Medicare Coverage: Lessons from the Past, Questions for the Future (original) (raw)
Related papers
Medicare is scrutinizing evidence more tightly for national coverage determinations
Health affairs (Project Hope), 2015
We examined Medicare national coverage determinations for medical interventions to determine whether or not they have become more restrictive over time. National coverage determinations address whether particular big-ticket medical items, services, treatment procedures, and technologies can be paid for under Medicare. We found that after we adjusted for the strength of evidence and other factors known to influence the determinations of the Centers for Medicare and Medicaid Services (CMS), the evidentiary bar for coverage has risen. More recent coverage determinations (from mid-March 2008 through August 2012) were twenty times less likely to be positive than earlier coverage determinations (from February 1999 through January 2002). Furthermore, coverage during the study period was increasingly and positively associated both with the degree of consistency of favorable findings in the CMS reviewed clinical evidence and with recommendations made in clinical guidelines. Coverage policy i...
2004
NHPF is a nonpartisan education and information exchange for federal health policymakers. Though the MMA offers a huge number and range of potential subjects, the discussion was focused around four primary areas: eligibility, enrollment, and outreach; the transition for dual eligibles; financing challenges; and administrative and systems issues. Each of these areas is discussed briefly below. The final section of this report contains a list of summary observations from the meeting. This report is not meant to provide extensive details or to define issues as legislative, regulatory, state, or federal, and the Forum does not intend to use this publication to propose specific recommendations or solutions to problems. Rather, the objective is to provide a general understanding of the problems expressed by state experts so that more attention will be directed to these problems by appropriate officials at both the state and federal level. (It should be noted that the Notice of Proposed Rule Making (NPRM), or draft regulation, governing the implementation of the MMA was released by CMS just a few days after the meeting. A few of the issues discussed at the Forum session were somewhat clarified in that NPRM; however, most issues still require additional consideration and clarification.) As always, NHPF hopes to assist beneficiaries, advocates, researchers, and other MMA stakeholders by providing a sharper understanding of the difficulties faced by states as the new Medicare drug benefit becomes available in January 2006.
Medicare Advantage in 2006-2007: What Congress Intended? Health Affairs, Web Exclusive
2007
Starting in 2006, almost all Medicare beneficiaries have at least one Medicare Advantage (MA) plan available to them. Although new regional preferred provider organization (R-PPO) plans authorized through the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 contribute to this growth, private fee-for-service (PFFS) plans are more numerous and more popular with beneficiaries. Almost 1.5 million beneficiaries are in PFFS plans, 84 percent living in "floor" counties paid more by Medicare to encourage MA offerings. Whether beneficiaries are well served by policies that use scarce resources to encourage competition among largely unmanaged FFS plans is an issue that warrants discussion.
Medicare Advantage: What Congress Intended? Orlando, FL: AcademyHealth Annual Research Meeting
2007
Changes in Medicare Advantage in the MMA reversed the prior erosion in private plan availability and enrollment under Medicare+Choice. Shift began before 2006 (Part D benefit and changes) but intensified thereafter Changes in Medicare Advantage in the MMA reversed the prior erosion in private plan availability and enrollment under Medicare+Choice. Shift began before 2006 (Part D benefit and changes) but intensified thereafter 2 Overview of Findings -II Overview of Findings -II PFFS accounts disproportionately for growth in MA availability and enrollment across the country. As a replacement supplement, PFFS provides attractive premiums with the promise of open access. But financial and access risk in PFFS typically is higher than in Medigap and perhaps higher than beneficiaries expect. PFFS accounts disproportionately for growth in MA availability and enrollment across the country.
Health Technology and U.S. Medicare Policy in the Late 20th Century
Journal of History Research, 2016
Much of the history of the American Social Welfare movement has been directed to the identification and development of entitlement programs needed to strengthen the health and economy of even the neediest members of the society. The emergence of health technologies have precipitated and supported policy advances. The Medicare Act (Title XVIII the United States Social Security Act of 1935) as such an entitlement program, was originally directed to resolving the health coverage concerns of the elderly without families or finances to afford coverage. The program entered crises periods over rising costs and continuity of funding concerns. Many have been assisted, in the U.S., in addition to the aged population, by the development of Medicare entitlements. These entitlements have emerged during periods of social need often accompanied by health technology or service delivery innovation. The program benefits more than its constituents and contributes to the health of the overall society. This paper will provide both a historical overview of the conflicts and uncertainties weathered by the Medicare Act in the later quarter of the 20 th Century in the U.S. (United States of America). The paper will also explore the implications of changes in the technology of federal and state funding mechanisms along with demographic changes that offered the greatest challenges to the continuation of the Medicare Act as a mainstay of stable health coverage to millions of needy Americans, into the 21 st century.
Value in Health, 2016
Background: The value of evidence about the performance of a technology and the value of access to a technology are central to policy decisions regarding coverage with, without, or only in research and managed entry (or risk-sharing) agreements. Objectives: We aim to outline the key principles of what assessments are needed to inform "only in research" (OIR) or "approval with research" (AWR) recommendations, in addition to approval or rejection. Methods: We developed a comprehensive algorithm to inform the sequence of assessments and judgments that lead to different types of guidance: OIR, AWR, Approve, or Reject. This algorithm identifies the order in which assessments might be made, how similar guidance might be arrived at through different combinations of considerations, and when guidance might change. Results: The key principles are whether the technology is expected to be cost-effective; whether the technology has significant irrecoverable costs; whether additional research is needed; whether research is possible with approval and whether there are opportunity costs that once committed by approval cannot be recovered; and whether there are effective price reductions. Determining expected cost-effectiveness is only a first step. In addition to AWR for technologies expected to be cost-effective and OIR for those not expected to be cost-effective, there are other important circumstances when OIR should be considered. Conclusions: These principles demonstrate that cost-effectiveness is a necessary but not sufficient condition for approval. Even when research is possible with approval, OIR may be appropriate when a technology is expected to be cost-effective due to significant irrecoverable costs.