Dual eligibles are low-income elderly or disabled people enrolled in both Medicare and Medicaid. The distinctions are sometimes bewildering. It’s easy to confuse which program pays for what, what each agency considers “appropriate” care, what factors go into measuring outcomes and how the separate structures of Medicare and Medicaid affect costs and quality.
According to the Congressional Budget Office, in 2009, the federal and state governments spent more than $250 billion, combined, on health care benefits for the 9 million dual eligibles. There is growing concern about the high costs of dual eligibles and the type of care they receive. They may be treated by a variety of health care providers who are not coordinating their care, potentially increasing costs and worsening outcomes.
Many states are already struggling to meet current Medicaid demand, and as boomers age, more stress will be placed on an already fragile system. Learn more about dual eligibles and what issues to look for in your state with this tip sheet.
Health insurers and the federal Centers for Medicare & Medicaid Services (CMS) pay much different rates for clinical services, depending on where care is delivered. Typically, hospitals are paid more than physician practices for the same clinical service.
This payment variation has drawn attention recently: CMS and the Medicare Payment Advisory Committee (MedPAC) have proposed eliminating different payments based on the site of service. In May, MedPAC Executive Director Mark Miller said Medicare should address these price differences immediately to eliminate the incentive to deliver care in high-cost settings, wrote John Tozzi at Bloomberg Businessweek.
Last year, the Society of General Internal Medicine also called for eliminating the site-of-service differential in a report on payment reform (PDF). “Medicare pays $450 for an echocardiogram done in a hospital and only $180 for the same procedure in a physician’s office,” the SGIM report said, citing MedPAC data.
There is some good news coming out of the latest report from the Medicare Trustees. They predict that the trust fund that finances Medicare’s hospital insurance coverage will remain solvent until 2030, four years beyond last year’s projections. Per capita spending is expected to grow more slowly than the overall economy for the next few years, partially due to costs controls under the Affordable Care Act.
However, the report concludes, “notwithstanding recent favorable developments, both the projected baseline and current law projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation.”
“Medicare Part A is moving in the right direction but the day of reckoning has merely been postponed to 2030,” said Rosemary Gibson, senior adviser at The Hastings Center and author of “Medicare Meltdown.” Unless something changes, by 2030 it will lack enough money to pay boomers’ hospital bills. “We’re not out of the woods.” Continue reading
The Center for Public Integrity’s series unearthing potential fraud and waste under the Medicare Advantage program had little help — and apparently little interest — from the Centers for Medicare & Medicaid Services. The insurance program, which Congress established to help control health care costs for older adults, could leave taxpayers on the hook for more than $36 billion, as AHCJ member Fred Schulte and the rest of the investigative team uncovered.
In this “How I did it” article, Schulte explains how the series follows up on CPI’s 2012 Medicare costs investigation, the extensive lengths taken to try to obtain CMS records, work-arounds and other sources the team used to piece together a puzzle that paints a clear picture of improper billing, missed opportunities by regulators, lack of oversight, and industry influence.
Every year, the Centers for Medicare & Medicaid issues a list of troubled nursing homes as part of its Special Focus Facility Initiative. CMS released an updated list on June 19 as a PDF and AHCJ has posted the list as a series of web pages and has made them available to download as Excel spreadsheets.
The initiative is intended to address nursing homes that cycle in and out of compliance. Homes in this program are visited by survey teams twice as frequently as other nursing homes. This list includes nursing homes added to the SFF initiative and updates the status of homes already in the program.
This year, 15 homes in 14 states were added to the list. Sixteen others were found to have “failed to show significant improvement,” 23 were deemed to have shown improvement, 33 have “graduated” from the program and four are no longer participating in Medicare/Medicaid.
Angelo Fichera of The Philadelphia Inquirer recently reported on one nursing home that will likely close after spending three years in the SFF Initiative, noting that CMS has not seen an improvement in care:
CMS expects that after two years on the watch list, nursing homes will either improve and “graduate” from the program; have funding terminated; or be granted an extension to improve because of “promising progress,” according to the agency.
To round out your reporting on nursing homes, AHCJ just updated its version of CMS’s Nursing Home Compare database, which includes details of the most severe deficiencies found during nursing home inspections for the past three years. AHCJ posted separate files covering the star ratings for nursing homes – from 1 to 5 – based on quality, inspection results, staffing and overall ratings.
With the Centers for Medicare & Medicaid Services release of new data showing what hospitals across the country charge Medicare for the same treatment or procedure in 2012, AHJC has gone a step further to help members compare hospitals from one year to the next.
CMS released data files that include bills submitted by 3,500 hospitals for the 100 most commonly performed inpatient conditions in 2011 and 2012. This allows a basis for some local or regional comparisons and a starting point for stories on hospital costs and services.
