Health Policy Commons^™

A New State Plan Option To Integrate Care And Financing For Persons Dually Eligible For Medicare And Medicaid, Jane H. Thorpe, Katherine J. Hayes

Health Policy and Management Faculty Publications

As health care costs continue to escalate, Congress, the U.S. Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), state Medicaid agencies, researchers, and policymakers are focusing on identifying new approaches to care delivery and reimbursement for individuals who are dually eligible for both Medicare and Medicaid. Although relatively few in number (9 million), dual eligible beneficiaries are more likely than others to experience poor health, including multiple chronic conditions, functional and cognitive impairments, and a need for continuous care. Sixty-six percent of dual eligibles have three or more chronic conditions; sixty-one percent are …

Accountable Care Organizations: Implications For Antitrust Policy, Taylor Burke, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

This analysis examines accountable care organizations (ACOs) and assesses their implications for antitrust policy. Consideration of the antitrust implications of ACOs is timely. Both the House and Senate health reform measures contemplate the creation of ACOs as a new class of Medicare provider while providing parallel legal authority under Medicaid.

Medicare Advantage Payment Provisions: Health Care And Education Affordability Reconciliation Act Of 2010 H.R. 4872, Brian Biles, Grace Arnold

Health Policy and Management Issue Briefs

The Health Care and Education Affordability Reconciliation Act of 2010 would make major changes to Medicare Advantage (MA) payment policies. Overall, payments to MA plans would be reduced from the current national average of 113 percent of local fee-for-service (FFS) costs to a new average of 101 percent of FFS costs. The Congressional Budget Office (CBO) has estimated that the new polices would reduce Medicare spending by $132 billion over 10 years. The new policies would set county payment benchmarks for MA plans at 115 percent, 107.5 percent, 100 percent, and 95 percent of local FFS costs depending of the …

Paying Medicare Advantage Plans By A Blend-Based System: Where Are The Gains And Losses?, Brian Biles, Jonah Pozen, Grace Arnold

Health Policy and Management Issue Briefs

Medicare Advantage (MA) plans are now paid $11 billion a year and $150 billion over 10 years more than costs in fee-for-service (FFS) Medicare. In the past two years there have been discussions about reducing MA payments to the level of FFS costs and using the savings to offset the costs of new Federal initiatives such as health care reform. These discussions have included a number of options on the specific new approach to pay plans including: average FFS costs in each county; a blend of local county FFS costs and national FFS average costs; and a regional system based …

Paying Medicare Private Plans By Competitive Bidding: Not The Same As Costs In Regular Medicare, Brian Biles, Jonah Pozen

Health Policy and Management Faculty Publications

Medicare Advantage plans are now paid $11 billion a year, and $150 billion over 10 years, more than costs in regular fee-for-service (FFS) Medicare. In the past two years there have been discussions about reducing MA payments to the level of 100 percent of average costs in FFS and using the savings to offset the costs of new Federal health initiatives such as health care reform. Earlier this year, OMB proposed "reducing Medicare overpayments to private insurers through competitive payments." Under this proposal, MA plan "payments would be based on an average of plans' bids submitted to Medicare." This issue …

The Application Of The Emergency Medical Treatment And Labor Act (Emtala) To Hospital Inpatients, Lara Cartwright-Smith, Sara J. Rosenbaum, Karen Belli, Elaine Purcell, Tasmeen S. Weik

Health Policy and Management Issue Briefs

This issue brief provides a brief overview of the Emergency Medical Treatment and Labor Act (EMTALA) and focuses on its application to hospital inpatients. EMTALA applies differently to patients than non-patients, and also applies differently to patients admitted through the emergency department than patients admitted as regular inpatients. In addition, courts and the Centers for Medicare and Medicaid Services (CMS) have differed in their interpretation of the statute. Depending on the specific facts of any particular case, EMTALA may or may not have implications for specialty-related transfers and discharges.

The Continuing Cost Of Privatization: Extra Payments To Medicare Advantage Plans In 2008, Brian Biles, Emily Adrion, Stuart Guterman

Health Policy and Management Faculty Publications

The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, every MA plan in the nation is paid more for its enrollees than they would have been expected to cost in traditional fee-for-service Medicare. The authors calculate that payments to MA plans in 2008 will be 12.4 percent greater than the corresponding costs in traditional Medicare—an average increase of $986 per MA plan enrollee, for a total of more than $8.5 billion. Over the five-year period 2004–2008, extra payments to MA plans are estimated to have totaled nearly $33 billion. Although …

Primer On Medicare Advantage Payments In 2008, Brian Biles, Emily Adrion

Health Policy and Management Faculty Publications

The Medicare Modernization Act of 2003 (MMA) included provision intended to increase the role of private health plans in Medicare. These provisions, building on policies adopted earlier in 1997 and 2000, set Medicare Advantage (MA) plan benchmark rates at levels higher than average costs in tradition free-for-service Medicare in every county in the nation. The total amount of extra payments to Medicare Advantage plans resulting from these policies total over $8.5 billion in 2008 and over $82 billion over the five year period between 2009 and 2013.

