Medicare and Chronic Conditions
http://www.100md.com
《新英格兰医药杂志》
When the Medicare program became operational in 1966, its primary orientation was the treatment of acute, episodic illness.1,2 The design of the program's benefits, coverage policies, payments to providers, and criteria for determining medical necessity were all oriented toward the treatment of acute diseases. Medicare retained this orientation for the next 40 years in spite of the growing number of Americans with chronic conditions.3,4 The Medicare Prescription Drug Improvement and Modernization Act of 2003 was an important first step in the reorientation of the Medicare program toward the care of patients with chronic disorders. Additional changes, however, will be necessary if the Medicare program is to be truly responsible to its millions of beneficiaries who have chronic conditions, especially those with multiple coexisting illnesses.
Beneficiaries with Five or More Chronic Conditions
A total of 83 percent of Medicare beneficiaries have at least one chronic condition. As additional diseases are diagnosed, expenditures and the probability of an adverse outcome increase rapidly. Any policymaker who is considering the modernization of Medicare must recognize that the 23 percent of beneficiaries with five or more chronic conditions account for 68 percent of the program's spending. In addition, the treatment of these beneficiaries is likely to remain a high-cost item until they die, since every year they see an average of 13 physicians and fill an average of 50 prescriptions.5 They are also the beneficiaries who are most likely to have a preventable hospitalization and have the highest out-of-pocket spending because of gaps in coverage and cost-sharing arrangements.
Beginning Modernization of Medicare
The part of the legislation to modernize Medicare that has received the most attention is the prescription-drug benefit.6 Coverage of prescription drugs can be viewed as part of a larger initiative to make the Medicare program more responsive to the needs of beneficiaries with chronic conditions (Table 1).
Table 1. Selected Provisions of the Medicare Modernization Act That Address the Needs of Patients with Chronic Conditions.
Section 721 created the Chronic Care Improvement Program, which represents an important new initiative to improve the quality of care for beneficiaries with chronic conditions in the Medicare fee-for-service program.7 It is not a demonstration program but a newly covered service. Initially, a pilot program will offer self-care guidance and support to Medicare beneficiaries who have one or more of three chronic conditions: complex diabetes, congestive heart failure, and chronic obstructive pulmonary disease (COPD). These three diseases were chosen by Congress for multiple reasons, including their high prevalence in the Medicare population and the likelihood that beneficiaries with any one of these chronic conditions has one or more coexisting illnesses. An analysis of Medicare claims data for 2001, for example, shows that 96 percent of beneficiaries with COPD have at least one other coexisting illness, and 68 percent have four or more coexisting illnesses. The objective of Section 721 is to increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications.
The program will be implemented in two phases. A pilot phase will help determine the final design. On December 8, 2004, pilot programs in Maryland, Pennsylvania, Oklahoma, Mississippi, Tennessee, Georgia, the District of Columbia, Florida, Chicago, and Brooklyn and Queens, New York, were selected.7 These regional programs will be responsible for providing appropriate services to all Medicare beneficiaries who have complex diabetes, congestive heart failure, or COPD. Most of the organizations selected to oversee these programs are disease-management organizations. Payments to the pilot programs will be dependent on improvement in the quality of clinical care, the satisfaction of beneficiaries and providers, and a demonstration of success in lowering costs — all with the use of comparisons with control groups. Phase 2, which is scheduled to begin after 2006, may expand to other geographic regions (or perhaps nationally) programs or program components that have proved to be successful.
Getting Physicians Involved
The Medicare program has developed its own companion initiative to Section 721. The focus of the companion initiative is high-cost beneficiaries with chronic conditions who do not have complex diabetes, congestive heart failure, or COPD. Unlike the Chronic Care Improvement Program, which awarded the funding primarily to disease-management organizations, the Care Management for High-Cost Beneficiaries demonstration is targeted primarily at physician groups, hospitals, and integrated delivery systems. One possible reason for this targeting is that Medicare wants to get the clinicians and delivery systems more directly involved in care management, especially for beneficiaries with multiple coexisting illnesses. One congressional study has reported that disease-management programs might not be cost-effective for beneficiaries with multiple coexisting illnesses.8 The demonstration will require that applicants specify performance standards to improve clinical quality, measure the satisfaction of beneficiaries and providers, and achieve financial savings. Program funding should be awarded later this year.
