Browsing by Subject "Medicare"
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Item Cancer and the medicare disabled.(2008-11) Habermann, Elizabeth AnneThis dissertation examines relationships between cancer in working-age adults and enrollment in Medicare due disability. We examine whether cancer diagnosis and treatments affect enrollment in Medicare due to disability, whether there is pent-up demand for cancer diagnosis during the 29-month waiting period between application and receipt of Medicare benefits, and whether disabled working-age adults receive quality cancer care when enrolled in Medicare.Item The effect of medicare's new technology add-on payment policy.(2010-06) Bockstedt, Lindsay A.The new technology add-on payment (NTAP) is the first payment incentive under Medicare's inpatient prospective payment system (IPPS) related to technology. Implemented in 2001, the NTAP reimburses hospitals up to fifty percent of the cost related to the use of eligible new technologies in addition to the prospective Medicare Severity Diagnostic Related Group (MS-DRG) payment. The NTAP was implemented to ensure access of new clinically beneficial technologies to Medicare beneficiaries while the prospective payment system recalibrated to reflect the cost of new technology. For a technology to be eligible for NTAP, it must meet three criteria: (1) the technology must be considered new, as defined by the Centers for Medicare and Medicaid Services (CMS) as within two to three years following FDA approval; (2) the technology must be considered costly and inadequately reimbursed under the current MS-DRG assignment; (3) the technology must provide a substantial clinical improvement to Medicare beneficiaries. Once a technology is granted new technology add-on payment status, a hospital is eligible to receive NTAPs for up to three years. Upon the sunset of the NTAP, the prospective DRG rates are recalibrated to reflect the utilization of the new technology and a hospital will receive only the associated DRG payment when the technology is used. As of September 30, 2007, seven technologies have been granted NTAP status. With the exception of one pharmaceutical technology, all of the technologies have been implantable medical devices. This research evaluates the effect of Medicare's NTAP program. The NTAP policy offers the unique opportunity to evaluate hospitals' response to payment incentives under a mature prospective system. This research is the first to evaluate the value of the NTAP policy and empirically estimate the effect of the NTAP policy on the utilization of new technology. The thesis is organized around three research questions: 1) does the presence of the NTAP policy affect the probability new technology is used? 2)does the amount of the NTAP affect the probability a new technology is used? 3) what is the value of the NTAP policy? The results increase the understanding of how hospitals respond to payment incentives, which is becoming increasingly important as health care reform seeks to develop incentives to improve the efficiency, quality and safety of health care delivered.Item Essays in Industrial Organization(2015-06) Miller, KeatonIn two essays, we examine several problems in industrial organization. In the first essay, we study the effectiveness of partially-privatized Medicare by estimating the costs that private firms face when providing care equivalent to that of the public sector. In contrast to previous studies, we take a dynamic approach, driven by the idea that consumers face large switching costs. We find that private firms face higher costs than the government after adjusting for patient characteristics and generosity of benefits. The second essay focuses on the effectiveness of U.S. merger policy by studying the acquisition behaviors of cable telecommunication companies. We construct a novel dataset of acquisitions in the cable industry from 2000-2012 and find the Hart-Scott-Rodino disclosure threshold only affects firm behavior when acquiring firms with overlapping geographic coverage areas.Item Essays in Industrial Organization and Health Economics(2019-07) Falcettoni, ElenaThis dissertation studies how physicians respond to incentives in terms of: their treatment choice, their geographical distribution in the United States, and their effect on health outcomes. To address this, I exploit micro-data from Medicare at a physician-procedure level. I then supplement this dataset with novel, granular data collected from physicians’ directories that follow physicians from their choice of medical school onward. Chapter 1 introduces the topic and presents an overview of the questions analyzed and results obtained throughout the dissertation. Chapter 2 analyzes primary care physicians’ response to fee-for-service pricing along the urban/rural divide. In particular, it first documents that primary care physicians provide more (remunerative) specialty procedures in less urban areas, where specialists are fewer; secondly, it analyzes how primary care physicians switch to the more