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Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The federal government has general rules that all state Medicaid programs must follow, but each state runs its own program.
This means eligibility requirements and benefits can vary from state to state. Find out if you qualify for your state's Medicaid program. Washington, D. A-Z Index. Medicare Medicare is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions. For more information, visit Medicare. Medicaid Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources.
For more information, visit Medicaid. Posted in: Medicare and Medicaid. Although these steps have been frequently debated, dialysis filter reuse does not appear to increase the risk of adverse outcomes Port et al. As payment to dialysis centers over time has stayed level or decreased, the importance of ongoing quality monitoring of dialysis care has increased Institute of Medicine Committee for the Study of the Medicare End-Stage Renal Disease Program, Another example of CMS' effect on clinical medicine was the decision to deny payment for erythropoietin EPO if a patient's hematocrit was greater than EPO is a naturally occurring protein produced by the kidneys that triggers the production of red blood cells; it improves survival and quality of life among dialysis patients Eschbach, Target hematocrit for patients on dialysis is 33 to 36, so it was thought reasonable to stop administration of EPO when the hematocrit was above this range.
However, the policy actually led to more frequent episodes of a hematocrit below 33 as physicians were concerned about reimbursement denial and more likely to withhold EPO therapy for patients in the higher range Berns et al. As such, many ESRD patients were not receiving optimal care for their disease.
CMS subsequently changed the policy to a cut-point of Through these policies, CMS inserted itself into the patient-specific clinical decisions of physicians. This also illustrates how data and analysis can help to inform policy as CMS was able to increase the cut-point based on effectiveness studies Berns et al. At the same time as they adjusted the payment rules for dialysis providers, CMS strengthened its oversight and management of dialysis providers and began to pay closer attention to the quality of care provided for ESRD patients.
In , Congress approved the creation of ESRD networks that served to collect data related to the care provided within the network and to initiate quality improvement Social Security Amendments of Public Law The networks meet at a national forum each year to share data and ideas for improving quality of care nationally. Additionally, the improvements made through the ESRD networks have reduced racial disparities in adequacy of hemodialysis Sehgal, By recognizing the relationship between financing and quality of care and then creating a framework for improvement, CMS has participated in improving the clinical care of hundreds of thousands of ESRD patients.
In light of skyrocketing costs in Medicare and Medicaid, as well as concerns over fraud and abuse, Congress decided by the early s that closer oversight of the medical care system was necessary. The concern was that excess budgetary costs were related to overuse of medical services, driven by uncontrolled financial incentive systems built into the original legislation.
These organizations reviewed health service use in an effort to improve the quality of care. Interestingly, the AMA involved itself in the development of the PSROs because they recognized the potential threat of such organizations to physicians' clinical autonomy Oberlander, In the end, Congress agreed with the AMA that physicians should perform the reviews, as they were uniquely suited for the role, but decided that State medical societies would not retain the right to provide this service Oberlander, In fact, PSROs were held accountable by Congress and their contracts could be terminated if they were not fulfilling their role adequately.
By the early s, continued frustration with rising program costs led to the development of new payment and monitoring systems that expanded CMS' regulatory authority and influence. A key response to escalating costs was to change regulatory tools, both in terms of payment and clinical oversight. This change was spurred by congressional action in slowing Medicare spending in the context of rising budget deficits. The prospective payment system PPS , enacted by Congress in , sought to control hospitalization costs by paying hospitals a fixed rate based on the patient's diagnosis during admission payment was based on diagnosis-related groups Social Security Amendments of Public Law Prior to prospective payment, hospitals and physicians did not have strong financial incentives to provide efficient care.
By implementing this strategy, CMS attempted to relate clinical compensation to the resources needed for patient care. The PPS provided a strong incentive for hospitals to provide fewer services during an admission and shorten the length of stay.
