Almost one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within thirty days; this cost Medicare $4.34 billion in 2006. ...Especially in an elderly population, cycling into and out of hospitals can be emotionally upsetting and can increase the likelihood of medical errors related to care coordination. Payment incentives in Medicare do not encourage providers to coordinate beneficiaries' care. Revising these incentives could achieve major savings for providers and improved quality of life for beneficiaries.
In this explosive exposé of our health care system, Paul Jesilow,
Henry N. Pontell, and Gilbert Geis uncover the dark side of
physician practice. Using interviews with doctors and federal,
state, and ...private officials and extensive investigation of case
files, they tell the stories of doctors who profit from abortions
on women who aren't pregnant, of needless surgery, overcharging for
services, and excessive testing. How can doctors, recipients of a
sacred trust and sworn to the Hippocratic Oath, violate Medicaid so
egregiously? The authors trace patterns of abuse to the program's
inauguration in the mid 1960s, when government authorities, not
individual patients, were entrusted with responsibility for
payments. Determining fees and regulating treatment also became the
job of government agencies, thus limiting the doctors' traditional
role. Physicians continue to disagree with Medicare and Medicaid
policies that infringe on their autonomy and judgment. The medical
profession has not accepted the gravity or extent of some members'
illegal behavior, and individual doctors continue to blame
violations on subordinates and patients. In the meantime, program
guidelines have grown more confusing, hamstringing efforts to
detect, apprehend, and prosecute Medicaid defrauders. Failure to
institute a coherent policy for fraud control in the medical
benefit program has allowed self-serving and greedy practitioners
to violate the law with impunity. Prescription for Profit
is a shocking revelation of abuse within a once-hallowed
profession. It is a book that every doctor, and every patient,
needs to read this year.
Health plans for the poor increasingly limit access to specialty hospitals. We investigate the role of adverse selection in generating this equilibrium among private plans in Medicaid. Studying a ...network change, we find that covering a top cancer hospital causes severe adverse selection, increasing demand for a plan by 50% among enrollees with cancer versus no impact for others. Medicaid’s fixed insurer payments make offsetting this selection, and the contract distortions it induces, challenging, requiring either infeasibly high payment rates or near-perfect risk adjustment. By contrast, a small explicit bonus for covering the hospital is sufficient to make coverage profitable.
•There are significant concerns with limited coverage of top specialty hospitals in Medicaid.•We find evidence that adverse selection strongly discourages Medicaid health insurers from covering a top cancer hospital.•These incentives persist despite the 100% premium subsidies in Medicaid (all plans are free).•Selection disincentives are difficult to offset within Medicaid’s fixed insurer payment structure, but can be addressed with a small explicit bonus for cancer hospital coverage.
Objectives
To estimate medical expenditures attributable to older adult falls using a methodology that can be updated annually to track these expenditures over time.
Design
Population data from the ...National Vital Statistics System (NVSS) and cost estimates from the Web‐based Injury Statistics Query and Reporting System (WISQARS) for fatal falls, quasi‐experimental regression analysis of data from the Medicare Current Beneficiaries Survey (MCBS) for nonfatal falls.
Setting
U.S. population aged 65 and older during 2015.
Participants
Fatal falls from the 2015 NVSS (N=28,486); respondents to the 2011 MCBS (N=3,460).
Measurements
Total spending attributable to older adult falls in the United States in 2015, in dollars.
Results
In 2015, the estimated medical costs attributable to fatal and nonfatal falls was approximately $50.0 billion. For nonfatal falls, Medicare paid approximately $28.9 billion, Medicaid $8.7 billion, and private and other payers $12.0 billion. Overall medical spending for fatal falls was estimated to be $754 million.
Conclusion
Older adult falls result in substantial medical costs. Measuring medical costs attributable to falls will provide vital information about the magnitude of the problem and the potential financial effect of effective prevention strategies.
In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nonelderly adults (persons aged 18-64 years) with incomes up to 138% of the federal poverty level. To our ...knowledge, the association of Medicaid expansion with suicide, a leading cause of death in the United States, has not been examined. We used 2005-2017 data from the National Violent Death Reporting System to analyze suicide mortality in 8 Medicaid expansion states and 7 nonexpansion states. Using a difference-in-differences approach, we examined the association between Medicaid expansion and the rate of suicide death (number of deaths per 100,000 population) among nonelderly adults. After adjustment for state-level confounders, Medicaid expansion states had 1.2 fewer suicide deaths (β = -1.2, 95% confidence interval: -2.5, 0.1) per 100,000 population per year during the postexpansion period than would have been expected if they had followed the same trend in suicide rates as nonexpansion states. Medicaid expansion was associated with reductions in suicide rates among women, men, persons aged 30-44 years, non-Hispanic White individuals, and persons without a college degree. Medicaid expansion was not associated with a change in suicide rates among persons aged 18-29 or 45-64 years or among non-White or Hispanic individuals. Overall, Medicaid expansion was associated with reductions in rates of suicide death among nonelderly adults. Further research on inequities in Medicaid expansion benefits is needed.
Medicare and Medicaid are the nation's 2 largest public health insurance programs, serving the elderly, those with disabilities, and mostly lower-income populations. The 2 programs are the focus of ...often deep partisan disagreement. Medicare and Medicaid payment policies influence the health care system and Medicare and Medicaid spending influences federal and state budgets. Debate about Medicare and Medicaid policy sometimes influences elections.
To review the roles of Medicare and Medicaid in the health system and the challenges the 2 programs face from the perspectives of the general public and beneficiaries, health care professionals and health care institutions, and policy makers.
Analysis of publicly available data and private surveys of the public and beneficiaries.
Together, Medicare and Medicaid serve 111 million beneficiaries and account for $1 trillion in total spending, generating 43% of hospital revenue and representing 39% of national health spending. The median income for Medicare beneficiaries is $23,500 and the median income for Medicaid beneficiaries is $15,000. Future issues confronting both programs include whether they will remain open-ended entitlements, the degree to which the programs may be privatized, the scope of their cost-sharing structures for beneficiaries, and the roles the programs will play in payment and delivery reform.
As the number of beneficiaries and the amount of spending for both Medicare and Medicaid increase, these programs will remain a focus of national attention and policy debate. Beneficiaries, health care professionals, health care organizations, and policy makers often have different interests in Medicare and Medicaid, complicating efforts to make changes to these large programs.
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