PURPOSE To assess the impact of vision loss on healthcare cost for patients with Medicaid and Medicare and whether these costs are adequately captured by Medicare hierarchical condition categories (HCC) risk adjustment methodology. DATA SOURCES The public use data set of the Program of All-Inclusive Care for the Elderly (PACE) for 1994-1998, and the Medicare 5% Sample datasets for 2003 and 20...

The Centers for Medicare & Medicaid Service's (CMS') end stage renal disease (ESRD) managed care demonstration offered an opportunity to assess patient selection among a chronically ill and inherently costly population. Patient selection refers to the phenomenon whereby those Medicare beneficiaries who choose to enroll or stay in health maintenance organizations (HMOs) are, on average, younger,...

The Health Care Financing Administration (HCFA) implemented risk adjustment for Medicare capitated organizations January 2000. The risk adjustment system used, the Principal Inpatient Diagnostic Cost Group (PIPDCG) method, had to be incorporated into the payment structure mandated by the Balanced Budget Act of 1997 (BBA). This article describes how risk adjustment was integrated into the paymen...

We estimated the effects of three Health Care Financing Administration (HCFA)-funded case management demonstrations for high-cost Medicare beneficiaries in the fee-for-service (FFS) sector. Participating beneficiaries were randomly assigned to receive case management plus regular Medicare benefits or regular benefits only. None of the demonstrations improved self-care or health or reduced Medic...

Rising Medicaid health expenditures have hastened the development of State managed care programs. Methods to monitor and improve health care under Medicaid are changing. Under fee-for-service (FFS), the primary concern was to avoid overutilization. Under managed care, it is to avoid underutilization. Quality enhancement thus moves from addressing inefficiency to addressing insufficiency of care...

"Any-willing-provider" (AWP) laws compel managed care plans to accept any provider willing to accept the plan's terms and conditions, potentially undermining managed care's ability to constrain spending. However. AWP laws potentially respond to inefficient risk-selection by providers of managed care. With risk selection, observed reductions in expenditures in the managed care sector may be offs...

BACKGROUND In 1995 in an effort to control costs, the State of Colorado implemented a pilot capitated payment system for individuals eligible for public financing of their mental health services. Contracts were with both Not-For-Profit (NFP) firms and For-Profit (FP) firms; the remainder were in the fee-for-service system (FFS). Pharmaceuticals were not included in the capitation rate. However,...

Medicare beneficiaries in fee-for-service (FFS) who had chronic illnesses and volunteered to participate in 15 care coordination programs were randomized to treatment or control status. Nurses provided patient education (mostly by telephone) to improve adherence and ability to communicate with physicians. Patients were contacted an average of two times per month. The findings after 2 years are ...

OBJECTIVE The objective of this study was to examine the association of patient- and county-level factors with the emergency department (ED) visits among adult fee-for-service (FFS) Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. METHODS A cross-sectional design using retrospective observational data was implemented. Patient-level data were obtained from 2010 Medicaid An...