Archive for the ‘Medicare and Medicaid’ Category

HHS OIG — Ensuring the Integrity of Medicare Part D

July 16, 2015 Comments off

Ensuring the Integrity of Medicare Part D
Source: U.S. Department of Health and Human Services, Office of Inspector General

In the 9 years since Part D began, OIG has produced a wide range of investigations, audits, evaluations, and legal guidance related to Part D program integrity. This work has resulted in the prosecution of individuals accused of defrauding Part D, as well as the identification of systemic program vulnerabilities that raise concerns related to both inappropriate payments and quality of care. OIG has made recommendations to strengthen Part D program integrity, and progress has been made. However, Part D remains vulnerable to fraud, as evidenced by ongoing investigations. OIG has prepared this portfolio to document key progress in addressing Part D program vulnerabilities and to highlight issues that need improvement.

See also: Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D

One Nation, Under Sedation: Medicare Paid for Nearly 40 Million Tranquilizer Prescriptions in 2013

July 15, 2015 Comments off

One Nation, Under Sedation: Medicare Paid for Nearly 40 Million Tranquilizer Prescriptions in 2013
Source: Pro Publica

In 2012, Medicare’s massive prescription drug program didn’t spend a penny on popular tranquilizers such as Valium, Xanax and Ativan.

The following year, it doled out more than $377 million for the drugs.

While it might appear that an epidemic of anxiety swept the nation’s Medicare enrollees, the spike actually reflects a failed policy initiative by Congress.

More than a decade ago, when lawmakers created Medicare’s drug program, called Part D, they decided not to pay for anti-anxiety medications. Some of these drugs, known as benzodiazepines, had been linked to abuse and an increased risk of falls and fractures among the elderly, who make up most of the Medicare population.

But doctors didn’t stop prescribing the drugs to Medicare enrollees. Patients just found other ways to pay for them. When Congress later reversed the payment policy under pressure from patient groups and medical societies, it swiftly became clear that a huge swath of Medicare’s patients were already using the drugs despite the lack of coverage.

In 2013, the year Medicare started covering benzodiazepines, it paid for nearly 40 million prescriptions, a ProPublica analysis of recently released federal data shows. Generic versions of the drugs — alprazolam (which goes by the trade name of Xanax), lorazepam (Ativan) and clonazepam (Klonopin) — were among the top 32 most-prescribed medications in Medicare Part D that year.

States Expanding Medicaid See Significant Budget Savings and Revenue Gains

July 6, 2015 Comments off

States Expanding Medicaid See Significant Budget Savings and Revenue Gains (PDF)
Source: Robert Wood Johnson Foundation

In examining Medicaid expansion across eight states—Arkansas, Colorado, Kentucky, Michigan, New Mexico, Oregon, Washington and West Virginia—it is clear that states are realizing savings and revenue gains as a result of expansion.

 Savings and revenues by the end of 2015 (just 1.5 years into expansion) are expected to exceed $1.8 billion across all eight states

 In Arkansas and Kentucky, savings and revenue gains are expected to offset costs of the expansion at least through SFY 2021

Findings from these eight states suggest that every expansion state should expect to:

 Reduce state spending on programs for the uninsured

 See savings related to previously eligible Medicaid beneficiaries now eligible for the new adult group under expansion

 See revenue gains related to existing insurer or provider taxes

Is 65 the Best Cutoff for Defining “Older Americans?”

June 10, 2015 Comments off

Is 65 the Best Cutoff for Defining “Older Americans?”
Source: American Institutes for Research

Baby Boomers are aging and the Congress is changing; public policy issues on aging have never been more important. Do the issues that define “old age” really begin at 65? Although Americans are living longer, other changes in health status and workforce behavior could be used to argue that age 65 is too late to begin to worry about the challenges of an aging population.

Two key areas of concern when considering age from a policy perspective are the health and economic status (including labor force behavior) of older individuals. These variables affect not only the well-being of older Americans but the pocketbooks of American taxpayers. If age for program eligibility can be increased without harming older Americans, billions of dollars in government spending could potentially be saved.

