Medicare Secondary Payer--liability of alleged tortfeasors. Mason v. American tobacco company

The Medicare Secondary Payer (MSP) statute does not provide individuals whose medical costs have been paid for by Medicare with a right of recovery against alleged tortfeasors (wrongdoers). Tobacco companies are not self-insured primary plans under the MSP statute because they have no existing contractual obligation to pay the health care costs of those injured by smoking.     

Potential “Savings” of Medicare: The Analysis of Medicare Advantage and Accountable Care Organizations

Medicare faces significant financial challenges because of rising health care costs. In response, Medicare reform efforts have been testing various payment and service delivery models, including accountable care organizations (ACOs), aiming to reduce expenditures while preserving or enhancing the coordination of quality care. The idea behind ACOs is to form an organizational network to coordinate all care for Medicare beneficiaries and in so doing, at least theoretically, improve quality of care and hopefully reduce medical costs. The purpose of this research is to apply Data Envelopment Analysis (DEA) to assess the potential savings of Medicare obtainable through optimally efficient implementation of ACOs and Medicare Advantage plans. DEA comparisons across plans achieve this purpose by identifying which Medicare plans operate relatively more efficiently and which are inefficient, and additionally, for inefficient plans, the DEA analysis generates target levels of “inputs” and “outputs” required to bring the plan into efficient operation. Knowing sources of inefficiency can also provide insights into Medicare reform, such as Medicare privatization and innovation models. Our results show that Medicare Advantage plans are more efficient in reducing health expenditures but incur higher administrative costs. Health expenditure savings can also be achievable by promoting government-sponsored managed Medicare such as ACOs. Finally, compared to the profit efficiency of Medicaid managed care plans, Medicare Advantage should have the potential for more Medicare market penetration from the supply (insurer) side.     

论发展我国非营利民营医疗保险制度

中国已经建立并正在完善多层次医疗保障体系,但同时也遇到了由于多支柱医疗保险制度之间的巨大差异所带来的困难和问题。为此,本文首先提出我国应走一条基本+补充,同时大力发展非营利民营医疗保险的中间型的发展医疗保险制度的新途径;其次探讨了英国、美国、澳大利亚和印度等国非营利民营医疗保险组织的发展经验,并总结了非营利民营医疗保险组织的一般特征;最后,文章就中国如何具体发展非营利民营医疗保险介绍了几点思路。     

Managed Care and Health Care Utilization: Specification of Bivariate Models Using Copulas

This article studies the effect of managed care on health care utilization compared to traditional fee-for-service plans in private health insurance market. To construct our hypothesis, we build a game-theoretic model to study health care utilization under a two-sided moral hazard: of patients and providers. In econometric modeling, we employ a copula regression to jointly examine individuals’ health plan choice and their utilization of medical care services, because of the endogeneity of insurance choice. The dependence parameter in the copula reflects the relation between the two outcomes, based on which the average treatment effects are further derived. We apply the methodology to a survey data set of the U.S. population and consider three types of curative care and three types of preventive care for the measurement of medical care utilization. We find that managed care is in general associated with higher care utilization. Evidence is also found on the underlying incentives of both patients and medical providers.     

Health care fraud control: understanding the challenge

The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control.     

Alternatives to traditional Medicare: Medicare Part C poised to prosper

Recent events indicate that Medicare Part C (Medicare Advantage) plans are poised to prosper. Yet many employers express hesitation to offer Medicare Advantage, formerly known as Medicare+Choice, plans to their retirees because they are concerned about the potential withdrawal of those plans if there is a reversal of federal funding rules. This article addresses those concerns. It provides a historical overview of Medicare Part C and describes the impact of the most recent agency guidance. The author cites plan trends, raises employer implications and concludes that Medicare Advantage plans will continue to expand, possibly facilitated by employers as they implement leading-edge retiree medical designs.     

Retiree health care benefits: strategies for a changing workforce.

