The federal program that covers medical care for people age 65 or older, younger people with disabilities, and people with End-Stage Renal Disease. Medicare covers about 13% of the US population and makes up a fifth of national health expenditures.

Applying Private Plan Rules for Prior Authorization to Traditional Medicare

Jun. 1, 2021

There is broad agreement that there is plenty of wasteful and low-value care in our health care system. But there’s less agreement about how to identify it and even less agreement about what to do about it. Health insurers have taken different approaches to this problem. Some insurers have adopted prior authorization, a managed care tool that requires physicians to obtain insurer approval before performing particular services.

The Future of Value-Based Payment: A Road Map to 2030

Feb. 18, 2021

The 2020s require a new strategy that moves from a short-term focus on testing new payment models to a long-term focus on expanding models that are most likely to generate substantial savings and improve quality. This white paper outlines a new direction for the federal government—primarily through the Centers for Medicare and Medicaid Services (CMS)—to chart over the next decade aimed at completing the transition to a health care system that pays for value and reduced health disparities, rather than high volumes of services.

The Future of Value-Based Payment

Feb. 18, 2021

A decade of innovation and experimentation has failed to transform the health care system to one that pays for value rather than volume. It is now time to reconsider how value-based payment models can generate substantial savings and improve quality and health equity. Experts from the University of Pennsylvania, with input from a national panel of experts, reviewed the effectiveness of past payment reforms implemented by the Centers for Medicare and Medicaid Services (CMS) and made recommendations about how to accelerate and complete the nation’s transformation to value-based payment. This brief summarizes recommendations that provide a path toward widespread adoption and success of alternative payment models, producing better health outcomes for all Americans, reducing wasteful spending, improving health equity, and more effectively stewarding taxpayer funds to support other national priorities.

The Effects of the Affordable Care Act on Access and Outcomes of Colon Surgery

Jan. 19, 2021

Ezra S. Brooks, Jason Tong, Catherine W. Mavroudis, Christopher Wirtalla, Giorgos C. Karakousis, Nicole M. Saur, Cary B. Aarons, Najjia N. Mahmoud, Rachel R. Kelz

Abstract [from journal]

Background: Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid expansion (ME) and adopt essential health benefits (EHB).

Methods: We performed a quasi-experimental difference-in-differences (DID) analysis of 2012-2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses


Low Sustainment of High-Dose Oral Medication Regimens for Advanced Parkinson's Disease in Medicare Beneficiaries

Jalpa Doshi, PhD
Dec. 26, 2020

Nabila Dahodwala, Jordan Jahnke, Amy R. Pettit, Pengxiang Li, Vrushabh P. Ladage, Prasanna L. Kandukuri, Yanjun Bao, Jorge Zamudio, Yash J. Jalundhwala, Jalpa A. Doshi

Abstract [from journal]

Background: Increasing doses of oral antiparkinson medications are indicated in advanced Parkinson's disease (PD), but little is known about sustainment of high-dose regimens.

Objective: To investigate sustainment of high-dose oral medication regimens in Medicare beneficiaries with incident advanced PD.

Methods: This retrospective cohort study utilized 100%fee-for-service Medicare claims from 2011-2013. We identified advanced PD using a pharmacy claims-based proxy and


Understanding Racial and Ethnic Disparities in Autism-Related Service Use Among Medicaid-Enrolled Children

Nov. 21, 2020

Lucy A. Bilaver, Sarah A. Sobotka, David S. Mandell

Abstract [from journal]

Racial and ethnic disparities in the use of nine common autism-related services among Medicaid-enrolled children with autism spectrum disorder (ASD) were examined, distinguishing between school and other community-based outpatient settings. Using 2012 Medicaid Analytic Extract data, we identified 117,848 continuously enrolled children with ASD. Several racial and ethnic disparities were found, varying by geography. Black, Asian, and Native American/Pacific Islanders received fewer outpatient services compared with white children, but


Costs and Outcomes for Patients with Dementia in Medicare Advantage Plans

Nov. 12, 2020

How do patients with Alzheimer's disease and related dementias (ADRD) fare in capitated Medicare Advantage (MA) managed care plans, compared to their peers in traditional Medicare (TM)? This question is increasingly important, as nearly one-third of beneficiaries now choose MA, and the human and financial cost of living with ADRD is substantial.

Identifying Cohabiting Couples In Administrative Data: Evidence From Medicare Address Data

Nov. 12, 2020

Sasmira Matta, Joanne W. Hsu, Theodore J. Iwashyna, Micah Y. Baum, Kenneth M. Langa & Lauren Hersch Nicholas

Abstract [from journal]

Marital status is recognized as an important social determinant of health, income, and social support, but is rarely available in administrative data. We assessed the feasibility of using exact address data and zip code history to identify cohabiting couples using the 2018 Medicare Vital Status file and ZIP codes in the 2011–2014 Master Beneficiary Summary Files. Medicare beneficiaries meeting our algorithm displayed characteristics consistent with assortative mating and resembled known married couples in the Health and Retirement Study linked to Medicare...

CMS’ Inpatient Psychiatric Facility Quality Reporting Program

Nov. 9, 2020

Patients in inpatient psychiatric care are especially vulnerable to physical and psychological harm, but they have largely been excluded from efforts to monitor, understand, and improve quality of care. In 2012, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program to ease inpatient psychiatry into the norms and scrutiny that general hospital care has received for a long time.

Using Medicare Claims In Identifying Alzheimer's Disease And Related Dementias

Oct. 8, 2020

Siddharth JainPaul R. Rosenbaum, Joseph G. Reiter, Geoffrey Hoffman, Dylan S. Small, Jinkyung Ha, Alexander S. Hill, David A. Wolk, Timothy GaultonMark D. Neuman, Roderic G. Eckenhoff, Lee A....

Abstract [form journal]

Introduction: This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims.

Methods: Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity.

Results: We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association