Biomedical subjects
Publications and source records attributed to Paul L Grimaldi.
Medicare's drug discount card program is expected to help participants save an average of 10 to 15 percent on the cost of outpatient prescription drugs. Many of the beneficiaries signing up for the program will also qualify for financial assistance. In 2006, the program will be replaced by Medicare's outpatient drug benefit. Data from the card program should help federal actuaries estimate the cost of the drug benefit.
Developed primarily for consumers, Medicare's Compare web sites permit immediate access to information about most nursing homes and home health agencies, including indicators of the quality of care they provide. But hospital staff, too--most notably strategic and discharge planners--can benefit by consulting Compare.
Since 1997, the method to establish capitation rates for Medicare beneficiaries who are members of risk-bearing managed care plans has undergone several important developments. This includes the factoring of beneficiary health status into the rate-setting calculations. These changes were expected to increase the number of participating health plans, accelerate Medicare enrollment growth, and slice Medicare spending.
Medicare's hospital outpatient prospective payment system (OPPS) went live on August 1, 2000, after a decade of developmental work. The new system introduced a fee schedule that replaced the cost-related methods that Medicare previously used to reimburse various hospital outpatient services. Hospitals are now paid predetermined rates or fees based on the Ambulatory Patient Classification (APC) groups assigned to the services that Medicare patients receive during outpatient encounters. The new system aims to simplify Medicare's intricate cost-based reimbursement policies, improve hospital efficiency, ensure that payments are sufficient to compensate hospitals for reasonable Medicare costs, and reduce Medicare coinsurance amounts for beneficiaries. Implementation of OPPS-related administrative and operational changes has been a major challenge for hospitals.
On January 1, 2002, Medicare began to replace its cost-related inpatient reimbursement method for rehabilitation hospitals and rehabilitation units in hospitals with a prospective payment system. Under the new system, Medicare pays a predetermined, fixed amount per discharge, depending on the patient's impairment level, functional status, comorbid conditions, and age. Reduced or additional amounts are paid for early transfers, short-stay outliers, patients who expire before transfer, and cost outliers. The overall objective of the new case-based system is to provide incentives for rehabilitation facilities to furnish intensive inpatient services efficiently without tarnishing the quality of care or constraining access to care. Federal actuaries estimate that the new system will cost Medicare an additional $70 million between January 1, 2002, and September 30, 2003. The actual increase may be larger.
On July 1, 1998, Medicare's cost-related reimbursement method for skilled nursing facility care was replaced with a prospective payment system that includes a case-mix adjustment based on the Resource Utilization Groups to which Medicare residents are assigned. Shortly thereafter, Congress modified the new system in response to the industry's complaints about low payment rates. The new system aims to align Medicare payments more closely with the costs facility's incur in serving Medicare residents and slow Medicare spending growth. Recent rate increases have reduced the new system's ability to trim Medicare outlays.
Starting October 1, 2000, Medicare began paying providers of home health care at fixed, predetermined rates for services and items bundled into 60-day episodes of home health care. The episode payment rates vary with the patient's clinical, functional, and services utilization characteristics. This new approach was expected to redistribute Medicare payments among home health agencies, extend the cost savings introduced by the Interim Payment System, improve the coordination of services, and reduce the number of unnecessary home health visits.
Beginning January 1, 1992, Medicare has relied on a resource-based relative value scale (RBRVS) to establish physician fees. Medicare pays 80 percent of the lower of the amount a physician bills for the service or the fee schedule amount. The patient is responsible for the remaining 20 percent, as well as the annual Part B deductible of $100, plus any additional amount the physician may be allowed to bill. Rarely is the billed amount below Medicare's fee schedule amount. Adoption of the RBRVS fee schedule severed the link between the amount a physician charged for a service and the amount Medicare paid for it. RBRVS implementation required significant changes in the coding system used to document and bill physician services, particularly medical visits and consultations.
Ambulance fees vary with the level of service and length of the beneficiary's trip. New fee schedule is expected to trim Medicare spending. Higher fees have been implemented for rural transports and air ambulance services. Lower fees have been implemented for urban transports. Providers and suppliers must revise chargemasters, policies, and procedures.