Medicare program; prospective payment system for long-term care hospitals: annual payment rate updates, policy changes, and clarification. Final rule

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The payment amounts and factors used to determine the updated Federal rates that are described in this final rule have been determined based on the LTCH PPS rate year July 1, 2005 through June 30, 2006. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and will continue to be effective each October 1. The outlier threshold for July 1, 2005 through June 30, 2006 is also derived from the LTCH PPS rate year calculations. We are adopting new labor market area definitions for the purpose of geographic classification and the wage index. We are also making policy changes and clarifications.     

Medicare program; prospective payment system for long-term care hospitals RY 2007: annual payment rate updates, policy changes, and clarification. Final rule

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The payment amounts and factors used to determine the updated Federal rates that are described in this final rule have been determined for the LTCH PPS rate year July 1, 2006 through June 30, 2007. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and will continue to be effective each October 1. The outlier threshold for July 1, 2006, through June 30, 2007, is also derived from the LTCH PPS rate year calculations. We are also finalizing policy changes and making clarifications.     

Physician-management relationships at HCA: a case study

The questions of whether Hospital Corporation of America (HCA), a for-profit hospital company, fostered an environment detrimental to the physician-patient relationship during the period of implementation of the Medicare Prospective Payment System (PPS) was explored. The transition to PPS provided an opportunity to evaluate whether hospital ownership differences affected responses to a payment system which encouraged institutional intervention in the practice of medicine. A case study approach was used to observe the influence of the then largest for-profit hospital corporation upon physicians' medical practice in four owned hospitals. Findings indicated that HCA hospital managers were most directly influenced by the local competitive environment and their own personal agendas in responding to PPS incentives. Corporate influence actually softened payment system incentives to intervene in medical practice by providing a generous supply of capital, and by fostering a corporate culture conducive to cooperative relationships with physicians. Better public understanding of the determinants of hospital behavior is needed to preserve or enhance important social goals such as the physician-patient relationship; easily measurable characteristics such as ownership or bed size explain little about hospital behavior or motivation.     

Medicare program; prospective payment system for long-term care hospitals RY 2008: annual payment rate updates, and policy changes; and hospital direct and indirect graduate medical education policy changes. Final rule

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The final payment amounts and factors used to determine the updated Federal rates that are described in this final rule were determined based on the LTCH PPS rate year July 1, 2007 through June 30, 2008. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and continue to be effective each October 1. The final outlier threshold for July 1, 2007, through June 30, 2008, is derived from the LTCH PPS rate year calculations. We are also finalizing policy changes which include revisions to the GME and IME policies. In addition, we are adding a technical amendment correcting the regulations text at Sec. 412.22.     

The role of Medicare reimbursement in contemporary hospital finance

A hospital, while performing its major function of providing health care, is also viewed as a business. It needs capital from a wide variety of sources, many of which are government regulated. Over the past few years, federal expenditures for Medicare have increased dramatically, as has regulation of hospital revenue sources. Congress enacted the Medicare Prospective Payment System (PPS) to curb hospital cost inflation. This Note examines historical trends in health care financing and analyzes the Medicare reimbursement system, with emphasis on PPS and its impact on hospital revenues. The Note suggests that hospitals, due to the effects of PPS, will be forced to reduce their levels of financial leverage and will have to look for corporate financial alternatives. PPS may signal a new era in hospital finance. Survival mandates an increased focus on efficient corporate, financial and managerial policies.     

The state of electroconvulsive therapy in Texas. Part 2: contact with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating equipment

Since mid-1993, all ECT treatments performed in the state of Texas (except for United States government hospitals) must be reported every quarter to the Texas Department of Mental Health and Mental Retardation (TXMHMR) on a data collection form provided by the Department. Part 1 of this paper reviewed that data. This paper reviews the responses to questionnaires and contacts made with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating devices regarding their experience with ECT in Texas. Questionnaires were sent to physicians and hospitals that had not performed ECT during the final two quarters of the review period. Medical liability insurance companies and the manufacturers of the stimulus generating equipment used in ECT were contacted regarding their experience with liability claims. The results indicate that medical liability in regards to the performance of ECT is extremely low. Physicians and hospitals that stopped performing ECT did so for reasons other than medical liability.     

Per case prospective payment for psychiatric inpatients: an assessment and alternatives

Psychiatric hospitals and clinics are exempted from the Medicare prospective payment system. In this paper we examine the appropriateness of the DRG classification system for psychiatric patients and argue that, using this system as the basis of payment, two types of problems are likely to arise. We categorize these problems as "risks to hospitals" and "risks to patients" and examine the existing literature to determine whether these risks are likely to be significant. We propose a different approach to paying prospectively for psychiatric care, and suggest modifications that could be made to the structure of PPS to mitigate negative incentives embedded in the current system. Although the main focus of the paper is on the unit of payment, we also make some observations about issues arising in connection with the level of payment.     

