Are Fewer Diagnoses Better? Assessing A Proposal To Improve The Medicare Advantage Payment System.

Medicare Advantage (MA) plans report diagnoses more completely than they are reported in traditional Medicare. As a result, payment to MA plans is greater than it would be if coding patterns were identical in the two sectors. The Medicare Payment Advisory Commission estimates that the overpayment to MA attributable to differential coding was $50 billion in 2024.

Updating the Chronic Illness and Disability Payment System.

Background: Of the 38 Medicaid programs that risk adjust payments to Medicaid managed care organizations (MCOs), 33 of them use the Chronic Illness and Disability Payment System (CDPS). There has been recent interest in adding social determinants of health (SDH) into risk-adjustment models.

Objective: To update the CDPS models using recent MCO data based on the International Classification of Diseases version 10 coding system and to explore whether indicators of SDH are predictive of expenditures.

Project Baby Bear: Rapid precision care incorporating rWGS in 5 California children's hospitals demonstrates improved clinical outcomes and reduced costs of care.

Genetic disorders are a leading contributor to mortality in neonatal and pediatric intensive care units (ICUs). Rapid whole-genome sequencing (rWGS)-based rapid precision medicine (RPM) is an intervention that has demonstrated improved clinical outcomes and reduced costs of care. However, the feasibility of broad clinical deployment has not been established.

The effects of coding intensity in Medicare Advantage on plan benefits and finances.

Objective: To assess how beneficiary premiums, expected out-of-pocket costs, and plan finances in the Medicare Advantage (MA) market are related to coding intensity.

Data Sources/study Setting: MA plan characteristics and administrative records from the Centers for Medicare and Medicaid Services (CMS) for the sample of beneficiaries enrolled in both MA and Part D between 2008 and 2015. Medicare claims and drug utilization data for Traditional Medicare (TM) beneficiaries were used to calibrate an independent measure of health risk.

Beyond The ACA: Paths To Universal Coverage In California.

California has long sought to achieve universal health insurance coverage for its residents. The state's uninsured population was dramatically reduced as a result of the Affordable Care Act (ACA). However, faced with federal threats to the ACA, California is exploring how it might take greater control over the financing of health care.

Getting What We Pay For: How Do Risk-Based Payments to Medicare Advantage Plans Compare with Alternative Measures of Beneficiary Health Risk?

Objective: To estimate the relative health risk of Medicare Advantage (MA) beneficiaries compared to those in Traditional Medicare (TM).

Data Sources/study Setting: Medicare claims and enrollment records for the sample of beneficiaries enrolled in Part D between 2008 and 2015.

Study Design: We assigned therapeutic classes to Medicare beneficiaries based on their prescription drug utilization.

Rapid whole-genome sequencing decreases infant morbidity and cost of hospitalization.

Genetic disorders are a leading cause of morbidity and mortality in infants. Rapid whole-genome sequencing (rWGS) can diagnose genetic disorders in time to change acute medical or surgical management (clinical utility) and improve outcomes in acutely ill infants. We report a retrospective cohort study of acutely ill inpatient infants in a regional children's hospital from July 2016-March 2017.

Projected Coding Intensity In Medicare Advantage Could Increase Medicare Spending By $200 Billion Over Ten Years.

Over the past decade, the average risk score for Medicare Advantage (MA) enrollees has risen steadily relative to that for fee-for-service Medicare beneficiaries, by approximately 1.5 percent per year. The Centers for Medicare and Medicaid Services (CMS) uses patient demographic and diagnostic information to calculate a risk score for each beneficiary, and these risk scores are used to determine payment to MA plans.

Measuring Medicaid Physician Participation Rates and Implications for Policy.

Policy makers continue to debate Medicaid expansion under the Affordable Care Act, and concerns remain about low provider participation in the program. However, there has been little research on how various measures of physician participation may reflect different elements of capacity for care within the Medicaid program and how these distinct measures correlate with one another across states. Our objectives were to describe several alternative measures of provider participation in Medicaid using recently publicly available data, to compare state rankings across these different metrics, and to discuss potential advantages and disadvantages of each measure for research and policy purposes.

Bringing Patient-Centered Outcomes Research to Life.

A substantial gap exists between medical evidence that is known and medical evidence that is put into practice. Although the Agency for Healthcare Research and Quality (AHRQ) has a long history of developing the content of evidence, the agency now pivots to close that gap by focusing on evidence dissemination and implementation. Achieving better health outcomes requires both the generation of new patient-centered outcomes research (PCOR) knowledge and the appropriate and timely implementation of that knowledge into practice.

Measuring coding intensity in the Medicare Advantage program.

Background: In 2004, Medicare implemented a system of paying Medicare Advantage (MA) plans that gave them greater incentive than fee-for-service (FFS) providers to report diagnoses.

Data: Risk scores for all Medicare beneficiaries 2004-2013 and Medicare Current Beneficiary Survey (MCBS) data, 2006-2011.

Measures: Change in average risk score for all enrollees and for stayers (beneficiaries who were in either FFS or MA for two consecutive years).