Download The disability waiting period for Medicare is related to

1. Does health reform do anything to shorten the disability waiting
period for Medicare? What is the difference in disability coverage for
Medicare versus Medicaid beneficiaries?
The disability waiting period for Medicare is related to the process of
applying for social security disability income (SSI) – which gives the
beneficiary access to income as well as health care. For the most
part, folks on SSI get their medical coverage through state Medicaid
programs. I don’t know of any effort to shorten that period.
It’s important to understand critical distinctions between Medicare and
Medicaid. Medicare is a federally sponsored program for the elderly
and those on kidney dialysis. Part A covers hospitalizations (and
there is a “trust fund” from premiums deducted from beneficiaries’
social security checks – that’s the trust fund that we often hear is
about to run out. Part B covers professional and outpatient services.
This is funded 25% by beneficiary premiums, and 75% by general tax
revenue. Part D covers outpatient prescriptions – and is delivered
through private insurers. It is famous for a “donut hole,” where after
initial coverage the beneficiary must pay the entire cost until reaching
a catastrophic level. Medicaid is a joint federal-state program for the
poor and disabled – and each state has different rules for eligibility
and for coverage. The mnemonic used when I went to school: we
“care” for the elderly and we “aid” the poor.
2. If an insurance company pays a provider with a capitated
payment, do patients still have to pay a co-pay?
Yes. The capitation payment is reduced by the expected copayment
that would be collected. This also means that the total revenue for
capitated groups that deliver few services is somewhat less.
3. If a patient has private insurance and is willing to pay extra for any
care that he receives, how does his over-consumption affect
spending and costs in the entire health care system? In other words,
since that patient is paying for care himself (he is not on Medicare or
Medicaid), how would his consumption affect the prices of services
for other people?
It all depends. Overconsumption by those paying privately increases
the portion of the GDP spend on health care. (But remember Victor
Fuchs’ statement: 100% of GDP has to be spent on something!) To
the extent that the rich person overconsuming creates more demand
with less price sensitivity, this can also raise price of health care for
all. Canada (until recently) prohibited purchase of any supplementary
insurance to prevent this. On the other hand, there is a long history in
the UK of the rich or employers purchasing supplementary insurance.
4. Do Medicare patients receive care mostly at AMCs or community
hospitals. Where is the line drawn on how expensive or how much
care Medicare and Medicaid patients can receive? I think the
question refers to the minimum level of benefits that these patients
receive. I responded to the student by saying that the minimum level
of benefits in Medicaid vary state to state, but I wanted to see what
else you can add.
This depends on geography. In the city of Boston, there is only a
single remaining community hospital – so Medicare (and other)
patients get most of their care at AMCs (academic medical centers).
In general, Medicare beneficiaries are probably a bit more likely to go
to community hospitals than the general population since some of
them are more mobile and able to make a choice. Also, most AMCs
do not see many patients transferred from nursing homes – and
these make up a substantial portion of total Medicare inpatient days.
In terms of Medicare- the benefits are uniform across the country
BUT there are regional administrators who make decisions on
coverage of new technology which are not always consistent. The
federal has minimum standards for Medicaid coverage – and states
must provide at least the mandatory benefits and coverage to be
eligible for matching federal funds. Here is a rundown of Medicaid
eligibility standards by state
http://www.kff.org/medicaid/upload/7993.pdf and a straightforward
description of both Medicare and Medicaid from the American Dental
Association.
http://www.ada.org/public/manage/insurance/medicare.asp
5. Do you have any studies that show that trying to cut costs in the
system reduces quality of care?
Sure. The one that comes to mind is a study showing that
implementing computerized physician order entry at the children’s
hospital in Pittsburgh was associated with an increase in mortality.
Here is a link to this study
http://pediatrics.aappublications.org/cgi/content/full/116/6/1506, which
is very relevant to class 7 (this Wednesday).
Here’s the question I think we should ask. Is there any study showing
that spending MORE is associated with higher quality. In fact, the
body of work from the Dartmouth Atlas group (Wennberg and
Fischer) suggests a strong association between high costs and lower
quality. This is an association – not causality – and the case would
be stronger if the Dartmouth researchers added non-Medicare data to
their database. This is not easy to do, though.