Report to Congress on monitoring the impact of Medicare physician payment reform on utilization and access

47 Pages·1996·1.6 MB·English

by  Shalala, Donna E

2001ReporttoCongresson
MonitoringtheImpactofMedicarePhysicianPayment
ReformonUtilizationandAccess
TommyG.Thompson
Secretary
DepartmentofHealthandHumanServices
2001
TableofContents
ExecutiveSummary
Introduction
PreviousReports
The2001Report •
cQhuaesntgieosnan1t:iDcoipeastetdhewiMtehdirecgaarredFteoeshSicfhtsedouflMeecdoinctairneuepatoymiennvtoskeftrhoemkpirnodcsedoufrpaalyment
servicestowardevaluationandmanagementservices?
Question2:Havetherebeenreductionsinaccesstophysicians'servicessince
theintroductionoftheMedicareFeeSchedule?
Question3:Haspaymentreformexacerbatedracialdifferencesinaccessto
servicesthatwerereportedinearlieranalyses?
Question4:AretheimpactsoftheMFSonphysicians'practicessimilarto
earlierimpactsdetected?
Conclusions
References
AppendixA
ToC-1
Tables:
Table1. MScehdeidcualreebAyllMoawjeodrCThyapregeosfSfoerrvPihcyesiCcaitaengso'ryS:er1vi9c9e0s-1P9a9i9dUndertheMedicareFee
Table2. MedicarePerCapitaAllowedChargesforPhysicians'ServicesPaidUnderthe
MedicareFeeSchedulebyMajorTypeofServiceCategory:1990-1999
Table3. MedicarePhysicians'servicesPaidUndertheMedicareFeeSchedule:Numberof
VisitsandConsultationsper1,000AgedMedicareBeneficiaries:1990-1999
Table4. MedicarePhysicians'ServicesPaidUndertheMedicareFeeSchedule:Numberof
Proceduresper1,000AgedMedicareBeneficiaries:1990-1999
Table5. MedicarePhysicians'ServicesPaidUndertheMedicareFeeSchedule:Numberof
ImagingServicesper1,000AgedMedicareBeneficiaries:1990-1999
Table6. MedicarePhysicians'ServicesPaidUndertheMedicareFeeSchedule:Ratioof
African-AmericantoWhiteVisitandConsultationUseRatesper1,000Aged
MedicareBeneficiaries:1990-1999
Table7. MedicarePhysicians'ServicesPaidUndertheMedicareFeeSchedule:Ratioof
African-AmericantoWhiteProcedureUseRatesper1,000AgedMedicare
Beneficiaries:1990-1999
Table8. MedicarePhysicians'ServicesPaidUndertheMedicareFeeSchedule:Ratioof
African-AmericantoWhiteImagingServicesUseRatesper1,000AgedMedicare
Beneficiaries:1990-1999
Table9. MeasuresofAccesstoCareforAfrican-AmericanandWhiteMedicareBeneficiaries.
DatafromtheMedicareCurrentBeneficiarySurvey:1991through1998
Table10. UsualSourceofCareforAfrican-AmericanandWhiteMedicareBeneficiaries. Data
fromtheMedicareCurrentBeneficiarySurvey:1991through1998
Table11 HAofsrpiictaanl-iAzmaetrioincaanndanModrWtahliitteyARgateedsMfeordiScealreectBeedneHfeiacritaraineds:Va1s9c9u0laarndPr1o9c9e8duresfor
Table12 HospitalizationandMortalityRatesforSelectedOrthopedicandBackProceduresfor
African-AmericanandWhiteAgedMedicareBeneficiaries:1990and1998
Table13 HospitalizationandMortalityRatesforSelectedProceduresforAfrican-American
andWhiteAgedMedicareBeneficiaries:1990and1998
ToC-2
Table14 HospitalizationandMortalityRatesforSelectedProceduresforAfrican-American
andWhiteAgedMedicareBeneficiaries:1990and1998
Table15 PhysiciansBillingforMedicareServices,AverageCaseload,PaymentsperPhysician,
PhysiciantoPopulationRatio,andTotalMedicarePayments,1995-1999:All
Physicians
Table16 PhysiciansBillingforMedicareServices,AverageCaseload,PaymentsperPhysician,
PhysiciantoPopulationRatio,andTotalMedicarePayments,1995-1999:Primary
CarePhysicians
Table17 PhysiciansBillingforMedicareServices,AverageCaseload,PaymentsperPhysician,
PhysiciantoPopulationRatio,andTotalMedicarePayments,1995-1999:Surgical
Specialties
Table18 PhysiciansBillingforMedicareServices,AverageCaseload,PaymentsperPhysician,
PhysiciantoPopulationRatio,andTotalMedicarePayments,1995-1999:Medical
Specialties
ToC-3
EXECUTIVESUMMARY
BACKGROUND
This2001reporttoCongresson"MonitoringTheImpactofMedicarePhysicianPayment
ReformonUtilizationandAccess"istheSecretary'sseventhannualreportsubmittedto
CongressinresponsetorequirementsofPublicLaw101-239,theOmnibusBudget
ReconciliationActof1989(OBRA'89). OBRA'89requiredtheSecretarytomonitor
andreportannuallytheimpactofchangesinMedicarephysicianpaymentonutilization
andaccesstocare. This2001reportisthelastreporttoCongressonthistopicin
accordancewiththeFederalReportsEliminationandSunsetActof1995(P.L.104-66,
Section3003). OBRA'89introducedsignificantchangesinMedicarephysicianpayment
policy. Theintentofthechangeswastoprovidemorerationalandequitablepaymentfor
physicians'servicesprovidedundertheMedicareprogram.