Managed Care
Section 231 will encourage managed-care organizations to offer specialized plans that serve beneficiaries who have special health care needs. It has been a long-standing concern that managed-care organizations do not have a financial incentive to enroll beneficiaries with multiple serious chronic conditions.9 Section 231 attempts to address this concern. Beneficiaries who are eligible for these specialized plans will be persons who live in institutions or who qualify for both Medicare and Medicaid; other persons who have chronic conditions or disabilities may be included. On November 8, 2004, the Centers for Medicare and Medicaid Services held a meeting to discuss issues involved with policy and operations. The specifics of this program are also scheduled to be announced later this year.
Electronic Prescriptions
Sections 101 and 108 begin the process that could lead to the integrated electronic medical record. Section 101 requires that the Medicare program work with industry experts to establish national standards for electronic prescriptions, and Section 108 will award grants to physicians to implement electronic-prescription programs. The legislation envisions a Medicare program in which a doctor can write a prescription on a computer and electronically transmit that prescription to a pharmacy. This is the first step toward a broader objective of creating integrated electronic medical records with shared data repositories.
The Medicare Modernization Act contains numerous other provisions that set the stage for additional transformations in the program. For example, Section 723 mandates that the secretary of the Department of Health and Human Services "develop a plan to improve quality of care and reduce the cost of care for chronically ill Medicare beneficiaries." One of the targets of this report will be beneficiaries with multiple chronic conditions.
Next Steps
Although the Medicare Modernization Act is an important first step toward reform, additional steps will be needed before the Medicare program is truly oriented toward the treatment of beneficiaries with multiple chronic conditions. The Medicare program cannot do this alone, however. It will also be necessary to change the delivery system, the research infrastructure, clinical education, and methods of financing medical care in order for the health care system to become more responsive to the needs of people with chronic conditions.10
One step is to restructure the cost-sharing arrangements in fee-for-service Medicare. Out-of-pocket spending by Medicare beneficiaries increases by an average of nearly $400 with each additional chronic condition (Figure 1).12 The current cost-sharing arrangements, such as the 20 percent coinsurance for physician visits or gaps in the prescription-drug benefit, are especially onerous to beneficiaries with multiple chronic conditions because these people are the highest users of medical services.13 One possible solution is an out-of-pocket maximum. Most private insurers place a limit on the patient's out-of-pocket expenses, and Medicare could adopt a similar approach. Accomplishing this objective while still maintaining budget neutrality could require greater cost sharing by Medicare beneficiaries who have few or no chronic conditions. Alternatively, additional funding could be sought.
Figure 1. Annual Out-of-Pocket Spending by Medicare Beneficiaries.
Data are from the Medical Expenditure Panel Survey of 2001.11
A second step is for Medicare to make an additional payment when a standardized electronic medical record is sent to a secure data repository. This would be an expansion of Sections 101 and 108 in the Medicare law and would allow for the creation of integrated electronic medical records, which would be especially helpful for beneficiaries with multiple chronic conditions. The Department of Veterans Affairs already has operational electronic medical records, and countries such as Canada and the United Kingdom are investing billions of dollars to create such systems.
One potential problem is the cost to the Medicare program. Given the tremendous volume of health care visits by Medicare beneficiaries, if Medicare were to pay $5 to a physician, hospital, or other provider to send an electronic medical record to the secure data repository, the cost to the Medicare program would exceed $4 billion annually. However, the Medicare program might be able to reduce costs and improve quality if widespread use of electronic medical records reduced the number of duplicate tests, adverse drug reactions, and unnecessary hospitalizations. To be successful, this program would require the active participation of clinicians — an area in which acceptance so far has been relatively slow.