This briefing paper outlines the three major Medicare policies that generate these extra …

Payments To Medicare Advantage Plans Exceed Fee-For-Service Costs: Options For Medicare Savings From 2008 Through 2012, Brian Biles, Emily Adrion

Health Policy and Management Faculty Publications

The Medicare Modernization Act of 2003 (MMA) and the Deficit Reduction Act (DRA) of 2005 include provision intended to increase the role of private health plans in Medicare. These provisions set Medicare Advantage plan payment rates at levels higher than average costs would be in tradition free-for-service Medicare in every county in the nation. The total amount of extra payments to Medicare Advantage plans resulting from these provisions is projected to total over $8 billion in 2008 and $70 billion over the five year period, 2008 to 2012.

This briefing paper outlines the specific MMA and DRA provisions that generate …

The Continuing Cost Of Privatization: Extra Payments To Medicare Advantage Plans: Updated Tables For 2007: February 2007 Ma Plan Enrollment, 2007 Ma And Ffs Payment Rates, Brian Biles, Emily Adrion

Health Policy and Management Faculty Publications

No abstract provided.

What Is Fair? Choice, Fairness And Transparency In Access To Prescription Medicines In The United States And Australia, Ruth Lopert, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

The importance of prescription drugs to modern medical practice, coupled with their increasing costs, has strengthened imperatives for national health policies that ensure safety and quality, facilitate affordable access, and promote rational use. Australia has made universal and affordable prescription drug coverage a priority for decades, within a policy framework that emphasizes equity and increasing transparency in coverage design and payment decisions. By contrast, the U.S. lacks such a national policy. Furthermore, federal Medicare reforms aimed at making appropriate drug coverage affordable and accessible employs two icons of the U.S. perception of fairness--the right to choose and the right to …

Payments To Medicare Advantage Plans Exceed Fee-For-Service Costs: Options For Medicare Savings From 2007 Through 2011, Brian Biles, Emily Adrion

Health Policy and Management Faculty Publications

The Medicare Modernization Act of 2003 (MMA) and the Deficit Reduction Act (DRA) of 2005 include provision intended to increase the role of private health plans in Medicare. These provisions set Medicare Advantage plan payment rates at levels higher than average costs would be in tradition free-for-service Medicare in every county in the nation. The total amount of extra payments to Medicare Advantage plans resulting from these provisions is projected at $5.7 billion in 2007 and nearly $30 billion over the five year period, 2007 to 2011.

This briefing paper outlines the specific MMA and DRA provisions that generate these …

Medicare Advantage: Déjà Vu All Over Again?, Brian Biles, Geraldine Dallek, Lauren Hersch Nicholas

Health Policy and Management Faculty Publications

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 expands the role of private health plans in Medicare through prescription drug plans and a revised Medicare+Choice (M+C), renamed Medicare Advantage, program. This paper discusses the factors responsible for the failure of M+C to develop as intended in 1997 and analyzes the challenges for MMA implementation in light of these factors. They include making a complex program understandable to beneficiaries; addressing plans? efforts to avoid enrolling high-cost beneficiaries; ensuring stability of benefits, providers, and plans; dealing with beneficiaries enrolled in unsuitable plans; providing equity of health benefits throughout the …

How Care Is Managed: A Descriptive Study Of Current And Future Trends In Care And Cost Management Practices Under Private Sector Employee Benefit Plans, Phyllis Borzi, Marsha Regenstein, Lee Repasch, Soeurette Cyprien, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

In the fall of 2001, the United States Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation (ASPE) asked the Center for Health Services Research and Policy in the School of Public Health and Health Services, The George Washington University Medical Center, to undertake a descriptive study of the current and future trends in cost and care management techniques used in the employment-based health insurance marketplace. The purpose of this study was to identify and report on (1) the cost and care management techniques currently in use in the private sector by health plans …

Medicare, Managed Care, And Behavioral Health Care, Sara J. Rosenbaum, Barbara Markham Smith

Health Policy and Management Issue Briefs

This issue brief examines Medicare and managed care for Medicare beneficiaries with behavioral health needs. Although only a relatively small proportion of Medicare beneficiaries are enrolled in managed care arrangements at the present time, proposals to expand the use of Medicare managed care can be expected to receive a good deal of attention in the coming years as part of a larger debate over Medicare's long term future. Thus, this issue brief examines the Medicare+Choice (M+C) program from the perspective of Medicare beneficiaries with mental illness and addiction disorders.