Demographic, economic and cultural trends foretell a dramatically different environment for retiree health care coverage. This article will focus on the redesign of retiree health benefits to meet the retirement objectives of employers and employees, anticipate changing demographics, and respond to changes in Medicare and other government initiatives, including the Consumer Bill of Rights. The material will discuss recent design trends, including managed care, and present results of a study the author co-authored for the Kaiser Family Foundation on changes in retiree health plans.     

新医改框架下我国商业健康保险发展策略探讨——国际经验和中国模式

我国商业健康保险市场虽饱受政府重视,但却始终发育不足。相当重要的一个原因是简单逐利,并不兼顾社会需求,忽略医疗保险源自社会互助的历史渊源,也就缺乏科学的发展模式。从国际看,在私营医疗保险发挥重要作用的国家,其私营医疗保险市场构成主体、管理费用、保险合同类型、费率设定方式、专业化程度等都与我国存在较大的差异,其背后的原因是制度所遵循的价值理念和发展方式的不同,特别是对制度目标的认识。因此,本文提出一系列方法,淡化我国商业健康保险市场的盈利动机,使其注重社会公众利益与其利润的共同实现,从而使整个市场走上科学的发展道路,更好的完成自己作为公立计划补充的角色。     

Medicare in the 21st century.

The authors provide an overview of the Medicare program in terms of how the current program operates, the current issues it faces that may shape possible options for reform, and the implications of these features and issues for employment-based health plans. Current issues include adoption of a premium support model, changes in the eligibility age for Medicare benefits, Medigap insurance, benefits covered and customer service.     

印美医疗保障体系私有化比较

美国和印度都是医疗保障体系高度私有化的国家,对我国未来医疗保障适度私有化之路具有借鉴意义。通过梳理和比较,本文得出印美医疗保障体系私有化的3个异同点:(1)政府责任定位:印度政府的目标是建立初级保健水平的全民医疗,美国政府则给予弱势群体较好的医疗保障;(2)私营医疗保障体系结构:美国的非营利、营利和公立医疗机构三足鼎立,印度的营利机构占有重要地位,而非营利机构比重甚至低于公立医院;(3)公私合作意愿:印度医疗服务提供方面公私合作意愿强,美国意愿相对较弱。     

The impact of health care reform on older workers, retirees and employers

The Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010 impacts everyone who uses or pays for the health care system. Among the new law's effects will be changes in older workers' health care choices as they transition from full-time employees to part-time work or other jobs and, ultimately, to retirement, and the retiree health benefit choices facing their employers. This article reviews the major issues surrounding these changes, including those affecting retiree health benefits, benefits for Medicare-eligible retirees and health care options for older Americans not yet eligible for Medicare. The authors conclude that although employers will be reacting in 2010 and 2011 with regard to some issues surrounding FASB ASC 715-60 and the early retiree reinsurance program, employers should consider waiting to make major changes until regulations are issued and the health plans for active employees have been fully vetted.     

Pitney Bowes: using comprehensive cost information to build provider networks

Wishing to develop a work partnership with a managed care organization, Pitney Bowes decided to select its own network providers. The company reached out to the medical community for input and participation in crafting both a clinical and a business partnership that would set new standards for health care delivery in the country. A methodology--described here--was developed for comparing medical plans and selecting providers.     

Versteilerung der alters- und geschlechtsspezifischen Ausgabenprofile von Krankenversicherern

It is well-known for a long time, that health care expenditure of elder people are a lot higher than expenditure of younger people, we call this correlation of average per-capita-expenditure and age expenditure profiles. If health care expenditures for the elderly grow faster than for younger people, the expenditure profiles become ?steeper“. Data of a German private health insurer are used to investigate the phenomenon growing steepness of profiles over a period of 18 years. In the article three instruments for measuring the phenomenon of growing steeper expenditure profiles are proposed. None of them is perfect, but the more or less common trend shows that the profiles of the investigated health insurance plans did grow steeper. The health plans of men do reflect this phenomenon clearer than those of women and the inpatient plans do show a stronger effect than the outpatient plans. Research of causes by data is not possible because of the given data structure. But neither the correlation between health expenditure and time til death nor the improving life expectancy can help to explain the phenomenon.     