For Medicare beneficiaries with five or more chronic conditions, who see an average of nine physicians on an outpatient basis and four hospital-based physicians annually, coordination of care is especially important. Both physicians and patients are aware of the problems that can occur when care is not coordinated.14 A third step in reforming the Medicare program might be to require that the program explicitly pay for care coordination. Under one proposal, each beneficiary with five or more chronic conditions would designate a care coordinator who would be required to communicate with all other clinicians on a periodic basis and help coordinate services.15 More research will be necessary in order to identify the precise characteristics of beneficiaries who will benefit from care coordination and the specific interventions that will be successful. A major stumbling block could be the minimal training in care coordination that most physicians currently receive.16 It may also be necessary to restructure the way in which Medicare pays for graduate medical education in order to emphasize training in care coordination in ambulatory settings.
Medicare Payment Rules
Important changes in Medicare's payment systems will be needed to pay for some of the proposed improvements in care for chronic conditions.15,17 Fee-for-service payments will need to be restructured to encourage clinicians to work cooperatively; to encourage additional means of communication, such as e-mail; and to permit doctors to see a group of patients at once and allow other providers to participate in, and be reimbursed for, the care of patients.15 Current Medicare rules make each of these improvements problematic. One problem is that the cost of processing claims for things such as e-mail communication could be greater than the amount Medicare would pay for the encounter. For some services, it could be difficult to limit the number of encounters between physicians and patients to a medically appropriate number. Patients could send five or more e-mail messages a day to a physician and expect a response if the physician were being reimbursed by Medicare. It is also difficult for the Medicare program to verify that an e-mail communication has occurred.
Current Medicare regulations are very specific about which providers are eligible to be paid and under which circumstances.18 Nonphysicians are generally not eligible to be paid by the Medicare program unless the service is "incident to" a physician's service, and even then, payment is possible only under certain circumstances. Existing rules preclude payment for services that are commonly furnished in a physician's office or rendered without charge. As a result, explicit payment for patient education, some group visits, and multidisciplinary group conferences will be difficult under existing Medicare rules unless Congress explicitly authorizes payment (e.g., for education about diabetes, as it currently does).
Payments to managed-care plans will need to cover the full expected cost of care for beneficiaries with multiple chronic conditions — something that the current system does not do. Beginning in 2007, Medicare will pay managed-care plans on the basis of a system that is 100 percent risk-adjusted for the types of patients the managed-care plan enrolls. In theory, this risk-adjusted payment would reflect the additional costs of treating a beneficiary with multiple chronic conditions. In reality, the payment will still underestimate the cost of treating a beneficiary who requires expensive care or multiple hospitalizations.18
There are several problems to overcome before Medicare can implement any of these recommendations in the next round of program reforms. Some of these proposals are likely to increase the costs of Medicare, at least in the short run. However, spending could be cut by reducing the number of hospitalizations, drug interactions, and duplicate tests. Any savings would need to be demonstrated. The second problem is the potential for fraud and abuse. The concern, as discussed earlier, is how to determine whether services are actually being provided, especially for activities such as e-mail communication. The third problem is how to demonstrate improvement in health outcomes. Both physicians and beneficiaries will need to be convinced that the reforms result in better clinical outcomes. The fourth problem is the unwillingness of some clinicians to participate in the reforms. In some ways, the fourth consideration may be the most important obstacle. Costs can be lowered, fraud and abuse minimized, and outcomes improved only if a high percentage of clinicians perceive that Medicare's new orientation is improving outcomes.
Because of the recent legislation, it can now be said that Medicare is becoming a program for people with chronic conditions. However, we have just begun the journey.
Supported by the Robert Wood Johnson Foundation.
Source Information
From the Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore.
References
Corrigan JM, Eden J, Smith BM, eds. Leadership by example: coordinating government roles in improving healthcare quality. Washington, D.C.: National Academies Press, 2003.