Medicare program; prospective payment system for long-term care hospitals: annual payment rate updates and policy changes. Final rule

This final rule updates the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). The payment amounts and factors used to determine the updated Federal rates that are described in this final rule have been determined based on the LTCH PPS rate year. The annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and will continue to be effective each October 1. The outlier threshold for July 1, 2004 through June 30, 2005 is also derived from the LTCH PPS rate year calculations. In this final rule, we also are making clarifications to the existing policy regarding the designation of a satellite of a LTCH as an independent LTCH. In addition, we are expanding the existing interrupted stay policy and changing the procedure for counting days in the average length of stay calculation for Medicare patients for hospitals qualifying as LTCHs.     

Medicare program; prospective payment system for long-term care hospitals: annual payment rate updates and policy changes. Final rule

This final rule establishes the annual update of the payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). It also changes the annual period for which the rates are effective. The rates will be effective from July 1 to June 30 instead of from October 1 through September 30, establishing a "long-term care hospital rate year" (LTCH PPS rate year). We also change the publication schedule for these updates to allow for an effective date of July 1. The payment amounts and factors used to determine the updated Federal rates that are described in this final rule have been determined based on this revised LTCH PPS rate year. The annual update of the long-term care diagnosis-related groups (LTC-DRG) classifications and relative weights remains linked to the annual adjustments of the acute care hospital inpatient diagnosis-related group system, and will continue to be effective each October 1. The outlier threshold for July 1, 2003, through June 30, 2004, is also derived from the LTCH PPS rate year calculations. In addition, we are making an adjustment to the short-stay outlier policy for certain LTCHs and a policy change eliminating bed-number restrictions for pre-1997 LTCHs that have established satellite facilities and elect to be paid 100 percent of the Federal rate or when the LTCH is fully phased-in to 100 percent of the Federal prospective rate after the transition period.     

The National Practitioner Data Bank: coping with the uncertainties

The National Practitioner Data Bank is a database of adverse events involving physicians and other practitioners. Querying the database is mandatory for hospitals in several situations. So too, hospitals are required to report specified adverse events. Thus, hospitals need to be able to identify incidents that are reportable events, events that require them to update the databases, and any possible liability issues that may surround the hospital's reporting duties. The author argues that the regulations are unclear in addressing these issues. Likewise, he notes that practitioners should be aware of other problems with the reporting system, including the lack of sufficient Data Bank security.     

PPS waivers: implications for Medicare, Medicaid, and commercial insurers

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.     

Hospital care for the "self-pay" patient

The number of hospitalized patients lacking an identifiable source of third-party payment has risen substantially in recent years. This study examines trends in the hospitalization of "self-pay" patients and investigates causal influences on the propensity of hospitals to accept such patients for treatment. Our analysis pays particular attention to the relationship between Medicare's prospective payment system (PPS) and hospitals' self-pay patient share. Our results show an overall increase in both the number and proportion of self-pay patients treated by hospitals between 1980 and 1985. Substantial differences existed among the types of hospitals that accepted such patients, with major teaching hospitals treating an increasingly disproportionate share. The mix of self-pay patients in terms of age, sex, and reason for hospitalization remained stable during the period under study. Our conclusion is that the regression analysis shows no evidence that PPS reduced hospitals' willingness to treat uninsured patients.     

Medicare program; change in methodology for determining payment for extraordinarily high-cost cases (cost outliers) under the acute care hospital inpatient and long-term care hospital prospective payment systems. Final rule

In this final rule, we are revising the methodology for determining payments for extraordinarily high-cost cases (cost outliers) made to Medicare-participating hospitals under the acute care hospital inpatient prospective payment system (IPPS). Under the existing outlier methodology, the cost-to-charge ratios from hospitals' latest settled cost reports are used in determining a fixed-loss amount cost outlier threshold. We have become aware that, in some cases, hospitals' recent rate-of-charge increases greatly exceed their rate-of-cost increases. Because there is a time lag between the cost-to-charge ratios from the latest settled cost report and current charges, this disparity in the rate-of-increases for charges and costs results in cost-to-charge ratios that are too high, which in turn results in an overestimation of hospitals' current costs per case. Therefore, we are revising our outlier payment methodology to ensure that outlier payments are made only for truly expensive cases. We also are revising the methodology used to determine payment for high-cost outlier and short-stay outlier cases that are made to Medicare-participating long-term care hospitals (LTCHs) under the long-term care hospital prospective payment system (LTCH PPS). The policies for determining outlier payment under the LTCH PPS are modeled after the outlier payment policies under the IPPS.     

Medicare program; photocopying reimbursement methodology. Final rule

This final rule increases the rate of reimbursement for expenses incurred by prospective payment system PPS) hospitals for photocopying medical records requested by Quality Improvement Organizations (QIOs), formerly known as Utilization and Quality Control Peer Review Organizations (PROs). We are increasing the rate from 7 cents per page to 12 cents per page to reflect inflationary changes in the labor and supply cost components of the formula. This final rule also provides for the periodic review and adjustment of the per-page reimbursement rate to account for inflation and changes in technology. The methodology for calculating the per-page reimbursement rate will remain unchanged. We are also providing for the payment of the expenses of furnishing photocopies to QIOs, to other providers subject to a PPS (for example, skilled nursing facilities and home health agencies), in accordance with the rules established for reimbursing PPS hospitals for these expenses.     