The Financial Accountability of Australia's Medicare System: A Generational Accounting Analysis

The financial sustainability of publicly funded health care systems is sensitive to the demographics of ageing populations, which have a significant bearing on their financial management, accountability and reporting of their financial performance. This paper examines historical and current trends in demographic structure of Australia's population that are likely to impact on the financial management and accountability practices affecting Australia'suniversal public health care system ('Medicare'). The pay-as-you-go financed funding status of Medicare as represented under both currently required, cash-based accounting principles and proposed accrual-based accounting principles are criticised for not recognising the obligations of the Australian government under Medicare. An alternative system of generational accounting is proposed that projects the financial management costs of Medicare. Data are taken from both historical trends in expenditure and ageing as well as projected demographics. The analysis implies that there is significant intergenerational-inequity in the funding of Medicare, which is not recognised under accrual-based accounting principles that are now being used to evaluate the financial accountability and performance of government entities.     

Monetized medicine: from the physical to the fiscal

This paper explores professional rivalries as one force driving market-driven healthcare. Extending their jurisdiction beyond industrial settings, industrial engineers calibrated the physician's labor against fiscal metrics by devising product lines for hospitals. These products––diagnostic related groups (DRGs)––were not, however, intended as commodities. Economists, in contrast, proffered theoretical arguments justifying why medical care was best provided using market-like mechanisms. They assumed care as a commodity. The passage of the law mandating prospective Medicare payments for DRGs created a functioning market in care by identifying the products of engineers with the assumption of economists. Accountants, meanwhile, took this as a business opportunity to increase revenues. The transformation of medical service to care was intended to reduce runaway medical costs. Market-driven healthcare has resoundingly failed to fulfill that intention. Nevertheless, it has won a symbolic success. The trade in care also implies a merger of the physical and the fiscal and puts a “price on life”. The fact that much of medical practice and ethics presuppose health as a matter of wealth says that life and death, no less than health and sickness, are professional artifacts and commodities rather than natural phenomena.     

Prices and Protocols in Public Health Care

This article addresses the problem of how to determine the optimalallocation of public expenditure in the health sector. The firstpart poses the question: How should the set of services providedin the public health care system and the fees charged for thembe chosen to maximize the health status of the population witha fixed budget? First, the findings show that policy reformshould take into account the response of the private sector.Substituting for a reasonably well-functioning private sectoris not as valuable as providing services the private sectorcannot. Second, the assumptions needed to justify the cost-effectivenessof medical interventions as a criterion for setting prioritiesare so restrictive as to make this method usable in few, ifany, circumstances. Third, prices for any one service shouldbe set to balance the conflicting goals of encouraging its useand of conserving the budget for more effective services. The second part broadens the objective of policy to cover thestandard welfare economics concerns of utility and market failure,that latter being extensive in the health sector. It reexamineswelfare maximization rules to show that only the market failurecomponents of shadow prices are needed to calculate the welfaregains from public investments.     

The effects of hospital ownership on medical productivity

To develop new evidence on how hospital ownership and other aspects of hospital market composition affect health care productivity, we analyze longitudinal data on the medical expenditures and health outcomes of the vast majority of nonrural elderly Medicare beneficiaries hospitalized for new heart attacks over the period 1985-1996. We find that the effects of ownership status are quantitatively important. Areas with a presence of for-profit hospitals have approximately 2.4% lower levels of hospital expenditures, but virtually the same patient health outcomes. We conclude that for-profit hospitals have important spillover benefits for medical productivity.     

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs. This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform. But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following:

• ? In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services.
• ? Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made.
• ? Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component.

As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”