Williams RD II. The unique needs of Medicare beneficiaries. Brief no. 10. Washington, D.C.: National Academy of Social Insurance, October 2004.
Thorpe KE, Florence CS, Joski P. Which medical conditions account for the rise in health care spending? Bethesda, Md.: Health Affairs, August 25, 2004 (Web exclusive). (Accessed June 30, 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.437/DC1.)
Wu S, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica, Calif.: RAND Health, October 2000.
Johns Hopkins University. Partnership for solutions: better lives for people with chronic conditions. (Accessed, June 30, 2005, at http://www.partnershipforsolutions.com.)
Frank RG. Election 2004: prescription-drug prices. N Engl J Med 2004;351:1375-1377.
Medicare health support. Baltimore: Centers for Medicare & Medicaid Services, 2005. (Accessed on June 30, 2005, at http://cms.hhs.gov/medicarereform/ccip.)
An analysis of the literature on disease management programs: letter to the honorable Don Nickles. Washington, D.C.: Congressional Budget Office, October 13, 2004.
Kuttner R. The risk-adjustment debate. N Engl J Med 1998;339:1952-1956.
Anderson GF, Knickman JR. Changing the chronic care system to meet people's needs. Health Aff (Millwood) 2001;20:146-160.
2001 Medical Expenditure Panel Survey. Rockville, Md.: Agency for Healthcare Research and Quality, 2001.
Hwang W, Weller W, Ireys H, Anderson GF. Out-of-pocket medical spending for care of chronic conditions. Health Aff (Millwood) 2001;20:267-278.
Anderson GF, Shea DG, Hussey PS, Keyhani S, Zephyrin L. Doughnut holes and price controls. Bethesda, Md.: Health Affairs, July 21, 2004 (Web exclusive). (Accessed June 30, 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.396/DC1.)
Anderson GF. Physician, public, and policymaker perspectives on chronic conditions. Arch Intern Med 2003;163:437-442.
Berenson RA, Horvath J. Confronting the barriers to chronic care management in Medicare. Bethesda, Md.: Health Affairs, January 22, 2003 (Web exclusive). (Accessed June 30, 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.37v1/DC1.)
Darer JD, Hwang W, Pham HH, Bass EB, Anderson GF. More training needed in chronic care: a survey of US physicians. Acad Med 2004;79:541-548.
Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-544.
Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev 2004;25:119-141.(Gerard F. Anderson, Ph.D.)
Beneficiaries with Five or More Chronic Conditions
A total of 83 percent of Medicare beneficiaries have at least one chronic condition. As additional diseases are diagnosed, expenditures and the probability of an adverse outcome increase rapidly. Any policymaker who is considering the modernization of Medicare must recognize that the 23 percent of beneficiaries with five or more chronic conditions account for 68 percent of the program's spending. In addition, the treatment of these beneficiaries is likely to remain a high-cost item until they die, since every year they see an average of 13 physicians and fill an average of 50 prescriptions.5 They are also the beneficiaries who are most likely to have a preventable hospitalization and have the highest out-of-pocket spending because of gaps in coverage and cost-sharing arrangements.
Beginning Modernization of Medicare
The part of the legislation to modernize Medicare that has received the most attention is the prescription-drug benefit.6 Coverage of prescription drugs can be viewed as part of a larger initiative to make the Medicare program more responsive to the needs of beneficiaries with chronic conditions (Table 1).
Table 1. Selected Provisions of the Medicare Modernization Act That Address the Needs of Patients with Chronic Conditions.
Section 721 created the Chronic Care Improvement Program, which represents an important new initiative to improve the quality of care for beneficiaries with chronic conditions in the Medicare fee-for-service program.7 It is not a demonstration program but a newly covered service. Initially, a pilot program will offer self-care guidance and support to Medicare beneficiaries who have one or more of three chronic conditions: complex diabetes, congestive heart failure, and chronic obstructive pulmonary disease (COPD). These three diseases were chosen by Congress for multiple reasons, including their high prevalence in the Medicare population and the likelihood that beneficiaries with any one of these chronic conditions has one or more coexisting illnesses. An analysis of Medicare claims data for 2001, for example, shows that 96 percent of beneficiaries with COPD have at least one other coexisting illness, and 68 percent have four or more coexisting illnesses. The objective of Section 721 is to increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications.