The role of CMS as regulatory agency became even more important: it had to monitor for both overuse and underuse of appropriate medical care. Structurally, the PROs differed in that they were consolidated into State level regions. Functionally, they still relied on retrospective review of cases and, consequently, delayed education or correction of outlying providers.
Physicians often maintained an adversarial relationship with the PROs. Nor did the PROs offer much in the way of tangible results: they did not achieve substantial cost savings or quality improvements Oberlander, The most important paradigm shift in Federal policy regarding quality of care began in the contract period starting in Taking advantage of quality improvement knowledge from other industries, CMS charged the PROs to develop prospective quality improvement initiatives.
This model required a change in the relationship between PROs and the physicians and hospitals they served. The PROs had to develop a cooperative relationship and move away from an adversarial culture Bradley et al. The idea was to focus on process improvement and systems based thinking rather than isolating unusual errors Jencks and Wilensky, In , better reflecting the evolution of their mission, the PROs were renamed as quality improvement organizations QIOs. Recent studies have come to differing conclusions regarding the effectiveness of QIOs at improving care Jencks, Huff, and Cuerdon, ; Snyder and Anderson, ; Gaul, ; Bradley et al.
The question of QIO effectiveness has remained elusive because of the difficulty of conducting rigorous studies that demonstrate cause and effect Jencks, Huff, and Cuerdon, ; Snyder and Anderson, QIOs clearly give CMS an important tool to influence quality outcomes, and ongoing evaluation of their effectiveness and improvement of that effectiveness is warranted.
In , CMS launched the effectiveness initiative to evaluate and improve the practice of medicine Roper et al. Because of the enormous potential for the use of data from large populations to study medical effectiveness, CMS committed itself to refining its data system and to linking with clinical researchers to better understand and analyze the data.
As a result, CMS could offer clearer information on the health outcomes achieved from health services in regular practice.
CMS has also used the effectiveness initiative to improve the work of the QIOs by helping to inform quality improvement through analysis and interpretation of outcomes data. Through understanding the effects of care and its variation, CMS was in a much better position to educate care providers on quality than it had been previously.
Through activities like the effectiveness initiative and advances in data management, CMS can begin to address the enormous variation in care according to geography Wennberg, Fisher, and Skinner, Such variation, which is not associated with differences in outcomes, represents a tremendous opportunity for CMS to control costs. By understanding the patterns of care that yield the best outcomes at the least cost, CMS can begin to use its influence to get physicians to adopt the most efficient models.
Although the process began as a regulatory model, it has evolved into a quality improvement function with the goal of changing how medicine is practiced. This reflects the evolution of Medicare administration from an initial charge of financing care to its current mission that incorporates concerns of improving the quality of care delivered to program beneficiaries as well as cost control.
As such, CMS helps to shape the quality and size of the workforce of future physicians. Additionally, CMS policy changes have substantial effects on the financial health of America's teaching hospitals.
Before the s, Medicare allowed teaching hospitals to be reimbursed for their reasonable costs, including the cost of GME. In the early s, along with the PPS, Medicare began making direct and indirect medical education payments to teaching hospitals. Direct medical education DME payments are intended to offset the actual cost of employing a resident.
The indirect medical education IME payments offset the higher cost of care at teaching hospitals because of the higher technology, increased testing, and increased severity of illness.
Contemporaneous with these payments, residency programs grew. The policy rationale for the indirect payments has been hotly debated, and many believe it should include compensation to hospitals for the greater severity of unmeasured case-mix associated with hospitals with teaching programs. The number of residents nationally totaled 61, in and 98, in At the same time, Congress began to reign in the IME budget by substantially reducing the additional payment to teaching hospitals.
Congress has modified the formulas determining the levels of DME and IME support several times over the past decade, attempting to reduce any fiscal incentives to increase the number of training slots.
Additional reduction in slots reimbursed and further cuts in IME levels have been considered; such possibilities raise great concern for the fiscal health of academic medical centers at a time when the U. The multiple incentives to use residents to provide clinical services include their low cost, high motivation, and skill levels; their work capacity, despite recently being reduced to 80 hours per week, is still far greater than that likely to be realized from any replacement physician or mid-level provider.
