Archive for the ‘Medicare and Medicaid’ Category

Medicare Part B Enrollment: Pitfalls, Problems and Penalties Recommendations to Improve the Medicare Enrollment System for Consumers

November 18, 2014 Comments off

Medicare Part B Enrollment: Pitfalls, Problems and Penalties Recommendations to Improve the Medicare Enrollment System for Consumers
Source: Medicare Rights Center

An often-reported fact is that 10,000 Baby Boomers turn 65 and become Medicare-eligible each day. Less well known, and commonly misunderstood, are the rules concerning how to enroll in Medicare. While most newly eligible Medicare beneficiaries are automatically enrolled, others must make a proactive choice to enroll in one or multiple parts of the program, including Part A, Part B, Part C and Part D. Through its direct service and educational programming, the Medicare Rights Center (Medicare Rights) regularly hears from older adults and people with disabilities who erred during this transition and struggle to cope with the consequences.

In this report, Medicare Rights details common enrollment challenges facing people new to the Medicare program and the policy solutions to simplify Medicare enrollment and ensure that fewer people make costly enrollment mistakes.

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High-Cost Generic Drugs — Implications for Patients and Policymakers

November 18, 2014 Comments off

High-Cost Generic Drugs — Implications for Patients and Policymakers
Source: New England Journal of Medicine

It is well known that new brand-name drugs are often expensive, but U.S. health care is also witnessing a lesser-known but growing and seemingly paradoxical phenomenon: certain older drugs, many of which are generic and not protected by patents or market exclusivity, are now also extremely expensive. Take the case of albendazole, a broad-spectrum antiparasitic medication. Albendazole was first marketed by a corporate predecessor to GlaxoSmithKline (GSK) outside the United States in 1982 and was approved by the Food and Drug Administration (FDA) in 1996. Its patents have long since expired, but no manufacturer ever sought FDA approval for a generic version. One reason may be that the primary indications for the drug — intestinal parasites, neurocysticercosis, and hydatid disease — occur relatively rarely in the United States and usually only in disadvantaged populations such as immigrants and refugees. In late 2010, the listed average wholesale price (AWP) for albendazole was $5.92 per typical daily dose in the United States and less than $1 per typical daily dose overseas.

By 2013, the listed AWP for albendazole had increased to $119.58 per typical daily dose.1 We found that at some pharmacies in Minnesota, an uninsured patient requiring 6 months of treatment would have faced costs amounting to tens of thousands of dollars.1 Although the AWP may not reflect the actual cost of the product, Medicaid data show that spending on albendazole increased from less than $100,000 per year in 2008, when the average cost was $36.10 per prescription, to more than $7.5 million in 2013, when the average cost was $241.30 per prescription (see graph).

The albendazole story is not unique. According to the National Average Drug Acquisition Cost pricing file, the price of captopril (12.5 mg), which is used for hypertension and heart failure, increased by more than 2800% between November 2012 and November 2013, from 1.4 cents to 39.9 cents per pill. Similarly, the price of clomipramine (25 mg), a long-established tricyclic antidepressant also used for obsessive–compulsive disorder, increased from 22 cents to $8.32 per pill, and the price of doxycycline hyclate (100 mg), a broad-spectrum antibiotic that has been around since 1967, increased from 6.3 cents to $3.36 per pill.2

Yet many of these drugs remain key therapeutic tools. The number of prescriptions for albendazole has increased dramatically, in part because the drug has increasingly been used to treat parasitic infections in refugees. The Centers for Disease Control and Prevention recommends presumptive treatment of refugees arriving in the United States if they have not had prior treatment. Because the people who need albendazole are generally disadvantaged, the costs resulting from the enhanced demand and associated price increases are largely borne by the patients themselves through substantial out-of-pocket payments or by taxpayers through public insurers such as Medicaid and the Refugee Medical Assistance program.

HHS OIG — CMS Needs To Do More To Improve Medicaid Children’s Utilization of Preventive Screening Services

November 18, 2014 Comments off

CMS Needs To Do More To Improve Medicaid Children’s Utilization of Preventive Screening Services
Source: U.S. Department of Health and Human Services, Office of Inspector General


In a 2010 report entitled Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, OEI-05-08-00520, OIG found that children enrolled in Medicaid were not receiving all required Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings. In addition, OIG also found that children who received medical screenings were not receiving complete medical screenings. The 2010 OIG report recommended improvements in both areas. CMS concurred, or partially concurred, with the recommendations. This memorandum report describes the steps that CMS has taken since the OIG’s 2010 report to encourage children’s participation in EPSDT screenings and to ensure that providers deliver complete medical screenings.

We conducted structured interviews with the CMS staff responsible for EPSDT and four representatives from a national workgroup that CMS created to address EPSDT issues. We also reviewed documents provided by CMS or workgroup representatives, including informational bulletins, strategy guides, Web seminars, and workgroup reports. In addition, we reviewed States’ reports on EPSDT participation from 2006-2013, as well as the national aggregate reports for those same years.

We found that CMS has taken actions toward encouraging participation in EPSDT screenings and toward encouraging the delivery of all components of medical screenings, but that it has not fully addressed OIG’s recommendations. Further, we found that children’s participation in EPSDT medical screenings remained lower than established goals. Although the national participation ratio improved from 56 percent in 2006 to 63 percent in 2013, both ratios are below the Secretary’s goal of 80 percent participation.