The program will be implemented in two phases. A pilot phase will help determine the final design. On December 8, 2004, pilot programs in Maryland, Pennsylvania, Oklahoma, Mississippi, Tennessee, Georgia, the District of Columbia, Florida, Chicago, and Brooklyn and Queens, New York, were selected.7 These regional programs will be responsible for providing appropriate services to all Medicare beneficiaries who have complex diabetes, congestive heart failure, or COPD. Most of the organizations selected to oversee these programs are disease-management organizations. Payments to the pilot programs will be dependent on improvement in the quality of clinical care, the satisfaction of beneficiaries and providers, and a demonstration of success in lowering costs — all with the use of comparisons with control groups. Phase 2, which is scheduled to begin after 2006, may expand to other geographic regions (or perhaps nationally) programs or program components that have proved to be successful.
Getting Physicians Involved
The Medicare program has developed its own companion initiative to Section 721. The focus of the companion initiative is high-cost beneficiaries with chronic conditions who do not have complex diabetes, congestive heart failure, or COPD. Unlike the Chronic Care Improvement Program, which awarded the funding primarily to disease-management organizations, the Care Management for High-Cost Beneficiaries demonstration is targeted primarily at physician groups, hospitals, and integrated delivery systems. One possible reason for this targeting is that Medicare wants to get the clinicians and delivery systems more directly involved in care management, especially for beneficiaries with multiple coexisting illnesses. One congressional study has reported that disease-management programs might not be cost-effective for beneficiaries with multiple coexisting illnesses.8 The demonstration will require that applicants specify performance standards to improve clinical quality, measure the satisfaction of beneficiaries and providers, and achieve financial savings. Program funding should be awarded later this year.
Managed Care
Section 231 will encourage managed-care organizations to offer specialized plans that serve beneficiaries who have special health care needs. It has been a long-standing concern that managed-care organizations do not have a financial incentive to enroll beneficiaries with multiple serious chronic conditions.9 Section 231 attempts to address this concern. Beneficiaries who are eligible for these specialized plans will be persons who live in institutions or who qualify for both Medicare and Medicaid; other persons who have chronic conditions or disabilities may be included. On November 8, 2004, the Centers for Medicare and Medicaid Services held a meeting to discuss issues involved with policy and operations. The specifics of this program are also scheduled to be announced later this year.
Electronic Prescriptions
Sections 101 and 108 begin the process that could lead to the integrated electronic medical record. Section 101 requires that the Medicare program work with industry experts to establish national standards for electronic prescriptions, and Section 108 will award grants to physicians to implement electronic-prescription programs. The legislation envisions a Medicare program in which a doctor can write a prescription on a computer and electronically transmit that prescription to a pharmacy. This is the first step toward a broader objective of creating integrated electronic medical records with shared data repositories.
The Medicare Modernization Act contains numerous other provisions that set the stage for additional transformations in the program. For example, Section 723 mandates that the secretary of the Department of Health and Human Services "develop a plan to improve quality of care and reduce the cost of care for chronically ill Medicare beneficiaries." One of the targets of this report will be beneficiaries with multiple chronic conditions.
Next Steps
Although the Medicare Modernization Act is an important first step toward reform, additional steps will be needed before the Medicare program is truly oriented toward the treatment of beneficiaries with multiple chronic conditions. The Medicare program cannot do this alone, however. It will also be necessary to change the delivery system, the research infrastructure, clinical education, and methods of financing medical care in order for the health care system to become more responsive to the needs of people with chronic conditions.10
One step is to restructure the cost-sharing arrangements in fee-for-service Medicare. Out-of-pocket spending by Medicare beneficiaries increases by an average of nearly $400 with each additional chronic condition (Figure 1).12 The current cost-sharing arrangements, such as the 20 percent coinsurance for physician visits or gaps in the prescription-drug benefit, are especially onerous to beneficiaries with multiple chronic conditions because these people are the highest users of medical services.13 One possible solution is an out-of-pocket maximum. Most private insurers place a limit on the patient's out-of-pocket expenses, and Medicare could adopt a similar approach. Accomplishing this objective while still maintaining budget neutrality could require greater cost sharing by Medicare beneficiaries who have few or no chronic conditions. Alternatively, additional funding could be sought.