In an effort to enlighten this debate, the Center on Aging developed this brief, in which AIR researchers explore data on income, resources, health, and family structure to look at how well age 65 captures a good cutoff for eligibility for programs and for discussing issues facing older Americans.

New Data and Updated Report Show Medicaid Is Expanding Insurance Coverage, with Major Benefits to States’ Citizens and Economies

June 8, 2015 Comments off

New Data and Updated Report Show Medicaid Is Expanding Insurance Coverage, with Major Benefits to States’ Citizens and Economies
Source: White House

The Affordable Care Act has dramatically expanded access to health insurance coverage. Since the law’s major coverage provisions took effect at the end of 2014, the Nation has seen the sharpest reduction in the uninsured rate since the decade following the creation of Medicare and Medicaid in 1965, and the Nation’s uninsured rate is now at its lowest level ever. Combining these recent gains with earlier gains due to the law’s provision allowing young adults to remain on a parent’s plan until age 26, more than 16 million Americans had gained health insurance coverage as of early 2015.

One important way the Affordable Care Act is expanding coverage is by providing generous financial support to States that elect to expand their Medicaid programs to cover all adults with incomes below 138 percent of the Federal poverty level. New data released this morning show that the number of people with coverage through Medicaid or the Children’s Health Insurance Program (CHIP) has risen by 12.2 million people from the start of the first open enrollment period under the Affordable Care Act through March 2015. From February to March alone, the number of people with Medicaid or CHIP coverage rose by more than 500,000 people.

Upcoding: Evidence from Medicare on Squishy Risk Adjustment

June 5, 2015 Comments off

Upcoding: Evidence from Medicare on Squishy Risk Adjustment
Source: National Bureau of Economic Research

Diagnosis-based subsidies, also known as risk adjustment, are widely used in US health insurance markets to deal with problems of adverse selection and cream-skimming. The widespread use of these subsidies has generated broad policy, research, and popular interest in the idea of upcoding—the notion that diagnosed medical conditions may reflect behaviors of health plans and providers to game the payment system, rather than solely characteristics of patients. We introduce a model showing that coding differences across health plans have important consequences for public finances and consumer choices, whether or not such differences arise from gaming. We then develop and implement a novel strategy for identifying coding differences across insurers in equilibrium in the presence of selection. Empirically, we examine how coding intensity in Medicare differs between the traditional fee-for-service option, in which coding incentives are weak, and Medicare Advantage, in which insurers receive diagnosis-based subsidies. Our estimates imply that enrollees in private Medicare Advantage plans generate 6% to 16% higher diagnosis-based risk scores than the same enrollees would generate under fee-for-service Medicare. Consistent with a principal-agent problem faced by insurers attempting to induce their providers to upcode, we find that coding intensity increases with the level of vertical integration between insurers and the physicians with whom they contract. Absent a coding inflation correction, our findings imply excess public payments to Medicare Advantage plans of around $10 billion annually. This differential subsidy also distorts consumers’ choices toward private Medicare plans and away from fee-for-service Medicare.

Only 251 Hospitals Score Five Stars In Medicare’s New Ratings

May 29, 2015 Comments off

Only 251 Hospitals Score Five Stars In Medicare’s New Ratings
Source: Kaiser Family Foundation

In an effort to make comparing hospitals more like shopping for refrigerators and restaurants, the federal government has awarded its first star ratings to hospitals based on patients’ appraisals.

Many of the nation’s leading hospitals received middling ratings, while comparatively obscure local hospitals and others that specialized in lucrative surgeries frequently received the most stars.

Evaluating hospitals is becoming increasingly important as more insurance plans offer patients limited choices. Medicare already uses stars to rate nursing homes, dialysis centers and private Medicare Advantage insurance plans. While Medicare publishes more than 100 quality measures about hospitals on its Hospital Compare website, many are hard to decipher, and there is little evidence consumers use the site very much.

Many in the hospital industry fear Medicare’s five-star scale won’t accurately reflect quality and may place too much weight on patient reviews, which are just one measurement of hospital quality. Medicare also reports the results of hospital care, such as how many died or got infections during their stay, but those are not yet assigned stars.


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