AHCJ combined the two files to include the hospital name and location, the number of patients with the specific conditions discharged, hospital charges and the amount paid to the hospital for both years. The file covers only inpatient charges. Members can download the file here and read details about each data element, links to other documentation, and how the datasets differ from one year to the next. Not every hospital will be listed for every top 100 condition. If the hospital records 10 or fewer discharges, CMS excludes those numbers because of privacy concerns.
In addition to comparing costs, reporters can see if local hospitals have increased or decreased the treatment of specific conditions. Those changes might indicate changes in local physician population, changes in community needs, opening or closing of hospital services, or even hospital marketing efforts.
When the Centers for Medicare and Medicaid released payment data last month, health reporters paid attention. It allowed an unprecedented look at how $77 billion of public funds have been spent.
Now, AHCJ has made the data more accessible for its members. Members can follow this link to download Microsoft Excel files by state. The page includes links to the actual files, plus links to documentation, a rundown of caveats and tips, and descriptions of the each spreadsheet column.
The data covers payment information for individual doctors and other providers for Medicare Part B services delivered in 2012 – a total of 9,153,272 records in the original data file, totaling 1.7 GB. The file covers more than 880,000 physicians and other providers who received payments from Medicare.
The comprehensive file is too large for common desktop database software, so AHCJ took the extra step of breaking down the data by state and posting the files for download, along with some tips and caveats for reporters.
The new data provide a more detailed picture of how physicians practice in the Medicare program, and the payments they receive. The data contain information on health care professionals in all 50 states – plus the District of Columbia, U.S. territories and a handful in other countries. Because of privacy concerns, the government files exclude providers who seek reimbursement for services done for 10 or fewer patients.
With these files, it will be possible to conduct a wide range of analyses that compare thousands of different services and procedures provided, as well as payments received by individual health care providers.
Attend AHCJ’s free Rural Health Journalism Workshop for a better understanding of what’s happening – or will be happening – in rural regions, and return to work with dozens of story ideas you can pursue.
Compared with city dwellers, people in rural America have higher rates of cancer, diabetes, disabling injuries, and other life-shortening health problems.
Among the less talked about aspects of the Affordable Care Act are measures intended to help reduce rural health disparities. But health professionals working in remote small towns aren’t convinced that the well-intentioned steps will bring enough relief – and do it quickly enough – to reverse problems that many fear are getting worse, such as lack of economic opportunity for rural residents, and limited access to high-quality medical clinics and hospitals.
“There’s definitely joys, but right now the change is huge. It’s going to make it hard for many of us to survive,” said Dean Bartholomew, M.D., a family medicine physician in Saratoga, Wyo., a town with 1,700 residents that is nearly an hour’s drive away from the nearest hospital. Bartholomew was among the panelists at the Health Journalism 2014 session on rural health.
Rural health difference
For Bartholomew, the joys include the rich relationships he’s been able to build with patients and the community. He’s found himself serving as the volunteer team physician for the local high school, for instance, and taking care of sick pets on occasion. Continue reading
AHCJ hosted a webcast
about the CMS data, featuring several CMS officials and Charles Ornstein, a senior reporter at ProPublica and member of AHCJ’s board of directors.
The federal government is expected Wednesday to release data on the services provided by – and money paid to – 880,000 health professionals who take care of patients in the Medicare Part B program. For 35 years, this data has been off limits to the public – and now it will be publicly available for use by journalists, researchers and others.
While the data offers a huge array of stories, which could take weeks or months to report out, it also has some pitfalls. Here are six things to be aware of before you dig in:
Have a strategy for storing and opening the data. This data set is big. About 10 million rows, from what I hear. Because of that, you won’t be able to analyze it in Microsoft Excel and you might not be able to open it in Microsoft Access. You’ll want to upload it onto a data server and analyze it in a more powerful program such as SQL or SPSS. This could well serve as a barrier to entry for smaller news organizations. You may want to partner with an academic institution or another news outlet to analyze the data. Continue reading
Image by Amanda M Hatfield via flickr.
Perhaps the federal Centers for Medicare & Medicaid Services (CMS) learned a lesson over the past few weeks when it tried to make changes in its Part D prescription drug program. The lesson: Don’t mess with Part D in an election year.
On Monday, CMS withdrew its proposal to revise the Part D program, a proposal that drew widespread criticism from congressional Republicans and Democrats and from groups of patients, among others. Those in opposition said the proposal would undermine Part D, which members of Congress called a successful and popular program. More than 36 million elderly and disabled Americans get prescription drug coverage through Part D.
“Late last week, more than 370 organizations representing insurers, drug makers, pharmacies, health providers and patients urged CMS to withdraw changes it had proposed for Medicare Part D,” wrote David Morgan of Reuters. “The Republican Party had already begun to look for ways to leverage popular anger over the changes into campaign attacks on Democratic incumbents who could be vulnerable in November’s election showdown for control of Congress.” Continue reading