The pressures that reductions in GME subsidies generate may influence the quality of education of future physicians. In this case, physicians argue that Congress, through CMS policy, substantially influences the direction of our workforce and the financial health of the institutions that drive innovation in medical care. Immediately after the legislative changes, several prominent teaching institutions had substantial financial losses Coughlan et al.
Since then, teaching hospitals have had increasing difficulty maintaining positive operating margins, which can be partially attributed to the reduction in IME payments Phillips et al. Because of the reduced funding of residency positions, as well as the diminished attractiveness of primary care specialties, some programs have closed, Phillips et al.
Teaching faculty are often encouraged to participate in activities that are revenue generating rather than focusing on their role as educators for tomorrow's physicians. The Medicare Payment Advisory Commission has issued recommendations to consider GME funding from a purely economic argument to allow more market-driven changes in GME Newhouse and Wilensky, , but the proposed market-driven approach may undermine the professional ethos of medicine Gbadebo and Reinhardt, GME financing has substantial influence on the nature of future medical care.
By altering GME payment structures or physician fee rates, CMS can dramatically change the medical education of future physicians. The immediate effects relate to actual patient care practices in teaching hospitals by altering the balance of teaching and medical care by the faculty. Long-term effects on the size of the workforce and specialty choice are both inevitable and difficult to predict given past problems in projecting workforce needs, as well as the multiple financial and clinical influences changing the staffing and clinical activities of the nation's academic medical centers.
On the Federal level, Medicare has received much more attention than Medicaid over the past 40 years, a consequence of Medicaid's decentralized administrative structure that gives States primary responsibility for its operations. However, within individual States, Medicaid initiatives have had specific influence on the practice of medicine. We focus here on North Carolina to illustrate how initiatives aimed at improving quality in Medicaid are pursued at the State level.
In North Carolina, the Medicaid Program has been active in promoting quality improvement and efficiency. The State's Department of Health and Human Services has fostered the development of Community Care of North Carolina which convenes networks of primary care providers to coordinate the care of populations of patients Ricketts et al.
These networks support local disease management and case coordination for Medicaid enrollees, and member physicians agree to participate in network activities and to follow network guidelines for the care of specific chronic illnesses.
An evaluation of this program revealed that, compared with the standard Medicaid Program within the State, the Community Care of North Carolina program saved money for the State and improved some outcomes for patients Ricketts et al.
Other States have implemented different models of disease management with varying levels of success, and all with the intent of improving health outcomes while controlling costs Wheatley, Much of the work has focused on care for children, and working with practices on quality improvement, the CCHI and Medicaid have documented improvements in preventive services Margolis et al. By supporting the infrastructure for such collaborative efforts, the State has enabled practices to improve the timeliness of care and also to reduce the rate of no-shows to clinic appointments.
Despite the successes seen in North Carolina and some other States, Medicaid Programs face constraints in pursuing quality initiatives. Because of State budget problems, policymakers frequently do not have the resources needed to administer adequately such programs, much less lead quality improvement efforts.
In addition, the information systems and data analysis capabilities developed under Medicare are not available for most Medicaid Programs and decisions on effectiveness are less well informed.
We have outlined selected examples of how Medicare and Medicaid have influenced clinical medicine. Medicare and Medicaid emerged from a fierce political process in with the charge to stay away from clinical medicine. Early on, however, Federal administrators recognized that Medicare and Medicaid could not control costs or ensure quality without regulation. As regulation developed, it took several years for the Federal Government to adopt the strategy of prospective quality improvement through partnership with the medical community.
This strategy has much promise for improving medical care. Was it a mistake for CMS to engage in changing clinical practice? We decided, as a country, to create a safety net of public health insurance for the elderly and the poor. Like every other payer in the country, CMS was responsible to those who pay for the services the American taxpayer and those who receive care under their auspices Medicare beneficiaries and Medicaid enrollees.