Risk Aversion, Liability Rules, and Safety

This paper investigates the performance of liability rules in two-party stochastic externality problems where negotiations are feasible and side payments are based on the realized level of externalities. Results show that an increase in polluter liability does not necessarily increase safety or efficiency in cases where the polluter is risk neutral. Complete polluter liability is found to yield Pareto optimality. When either party is risk averse, an increase in polluter liability may sometimes reduce safety and efficiency. If the polluter is risk neutral and the victim is risk averse, Pareto optimality is only achieved by assigning full liability on the polluter, i.e. giving the victim complete property rights to a clean environment. If the polluter is risk averse and the victim is risk neutral, no level of polluter liability is optimal. In this case, optimality can only be achieved through a contract on abatement activities, such that the risk-averse polluter receives a guaranteed payment regardless of the stochastic outcome.     

Victim or injurer, small car or SUV: Tort liability rules under role-type uncertainty

In this paper we modify the standard tort model by introducing role-type uncertainty. That is, we assume that neither party knows in advance whether she will be the victim or the injurer when an accident occurs. When the standards of care of the two parties are set at the socially optimal levels, only pure comparative negligence and the equal division rule guarantee efficiency, while the rules of simple negligence, contributory negligence, and comparative negligence with fixed division (other than a 50:50 split) may produce inefficient equilibria. Since pure comparative negligence splits liability between negligent parties according to each party's degree of fault, it makes the accident loss division independent of one's role-type. This produces its efficiency advantage.We extend the model to the choice of vehicle size, as a factor determining who will be the injurer and who the victim in motor vehicle collisions. In the extension we analyze various standard negligence-based liability rules, and tax rules, as instruments to mitigate inefficiency resulting from the vehicle size “arms race.” We also examine two strict liability rules, one of which incorporates a comparative negligence feature; this rule prevents inefficiency from both role-type uncertainty and from the “arms race.”     

Independent auditors as fiscal gatekeepers

This paper develops a framework for the analysis of gatekeeping in tax enforcement, whereby independent auditors are assigned the duty of attesting taxpayers’ returns. The equilibrium of the market for gatekeepers’ services is characterized, as well as taxpayers’ and auditors’ optimal behavior. The paper identifies the conditions under which the introduction of a mandatory attestation system is likely to be desirable.The results of the paper suggest that: (1) collusion may disrupt the gatekeeping system if the compounded liability of the auditor and the taxpayer is not sufficiently high; (2) a more extended delegation of the enforcement power to private auditors is generally desirable; (3) the cartelization of the gatekeepers’ market has definitely detrimental effects; and (4) when the probability that erroneous attestations are detected and sanctioned depends on the effort exerted by a public enforcer, multiple equilibria may arise, due to the substitutability of public and private monitoring.     

Independent auditors as fiscal gatekeepers

This paper develops a framework for the analysis of gatekeeping in tax enforcement, whereby independent auditors are assigned the duty of attesting taxpayers’ returns. The equilibrium of the market for gatekeepers’ services is characterized, as well as taxpayers’ and auditors’ optimal behavior. The paper identifies the conditions under which the introduction of a mandatory attestation system is likely to be desirable.The results of the paper suggest that: (1) collusion may disrupt the gatekeeping system if the compounded liability of the auditor and the taxpayer is not sufficiently high; (2) a more extended delegation of the enforcement power to private auditors is generally desirable; (3) the cartelization of the gatekeepers’ market has definitely detrimental effects; and (4) when the probability that erroneous attestations are detected and sanctioned depends on the effort exerted by a public enforcer, multiple equilibria may arise, due to the substitutability of public and private monitoring.     

Motivating Environmental Action in a Pluralistic Regulatory Environment: An Experimental Study of Framing,Crowding Out,and Institutional Effects in the Context of Recycling Policies

In designing a recycling policy, the regulator must choose among multiple instruments. Our study seeks to address the linkages between the choice of regulatory instruments and institutional frameworks, people's intrinsic motivation, and various attitudinal measures. We examined the behavioral repercussions of several instruments that are used widely in recycling regulation, using an experimental survey on a representative sample of the Israeli population (N = 1,800 participants). Our findings suggest that the design of recycling policies should be sensitive to the framing effects of varied regulatory instruments and to the interplay between intrinsic and extrinsic motivation on the desirability and efficacy of the law. In particular, we point out the potential regulatory advantage of using deposit schemes over other instruments and of using private organizations as regulatory agents. Drawing on these findings, we discuss the potential value of using differentiated regulatory policies to provide incentives for recycling in societies characterized by broad heterogeneity in levels of intrinsic motivation.     

Tacit collusion and liability rules

This paper demonstrates that the likelihood of tacit collusion in a given oligopolistic industry may depend on the kind of liability rule applied to the industry. We study typical settings for the analysis of product liability and environmental liability. For the latter, it is established that tacit collusion is more likely under strict liability than under negligence. However, the two liability rules are equivalent with regard to their effects on tacit collusion in the model pertaining to product liability. This context-dependent impact on tacit collusion can be traced back to a difference in the shape of firms’ cost functions.