Medicare

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.

Where Patients Go After Hospital Discharge: Trends in Post-Acute Care

Apr. 17, 2018

As the largest single source of health care spending, hospitals have drawn considerable attention from policymakers. Efforts to reduce costs have led to decreased lengths of hospital stays, but far less attention has been paid to where those patients go immediately after discharge. Medicare payment reforms implemented in the wake of the Affordable Care Act, such as hospital readmissions penalties and bundled payments, have made hospitals accountable for care beyond their walls, including institutional post-acute care.

Prior Authorization Requirements for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Across US Private and Public Payers

Research Brief
Mar. 28, 2018

A comprehensive review of prior authorization (PA) requirements for a new class of expensive cholesterol-lowering drugs known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has found unusually complex and burdensome demands across public and private insurance plans in the United States. These findings raise concerns that current policies may create undue barriers to care even in medically appropriate patients, particularly since requirements were just as stringent for patients with a genetic condition that creates more clear-cut eligibility for PCSK9 inhibitor treatment.

Characteristics of Hospitals Earning Savings in the First Year of Mandatory Bundled Payment for Hip and Knee Surgery

Mar. 8, 2018

Amol S. NavatheJoshua M. Liao, Yash Shah, Zoe Lyon, Paula ...

In JAMA, Amol Navathe and LDI colleagues Joshua Liao, Paula Chatterjee, Dan Polsky, and Ezekiel Emanuel examine hospital savings and quality results for the first year of the Comprehensive Care for Joint Replacement (CJR) bundled payment program. Since April 2016, Medicare has bundled payments for hip and knee replacements at 799 hospitals through CJR. The program incentivizes quality and cost containment by providing retrospective bonus payments that increase as hospitals exceed their cost and quality benchmarks, or imposing penalties if hospitals fall short. While the CJR...

The Effect of Integration of Hospitals and Post-Acute Care Providers on Medicare Payment and Patient Outcomes

Research Brief
Mar. 6, 2018

Vertical integration between hospitals and skilled nursing facilities (SNFs) increases Medicare payments for the first 60 days of care by $2,424 (17%), compared to hospital-SNF pairs that are not vertically integrated. These integrated hospital–SNF pairs also experience a decline in 30-day rates of rehospitalization or death of 5 percentage points on a base rate of 31.3%. Vertical integration between hospitals and home health agencies (HHAs) has little effect on Medicare payments and patient outcomes, nor does informal integration in either setting.

Association of Patient Out-of-Pocket Costs With Prescription Abandonment and Delay in Fills of Novel Oral Anticancer Agents

Research Brief
Jan. 19, 2018

High out-of-pocket (OOP) costs may limit access to novel oral cancer medications. In a retrospective study, nearly one third of patients whose OOP costs were $100 to $500 and nearly half of patients whose OOP costs were more than $2,000 failed to pick up their new prescription for an oral cancer medication, compared to 10% of patients who were required to pay less than $10 at the time of purchase. Delays in picking up prescriptions were also more frequent among patients facing higher OOP costs. 

Association of high cost sharing and targeted therapy initiation among elderly Medicare patients with metastatic renal cell carcinoma

Dec. 12, 2017

Pengxiang (Alex) Li, Yu-Ning Wong, Jordan Jahnke, Amy R. Pettit, and Jalpa A. Doshi

In Cancer Medicine, Pengxiang (Alex) Li and colleagues, including Jalpa Doshi, explore whether high out-of-pocket costs limit access to oral therapies for Medicare patients newly diagnosed with metastatic renal cell carcinoma. Using 2011–2013 Medicare claims, the investigators identified 1,721 patients newly diagnosed with metastases in the liver, lung, or bone. They compared low-income Medicare Part D beneficiaries (who had low out-of-pocket costs due to...

Reimagining the Future of Medicare Across the Care Continuum

Oct. 30, 2017

Reforming Medicare to protect the health of an aging and vulnerable population is a pressing policy concern. To share some perspective, Dr. Mary Naylor led a panel entitled “Shaping the Future of Medicare” at Penn LDI’s 50th Anniversary Symposium.

The panelists addressed several core themes, including cost-effective personal care in the home, end-of-life care, Medicare payment reforms, and reimagining care for families of an aging population.

Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes

Jun. 29, 2017

Laura A. Dummit, Daver Kahvecioglu, Grecia Marrufo, Rahul Rajkumar, Jaclyn Marshall, Eleonora Tan, Matthew J. Press, Shannon Flood, L. Daniel Muldoon, Qian Gu, Andrea Hassol, David M. Bott, Amy Bassano, Patrick H. Conway

In JAMA, Laura Dummit and colleagues, including Matthew Press, evaluate whether a Centers for Medicare and Medicaid Services (CMS) bundled payment pilot program is associated with a reduction in Medicare payments. Specifically, the authors assess if Bundled Payments for Care Improvement (BPCI) reduced Medicare payments and maintained quality in lower extremity joint replacement. This CMS program was launched in 2013 to test whether linking payments for services provided during an episode of care can reduce Medicare payments and maintain quality. The authors used a difference-in-...

Effects of the ACA on Health Care Cost Containment

Issue Brief
Mar. 2, 2017

This brief reviews the evidence on how key ACA provisions have affected the growth of health care costs. Coverage expansions produced a predictable jump in health care spending, amidst a slowdown that began a decade ago. Although we have not returned to the double-digit increases of the past, the authors find little evidence that ACA cost containment provisions produced changes necessary to “bend the cost curve.” Cost control will likely play a prominent role in the next round of health reform and will be critical to sustaining coverage gains in the long term.

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