Figure 1. Annual Out-of-Pocket Spending by Medicare Beneficiaries.
Data are from the Medical Expenditure Panel Survey of 2001.11
A second step is for Medicare to make an additional payment when a standardized electronic medical record is sent to a secure data repository. This would be an expansion of Sections 101 and 108 in the Medicare law and would allow for the creation of integrated electronic medical records, which would be especially helpful for beneficiaries with multiple chronic conditions. The Department of Veterans Affairs already has operational electronic medical records, and countries such as Canada and the United Kingdom are investing billions of dollars to create such systems.
One potential problem is the cost to the Medicare program. Given the tremendous volume of health care visits by Medicare beneficiaries, if Medicare were to pay $5 to a physician, hospital, or other provider to send an electronic medical record to the secure data repository, the cost to the Medicare program would exceed $4 billion annually. However, the Medicare program might be able to reduce costs and improve quality if widespread use of electronic medical records reduced the number of duplicate tests, adverse drug reactions, and unnecessary hospitalizations. To be successful, this program would require the active participation of clinicians — an area in which acceptance so far has been relatively slow.
For Medicare beneficiaries with five or more chronic conditions, who see an average of nine physicians on an outpatient basis and four hospital-based physicians annually, coordination of care is especially important. Both physicians and patients are aware of the problems that can occur when care is not coordinated.14 A third step in reforming the Medicare program might be to require that the program explicitly pay for care coordination. Under one proposal, each beneficiary with five or more chronic conditions would designate a care coordinator who would be required to communicate with all other clinicians on a periodic basis and help coordinate services.15 More research will be necessary in order to identify the precise characteristics of beneficiaries who will benefit from care coordination and the specific interventions that will be successful. A major stumbling block could be the minimal training in care coordination that most physicians currently receive.16 It may also be necessary to restructure the way in which Medicare pays for graduate medical education in order to emphasize training in care coordination in ambulatory settings.
Medicare Payment Rules
Important changes in Medicare's payment systems will be needed to pay for some of the proposed improvements in care for chronic conditions.15,17 Fee-for-service payments will need to be restructured to encourage clinicians to work cooperatively; to encourage additional means of communication, such as e-mail; and to permit doctors to see a group of patients at once and allow other providers to participate in, and be reimbursed for, the care of patients.15 Current Medicare rules make each of these improvements problematic. One problem is that the cost of processing claims for things such as e-mail communication could be greater than the amount Medicare would pay for the encounter. For some services, it could be difficult to limit the number of encounters between physicians and patients to a medically appropriate number. Patients could send five or more e-mail messages a day to a physician and expect a response if the physician were being reimbursed by Medicare. It is also difficult for the Medicare program to verify that an e-mail communication has occurred.
Current Medicare regulations are very specific about which providers are eligible to be paid and under which circumstances.18 Nonphysicians are generally not eligible to be paid by the Medicare program unless the service is "incident to" a physician's service, and even then, payment is possible only under certain circumstances. Existing rules preclude payment for services that are commonly furnished in a physician's office or rendered without charge. As a result, explicit payment for patient education, some group visits, and multidisciplinary group conferences will be difficult under existing Medicare rules unless Congress explicitly authorizes payment (e.g., for education about diabetes, as it currently does).
