Technocratic corporatism and administrative reform in Medicare

For two decades administrators of Medicare have tried to reconcile the competing goals adopted by the program's political creators--meeting obligations to the beneficiaries of a social insurance system, maintaining peace with and the participation of providers, and protecting the federal budget. Administrative efforts to balance these objectives have evolved in three phases. The search of the late 1960s for measures to placate providers and win consensus among them, gave way in the early and mid-1970s to new organizations and programs (Professional Standards Review Organizations, capital expenditure review, and others) that would impose controls on the program at the state and local levels, which in turn have yielded to more centralized and direct strategies, notably the prospective payment system adopted in 1983. The new federal activism may be initiating a period of "technocratic corporatism," in which administrators and providers will engage in increasingly structured negotiations over the details of reimbursement policies.     

Medicare reform: social and ethical perspectives

Despite Medicare's success as a social program, its future is in question because of the program's enormous costs. Because the issue of Medicare reform has been forced upon us at this juncture by a crisis of finance rather than by the long-standing inequities in the present system of paying for the health care of the elderly, questions about how best to secure its fiscal integrity have seized the attention of the public. Yet, such questions are hard to contain; they force an examination of broader and more fundamental issues. In this article, we examine the validity of the ultimate moral and social rationales for continuing Medicare in something approximating its present form; the legitimacy of a social entitlement program that is age- rather than means-based; the implications for the future of health care reform if significant changes were to be made in the Medicare program and its underlying rationale; and the possibility that changes in that program may jeopardize the chances for a more rational, just, and systematic approach to the provision of health care to all Americans.     

Considerations in Medicare reform: the impact of Medicare preemption on state laws

This article explores the key issues involved in understanding the impact of Medicare preemption on state laws affecting the federal purchase of managed care products, as a consideration in future Medicare reform. Author Commander Jackonis argues that any further Medicare reform must address the impact of federal preemption on quality and quantity of care purchased in order to ensure the existence of a market of product providers, as well as to ensure protection of patient rights and benefits.     

Real reform begins within: an organizational approach to health care reform

Health care systems are under pressure to control their increasing costs, to better adapt to evolving demands, to improve the quality and safety of care, and ultimately to ameliorate the health of their populations. This article looks at a battery of organizational options aimed at transforming health care systems and argues that more attention must be paid to reforming the delivery mechanisms that are so crucial for health care systems' overall performance. To support improvement, policies can rely on organizational assets in two ways. First, reforms can promote the creation of new organizational forms; second, they can employ organizational levers (e.g., capacity development, team-based organizations, evidence-informed practices) to achieve specific policy goals. In both cases organizational assets are mobilized with a view to creating complete health care organizations -- that is to say, organizations that have the capacity to function as high-performing systems. The challenges confronting the development of more complete health care organizations are significant. Real health care system reforms may likewise require implementing ecologies of complex innovation at the clinical, organizational, and policy levels. Policies play a determining role in shaping these new spaces for action so that day-to-day practices may change.     

Physician payment and cost-containment strategies in West Germany: suggestions for Medicare reform

The West German health care system pays ambulatory care physicians on a fee-for-service basis but employs a national relative value scale and regional capitation-based revenue pools to achieve expenditure controls on total physician reimbursement. Physician-controlled organizations manage these pools and conduct utilization reviews on their own members. The capitation rates are determined by negotiations between the physician associations and health insurers. The West German government has been able to exert some influence on the outcome of these negotiations through a quasi-governmental advisory body. Aspects of this structure could be adopted by Medicare in order to determine conversion factors for resource-based relative value scales or to create expenditure control and incentive structures for Medicare-participating physicians.     