The American taxpayer, through Congress, should have oversight of the care provided by those who invoice CMS and, therefore, receive public funds. CMS and Congress have the responsibility of ensuring the best quality of care possible for program beneficiaries.
Additionally, because CMS is the largest single insurance organization in the Nation, its initiatives are likely to shape policy well beyond its programs, in the commercial market in the United States and even abroad. Eliminating CMS influence from clinical medicine would not only be infeasible, it would be a tremendous opportunity lost.
We anticipate that CMS will continue its role to improve health care quality by informing clinical care with data, taking a larger role in chronic disease management, and developing new systems that reward high quality care.
Data technology will now allow analysis of close to real-time data and linkage of inpatient, outpatient, and pharmacy databases to facilitate more rapid cycles in quality improvement.
CMS' most recent initiative for the QIOs will actively help physician practices to adopt electronic health records Medicare News, In addition to the inpatient efforts noted, CMS also participates with the Ambulatory Care Quality Alliance, along with other insurers and major physician organizations, to advance quality in outpatient care settings.
And CMS has embarked on large-scale demonstration projects to determine whether pay-for-performance and disease management programs can save money and improve quality.
All these programs reflect the growing partnerships between CMS and hospitals and physician organizations. It has taken almost 40 years to develop these types of relationships across American health care, but such partnerships now have the potential to yield substantial benefits in the health care system. We can identify four key areas that CMS should address in the coming years with respect to influencing clinical medicine.
Second, CMS should devote more resources toward understanding the appropriate role for the Medicaid Program and how the Nation finances care for the most vulnerable segments of society. The States have conducted many experiments with payment and disease management, and CMS should facilitate sharing the lessons learned.
Third, CMS should improve and develop close collaboration with other private insurers to enable the pooling of data and cooperative improvement of care.
And fourth, CMS can lead by changing the paradigm of financing medical care based on acute care to one that pays for chronic illness care. The MMA authorized several key programs that will enhance the quality of medical care for the elderly in the U.
Of particular note is the emphasis on chronic disease management programs. Our entire health care system has struggled with how to retool to care for patients with chronic disease rather than acute illness. CMS is directly assessing the effect of disease management programs operated outside of routine clinical care settings.
Other movements across the country are trying to remodel the clinical care system from within to provide better chronic illness care Casalino, Regardless of the model used, these strategies have promise for improving quality and reducing costs by changing the way physicians and their practices care for their patients. Over the past 40 years, Federal administrators have focused more attention on the Medicare Program than on Medicaid. Nonetheless, Medicaid today is a far different—and dramatically larger—program than it was in its early years, and, as its enrollment has expanded, eligibility is no longer as tightly connected to welfare status as it was at Medicaid's start.
The unique nature of the Federal-State partnership for Medicaid has led to substantial diversity in program operations, including eligibility levels and delivery systems, across the States. The local infrastructure and efficiency of a State-based program remains attractive, but translation of innovation from one State to the next has been slow. Moreover, although a few States have used Medicaid expansions to reduce significantly their rates of uninsurance, most States have lacked the financial capacity and political will to follow their lead.
In its role overseeing the State programs, CMS should continue to push the States to expand coverage and improve quality in Medicaid, although the financing challenges will be substantial. Additionally, rapid availability of State Medicaid data, similar to the planned rapid availability of Medicare data, will facilitate cross-State comparisons.
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Organizations that are hired by the CMS to carry out day-to-day Medicare program operations are known as: Contractors. A spouse of a deceased, retired, or disabled individual who was or is . Dec 19, · Under the Medicare program, eligible beneficiaries may receive covered services from a hospital, provided certain requirements are met. Section (e) of the Social . Centers for Medicare & Medicaid Services (CMS) andypickfordmusic.com Health care organizations that want to participate in and receive payment from the Medicare or Medicaid programs must be .