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

This issue brief explains how the Medicare Part D low income benchmark premium is calculated, what factors influence the level of the low-income benchmark premium in any given year, and the implications of the benchmark amount for Medicare drug plans and beneficiaries as it changes from year to year. The paper provides a simplified, two-year example of how the low-income benchmark premium is calculated in order to illustrate the key factors that influence it.

This issue brief explores the use of premium assistance in publicly financed health insurance coverage programs. In the context of Medicaid and the State Children's Health Insurance Program (SCHIP), premium assistance entails using federal and state funds to subsidize the premiums for the purchase of private insurance coverage for eligible individuals. This paper considers the evolution of premium assistance and some of the statutory and administrative limitations, as well as private market factors, that have prevented widespread enrollment in Medicaid or SCHIP premium assistance programs. Finally, this issue brief offers some ideas for potential legislative and/or programmatic changes that could facilitate the use of premium assistance as a mechanism for health coverage expansion.

If the time comes, people expect that the emergency department (ED) will have the resources necessary to treat them in a timely, high-quality manner. Increasingly, however, EDs may not be able to meet that expectation. Hospitals in urban areas with large populations, high population growth, and higher-than-average numbers of uninsured are particularly crowded: ambulances are often diverted to other hospitals and patients are frequently forced to "board" in the hallways (while they wait to be transferred to another facility or part of the hospital). This issue brief places EDs in the context of the U.S. health care system and its economics, discusses existing ED capacity and utilization, where crowding is happening and ways of measuring it, what is causing crowding in EDs, and the consequences of crowding. It highlights a number of potential ways to alleviate crowding at both the health system and the individual hospital level.

This issue brief explores the continuing evolution of the Medicaid program on several fronts. It discusses the benefits and cost-sharing flexibility that is included in the Deficit Reduction Act of 2005 (DRA) and examines the implications of these provisions for states, beneficiaries, and providers. The paper also explores recent trends in section 1115 waiver development and considers the use of waivers as a vehicle for restructuring Medicaid financing systems and for testing completely new approaches to health care delivery. The role of section 1115 waivers in the context of the DRA and as a mechanism for continued state innovation is also discussed.

The informed and empowered consumer is an ideal invoked by many would-be health care reformers. An actual consumer wishing to don the mantle of power may be hindered by the scarcity of information available, particularly with respect to choosing among physicians. How is one to know who is best qualified? This issue brief looks at the basics of physician qualification and the processes by which physicians are licensed, credentialed, and board-certified. It examines how the evolution of these processes (for example, the move from lifetime certification to ongoing maintenance of certification) affects clinicians and their patients. The rise of quality measurement and pay-for-performance programs is considered as well.

Medicare Advantage special needs plans (SNPs) are a new type of coordinated care plan established by the Medicare Prescription Drug, Improvement and Modernization Act. SNPs were created to encourage greater access to Medicare managed care for certain special needs populations: the institutionalized, persons dually eligible for Medicare and Medicaid, and the chronically ill. Some view SNPs as a new opportunity to integrate acute and long-term care services as well as Medicare and Medicaid financing. Others, however, question the degree to which full integration will become a widespread reality. This issue brief examines the SNP option and the promises and challenges it presents for better coordinated care.

This paper updates a June 2002 National Health Policy Forum Issue Brief, "Average Wholesale Price for Prescription Drugs: Is There a More Appropriate Pricing Mechanism?" Since the release of that paper, Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which created a new, comprehensive outpatient prescription drug benefit and reduced Medicare's reliance on the average wholesale price (AWP) in paying for prescription drugs. This paper discusses the continued use of AWP as well as other pricing benchmarks that pertain to prescription drugs. It explains the relevance of these pricing mechanisms to different government programs and sets forth some of the issues that have arisen in their use. The paper also contains a glossary of commonly used drug pricing terms, as well as an appendix that lists state Medicaid drug payment formulas.

This paper provides an overview of clinical preventive services, including a definition of such services and the role of the U.S. Preventive Services Task Force in recommending which services should be routinely offered to patients. It also describes efforts to analyze the cost effectiveness of clinical preventive services and reviews the insurance coverage policies of private and public payers. Barriers to increased uptake of appropriate services are discussed, and policy-relevant issues are summarized.

This issue brief discusses the mental health needs of youth who are involved with the juvenile justice system, how they come into contact with the system, and the evidence of the availability and quality of mental health services for such youth. The paper also explores public policy options for avoiding dependence on the juvenile justice system as a last resort for treating youth with mental disorders.

The rapid increase in specialty cardiac, surgical, and orthopedic hospitals has captured the attention of general hospitals and policymakers. Although the number of specialty hospitals remains small in absolute terms, their entry into certain health care markets has fueled arguments about the rules of "fair" competition among health care providers. To allow the smoke to clear, Congress effectively stalled the growth in new specialty hospitals by temporarily prohibiting physicians from referring Medicare or Medicaid patients to specialty hospitals in which they had an ownership interest. During this 18-month moratorium, which expired June 8, 2005, two mandated studies of specialty hospitals provided information to help assess their potential effect on health care delivery. This issue brief discusses the research on specialty hospitals, including their payments under Medicare's hospital inpatient payment system, the quality and cost of care they deliver, their effect on general hospitals and on overall health care delivery, and the regulatory and legal environment in which they have proliferated. It concludes with open issues concerning physician self-referral and the role of general hospitals in providing a range of health care services.