THE2001REPORT
KeyfindingsfrompastreportsindicatedthatintroductionoftheMedicareFeeSchedule
(MFS)producedthekindsofshiftsinpaymentsthatwereanticipated. Inparticular,there
wasarelativeincreaseinallowedchargesforvisitsandconsultationsandarelative
decreaseinallowedchargesforprocedure-basedservices. Thepreviousreportsalso
showedthatmanyvulnerablegroupsfacebarrierstocare.
Whilethedifferencesamongvulnerablegroupsareacauseforconcern,pastreports
showedthattheintroductionofthenewpaymentsystemforphysiciansproducednonew
barrierstocareforthevulnerablepopulationsstudied. PreviousworkbytheHealthCare
FinancingAdministrationandthePhysicianPaymentReviewCommissionhas
establishedthatthenewpaymentsystemdidnotexacerbateexistingbarriers. The
Secretary's2001reportfocusesonupdatingthetrendsinphysicianaccessshownin
previousreportsanddescribesongoingeffortsbytheDepartmenttoreducedisparitiesin
healthcare. This2001reportupdatesthreeofthebasicstudiesincludedinprevious
reportsandaddsanewanalysisbasedonsurveysofMedicarebeneficiaries.
FOURMAJORPOLICYISSUESADDRESSED
• DoestheMFScontinuetoinvokethekindsofpaymentchangesanticipatedwith
regardtoshiftsofMedicarepaymentsfromproceduralservicestowardevaluation
andmanagementservices?
• Havetherebeenreductionsinaccesstophysicians'servicessincetheintroduction
oftheMFS?
• Haspaymentreformexacerbatedexistingracialdifferencesinaccesstoservices?
ES-1
• ArethereimpactsoftheMFSonphysicians'practices?
HIGHLIGHTS
• Theshiftinpaymentsdescribedinpreviousreports,fromproceduralservices
towardevaluationandmanagementservices,wassustainedthrough1998andfor
preliminaryestimatesfor1999. Priortophysicianpaymentreform,procedures
includedunderthefeescheduleaccountedfor46percentofallowedcharges,and
visitsandconsultsaccountedfor40percent. Thispatternwasreversedduring
1992,thefirstyearofphysicianpaymentreform. Datafrom1998andpreliminary
1999datashowthatvisitsandconsultscontinuetoaccountforanincreasingly
largershareofallowedcharges(51percentofallowedcharges)thanprocedures
(36percentofallowedcharges).
• TotalMedicareallowedchargesforphysicians'servicesundertheMFSincreased
byonly2.8percentduringtheperiod1995through1998,from$41.1billionto
$42.2billion. Thislowrateofgrowthwasduemostlytoadecreasingnumberof
Medicarebeneficiariesreceivingservicesinthefee-for-servicearea. Forthose
beneficiariesreceivingcareinthefee-for-servicesector,percapitaallowed
chargesforMFSphysicians'servicesincreasedby9.4percentduringtheseyears,
from$1,292to$1,413.
• Useofmosttypesofphysicians'serviceshaveincreasedsincetheintroductionof
theMFS. Totalphysicianvisitsandconsultationshaveincreasedfrom12.2visits
perpersonin1992to13.4visitsperpersonin1998. Physicianvisitsintheoffice
setting,usuallyconsideredtheprincipalsiteforaccesstohealthcare,increased
from5.4visitsperpersonin1992to6.5visitsperpersonin1998. Therewere
alsoincreasesintheuseofanumberofproceduralandimagingcategoriesas
well. Percapitauseratesincreasedbetween1992and1998by11percentfor
coronaryarterybypassgrafts(CABG),80percentforpercutaneoustransluminal
coronaryangioplasty(PTCA),22percentforcataractremovalwithlensimplant,
44percentforcomputedaxialtomographyscans,andby117percentformagnetic
resonantimagingservices. Servicesforwhichthereweresignificantreductionsin
userates,suchastransurethralprostatectomy,weremorelikelyduetochanging
medicalpracticeunrelatedtopaymentpolicy.