Fertility control in historical China revisited: New methods for an old debate

We revisit the debate over the deliberate control of reproduction in historical China through a reanalysis of data from the Qing (1644–1911) Imperial Lineage that accounts for physiological or other differences between couples that affected their chances of having children. Even though studies of contemporary and historical European fertility suggest that failing to control for such differences may obscure evidence of parity-specific control, previous studies of historical Chinese fertility have not accounted for them. We show that in the Lineage, failure to account for such differences leads the association between the number of children already born and the chances of having another birth to appear to be positive, but that once they are accounted for properly, the relationship is inverted. Based on this, we conclude that lineage members adjusted their reproductive behavior based on the number of children. We also show that the sex composition and survival of previous births affected reproductive behavior. We conclude by suggesting that one way forward in the ongoing debate over fertility control in historical China is through application of such methods to other datasets and comparison of results. We also suggest that progress in the debate over fertility in historical China has been impeded by confusion over the definition of fertility control, so that some behaviors are recognized as fertility control by some parties in the debate but not others.     

Medicare program; "without fault" and waiver of recovery from an individual as it applies to Medicare overpayment liability--HCFA. Proposed rule

This rule would amend the Medicare regulations governing liability for overpayments to eliminate application of certain regulations of the Social Security Administration and to replace them with HCFA regulations more specific to circumstances involving Medicare overpayments. The following specific changes are included in this rule. Explicit criteria and the circumstances under which a provider or supplier can be relieved of liability for an overpayment on the basis of being "without fault" with respect to the overpayment. Specific criteria and circumstances of the conditions under which a waiver of recovery for Medicare overpayments would apply to individuals. A provision to ordinarily consider it inequitable to recover an overpayment from a without-fault individual when an overpayment is made to a without-fault provider. Specific provisions that enable Medicare intermediaries and carriers to determine without fault in Medicare overpayments resulting from Medicare secondary payer conditional payments. Provisions that grant Peer Review Organizations the authority to make without-fault determinations. Provisions for an administrative appeals process for providers and suppliers with regard to a "not-without-fault" determination. We expect this rule would prevent some providers and suppliers from claiming without-fault status. This could reduce the number of overpayment liabilities passed on to individuals and result in a slight increase in the amount of money recovered.     

Medicare and Medicaid programs; reform of hospital and critical access hospital conditions of participation. Final rule

This final rule revises the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in the Medicare and Medicaid programs. These changes are an integral part of our efforts to reduce procedural burdens on providers. This rule reflects the Centers for Medicare and Medicaid Services' (CMS) commitment to the general principles of the President's Executive Order 13563, released January 18, 2011, entitled "Improving Regulation and Regulatory Review.'     

New families,new governance and old habits

In December 2011, the UK Government formally launched its ‘troubled families’ initiative. This is a focused programme of interventions, coordinated at local level and paid for by results. It has been described by the Prime Minister as a part of the ‘social recovery’ that has to be set alongside the economic recovery that is his government's priority. It is illustrative of a decisive shift in the nature of the welfare state as it reflects the neo-liberal political project. It also reflects a purposed shift in social attitudes towards troubled and troublesome families, driven to a considerable degree by a vicious popular press. It is indicative of a marked shift in the pendulum from ‘rehabilitation’ to ‘rescue’ as the focus of welfare practice with children and families. Recent developments in the promotion of adoption of children in the UK should be viewed in this light. This paper considers how those families with tense or divergent relationships with the state are to be governed in the context of a state and a set of social attitudes that represents a decisive break with the post-war welfare consensus.     

Medicare program; requirements for providers and suppliers to establish and maintain Medicare enrollment. Final rule

This final rule requires that all providers and suppliers (other than physicians or practitioners who have elected to "opt-out" of the Medicare program) complete an enrollment form and submit specific information to us. This final rule also requires that all providers and suppliers periodically update and certify the accuracy of their enrollment information to receive and maintain billing privileges in the Medicare program. In addition, this final rule implements provisions in the statute that require us to ensure that all Medicare providers and suppliers are qualified to provide the appropriate health care services. These statutory provisions include requirements meant to protect beneficiaries and the Medicare Trust Funds by preventing unqualified, fraudulent, or excluded providers and suppliers from providing items or services to Medicare beneficiaries or billing the Medicare program or its beneficiaries.