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.     

Opening a dialog: communicating with retirees about Medicare+Choice.

In October 1998, the Health Care Financing Administration sent information to 38 million Medicare beneficiaries in five pilot states, consisting of a comprehensive handbook entitled Medicare and You. The purpose of the handbook is to clarify new options under Medicare+Choice to participants. Such clarification is bound to initiate contact by Medicare beneficiaries to former employers/unions. This article addresses employers' need to develop a communication strategy for beneficiaries and suggests a methodology and possible questions that may arise.     

Medicare on the critical list. Understanding the etiology of the disease will help in the search for a cure.

Medicare, and its companion program Medicaid, came into being as part of Lyndon Johnson's Great Society. Their purpose was to provide the elderly with equal access to high-quality medical care. Though the goals were laudable, the magnitude of the costs and of the effects was unforeseen. As the two programs made medical care available to a large segment of the population, the demand grew. At the same time, private industry became more generous with its health insurance plans. Because of their emphasis on hospital care, the governmental and private industry plans helped push hospital prices up. Now that both sectors are finding the cost of medical care unacceptably high, Congress is proposing remedial legislation and corporations are trying alternative health care plans. These authors explore how well the maladies of Medicare may respond to the various cures that are being proposed.     

A framework for redesigning or fine-tuning your benefit package--results from a national survey of stressful life events

The results of a national survey of stressful life events are introduced as a useful framework for redesigning or fine-tuning corporate benefit packages to better meet employee needs, as well as to attract and retain top talent. Among the specific recommendations are (a) expanded bereavement leave, (b) hospice services, (c) employee assistance program access, (d) child care/elder care and (e) group legal services. Offering benefits that enable individuals to cope more effectively with major life event stressors is viewed as a powerful way of strengthening the psychological contract between employee and employer.     

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.     

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.     

Uncertainty, Real Options, and Cost Behavior: Evidence from Washington State Hospitals

This study tests an implication of the real‐options theory of investment, that uncertainty leads firms to prefer technologies with low fixed and high variable costs. In 1983, a change in Medicare reimbursement increased the uncertainty of revenues for hospitals. Using a sample of 831 departments in 59 Washington State hospitals over the 1977–1994 period, we find that the ratio of variable to total costs increased after 1983. This increase is not attributable to a gradual increase in the ratio over time: We estimate a significant increase after 1983 even after controlling for a time trend. Further, we find a greater increase in the variable‐to‐total cost ratio for hospitals that had higher percentages of Medicare patients, increasing our confidence in the conclusion that the change in cost behavior is attributable to Medicare's change in reimbursement.     

The clock is ticking on readmission penalties

Hospital leaders who are considering initiatives to reduce readmissions by improving discharge processes and postdischarge care should begin with five action steps: Ascertain the hospital's Medicare 30-day readmission rates from July 1, 2011, to June 30, 2012. Based on these numbers, estimate the potential readmission penalties the organization may face. Identify a clear strategy or program for the organization to reduce 30-day readmissions and avoid Medicare penalties. Determine the overall direct and indirect costs of this strategy or program. Calculate the potential ROI of the initiative.     

Do report cards tell consumers anything they don't already know? The case of Medicare HMOs

Estimated responses to report cards may reflect learning about quality that would have occurred in their absence (“market‐based learning”). Using panel data on Medicare HMOs, we examine the relationship between enrollment and quality before and after report cards were mailed to 40 million Medicare beneficiaries in 1999 and 2000. We find consumers learn from both public report cards and market‐based sources, with the latter having a larger impact. Consumers are especially sensitive to both sources of information when the variance in HMO quality is greater. The effect of report cards is driven by beneficiaries' responses to consumer satisfaction scores.     

Improving the delivery of clinic care

There has been an increasingly widespread movement toward the delivery of health care in outpatient settings. Hospitals must start to prepare for the shift from inpatient to outpatient services. Reductions in reimbursement and increasing costs will force hospitals to collect and obtain more data on outpatient services. Projecting future demands and assessing current utilization rates are two of the key factors in maintaining stability. This article is a case study of a major urban medical center's outpatient clinic. It includes a summary of observations on the clinic's daily operations and several recommendations for improvement. While the original analysis was highly specific to the actual facility observed, this article has been structured so that it may be applied to other institutions.     

The effects of reputation and relationships on lead banks’ certification roles

We investigate the certification roles of lead bank retention in US syndicated loans with respect to interest rates, then explore how lead banks’ reputation and previous relationships with the borrower alter such certification effects. Our findings support the certification hypothesis. Loan spreads are found to decrease with a higher retention ratio, after controlling for the endogeneity of loan price and retention. The magnitude of certification effect is reduced when the lead bank is a more reputable lender and when there are prior bank–borrower relationships. Lead bank reputation and prior lending relationships can therefore substitute for the need to certify.     