• WhiletheupdatedstudiescontinuetoshowthatAfrican-AmericanMedicare
beneficiariesfacebarrierstocare,theaccessdifferentialshavenotworsenedandin
somecasesappeartohaveimprovedslightly. Forexample,thereissomeevidenceto
suggestthatAfrican-Americanbeneficiariesareexperiencingimprovedaccessto
referral-sensitiveprocedures. Therateofcardiacrevascularizationprocedures
(CABGandPTCA)isincreasingmorerapidlyamongAfrican-Americanbeneficiaries
thanamongwhitebeneficiaries. Thishasresultedinanarrowingofthedifference
ES-2
betweenwhiteandAfrican-AmericanMedicarebeneficiaries. Inaddition,disparities
inthe30-daypost-admissiondeathrate,reflectingtosomeextentdifferencesinhealth
statusatthetimeoftheprocedure,arediminishing. Forexample,in1998the30-day
post-admissiondeathratesfollowingCABGwerenearlyequalforAfrican-American
andwhitebeneficiaries,whileAfrican-Americanbeneficiarieshavelowermortality
ratesthandowhitebeneficiariesfollowingPTCA.
Asdiscussedabove,physicianofficevisitratesincreasedbetween1992and1998.
However,theratesincreasedfasterforwhitebeneficiariesthanforAfrican-American
beneficiaries. Asaresult,in1998African-AmericanMedicarebeneficiarieshad
19percentfeweroffice-basedphysicianvisitsthanwhitebeneficiaries,comparedtoa
14percentdifferentialin1992. Thisisoneofthefewareasinwhichtheracial
differentialwasincreasing. Inaddition,African-Americanbeneficiarieshad39
percentmoreemergencyroomvisitsin1998thandidwhitebeneficiaries. Whilethe
officevisitrateforAfrican-Americanswaslowerthanwhitesandtheemergency
roomvisitratewashigher,thiswaspartiallymitigatedbythehigherrateof
consultationsforAfrican-Americanbeneficiariesascomparedtowhitebeneficiaries.
Moreover,othermeasuresofaccesstoprimarycare,basedondatafromtheMedicare
CurrentBeneficiarySurvey,suggestthatbothwhiteandAfrican-American
beneficiariesreportimprovedaccesstocare.
IndicatorsforthenumberofphysiciansprovidingservicesundertheMFS,aswellas
thenumberofuniqueMedicarepatientsseenbyaphysician(i.e..Medicarecaseload)
andallowedcharges,continuetosuggestthataccesstophysicians'serviceshasnot
deterioratedfollowingtheintroductionoftheMFS. Physiciansupplyincreasedby
3.8percentbetween1995and1998. However,duetodecreasingMedicare
enrollmentinfee-for-service,thephysiciantoMedicarepopulationratioincreasedby
over1 percentduringthistime.
ES-3
INTRODUCTION
ThisreporttoCongressfortheyear2001istheSecretary'sseventhannualreportsubmittedto
CongressinresponsetorequirementsofPublicLaw101-239,theOmnibusBudget
ReconciliationActof1989(OBRA'89). OBRA'89requiredtheSecretarytomonitorandreport
annuallytheimpactofchangesinMedicarephysicianpaymentonutilizationandaccesstocare.
ThisreportisthelastreporttoCongressonthistopicinaccordancewiththeFederalReports
EliminationandSunsetActof1995(P.L.104-66,Section3003).
OBRA'89introducedsignificantchangesinMedicarephysicianpaymentpolicy. Thethree
majorcomponentsofthelawwere:(1)theintroductionofaMedicareFeeSchedule(MFS),
whichwasimplementedbeginningJanuary1,1992,underatransitionperiodendingin1996;(2)
theestablishmentoflimitsonphysicians'chargesexceedingthefeescheduleamount;and(3)the
institutionoftargetratesofgrowthinexpendituresforphysicians'services. Theintentofthese
changeswastoprovidemorerationalandequitablepaymentforphysicians'servicesprovided
undertheMedicareprogram.1 Therehavebeenanumberofchangesinpaymentpolicyinrecent
yearsaswell. Thefinalruleconcerningrevisionstopaymentpoliciesunderthephysicianfee
scheduleforcalendaryear2000includeanumberofrevisionssuchasimplementationof
resource-basedmalpracticeexpenserelativevalueunits(RVUs)andrefinementof
resource-basedpracticeexpenses.