Payments to managed-care plans will need to cover the full expected cost of care for beneficiaries with multiple chronic conditions — something that the current system does not do. Beginning in 2007, Medicare will pay managed-care plans on the basis of a system that is 100 percent risk-adjusted for the types of patients the managed-care plan enrolls. In theory, this risk-adjusted payment would reflect the additional costs of treating a beneficiary with multiple chronic conditions. In reality, the payment will still underestimate the cost of treating a beneficiary who requires expensive care or multiple hospitalizations.18
There are several problems to overcome before Medicare can implement any of these recommendations in the next round of program reforms. Some of these proposals are likely to increase the costs of Medicare, at least in the short run. However, spending could be cut by reducing the number of hospitalizations, drug interactions, and duplicate tests. Any savings would need to be demonstrated. The second problem is the potential for fraud and abuse. The concern, as discussed earlier, is how to determine whether services are actually being provided, especially for activities such as e-mail communication. The third problem is how to demonstrate improvement in health outcomes. Both physicians and beneficiaries will need to be convinced that the reforms result in better clinical outcomes. The fourth problem is the unwillingness of some clinicians to participate in the reforms. In some ways, the fourth consideration may be the most important obstacle. Costs can be lowered, fraud and abuse minimized, and outcomes improved only if a high percentage of clinicians perceive that Medicare's new orientation is improving outcomes.
Because of the recent legislation, it can now be said that Medicare is becoming a program for people with chronic conditions. However, we have just begun the journey.
Supported by the Robert Wood Johnson Foundation.
Source Information
From the Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore.
References
Corrigan JM, Eden J, Smith BM, eds. Leadership by example: coordinating government roles in improving healthcare quality. Washington, D.C.: National Academies Press, 2003.
Williams RD II. The unique needs of Medicare beneficiaries. Brief no. 10. Washington, D.C.: National Academy of Social Insurance, October 2004.
Thorpe KE, Florence CS, Joski P. Which medical conditions account for the rise in health care spending? Bethesda, Md.: Health Affairs, August 25, 2004 (Web exclusive). (Accessed June 30, 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.437/DC1.)
Wu S, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica, Calif.: RAND Health, October 2000.
Johns Hopkins University. Partnership for solutions: better lives for people with chronic conditions. (Accessed, June 30, 2005, at http://www.partnershipforsolutions.com.)
Frank RG. Election 2004: prescription-drug prices. N Engl J Med 2004;351:1375-1377.
Medicare health support. Baltimore: Centers for Medicare & Medicaid Services, 2005. (Accessed on June 30, 2005, at http://cms.hhs.gov/medicarereform/ccip.)
An analysis of the literature on disease management programs: letter to the honorable Don Nickles. Washington, D.C.: Congressional Budget Office, October 13, 2004.
Kuttner R. The risk-adjustment debate. N Engl J Med 1998;339:1952-1956.
Anderson GF, Knickman JR. Changing the chronic care system to meet people's needs. Health Aff (Millwood) 2001;20:146-160.
2001 Medical Expenditure Panel Survey. Rockville, Md.: Agency for Healthcare Research and Quality, 2001.
Hwang W, Weller W, Ireys H, Anderson GF. Out-of-pocket medical spending for care of chronic conditions. Health Aff (Millwood) 2001;20:267-278.
Anderson GF, Shea DG, Hussey PS, Keyhani S, Zephyrin L. Doughnut holes and price controls. Bethesda, Md.: Health Affairs, July 21, 2004 (Web exclusive). (Accessed June 30, 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.396/DC1.)
Anderson GF. Physician, public, and policymaker perspectives on chronic conditions. Arch Intern Med 2003;163:437-442.
Berenson RA, Horvath J. Confronting the barriers to chronic care management in Medicare. Bethesda, Md.: Health Affairs, January 22, 2003 (Web exclusive). (Accessed June 30, 2005, at http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.37v1/DC1.)
Darer JD, Hwang W, Pham HH, Bass EB, Anderson GF. More training needed in chronic care: a survey of US physicians. Acad Med 2004;79:541-548.
Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-544.
Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev 2004;25:119-141.(Gerard F. Anderson, Ph.D.)