remunerative procedures when their fees are increased. Chapter 3 develops a model of physicians’ location choices and uses it to explore the impact of policy changes (loan forgiveness and salary incentives) on the geographical distribution of physicians. Chapter 4 provides evidence on the impact of the physician workforce on health outcomes by exploiting the policy-set fees and the micro-data availability.Item Essays in International Economics and Labor Economics(2017-08) Viana Costa, DanielaThe three chapters of this dissertation investigate major puzzles in international economics and labor economics. The first chapter investigates the macroeconomic effects of primary commodities trade flows across countries with different export composition. The second chapter studies labor flows of workers with similar skill-level and across countries with similar income. Lastly, the third chapter evaluates the macroeconomic effects of a health policy in the United States. Chapter 1 analyzes how the production and price volatility of primary commodities account for the co-movement between real GDP and terms of trade. Primary commodity exporter countries face large terms of trade fluctuations, largely driven by primary commodity price shocks and amplified by the relative importance of primary commodities in the countries’ exports. In this chapter, I document that an increase in the price of a primary commodity is usually followed by a decrease in terms of trade, defined as the relative price of imports over exports, and an increase in real GDP in these countries. Meanwhile, countries that do not export primary commodities enjoy more stable terms of trade, and their real GDP is positively correlated with terms of trade. Although the literature on primary commodity exporters has focused on developing countries, I show that this relation is independent of a country’s income level. Since standard models are unable to generate real aggregate fluctuations from price shocks if real GDP is correctly measured, this paper identifies a puzzle. I propose a class of mechanisms that is capable of explaining the heterogeneous impact of terms of trade fluctuations across countries. I show that a possible resolution is to incorporate the presence of idle resources and a production cost externality in the primary commodity producing sector in order to connect terms of trade fluctuations to real GDP fluctuations. When subjected to a primary commodity price shock, the model successfully accounts for the behavior of terms of trade and its relation to real GDP for different export compositions. Chapter 2, joint work with Maria Jose Rodriguez Garcia and Rocio Madera, revisits empirical evidence on migration within the European Union-15, disaggregated by occupation. We find that workers move to countries where their type is relatively more abundant among natives. This is at odds with traditional models of migration. We develop a model with external economies of scale that generates an agglomeration force in high-educated labor. Our main result is that a country that is relatively abundant in highly educated labor force will attract foreign labor of the same type. We argue this type of model is more suitable to analyze migration flows between countries of similar income level. Finally, Chapter 3, joint with Juan Carlos Conesa, Parisa Kamali, Timothy Kehoe, Vegard Nygard, Gajendran Raveendranathan, and Akshar Saxena, develops an overlapping generations model to study the macroeconomic effects of an unexpected elimination of Medicare. We find that a large share of the elderly respond by substituting Medicaid for Medicare. Consequently, the government saves only 46 cents for every dollar cut in Medicare spending. We argue that a comparison of steady states is insufficient to evaluate the welfare effects of the reform. In particular, we find lower ex-ante welfare gains from eliminating Medicare when we account for the costs of transition. Lastly, we find that a majority of the current population benefits from the reform but that aggregate welfare, measured as the dollar value of the sum of wealth equivalent variations, is higher with Medicare.Item Low Income Subsidy (Lis): An Evaluation Of Expenditure, Utilization And Health Care Outcomes(2014-05) Doherty, DelBACKGROUND: This study focuses on the Low Income Subsidy (LIS) of the Medicare Part D program. LIS is a federal program which provides government subsidized prescription drug coverage for Medicare beneficiaries in order to reduce or eliminate low- income enrollees' out-of-pocket expenses associated with prescription drugs. A plethora of studies have been conducted on the effect of insurance on health care utilization and the corresponding effect on health and health outcomes. Within the Medicare Part D population, a myriad of studies have shown conflicting results regarding the effects of subsidized cost-sharing on expenditure, utilization and health outcomes. Results from studies specifically comparing deemed vs. non-deemed LIS beneficiaries' expenditure, utilization and health