PREVIOUSREPORTS
TheHealthCareFinancingAdministration(HCFA)hastakenabroadandvariedapproachto
monitoringaccesstocare. Previousreports(the1994,1995,and1996reportstoCongress)
summarizedtheresultsofseveralstudies,whichprimarilyusedtheMedicarePartBmonitoring
system,PartAdata,andtwonationalsurveys. Themulti-prongedapproachtomonitoringaccess
tocarehasallowedHCFAtoexamineaccessfromvariousperspectives.
1 Asdescribedinpreviousreports,paymentreformispartofacontinuum. Beforethe
OBRA'89reformswereinstituted,anumberofsignificantchangeswereinitiatedinphysician
paymentpolicythataffected,andwillcontinuetoaffect,utilizationandaccess. Theseinclude
theimplementationin1975oftheMedicareEconomicIndexasalimitonincreasesinprevailing
charges;theinitiationin1984oftheparticipatingphysicianprogramtoprovideincentivesfor
physicianstoacceptassignment;theintroductionin1987oftheMaximumAllowableActual
Chargelimitswhichrestrictedtheamountnon-participatingphysicianscouldcharge;the
reductionsinprevailingchargesforoverpricedproceduresinstitutedforonegroupofprocedures
in1988andforanotherin1990;andtheinstitutionoffeeschedulesforradiologyin1989and
anesthesiologyin1990. Manyotherforcesarealsolikelytocontinuetoinfluencethediffusion
ofnewtechnologyintothehealthdeliverysystem. Itisimportant,therefore,toviewanychanges
foundinaccess,utilization,andappropriatenessinlightofthemanyfactorsthatmayinfluence
thehealthcaresystemingeneralandMedicareinparticular.
1
Inpreviousreports,severalvulnerablepopulationgroupswereidentifiedandmonitored. These
includebeneficiarieswhoarelivinginpovertyareas;thoseduallyeligibleforMedicareand
Medicaid;African-AmericanMedicarebeneficiaries;disabledMedicarebeneficiaries;thevery
old(i.e.,age85andover);Medicarebeneficiarieswithoutsupplementalinsurance;Medicare
beneficiariesresidinginruralareasorresidinginareasdesignatedashealthprofessionalshortage
areas;andMedicarebeneficiariesresidinginareasexpectedtoexperiencethegreatestdecreases
inaverageMedicarefees.
Therewereseveralkeyfindingsfromthepastreports. Previousreportsshowedthatthe
introductionoftheMFSproducedthekindsofshiftsinpaymentsthatwereanticipated. In
particular,therewasarelativeincreaseinallowedchargesforvisitsandconsultationsanda
relativedecreaseinallowedchargesforprocedure-basedservices.
However,thesereportsalsoshowedthatmanyvulnerablegroupsfacebarrierstocare. For
example,theyshowedthatraceandincomearemajorfactorsthatinfluencetheamountandtype
ofservicesMedicarebeneficiariesreceive. African-AmericanMedicarebeneficiaries,regardless
ofincome,visitedaphysicianlessfrequentlythanwhitebeneficiaries,receivedfewerpreventive
services,butwerehospitalizedmoreoften. Amongbothraces,thepoorestoftheelderlyhad
fewerphysicianvisitsandpreventiveservices,butwerehospitalizedmoreoftenthanthemost
affluent. ThesepatternssuggestthatAfrican-Americanbeneficiariesoverallandthepoorestof
bothracesmaybereceivinglessprimaryandpreventivecarethanwhitesandmoreaffluent
Medicarebeneficrafiesinbothraces.
Similarly,thefindingsinthepreviousreportsalsosuggestthatAfrican-Americanandlow-
incomeMedicarebeneficiariesarereceivinglessthanoptimalmanagementofdisease. In
particular,African-AmericanandlowerincomewhiteMedicarebeneficiarieshaveahigherrate
ofbilateralorchiectomy,aprocedureperformedforlatestageprostatecancer. African-American
andlow-incomeMedicarebeneficiariesalsohavehigherratesofhospitaladmissionfor
conditionsthatarepotentiallyavoidablewithtimelyandappropriateambulatorycare
(ambulatorycaresensitiveconditions). Anarticlebasedondatadevelopedforthesereports
(Gornick,Eggers,Reillyetal.1996)highlightedtheanalysesthatshowedthatAfrican-American
andlowerincomewhiteMedicarebeneficiariesarealsomorelikelytohaveanamputationofall
orpartofthelowerlimb,aprocedureoftenperformedbecauseofcomplicationsofdiabetes.
