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Concept: Medicare


Struggling to keep up with The Centers for Medicare and Medicaid Services out-patient throughput metrics, an adult emergency department serving Burlington and Camden Counties, New Jersey, sought to redefine its care delivery model by adopting the patient segmentation initiatives of the split-flow process of patient care.

Concepts: Medicare, Patient, Hospital, New York City, Centers for Medicare and Medicaid Services, New Jersey


The U.S. Physician Payments Sunshine Act mandates the reporting of payments or items of value received by physicians from drug, medical device, and biological agent manufacturers. The impact of these payments on physician prescribing has not been examined at large scale.

Concepts: Pharmacology, Medicare, Medicine, Physician, Anatomy, Health insurance in the United States, Medicare Part D, Medicare Prescription Drug, Improvement, and Modernization Act


For the fourth consecutive year, growth in health care spending remained low, increasing by 3.7 percent in 2012 to $2.8 trillion. At the same time, the share of the economy devoted to health fell slightly (from 17.3 percent to 17.2 percent) as the nominal gross domestic product (GDP) grew by 4.6 percent. Faster growth in hospital services and in physician and clinical services was mitigated by slower growth in prices for prescription drugs and nursing home services. Despite an uptick in enrollment growth, Medicare spending growth slowed slightly in 2012, mainly due to lower payment updates. For Medicaid, slowing enrollment growth kept spending growth near historic lows. Growth in private health insurance spending also remained near historically low rates in 2012, largely influenced by the nation’s modest economic recovery and its impact on enrollment.

Concepts: Health care, Medicare, Health economics, Medicine, Health insurance, Hospital, Gross domestic product, Health care in the United States


The increasing cost of prescription drugs is a burden for patients and threatens the financial stability of the US health care system. Rebates are a form of price concession paid by a pharmaceutical manufacturer to the health plan sponsor or the pharmacy benefit manager working on the plan’s behalf. Proponents argue that rebates result from vigorous negotiations that help lower overall drug costs. Critics argue that rebates have perversely increased the costs patients pay out of pocket, as well as the costs for Medicare as a whole. This special communication discusses how the availability of rebates for drugs covered by the Medicare Part D program may raise costs for patients and Medicare while increasing the profits of Part D plan sponsors and pharmaceutical manufacturers. Two policy alternatives are herein proposed that would reconfigure cost sharing to lower patient out-of-pocket costs and reduce cost shifting to Medicare.

Concepts: Pharmacology, Medicare, Medicine, Health insurance, Illness, Drugs, Food and Drug Administration, Pharmaceuticals policy


The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the “sickest” patients from the liver transplant waitlist.

Concepts: Medicare, Liver, Decision theory, Organ transplant, 2000s music groups, Policy, Centers for Medicare and Medicaid Services, Medicaid


Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2-9.3 percentage points in the probability of an all-cause hospitalization and 1.4-7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60-$2,248 for all-cause hospitalizations and by $98-$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.

Concepts: Medicare, Hospital, Nursing, Nursing home, Nurse, Centers for Medicare and Medicaid Services, Medicare and Medicaid, Registered nurse


The improvement of medication use is a critical mechanism that accountable care organization (ACO) could use to save overall costs. Currently pharmaceutical spending is not part of the calculation for ACO-shared savings and risks. Thus, ACO providers may have strong incentives to prescribe more medications hoping to avoid expensive downstream medical costs.

Concepts: Pharmacology, Medicare, Medicine, Drug, Management, Pharmaceutical drug, Medicare Part D, Medicare Prescription Drug, Improvement, and Modernization Act


Inappropriate prescribing is a rising threat to the health of Medicare beneficiaries and a drain on Medicare’s finances. In this study we used a randomized controlled trial approach to evaluate a low-cost, light-touch intervention aimed at reducing the inappropriate provision of Schedule II controlled substances in the Medicare Part D program. Potential overprescribers were sent a letter explaining that their practice patterns were highly unlike those of their peers. Using rich administrative data, we were unable to detect an effect of these letters on prescribing. We describe ongoing efforts to build on this null result with alternative interventions. Learning about the potential of light-touch interventions, both effective and ineffective, will help produce a better toolkit for policy makers to improve the value and safety of health care.

Concepts: Health care, Pharmacology, Medicare, Experimental design, Clinical trial, Randomized controlled trial, Pharmaceutical industry, Medicare Part D


With many states resisting Medicaid expansion, the Obama administration has moved to let states use Medicaid funds to buy private health plans sold through the exchanges. Moving Medicaid beneficiaries into an untested marketplace creates opportunities and challenges.

Concepts: Health care, Medicare, Health economics, Health insurance, Economics, Medicaid, Barack Obama, Self-funded health care


Although health policy experts disagree on many issues, they largely agree on the shortcomings of fee-for-service payment. The inefficiency of a payment method that rewards increases in service volume, regardless of health benefit, has become practically indefensible. But replacing discrete payments for each service with bundled payment for a set of services does not simply promote efficiency; it also potentially promotes skimping on care or avoidance of costly patients. The Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services recently announced a large-scale demonstration of bundled payments for hospital and post-acute care services, and President . . .

Concepts: Medicare, Health economics, Health insurance, Economics, Centers for Medicare and Medicaid Services, Medicaid, Health insurance in the United States, Medicare and Medicaid