Medicaid/Medicare

CMMI and its revised strategy

Created by Section 3021 of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Innovation (CMMI; aka The CMS Innovation Center) has been tasked with creating new reimbursement strategies to improve quality and decrease costs. Over the past decade, CMMI has tested over 50 new payment models, and in just the last 3 …

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GAO Report on MIPS

The Government Accountability Office (GAO) last week published a report evaluating the Merit-based Incentive Payment System (MIPS). MIPS is an approach for CMS to pay physicians caring for Medicare beneficiaries based not just on volume but on value. MIPS evaluates provider value along four dimensions: (1) quality, (2) improvement activities, (3) promoting interoperability, and (4) …

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Impact of Medicare Pay-for-Performance Program for Surgical Procedures on Cost and Outcomes

In 2008, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital-Acquired Conditions Present on Admission (HAC-POA) program. The goal of this program was to reduce the frequency of high-cost complications among Medicare beneficiaries. The mandatory program penalized hospitals as it would no longer reimburse them for treating of preventable complications that developed during …

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Medicare vaccine coverage (including how the COVID-19 vaccines are covered)

How does Medicare cover vaccines? Are the paid for by Medicare Part B or Part D? MedPAC’s June 2021 report provides a nice overview. Medicare covers vaccines under Part B and Part D. Part B covers vaccines for influenza, pneumococcal disease, hepatitis B (for patients at high or intermediate risk), and coronavirus disease 2019 (COVID-19), …

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Elimination of the Medicaid asset test?

No, this is not coming nation-wide, but it may be on its way in California. Kaiser Health News reports: A provision in California’s newly approved state budget will eliminate the asset test for the 2 million Californians enrolled in both Medi-Cal and Medicare, the federal health insurance program for people 65 and older and people …

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Do most Medicare Part D drugs have CEA studies?

That is the question that a recent study by Tisdale et al. (2021) aim to answer. They first look at the top 250 Medicare Part D drugs in terms 2016 total spending based on the 2016 Medicare Part D Prescriber Public Use File. Drug characteristics were identified from the 2016 FDA Orange Book. The authors …

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GAO report on prescription drug advertising

Medicare beneficiaries are largely elderly individuals, many of whom suffer from a variety of health conditions. Pharmaceutical manufacturers want these patients and their physicians to be aware of new medical treatments that become available (i.e., new approvals) as well as new uses for existing drugs (i.e., new FDA indications). Direct-to-consumer advertising (DTCA) is one way …

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Medicare Advantage vs. Medicare FFS: A Systematic Review

Medicare Advantage has grown over time. In 2020, nearly four in ten (39%) of all Medicare beneficiaries – 24.1 million people out of 62.0 million Medicare beneficiaries overall – were enrolled in Medicare Advantage (MA) plans. With MA enrollment growing, a key question is who provides higher quality care: Medicare fee-for-service (FFS) or MA? Who …

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Impact of COVID-19 on CMS’ value-based programs

Many Medicare payment initiatives aim to link reimbursement to value. Value includes both cost and quality of care. However, measuring quality of care during a pandemic is problematic. Further, most of CMS’ value-based purchasing programs–such as Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition (HAC) Reduction Program all …

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Medicare eats the world

In 2020, Medicare premiums and cost sharing were estimated to consume 24 percent of the average Social Security benefit, up from 14 percent in 2000. The Medicare Trustees estimate that in another 20 years, these costs will consume 31 percent of the average Social Security benefit. Medicare Payment Advisory Committee (MedPAC), March 2021 report

How much does the U.S. federal government pay for pharmaceuticals?

A number of different federal agencies buy prescription drugs. However, the price at which these pharmaceuticals are purchased varies dramatically. To quantify this variation, a 2021 report from the Congressional Budget Office examines the following prices: Medicare Part D: the prescription drug program for Medicare beneficiaries. Prices are set when private insurers (or pharmacy benefit …

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Medicare Part D: Do beneficiaries shop for high-value plans?

Medicare Part D covers prescription drugs for largely elderly Americans in the U.S. Those who qualify for both Medicare and Medicaid receive Part D drug coverage with no premiums and reduced copayments through the low-income subsidy program (LIS). Although federal and state government pays for about 6 out of every 7 dollars of the Part …

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Dual Eligibles’ Medicaid Policy Database

Poor, elderly individuals who may qualify for both Medicaid (for being poor) and Medicare (for being elderly, blind, disabled or have ESRD). In these cases, Medicaid serves as a supplemental insurer, covering Medicare coinsurance and deductibles. The generosity of this supplemental coverage for so-called ‘dual-eligibles’ varies across states. These differences in Medicaid payments arise from …

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CBO: COVID-19’s impact on the federal budget

Earlier this month, the Congressional Budget Office (CBO) gave an update to its federal budget projections between 2020 and 2030. As expected, things look grim for 2020. CBO projects a federal budget deficit of $3.3 trillion in 2020, more than triple the shortfall recorded in 2019. That increase is mostly the result of the economic …

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