Medicare & Medicaid Research Review

OBJECTIVE: To assess the availability, completeness, and quality of the Behavioral Health Organization (BHO) encounter data in MAX 2009. DATA SOURCE: The Medicaid Analytic Extract (MAX) 2009. METHODS: We compared metrics of reporting completeness and quality for BHOs to similar metrics for six states that primarily cover MH and SA services on a FFS basis. For the IP file, number of encounters per 1,000 person months of enrollment were compared...

OBJECTIVE: To describe the characteristics of hospitalists serving Medicare beneficiaries. DATA SOURCES: Medicare claims from 2009 and 2011 merged with the Provider Enrollment, Chain, and Ownership System file for physician characteristics. STUDY DESIGN: Our construction of the Medicare Data on Physician Practice and Specialty (MD-PPAS) enabled identification of hospitalists based on the attending physician for Medicare admissions (medical and surgical) in 2009 and 2011...

OBJECTIVE: The primary aim is to explore whether prescription drug expenditures by enrollees changed in Alabama's CHIP program, ALL Kids, after copayment increases in fiscal year 2004. The subsidiary aim is to explore whether non-pharmaceutical expenditures also changed. DATA SOURCES: Data on ALL Kids enrollees between 1999-2007, obtained from claims files and the state's administrative database. STUDY DESIGN: We used data on children who were enrolled between one and three years both before and after the changes to the copayment schedule, and estimate regression models with individual-level fixed effects to control for time-invariant heterogeneity at the child level...

OBJECTIVE: Document trends in time to post-discharge follow-up visit for Medicare patients with an index admission for heart failure (HF), acute myocardial infarction (AMI), or community-acquired pneumonia (CAP). Determine factors predicting whether the first post-discharge utilization event is a follow-up visit, treat-and-release emergency department (ED) visit, or readmission. METHODS: Using Medicare claims data from 2007-2010, we plotted annual cumulative incidence functions for the time frame post-discharge to follow-up visit, accounting for competing risks with censoring at 30 days...

OBJECTIVE: Examine the factors that are associated with awareness of physician quality information (PQI) among older people with one or more chronic illnesses and the implications for Medicare. DATA SOURCES/STUDY SETTING: Random digit-dial survey of adults with one or more chronic illnesses. RESEARCH DESIGN: Structural equation modeling to examine factors related to awareness of PQI. RESULTS: Awareness of PQI is low (13 percent), but comparable to findings in general population surveys...

PURPOSE: To examine the cost structure of home health agencies by estimating an empirical cost function for those that are Medicare-certified, ten years following the implementation of prospective payment. DESIGN AND METHODS: 2010 national Medicare cost report data for certified home health agencies were merged with case-mix information from the Outcome and Assessment Information Set (OASIS). We estimated a fully interacted (by tax status) hybrid cost function for 7,064 agencies and calculated marginal costs as percent of total costs for all variables...

BACKGROUND: Peer support programs have proliferated over the past decade, building on recovery oriented programming, yet relationships between peer support services and the costs to public programs have not been well described in literature. The purpose of this study is to fill gaps in the literature related to peer support programs and cost: lack of comparison groups, small sample sizes, and the availability of research examining utilization of Medicaid mental health services. METHODS: The study employed a retrospective design with treatment and comparison groups created from three administrative databases...

BACKGROUND: The purpose of this paper is to examine service use in an episode of acute and post-acute care (PAC) under alternative episode definitions and to look at geographic differences in episode payments. DATA AND METHODS: The data source for these analyses was a Medicare claims file for 30 percent of beneficiaries with an acute hospital initiated episode in 2008 (N = 1,705,794, of which 38.7 percent went on to use PAC). Fixed length episodes of 30, 60, and 90 days were examined...

OBJECTIVE: Potentially avoidable hospitalizations have been identified by experts as leading to poor health outcomes and costly care. Potentially avoidable hospitalizations are particularly common among full-benefit dual eligible beneficiaries. This paper examines potentially avoidable hospitalizations rates by setting, state, and medical condition, and the average cost of these events. METHODS: This analysis identifies potentially avoidable hospitalizations using diagnosis codes identified by an expert panel...

OBJECTIVE: This study estimates the effects of generic competition, increased cost-sharing, and benefit practices on utilization and spending for prescription drugs. DATA AND METHODS: We examined changes in Medicare price and utilization from 2007 to 2009 of all drugs in 28 therapeutic classes. The classes accounted for 80% of Medicare Part D spending in 2009 and included the 6 protected classes and 6 classes with practically no generic competition. All variables were constructed to measure each drug relative to its class at a specific plan sponsor...

