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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.