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. 2004 Feb;39(1):111-30.
doi: 10.1111/j.1475-6773.2004.00218.x.

The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans

Melinda Beeuwkes Buntin  1 , Alan M Garber, Mark McClellan, Joseph P Newhouse
Affiliations

The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans

Melinda Beeuwkes Buntin et al. Health Serv Res. 2004 Feb.

Abstract

Objective: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures.

Data source: Medicare administrative claims for 1994 and 1995.

Study design: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters.

Data extraction methods: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors.

Principal findings: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments.

Conclusions: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.

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References

    1. Brown RS, Clement DG, Hill JW, Retchin SM, Bergeron JW. Do Health Maintenance Organizations Work for Medicare? Health Care Financing Review. 1993;15(1):7–23. - PMC - PubMed
    1. Busse R. Nashville, TN: Paper presented at the Academy Health Annual Research Meeting, June 28; 2003. Social Insurance Systems: Where Are They Coming from and Where Are They Going?
    1. Congressional Budget Office . Predicting How Changes in Medicare Payment Rates Would Affect Risk-Sector Enrollment and Costs. Washington, DC: Congressional Budget Office; 1997.
    1. Dudley RA, Medlin CA, Hammann LB, Cisternas MG, Brand R, Rennie DJ, Luft HS. The Best of Both Worlds? The Potential of Hybrid Prospective/Concurrent Risk Adjustment. 2003;41(1):56–69. - PubMed
    1. Glaser B, Strauss AL. Time for Dying. Chicago: Aldine; 1968.

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