that has modeled the impact of eliminating first-dollar coverage, modifying Medicare's cost-sharing requirements, and adding an out-of-pocket limit on beneficiaries' spending.