outcomes have been equivocal. OBJECTIVE: To evaluate the impact of subsides on expenditures, medication and health care utilization and health outcomes between LIS groups. METHODS: Using 5% Medicare administrative sample, interrupted time series (differences-in-differences) regression models were developed to evaluate the impact of LIS enrollment (subsidy amount) between LIS groups and estimate changes in utilization and expenditures and for beneficiaries who switched LIS status between 2009 and 2010. RESULTS: The results from this study showed that beneficiaries with no subsidy had significantly higher total health services utilization and expenditure, compared to beneficiaries with no subsidy. However, for beneficiaries who switched LIS status, the effect of LIS on health services utilization was equivocal. For prescription drugs, the results showed a significant increase in medication utilization with increasing subsidy amount (i.e. deemed > non-deemed > non-LIS). Yet, there was virtually no difference in prescription drug expenditures and medication adherence between LIS groups. These results were consistent for beneficiaries who switched LIS status between 2009 and 2010. CONCLUSION: The findings from this study suggests the LIS program, like Part D itself, improves beneficiaries' access to affordable prescription drugs. While there was a positive association between subsidy amount and prescription utilization and expenditure, there was no impact on medication adherence, and the impact of LIS status on health services utilization was equivocal. Essentially, LIS provided no medical spending offsets, consistent with findings in the literature.Item Measuring Quality of Diabetes Care for Medicare Beneficiaries(2013-05) Parashuram, ShriramThis dissertation consists of three papers studying existing practices in measuring quality of care for Medicare beneficiaries that warrant further examination. Quality of diabetes care is currently reported at the practice or plan level as a composite, summarizing multiple binary measures in the diabetes measure set. Medicare's Accountable Care organization demonstration uses an all-or-none approach deeming only diabetics who receive all measures in the diabetes care measure set to have met the quality threshold. This approach while simple might not be as meaningful as a graduated approach. Other approaches to composite quality measurement, like Medicare's value based payment system for physicians, add up binary measures in the diabetes care measure set, weighting them equally. But all measures in the set might not be equally important for quality, making the case for weighting measures accordingly. Finally, Medicare's Physician Quality Reporting System (PQRS) offers incentive payments to physicians for reporting quality for their patients. In the absence of incentives for outcomes, the impact of reporting on outcomes is questionable. The dissertation employs Medicare administrative claims to answer the above questions. Paper 1 compares prediction of subsequent outcomes for Medicare beneficiaries using all-or-none approach against a graduated approach to quality measurement. Paper 2 compares measure weights for diabetes care processes obtained using three alternate approaches to weighting composites, to study whether equal weighting is justified in practice. Paper 3 studies whether PQRS quality reporting for diabetics is linked to receipt of more recommended diabetes care processes and better outcomes. This dissertation ultimately emphasizes the need to better understand quality mechanisms to measure it appropriately for quality improvement.Item Medicare for All: Medical bills and middle class struggles(2019-12-10) Levey, Noam; Jacobs, Lawrence R.Item Nursing in a Prospective Payment System Health Care Environment.(School of Nursing, University of Minnesota., 1986) Newman, Margaret; Autio, SharonItem Out-Of-Pocket Costs, Subsidies, And The Delivery Of Breast Cancer Care Among Elderly Women(2020-11) Qin, XuanziOut-of-pocket (OOP) costs can affect patients’ access to care and clinical outcomes. This dissertation takes advantage of the natural experiment provided by the combination of the introduction of generic aromatase inhibitors (AIs) and Medicare Part D low-income subsidy (LIS) policy to understand the role of OOP costs and subsidies in the delivery of breast cancer care. Guidelines suggest postmenopausal women diagnosed with hormone receptor-positive (HR+) breast cancer initiate adjuvant hormonal therapy with either AIs or tamoxifen. Switching to another therapy drug is an important strategy to manage treatment related side effects. Those diagnosed at early stages should also receive surgery and/or radiation before or after the initiation of hormonal therapy. The three AIs, anastrozole, exemestane and letrozole, went off patent sequentially in 2010 and 2011. Generic entry lowered OOP costs for AIs. Medicare Part D beneficiaries receiving LIS (subsidized) have substantial lower OOP costs for prescription drugs than those without LIS (unsubsidized), and thus