Efforts are underway throughout the Medicare program to better manage beneficiaries’ chronic conditions, with the goal of improving quality and lowering the costs of care. With an estimated 31 million Medicare beneficiaries suffering from a chronic condition such as cardiovascular disorders, diabetes and cancer, many still do not receive the coordinated services they need to manage their chronic conditions, and beneficiaries with multiple chronic conditions incur higher-than-average spending. However, traditional fee-for-service Medicare, Medicare Advantage, and newer models such as Accountable Care Organizations (ACOs) differ in the tools and methods available to manage chronic care.
Almost three in ten Medicare beneficiaries are enrolled in the Medicare Advantage (MA) program, which offers a choice of competing private health plans – typically managed care plans such as HMOs and PPOs. The Affordable Care Act (ACA) made significant changes to the way Medicare Advantage plans are paid, including tying a portion of payments to a quality star rating system. Despite predictions that MA enrollment would drop in the wake of scheduled payment reductions to the program, the percentage of seniors who are choosing to enroll in MA plans is still growing. However, the impact of upcoming reductions remains the subject of much debate.
While the Patient-Centered Medical Home (PCMH) model has increasingly been embraced by providers and payers as a way to improve health care and lower costs, many questions remain about its effectiveness. Definitions of medical homes vary, but they are generally known as a model that aims to transform primary care through increased coordination and communication among a team of providers. Recent medical home initiatives have encouraged primary care practices to invest in capabilities such as patient registries and electronic health records, and to achieve medical home recognition. Health plans offer to pay more to the practices that achieve recognition.
Preventive services were a priority in the Patient Protection and Affordable Care Act (ACA), which required that a set of services be available to consumers with no cost sharing. This has improved access for some people to some services. But persistent barriers for consumers are limiting the utilization of preventive services. These barriers include the variability of insurance coverage, the affordability of out-of-pocket costs, the challenges of education and outreach, and the funding of public health initiatives.
With the cost of repealing the Sustainable Growth Rate for Medicare Physician Payment lower than ever, many suggest that 2014 is the year that permanent change may finally be realized. This toolkit provides a brief summary of the history of the SGR, including the recent actions by the House Energy and Commerce, House Ways and Means, and Senate Finance committees to repeal and reform the flawed physician payment system.
Congress is as close as it has ever been to scrapping the Medicare sustainable growth rate (SGR) for an alternative system of paying doctors based on the quality – rather than the quantity – of services.
Healthier and Wealthier, or Sicker and Poorer? Prospects for Medicare Beneficiaries Now and in the Future
Although Medicare reform is not currently a front-burner issue, proposals to reduce Medicare spending appear regularly on the policy agenda. Various Medicare savings proposals have recently emerged in the context of efforts to control the national deficit and debt, and could arise in the next few months when Congress considers how to modify Medicare’s physician payment policy to avoid a precipitous reduction in physician fees. The recently passed bipartisan budget deal delayed a reduction in Medicare payments to physicians until April, and any effort to permanently replace the existing system by which Medicare pays physicians will be costly.
Increasingly, hospitals are “observing,” instead of admitting, Medicare beneficiaries, even when they are there for more than 48 hours.
Health care policy leaders are counting on public and private initiatives, such as paying for performance, to improve value in the health care equation in which cost and quality at times seem to be at odds.
More than a third of Pioneer ACOs succeeded in reducing costs in Medicare in their first year, according to a recent Centers for Medicare and Medicaid Services (CMS) report. The program initially saved Medicare about $87 million and cut Medicare spending by 0.5 percent.
Top congressional health care staff members will meet with reporters Wednesday, August 28 to discuss upcoming pressing health care policy topics.
A new Alliance for Health Reform video features two former Medicare administrators — Gail Wilensky and Bruce Vladeck — on their ideas about how to save the program.
Recent proposals to combine the two main parts of Medicare would mean streamlining deductibles and other cost-sharing for beneficiaries. But health care policy experts are cautioning that such a change is complicated and requires analysis. A July 22 briefing explored the impact on beneficiaries.
Big changes are coming to Medicare Advantage, through which 28 percent of Medicare beneficiaries now get coverage in such private health plans as HMOs and PPOs. A June 10 Alliance briefing looked at the program’s chances for survival and growth.
The federal government currently spends about 15 percent of its budget on Medicare, and the program faces substantial growth in beneficiaries as baby boomers continue to age into eligibility. A June 3 briefing, “Medicare for the 21st Century,” addressed the sustainability of Medicare under its current design.
Beginning on Oct. 1, 2012, hospitals for the first time faced a financial penalty for readmitting a Medicare patient whom they had already cared for in the past month. Data shows that readmissions have already fallen, although the policy remains controversial.
Over nine million Americans receive benefits from both Medicare and Medicaid costing over $315 billion in health care services in the two programs combined. The dual eligibles account for 15 percent of the Medicaid population and almost 40 percent of all Medicaid expenditures for medical services; and 20 percent of the enrollees in Medicare, but 30 percent of the expenditures.