OBJECTIVES: Under the Ticket to Work and Work Incentives Improvement Act (PL 106-170), states may extend Medicaid Buy-In coverage to a medically improved group. Improved group coverage allows adults with disabilities to retain Medicaid coverage even once they lose disability status due to medical improvement, as long as they retain the original medical impairment. The goal of this paper is to describe who participated, the patterns of their participation, and employment outcomes. METHODS: The study population consists of all individuals (n = 315) who participated in medically improved group coverage 2002-2009 in the seven states with coverage by 2009 (Arizona, Connecticut, Kansas, New York, North Carolina, Pennsylvania, and West Virginia)...

BACKGROUND: The Affordable Care Act (ACA) dramatically expands Medicaid in 2014 in participating states. Meanwhile, six states have already expanded Medicaid since 2010 to some or all of the low-income adults targeted under health reform. We undertook an in-depth exploration of these six "early-expander" states-California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington-through interviews with high-ranking Medicaid officials. METHODS: We conducted semi-structured interviews with 11 high-ranking Medicaid officials in six states and analyzed the interviews using qualitative methods...

OBJECTIVE: Evaluate the growth in various types of Medicare-paid telehealth services. BACKGROUND: There has been a long-standing hope that telehealth could be used to reduce rural patients' travel times to specialty physicians. Medicare covers telehealth services provided through live, interactive videoconferencing between a beneficiary located at a certified rural site and a distant practitioner. METHODS: We analyzed 100% of telehealth Medicare claims for 2009 matched to individual patient ZIP codes and individual provider characteristics...

BACKGROUND: Although Medicaid is a federal program, it is administered primarily by the states. Enrollees move from state to state, but their migration patterns have remained largely unknown. There are concerns about the possibility of enrollment gaps, lack of health insurance coverage, breaks in continuity of care, unmet need, risks to health status, and increased system-wide costs due to uncompensated care and the use of higher cost emergency room services because of enrollment gaps...

OBJECTIVE: To determine if the asthma medication ratio predicts subsequent emergency department (ED) visits and hospital admissions in children. DESIGN: Retrospective cohort with two year pairs. SETTING/PARTICIPANTS: 2007-2009 South Carolina Medicaid recipients with persistent asthma age 2-18. MAIN EXPOSURE: Controller-to-total asthma medication ratios were calculated for each patient in 2007 and 2008. Ratios range from 0-1 (1 = ideal, 0 = no controller)...

OBJECTIVE: Determine the factors that impact HIT use and MU readiness for community health centers (CHCs). BACKGROUND: The HITECH Act allocates funds to Medicaid and Medicare providers to encourage the adoption of electronic health records (EHR), in an effort to improve health care quality and patient outcomes, and to reduce health care costs. METHODS: We surveyed CHCs on their Readiness for Meaningful Use (MU) of Health Information Technology (HIT) and Patient Centered Medical Home (PCMH) Recognition, then we combined responses with 2009 Uniform Data System data to determine which factors impact use of HIT and MU readiness...

OBJECTIVE: To describe the prevalence and correlates of unobservable medication exposure time, and to recommend approaches for minimizing bias, in studies using Medicare Part D data.. SAMPLE: 179,065 Medicare patients hospitalized for an AMI in 2007 or 2008. METHODS: We compared two methods for creating medication exposure observation periods using acute care discharge vs. post-acute care discharge dates. We examined options for increasing cohort sizes by requiring different thresholds for observable days, or by using as a covariate, in the observation period...

OBJECTIVE: In this paper, we describe the methods underlying the econometric model developed by the Office of the Actuary in the Centers for Medicare & Medicaid Services, to explain differences in per capita total personal health care spending by state, as described in Cuckler, et al. (2011). Additionally, we discuss many alternative model specifications to provide additional insights for valid interpretation of the model. DATA SOURCE: We study per capita personal health care spending as measured by the State Health Expenditures, by State of Residence for 1991-2009, produced by the Centers for Medicare & Medicaid Services' Office of the Actuary...

OBJECTIVE: Pressure ulcers (PU) are considered harmful conditions that are reasonably prevented if accepted standards of care are followed. They became subject to the payment adjustment for hospitalacquired conditions (HACs) beginning October 1, 2008. We examined several aspects of the accuracy of coding for pressure ulcers under the Medicare Hospital-Acquired Condition Present on Admission (HAC-POA) Program. We used the "4010" claim format as a basis of reference to show some of the issues of the old format, such as the underreporting of pressure ulcer stages on pressure ulcer claims and how the underreporting varied by hospital characteristics...

OBJECTIVE: To assess limitations of using select Children's Health Insurance Program Reauthorization Act (CHIPRA) core claims-based measures in capturing the preventive services that may occur in the clinical setting. METHODS: We use claims data from ALL Kids, the Alabama Children's Health Insurance Program (CHIP), to calculate each of four quality measures under two alternative definitions: (1) the formal claims-based guidelines outlined in the CMS Technical Specifications, and (2) a broader definition of appropriate claims for identifying preventive service use...