are unlikely to be affected by changes in OOP costs due to generic entry. Medicare and Medicaid dually eligible beneficiaries (duals) receive LIS and Medicaid support for other medical services. This dissertation uses the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify the main study cohort that consists of women first diagnosed with HR+ breast cancer at age 65 years and older between 2007 and 2013 (N=93,650). I find the introduction of generic AIs was associated with improved pharmaceutical access indicated by increased probability of initiating any hormonal therapy drugs, increased timeliness of initiation and increased probability of receiving AIs over tamoxifen. Despite the minimal reduction in OOP costs for AIs after generic entry among the subsidized group, the subsidized experienced similar changes in outcomes like the unsubsidized group who had large reductions in OOP costs after generic entry. Thus, reduced OOP costs due to generic entry can only partially explain the improved access after generic entry. I also find that generic entry increased therapy adherence and reduced early discontinuation both directly through reduced OOP costs and through intermediary changes in switching behaviors resulted from reduced OOP costs. Generic entry affected therapy adherence and continuation without drug switches directly through reduced OOP costs, and thus increased adherence and continuation without drug switches after generic entry were only observed in the unsubsidized group. Generic entry might affect adherence and continuation with drug switches through both reduced OOP costs and improved management of side effects, and thus increased adherence and continuation with drug switches were observed in both the subsidized and unsubsidized groups. Finally, I find that although duals have their medical service use and prescription drug use subsidized, duals were less likely to be diagnosed at early stages, receive guideline-compliant treatment and initiate hormonal therapy than non-duals. Among duals, those with Medicaid coverage gaps or coverage changes were less likely to be diagnosed at early stages and more likely to discontinue their hormonal therapy than duals without any coverage changes. These results demonstrate that interventions simply reducing OOP costs may be not enough for improving access to care. The inconsistent relationships between costs and health care use and outcomes among the subsidized group highlight the importance to understand non-financial barriers to access, such as health insurance literacy, physician and pharmacist behaviors.Item A Quest for Justice: A Historic Look at Comprehensive Health Care Reform Efforts in America 1945 - 2007(Hubert H. Humphrey Institute of Public Affairs, 2009-05-05) Hoerle, EllenIt is 2009 and health care reform is back, after a fifteen-year hiatus from the national political spotlight. A sixty-year history of various legislative initiatives has led to an expansion of the public sector of health insurance coverage, known as Medicare and Medicaid, but has continued to fall short of comprehensive reform. Comprehensive health care reform would provide universal health care insurance coverage for all Americans and include some type of system of cost controls so health care expenditures don't continue to increase at rates that threaten the budgets of other public programs such as K-12 and higher education.Item Reforming Medicare: Where Do We Go From Here?(2006-05-15) Jacobs, Lawrence R.Item Skilled Nursing Facility Use Under Hospital Controlled Bundled Payments(2019-11) Weissblum, LiannaHospitals increasingly bear financial risk for health care spending after hospital discharge through payment reforms such as bundled payments and accountable care organizations. Under Model 2 of Medicare’s Bundled Payments for Care Improvement (BPCI) initiative, hospitals took on financial responsibility for health care use during an episode of care beginning at hospital admission and lasting up to 90 days after discharge. The financial success of Model 2 participants hinged on managing post-acute care use, including skilled nursing facility (SNFs) care. During BPCI, the primary drivers of SNF Medicare spending were length of stay and therapy intensity, which determined daily payment rates. SNF therapy intensity increased considerably in recent years, despite no significant changes in SNF patient frailty or outcomes. Reducing unnecessary overuse of SNF therapy would have lowered Medicare spending without decreasing quality of care. The objective of this study is to assess changes in SNF treatment intensity (length of stay, therapy intensity, payments) under BPCI Model 2, as well as changes in SNF referral patterns and the impact of SNF market power. I focus on lower extremity joint replacement (LEJR) episodes and compare the impact of Model 2 in a cohort of hospital participants that took on risk before it was mandatory (early adopters) to a cohort of hospitals that took on risk when it was mandatory (late adopters). I find that Model 2 hospital participation