Medicare Policy in the 1990s

I describe several changes to Medicare in the 1990s, their rationale, and their likely effects. I focus principally on issues in the administered price systems Medicare uses to pay medical providers, especially those used for post-acute care providers, Health Maintenance Organizations (HMOs), and physicians. The changes to these systems in the 1990s, although directed at important problems, have introduced new and serious problems of their own. For example, the post-acute care system now pays different amounts for the same service, depending on the site of care, and the HMO system is on a trajectory to pay substantially less than traditional Medicare in high rate areas and more in low rate areas, thereby unbalancing local medical markets. I consider future directions for the program, including its long-term financing and a prescription drug benefit.

Are Medical Prices Declining?

We address long-standing problems in measuring health care prices by estimating two medical care price indices. The first, a Service Price Index, prices specific medical services, as does the current CPI. The second, a Cost of Living Index, measures the net valuation of treating a health problem. We apply these indices to heart attack treatment between 1983 and 1994. Because of technological change and increasing price discounts, the current CPI overstates a chain-weighted price index by three percentage points annually. For plausible values of an additional life-year, the real Cost of Living Index fell about 1 percent annually.

A New Medicare End-of-Life Benefit for Nursing Home Residents

A new Medicare benefit is needed to support end-of-life care for those spending their final days in a nursing home, say the authors of this article. Arguing that the current hospice benefit is a poor fit with the nursing home setting, the authors recommend a new benefit that would enable nursing home residents to receive individualized palliative and psychosocial services in addition to rehabilitative services

Pricing Heart Attack Treatments

In this paper, we estimate price indices for heart attack treatments, demonstrating the techniques that are currently used in official price indices and presenting some alternatives. We consider two types of price indices, a Service Price Index, which prices specific treatments provided, and a Cost of Living Index, which prices the health outcomes of patients. Both indices are complicated by price measurement issues: list prices and transactions prices are fundamentally different in the medical care field. The development of new or modified medical treatments further complicates the comparison of like' goods over time. And the Cost of Living Index is hampered by the need to determine how much of health improvement results from medical treatments in comparison to other factors. We describe methods to address each of these obstacles. We conclude that whereas traditional price indices when applied to heart attack treatments are rising at roughly 3 percent per year above general inflation, a corrected service price index is rising at perhaps 1 to 2 percent per year above general inflation, and the cost of living index is falling by 1 to 2 percent per year relative to general inflation. We discuss the implications of these results for official price index calculations.

Reimbursing for Health Care Services

The literature on contracting has focused on the power of the contract and especially the mix of fixed price and cost reimbursement type contracts. For health care services there is the additional issue of what the base of any fixed price contract should be ; e.g., for hospitalized patients, per day, per stay, or per episode (including post acute care). More aggregate bases are more powerful. I suggest that more aggregate bases are more likely optimal, the less independent are various inputs (typically, the more substitutable). I illustrate with the experience of the American Medicare program

Reimbursing for Health Care Services

The literature on contracting has focused on the power of the contract and especially the mix of fixed price and cost reimbursement type contracts. For health care services there is the additional issue of what the base of any fixed price contract should be ; e.g., for hospitalized patients, per day, per stay, or per episode (including post acute care). More aggregate bases are more powerful. I suggest that more aggregate bases are more likely optimal, the less independent are various inputs (typically, the more substitutable). I illustrate with the experience of the American Medicare program

Pricing and Reimbursement in U.S. Pharmaceutical Markets

In this survey chapter on pricing and reimbursement in U.S. pharmaceutical markets, we first provide background information on important federal legislation, institutional details regarding distribution channel logistics, definitions of alternative price measures, related historical developments, and reasons why price discrimination is highly prevalent among branded pharmaceuticals. We then present a theoretical framework for the pricing of branded pharmaceuticals, without and then in the presence of prescription drug insurance, noting factors affecting the relative impacts of drug insurance on prices and on utilization. With this as background, we summarize major long-term trends in copayments and coinsurance rates for retail and mail order purchases, average percentage discounts off Average Whole Price paid by third party payers to pharmacy benefit managers as well as average dispensing fees, and generic penetration rates. We conclude with a summary of the evidence regarding the impact of the 2006 implementation of the Medicare Part D benefits on pharmaceutical prices and utilization, and comment on very recent developments concerning the entry of large retailers such as Wal-Mart into domains traditionally dominated by large retail chains and the "commoditization" of generic drugs.

Medical Care Price Indices: Problems and Opportunities / The Chung-Hua Lectures

These Chung-Hua Lectures, given at the Academia Sinica in Taiwan in December 2000, summarize work that has been done by myself and others on biases in medical care price indices. I begin by reviewing various uses of price indices and therefore why biases in the overall indices - and changes in those biases - matter. I then describe briefly the assumptions and theory underlying the official price indices. I next turn to the problems of measuring medical prices, assuming the basic applicability of the theory upon which the official indices are based. Finally I take up the potential inapplicability of the assumptions made by that theory and the resulting issues for measuring medical price changes. I describe an alternative theory and its implications for the measurement of medical prices. I conclude that the biases in the official medical care index, while substantially reduced by recent improvements, likely remain substantial enough to affect the overall official indices in the United States, especially the GDP deflator, where the weight of medical care is around 13 percent.