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.     

HOUSEHOLD RESPONSES TO PUBLIC HEALTH SERVICES: COST AND QUALITY TRADEOFFS

The effectiveness of government investments in health care dependson the public's response to price and quality as well as onwhether these expenditures actually improve health outcomes.Consumers, even those in low-income households, are willingto pay fees for better health care if the fees translate intoimproved access and reliability. But when prices rise withouta concomitant improvement in services, malnutrition and childmortality rates increase. The availability of basic health carehas a relatively greater impact on households with low incomesor low education, or both, than does the provision of more specializedservices. This article describes the types of services for whichhouseholds indicate they are willing to pay increased fees.It also indicates the potential gains from improving these services,as well as the consequences of moving faster on cost recoverythan on providing improved or better-targeted services.      

Health care reform: universal access is feasible and necessary

While other industrial nations' health care systems have their own problems, they have more leeway to address those problems than does the United States, which spends twice as much on per capita health care as the average for other industrial capitalist democracies yet ranks average or below average in many comparative measures of health care quality. In fact, the authors of this article argue that international experience shows that assurance of universal access through expanded government involvement could provide savings while actually improving the quality of U.S. health care. In addition, universal access would recognize health care as a basic human right, not a commodity to be bartered in the marketplace and allocated based on class, race and social position.     

THE EFFECTS OF ALTERNATIVE REIMBURSEMENT SYSTEMS ON THE OPERATING BEHAVIOUR OF NURSING HOMES

Nursing home care in Australia is provided by both for-profit and not-for-profit nursing homes. Operating expenditure in nursing homes is funded by the Commonwealth Government. The reimbursement system currently in operation is linked to ownership structure. This paper examines differences in operating behaviour as a result of a reimbursement system based on ownership structure. The results of this study indicate that differences in behaviour occur as a result of ownership differences, ineffective controls and the lack of incentives in the reimbursement system to operate efficiently. These differences have important implications for policy change affecting the funding of nursing home care.     

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.     

Who Will Pay for Long‐Term Care in the UK? Projections Linking Macro‐ and Micro‐Simulation Models

The long‐term care funding system continues to attract much debate in the UK. We produce projections of state and private long‐term care expenditure and analyse the distributional impact of state‐financed care, through innovative linking of macro‐ and micro‐simulation models. Variant assumptions about life expectancy, dependency and care costs are examined and the impact of universal state‐financed (‘free’) personal care, based on need but not ability to pay, is investigated. We find that future long‐term care expenditure is subject to considerable uncertainty and is particularly sensitive to assumed future trends in real input costs. On a central set of assumptions, free personal care would, by 2051, increase public spending on long‐term care from 1.1 per cent of GDP to 1.3 per cent, or more if it generated an increase in demand. Among the care‐home population aged 85 or over, the immediate beneficiaries of free personal care would be those with relatively high incomes.     

How to solve the cost crisis in health care

U.S. health care costs currently exceed 17% of GDP and continue to rise. One fundamental reason that providers are unable to reverse the trend is that they don't understand what it costs to deliver patient care or how those costs compare with outcomes. To put it bluntly, few health care providers measure the actual costs for treating a given patient with a given medical condition over a full cycle of care, or compare the costs they incur with the outcomes they achieve. What isn't measured cannot be managed or improved, and this is all too true in health care, where poor costing systems mean that effective and efficient providers go unrewarded, and inefficient ones have little incentive to improve. But all this can be remedied by exploring the concept of value in health care and carefully measuring costs. This article describes a new way to analyze costs that uses patients and their conditions--not organizational units or narrow diagnostic treatment groups--as the fundamental unit of analysis for measuring costs and outcomes. The new approach, called time-driven activity-cased costing, is currently being implemented in pilots at the Head and Neck Center at MD Anderson, the Cleft Lip and Palate Program at Children's Hospital in Boston, and units performing knee replacements at Sch?n Klinik in Germany and Brigham & Women's Hospital in Boston. As providers and payors better understand costs, they will be positioned to achieve a true "bending of the cost curve" from within the system, not in response to top-down mandates. Accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation.     

Medicare--substitute HMOs--reimbursement from other insurance. Care Choices HMO v. Engstrom

The federal statute that permits Medicare-substitute HMOs to seek reimbursement from other insurers does not provide the HMOs with a private federal remedy for reimbursement. It permits Medicare-substitute HMOs to provide in their policies that they are entitled to reimbursement in cases where other insurance, such as the third-party liability insurance of a party responsible for causing an injury, is available. The HMO must sue in state court for its contractual right to reimbursement. It may not sue in federal court under the federal statute that merely allows it to provide for reimbursement in their policies.