was associated with differential reductions in SNF use. During both early adopter and late adopter episodes, I found differential reductions in SNF days and Medicare payments. SNF therapy intensity declined for early adopter episodes only. Within SNF changes drove reductions in SNF length of stay and Medicare payments. However, SNF therapy intensity reductions in the early adopter population were driven by changes in SNF referral patterns. I find limited evidence for large changes in referral concentration or historical SNF quality and efficiency under BPCI Model 2 across both early and late adopter hospitals. In terms of the impact of SNF market power, I find that SNF treatment intensity reductions were greatest in SNF markets with the greatest excess capacity and competition when using counties to define markets across both the early and late adopter cohorts. However, differences were not typically significant due to low statistical power. Based on the results of a power analysis, more hospital participants, may be required to detect statistically significant differences, particularly when stratifying participants into groups. Alternative results using health service areas (HSAs) to define SNF markets were less conclusive.Item Sleep disturbances and sleep disorders in older adults: epidemiology, identification and associations with inpatient healthcare utilization(2014-09) Paudel, Misti LynComplaints of insufficient or poor sleep are highly prevalent in older adult populations, with up to 50% reporting symptoms of fragmented sleep, difficulty falling asleep, early awakening and short sleep duration. In this dissertation, I focus on improving our understanding of the epidemiology of sleep disturbances in older adults by addressing three important gaps in the literature.Aim 1: I evaluated the ability of a clinical tool, the STOP-BANG screening questionnaire, to detect obstructive sleep apnea(OSA) in 2,953 older men. The STOP-BANG identified 88.4% of men as having a high likelihood of OSA, resulting in a large number of false positives (sensitivity=94%, specificity=12.7, PPV=18.6%). Results suggest that the STOP-BANG has limited clinical value in a community-dwelling older male population. Aim 2: Little is known about the intra-individual variability of sleep, especially in older adult populations who have a greater burden of sleep complaints. In a cohort of 2,804 older men, significant intra-individual variability in sleep measures was observed, and the strongest independent associative factors with greater sleep variability included race, living alone, smoking, antidepressant use, benzodiazepine use, depression, greater BMI and greater comorbidity burden. Aim 3: Sleep disturbances are associated with comorbid medical conditions, however the extent to which sleep disturbances independently impact inpatient healthcare utilization is not well understood. Data from the Study of Osteoporotic Fractures (SOF), linked to Medicare claims and Kaiser Permanente encounters among 2,103 older women was used to address this question. During 3 years of follow-up, 55% of the cohort was hospitalized at least once. Significant associations between sleep disturbances and greater odds of being hospitalized (31-72% increased odds) were largely explained by greater comorbidity burden, depression and health-related factors in multivariable adjusted models. Findings suggest that sleep disturbances are not independently associated with greater inpatient health-care utilization in older women.Item The timing of arteriovenous fistula placement and medicare costs during dialysis initiation.(2011-02) Solid, Craig AnthonyAlthough considered a rare disease in 1972 when its treatment was added to the Medicare program, the incidence and prevalence of total kidney failure, called End Stage Renal Disease (ESRD), has grown substantially in the last half-century. There are now over 500,000 patients with ESRD, comprising about 1% of all Medicare patients but accounting for over 6% of total expenditures. There were over 110,000 incident ESRD patients in 2006, projected to grow to over 150,000 by the year 2020, with a total of almost 800,000 ESRD patients by that time (Gilbertson, 2005; USRDS, 2008, Vol 2, Fig 2.1). Although kidney transplants have become more common, organ shortages as well as the complex disease burden of patients result in the majority of patients having their ESRD treated by clinic-provided hemodialysis (HD). This process, which represents the type of renal replacement therapy for 90% of new ESRD patients, involves pumping a patient's blood through an external dialysis machine to filter and clean the blood before returning it to the body. This process requires a vascular access be placed in the patient to allow the blood to flow from the patient to the dialysis machine and back again. There are two main types of vascular access: a temporary catheter, which is simply a plastic tube inserted through the skin and into a vein, and an internal access, which connects an artery and vein together to produce a