The Best Solution for Declining Medicare Reimbursements

Editor’s Note: Originally writtenJuly 9, 2013,Bobbi为2018年3月更新了这篇文章。

Given the continued trends for declining Medicare reimbursements, I am one of the brave souls who takes the time to read the report issued each spring by the Medicare Payment Advisory Commission (Medpac). MedPAC is a nonpartisan agency that provides Congress with analysis about the Medicare program. Many of their reports are used to set policy for the Medicare program. The push for quality is strong and MedPAC is working to provide the right incentives for quality.

Though the reading can be a bit dry, the information contained in the report is important—particularly considering the fact that the commission’s recommendations are influential in shaping policy. Medicare payment policies tend to set a precedent for other payers.

I had the chance to read a variety of the documents published by MedPAC (Medicare Payment Advisory Commission). I reviewed two documents:

• June 2017 A Data Book, Health Care Spending and the Medicare Program
• 2017年6月提交给国会医疗保险和医疗保健服务系统的报告

The Report to Congress covers 10 areas from stand-alone ED to provider payment. I am just focusing on a couple of the areas and showing a few key findings from the data distributed.

Spending

报告显示，从长期来看，这种支出趋势是无法承受的。We have been able to lower the per beneficiary spend but we need to sustain that trend

• Medicare per beneficiary spend has fallen to an annual increase rate of 1 percent for the period 2010 to 2015.
• 对2016-2025年的预测显示，人均受益支出将以每年4%的速度增长。
• During the same time-period the aging of the baby-boom generation will cause an increase of enrollment of 3 percent annually. By 2030 there will be 81 million beneficiaries in the Medicare program.
• Overall Medicare spending will increase 6-7 percent each year and this is a higher projection than the GDP (Gross Domestic Product). GDP is projected to increase 5 percent annually.

Utilization trends

从2006年到2015年，在医疗保险计划中，每个受益人的门诊次数增加了47%，住院次数减少了近20%。请看下面的图表，它说明了服务业的这种转变。

During the same time, Medicare length of stay decreased 7.7 percent. These facts will impact the location of services for the populations served.

Source: MedPAC analysis of CMS claims

There have been a couple of shifts in the type of cases admitted to the hospital between 2006 and 2015.

• 2015年，循环系统病例占住院患者出院总数的五分之一，比2006年下降了6个百分点。
• 肌肉骨骼系统病例占所有住院病例的14%，比2006年增加了2个百分点。
• Up 5 percentage points is infectious and parasitic disease cases which accounted for 9 percent of all inpatient discharges.

门诊病人的轮班还会继续，我们需要根据设施和消费者偏好来规划。

Readmission

2013年，减少医院再入院计划(HRRP)开始计算对某些特定情况再入院率高于平均水平的医院的惩罚。从2010年到2015年，所有情况下可能可以预防的再入院率从12.9%下降到10.5%。从2013年开始，HRRP涵盖的三种情况的再入院率都出现了下降，而这可能是可以预防的。因AMI再次入院的人数下降了3.6个百分点，心力衰竭下降了3.1个百分点，肺炎下降了2.5个百分点。

CMS started a program that involves a negative payment and hospitals have responded to the penalty by working to lower readmissions.

Discharge disposition

2015年，在所有接受医疗保险收费服务的患者中，约有46%从急症护理医院出院回家，没有任何有组织的急症后护理。这比2006年减少了7个百分点。越来越多的老年医保患者出院后接受急性期护理服务。21%的人出院接受专业护理，17%的人回家接受有组织的家庭保健服务。MedPAC建议对急性期后护理实施统一的支付系统。医疗保险目前已经发现，根据急性期后的治疗地点的选择，类似的患者存在差异。急性期后医疗服务提供者的供应和使用在全国各地差异很大。MedPAC希望根据患者的特点而不是服务地点进行支付。

Bundle payments would help in this area and place accountability with the organization that assumes the risk. Also CMS may revamp the payment system for post-acute care by 2020.

Concentration of spending

最昂贵的25%的受益人占了84%的支出。最昂贵的支出领域包括双重资格(医疗保险、医疗补助)、患有多种慢性疾病的受益人、住院服务的用户和生命的最后一年的人。

CMS needs to develop programs that target and value care coordination.

Low-value care

MedPac提供了几张图表来展示低价值的医疗服务。低价值护理的定义是提供很少或没有临床效益的服务。他们使用了一组研究人员开发的31种测量方法。然后他们用美元来计算，2014年的支出在24亿到65亿美元之间。该清单包括检测、成像和筛查。一些高花费的例子是稳定冠状动脉疾病的压力测试和非特异性腰痛的成像。他们表示，这只是确定低价值医疗成本的一个开始。

Providers should be evaluating the 31 measures in their institutions. We may currently get revenue for the services, but we need to shift to a value lens.

Addressing Declining Medicare Reimbursements

我希望你能从这些事实中看到，那些推荐新政策的人将继续推动提供商追求质量和价值。越来越多的受益者正在加入这个项目，控制成本的压力将持续存在。人们愿意为更好的结果付费。通过健康催化剂®数据操作系统(DOS™)等平台，利用数据导出有洞察力的分析，医疗保健组织可以自信地应世界杯厄瓜多尔vs塞内加尔波胆预测对这些变化，他们可以在一个更基于价值的环境中世界杯葡萄牙vs加纳即时走地适应和发展。

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