Merging Medicare Parts A and B: potential effects on beneficiaries, surgeons, and other stakeholders.

Describes the reasons Medicare Parts A and B are currently paid under different mechanisms Explains why the time is ripe to merge Parts A and B Examines the potential effects on delivery of patient care, the federal government, and providers

Home health to hospice: the case for a smooth transition.

Changes in regulations and reimbursement are a continual challenge for home health and for hospice clinicians and administrators. Home health agencies are keenly aware of quality measures and related reimbursement effects. This article explores opportunities for home health and hospice to develop a provider relationship that benefits both patients and providers.

Comparison of risk of cerebrovascular events in an elderly VA population with dementia between antipsychotic and nonantipsychotic users.

INTRODUCTION: The credibility of an increased risk of cerebrovascular events (CVEs) in elderly patients with dementia being treated with second-generation antipsychotics (SGAs) is debatable. Although early published and unpublished data indicated a risk, much of the subsequent literature has not supported this initial finding. Previously published studies were flawed in part because they lacked a control group and did not stratify by dementia subtype. This study examined the risk of a CVE in patients diagnosed with Alzheimer or vascular dementia while being treated with SGA, first-generation antipsychotics, or no antipsychotic medication. METHODS: Data from 14,029 patients aged 65 years and older were evaluated using patient information from Veterans Administration and Medicare databases. Patients who received care for dementia were categorized according to dementia subtype (vascular or Alzheimer) and antipsychotic use during an 18-month period. Patients were observed until they were admitted to a hospital for a CVE, stopped taking or switched antipsychotics, died, or until the 18-month observation period ended. RESULTS: Overall, CVE risk did not differ whether patients were receiving a first-generation antipsychotic, SGA, or no antipsychotic therapy. However, patients with vascular dementia had an increased risk in hospitalization for a CVE. There was no increase in risk of a CVE for patients treated with quetiapine, olanzapine, or risperidone relative to haloperidol, or for patients receiving olanzapine or risperidone relative to quetiapine. Stratified subgroup analyses demonstrated no difference in risk for CVE-related admission patients with Alzheimer dementia among individual agents. However, patients with vascular dementia receiving risperidone, but not olanzapine or quetiapine, were found to be at decreased risk for CVE admission relative to haloperidol. CONCLUSIONS: This study found no increase in overall risk for CVE-related hospital admission in patients treated with antipsychotic medications.

Impact of organizational infrastructure on beta-blocker and aspirin therapy for acute myocardial infarction.

BACKGROUND: Although organizational change has been advocated as a critical component of quality improvement, there is little data available on the variation and effectiveness of organizational elements in the care of acute myocardial infarction (AMI). PURPOSE: This study was designed to examine the impact of organizational infrastructure on the use of aspirin and beta-blockers during and after AMI. METHODS: We assessed organizational infrastructure for AMI care in 44 hospitals in Kansas and linked these data to patient-specific process of care data collected in Kansas as part of the Cooperative Cardiovascular Project. While controlling for clustering within hospitals, we examined the relationships between hospital infrastructure and use of aspirin and beta-blocker both at admission and discharge. RESULTS: Hospitals varied widely in their inclusion of aspirin and beta-blockers in AMI pathways, protocols, and standardized order sets. Hospitals also varied in the involvement of their physicians in AMI quality improvement and in their ability to identify a physician champion for AMI care. Patients were more likely to receive aspirin on admission in hospitals that included aspirin in their emergency department order sets (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.48) and were more likely to receive beta-blockers on admission and at discharge if beta-blockers were included in an emergency department protocol or pathway (OR 2.14, 95% CI 1.25-3.77 and OR 3.5, 95% CI 1.14-14.38, respectively). Use of beta-blockers at discharge was also associated with commitment of administration to AMI care and the presence of a physician champion. CONCLUSIONS: Quality improvement efforts should include a close examination of the organization of AMI care to assure that critical elements in the care of AMI patients are not inadvertently omitted.

A comparison of inpatient severity, average length of stay, and cost for traditional fee-for-service medicare and medicare HMOs in Florida.

This research compares the mean severity level, length of stay, and cost of Medicare health maintenance organization (HMO) and Medicare fee-for-service (FFS) inpatients. The results suggest Medicare HMOs have healthier inpatients and shorter lengths of stay, but more costly per-day utilization. These findings are contrary to the assumption that HMOs reduce daily utilization.

Medicare payment options for rural hospitals: the name game.

Within the framework of Medicare laws and regulations governing payments for acute-care services are various options affecting payments to individual hospitals, many of which are directed at rural hospitals. Several changes in the classifications for sole community hospitals, Medicare-dependent hospitals, and rural referral centers have been implemented through the Balanced Budget Act (BBA) of 1997 and subsequent legislation. The critical access hospital classification implemented through the BBA makes available on a national level the former rural primary care hospital classification. Each of these four classifications provides for different payment enhancements.

Using grant funding for innovative projects.

As part of the Balanced Budget Act of 1997, Congress created the Medicare Rural Hospital Flexibility Program for limited-service hospitals. The program is intended to bolster fragile rural service through network development. As part of the program, states may create a program to convert hospitals to critical access hospital (CAH) status. CAH designation gives very small, rural hospitals staffing flexibility for providing emergency, outpatient, and short-stay inpatient services and Medicare reimbursement on a reasonable cost basis. Michigan now has 14 critical access hospitals.

Including hospice in Medicare capitation payments: would it save money?

Hospice services received by Medicare risk-based health maintenance organization (HMO) enrollees are paid on a non-capitated basis, creating financial incentives for HMOs to encourage their terminally ill patients to elect hospice. Using Medicare administrative records for 1998, we found that hospice enrollment in the last month of life was significantly higher among HMO enrollees than among beneficiaries in fee-for-service (FFS). However, low mortality rates among HMO enrollees produced similar population-based rates of hospice use in the HMO and FFS sectors. Simulations showed that including hospice care under capitation payments in July 1998 would have produced very small savings for Medicare.

Effects of institutional services and characteristics on use of postacute care settings.

Postacute care under Medicare may be provided in several institutional settings, some of which function as substitutes for each other, including rehabilitation care in either specialty hospitals and hospital units excluded from Medicare PPS or skilled nursing facility care. This study uses Medicare billing data to examine institution-based postacute care utilization for beneficiaries' hospital episodes occurring from February 1, 1992 through June 30, 1992. Data on inpatient and postacute Part A services used by Medicare inpatients receiving care in rehabilitation facilities or skilled nursing facilities are presented. The results indicate that, even after casemix is controlled for, inpatient stay treatment variables affect postacute care utilization patterns. Nonclinical factors such as age and sex also affect choice of postacute care site.