Inadditiontoindicationsoflessthanoptimalprimarycareandmanagementofdisease,the
findingsfrompastreportsalsosuggestthatAfrican-AmericanMedicarebeneficiarieshaveless
accessthanwhitebeneficiariestoreferral-sensitiveprocedures2. Forexample,African-American
Medicarebeneficiarieshavelowerratesofcoronaryarterybypassgraft(CABG),percutaneous
transluminalcoronaryangioplasty(PTCA),andjointreplacementsthanwhitebeneficiaries.
Whilethesedifferencesbetweenvulnerablegroupsareacauseforconcern,previousreportsdid
notfindevidencethattheintroductionofthenewpaymentsystemforphysiciansproducednew
2 Referral-sensitiveproceduresarethoseproceduresforwhichabeneficiarytypically
receivesareferralfromaprimarycarephysiciantoaspecialist.
2
barrierstocareforthevulnerablepopulationsstudied. WorkbytheMedicarePayment
AssessmentCommissionanditspredecessor,thePhysicianPaymentReviewCommissionalso
foundnoevidenceofapaymentpolicyeffectonaccesstocare. Therefore,thecurrentreport
focusesonupdatingthetrendsinphysicianaccessshowninpreviousreportsanddescribing
ongoingeffortsbytheDepartmenttoreducedisparitiesinhealthcare. Thisreportupdatesthree
ofthebasicstudiesincludedinpreviousreportsandaddsanewanalysisbasedonsurveysof
Medicarebeneficiaries.
THE2001REPORT
Thisreportpresentsresultsfromupdatingthreeofthebasicstudiesincludedinpreviousreports.
TsehreviPcaerstaBndmotnoiatsosreisnsgcshyasntgeemsiisnuascecdestsotuopdphaytseictoitaanls'exspeernvdiicteusrienggreonwertahl.forPaMrtFSAcdaotvaeraerdeused
intheseanalysestoassesstrendsintheuseofin-patienthospitalservices. Thelevelofphysician
participationinMedicare'sfee-for-serviceprogramisassessedthroughananalysisofMedicare's
ProviderSummaryfiles. Finally,thisyear'sreportincludesanalysesoftrendsinaccesstocare
usingtheMedicareCurrentBeneficiarySurvey.3
Thisreportexaminesthesamespecificpolicyissuesaddressedinpreviousreports:
Question1: ^ DoestheMFScontinuetoinvokethekindsofpaymentchanges
anticipatedwithregardtoshiftsofMedicarepaymentsfrom
proceduralservicestowardevaluationandmanagementservices?
Table1showsthetrendintotalallowedchargesforphysicians'servicescoveredundertheMFS
fortheyears1990through1999. Between1990and1991allowedchargesincreasedby
10.4percent,from$29.9billionto$33.0billion,arateofincreaseconsistentwiththedouble
digitpercentincreasesduringthe1970sand1980s. Therewasaslightdecreaseof0.8percentin
allowedchargesin1992,thefirstyearoftheMFS. Thisreflectsthe8.2percentincreaseinvisits
andconsults,offsetbya9.1percentdecreaseinprocedures. Increasesin1993,1994and1995
were4.0percent,11.5percent,and8.1percent,respectively. Thegrowthinexpenditures
between1993and1994forprocedure-basedservices,ascomparedtothedecreasein
expendituresbetween1992and1993,reflectsalargeadjustmenttothefeescheduleupdatein
1994forthesurgicalservices.4 From1995to1998allowedchargesincreasesbyonly
3 ThetablesinthisreportwithdatafromthePartBmonitoringsystemincludedatathrough
1999,thoughduetotheincompletenatureofthe1999data,analysesofthesetablesaregenerally
through1998. MedicarePartAdataonhospitalizations,anddatafromtheMedicareCurrent
BeneficiarySurveyarethrough1998.
4 Feescheduleupdateswerebasedonexpenditureperformancerelativetotheexpenditure
targetsetundertheMedicareVolumePerformanceStandard(MVPS)from1992-1998. There
wasabouta2-yeartimelagbetweentheperformanceyearusedtocalculatetheupdateandthe
yeartheupdateactuallytakeseffect. Thatis,foraspecifiedgroupofservices,suchassurgery,
theJanuary1,1994feescheduleupdatereflectsexpenditureperformanceduringfiscalyear
3