strong location from which blood can be drawn. The internal access is called an arteriovenous fistula (AVF) if the vein and artery are joined directly together. If they are joined with a synthetic tube it is called an arteriovenous graft (AVG). Catheters are quick to insert, cost very little and can be used almost immediately. However, they are prone to infections and complications like clotting. AVFs and AVGs, on the other hand, are surgically created, causing them to be more expensive and require time to mature before they can be used. However, since they are completely internal they are much less at risk for infections and complications. For those who are good candidates for an AVF, the timing of their AVF placement in relation to dialysis initiation can be classified into three distinct groups: (i) those who have had an AVF placed early enough so that it is mature and ready for use when it is time to begin chronic dialysis; (ii) those who have had an AVF placed prior to dialysis initiation that has not had enough time to mature, forcing them to begin dialysis using temporary catheters until the AVF is ready; and (iii) those who do not have an AVF placed until after they have already begun regular dialysis, resulting in the full maturation time occurring while they dialyze with catheters. The main research question I wish to address is: Does having a mature AVF at the start of dialysis result in a net cost-savings to Medicare compared to either: having an AVF in place but not yet mature at initiation, or having an AVF placed soon after the start of dialysis? Currently, Medicare makes a few exceptions regarding coverage of ESRD patients for those not already Medicare eligible. While Medicare does not have any exceptions involving AVF placement prior to dialysis, if doing do would actually result in lower overall costs it might benefit Medicare to make such an exception.Item Variation in the use of differentially-reimbursed hip fracture procedures.(2010-02) Forte, Mary LeeBackground: This series of three papers examine the patient, surgeon and hospital factors that were associated with intramedullary nail (IMN) use, the geographic variation in IMN use, and the association between provider volume and short-term mortality following the surgical treatment of Medicare intertrochanteric hip fracture patients during 2000 through 2002. Methods: Medicare claims and enrollment data 2000-2002 identified Medicare beneficiaries age 65 or older who underwent an inpatient surgery to treat an intertrochanteric femur fracture using either an IMN or plate/screws. Surgeon and hospital characteristics from the MPIER physician enrollment and Provider of Services (hospital) files were merged with the claims. Logistic regression was used to examine the geographic variation in IMN use by state and year, with and without adjustment for patient factors. Generalized linear mixed models with fixed and random effects were used to model the association between surgeon and hospital factors, and device choice (IMN or plate/screws), while controlling for patient factors. Fixed effects regression analyses using generalized estimating equations (GEE) were used to examine the association of provider volume and inpatient through 90-day mortality following intertrochanteric hip fracture surgery with internal fixation. Results: Geographic variation in IMN use from 2000-2002 was extensive, was largely not explained by patient factors, and the observed surgeon practice patterns persisted over time. Surgeon factors, resident case involvement and teaching hospital status were strong predictors of IMN use. Surgeons under age 45, those operating at more than one hospital and doctors of osteopathy were significantly more likely to use IMN. Surgeon more than hospital factors accounted for high IMN use. For the short-term mortality outcomes, the magnitude of the positive hospital volume effect was smaller among hip fracture patients than has been noted among elective arthroplasty patients. There were no significant mortality differences among patients of the lowest compared with the highest volume hip fracture surgeons. Conclusions: Device choice for Medicare intertrochanteric hip fracture patients was not based primarily on patient factors in 2000-2002. Device choice was and continues to be driven by factors other than substantial clinical outcomes evidence, particularly within certain subsets of providers. Both orthopaedic faculty involved in the training of new surgeons and early-career surgeons who are taught evidence-based medicine principles were the providers observed to have the highest IMN use. In addition to preferential training, higher Medicare reimbursement to surgeons for IMN is likely contributing to substantial increases in IMN use when a less-expensive procedure would give similar outcomes in the majority of cases. Subsequent to an RVU payment incentive, IMN use has increased dramatically, yet this increased IMN use has resulted in no better quality for most patients and at a higher cost to both hospitals and Medicare.