Given the results of our review, OIG considers all four of the recommendations from the 2010 report to remain open. This report contains no new recommendations, but we reiterate the following recommendations from 2010: CMS should (1) require States to report vision and hearing screenings, (2) collaborate with States and providers to develop effective strategies to encourage beneficiary participation in EPSDT screenings, (3) collaborate with States and providers to develop education and incentives for providers to encourage complete medical screenings, and (4) identify and disseminate promising State practices for increasing children’s participation in EPSDT screenings and providers’ delivery of complete medical screenings.

CBO — Medicare’s Payment to Physicians

November 17, 2014 Comments off

Medicare’s Payment to Physicians
Source: Congressional Budget Office

On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) issued a final rule in which CMS announced the update to the conversion factor update for the Physician Fee Schedule (PFS) under Medicare will be a reduction of 21.2 percent for services furnished during calendar year 2015.

Following long-standing practice, CBO will incorporate that information in its next regular baseline update. It will also immediately take that information into account when analyzing legislation being considered by the Congress.

The table, Medicare’s Payment to Physicians: the Budgetary Effects of Alternative Policies, includes estimates for several replacement and short-term alternatives to the current rules for setting Medicare’s payment rates for physicians’ services. The starting date for all of these alternative policies would be April 1, 2015.

Designing Smarter Pay-for-Performance Programs

November 14, 2014 Comments off

Designing Smarter Pay-for-Performance Programs
Source: Journal of the American Medical Association

Over the past decade, public and private payers have experimented with the use of financial incentives to motivate physicians to achieve quality and efficiency. The idea behind pay for performance is simple. Because individuals and organizations respond to incentives, physicians whose patients achieve desirable outcomes should be paid more as an incentive to improve their performance. Yet the results of pay-for-performance programs have been largely disappointing. One argument is that neither the right set of incentives nor the right set of metrics has been identified. Another explanation, which has received far less attention, is that the right set of patients has not been identified for targeted efforts.

Measuring Coding Intensity in the Medicare Advantage Program

November 13, 2014 Comments off

Measuring Coding Intensity in the Medicare Advantage Program
Source: Centers for Medicare and Medicaid Services (HHS)

In 2004, Medicare implemented a system of paying Medicare Advantage (MA) plans that gave them greater incentive than fee-for-service (FFS) providers to report diagnoses.

Risk scores for all Medicare beneficiaries 2004–2013 and Medicare Current Beneficiary Survey (MCBS) data, 2006–2011.

Change in average risk score for all enrollees and for stayers (beneficiaries who were in either FFS or MA for two consecutive years). Prevalence rates by Hierarchical Condition Category (HCC).

Each year the average MA risk score increased faster than the average FFS score. Using the risk adjustment model in place in 2004, the average MA score as a ratio of the average FFS score would have increased from 90% in 2004 to 109% in 2013. Using the model partially implemented in 2014, the ratio would have increased from 88% to 102%. The increase in relative MA scores appears to largely reflect changes in diagnostic coding, not real increases in the morbidity of MA enrollees. In survey-based data for 2006–2011, the MA-FFS ratio of risk scores remained roughly constant at 96%. Intensity of coding varies widely by contract, with some contracts coding very similarly to FFS and others coding much more intensely than the MA average. Underpinning this relative growth in scores is particularly rapid relative growth in a subset of HCCs.

Medicare has taken significant steps to mitigate the effects of coding intensity in MA, including implementing a 3.4% coding intensity adjustment in 2010 and revising the risk adjustment model in 2013 and 2014. Given the continuous relative increase in the average MA risk score, further policy changes will likely be necessary.

What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

November 13, 2014 Comments off

What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?
Source: Kaiser Family Foundation

While the majority of Medicare beneficiaries still receive their benefits through the traditional Medicare program, 30 percent now obtain them through private health plans participating in Medicare Advantage. As the number of Medicare Advantage enrollees continues to climb, there is growing interest in understanding how the care provided to Medicare beneficiaries in Medicare Advantage plans differs from the care received by beneficiaries in traditional Medicare.

Despite the interest, the last comprehensive review of research evidence on health care access and quality in Medicare Advantage and traditional Medicare is more than 10 years old and did not focus exclusively on Medicare (Miller and Luft 2002). That study found that health maintenance organizations (HMOs) provide care that is roughly comparable in quality to the care provided by non-HMOs (mainly traditional indemnity insurance), and that quality varied across health plans. It also found that HMOs used somewhat fewer hospital and other expensive resources in delivering care, with enrollees rating them worse on many measures of access and satisfaction. However, the market has changed substantially over the last decade, making it important that policymakers have available more current analysis, particularly on Medicare health plans.

This literature review synthesizes the findings of studies that focus specifically on Medicare and have been published between the year 2000 and early 2014. Forty-five studies met the criteria for selection, including 40 that made direct comparisons between Medicare health plans and traditional Medicare. An additional five studies are included, even though they have no traditional Medicare comparison group, because they include a comparison of health care access and quality in different types of Medicare Advantage plans. A full list of the studies included in this analysis is found in the Works Cited.


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