Kip Piper's Health Care Blog
Medicare, Medicaid, Health Reform

Health insurers, whether commercial health plans or public programs like Medicaid and Medicare, only wish to pay for care that is necessary. Every day they make decisions on what is and is not "medically necessary." Gov. Phil Bredesen has proposed a new definition of medical necessity for TennCare, Tennessee's long-troubled...
If President Clinton had to wait weeks or months for urgent bypass surgery like patients in Canada or the UK, he would be dead. Mr. Clinton's physicians said he was at serious risk of a major, life-threatening heart attack. He needed the bypass quickly and got it. In Canada, patients...
Over nine million American children - 12.8 percent of kids - have special health care needs. They face a wide range of conditions, including congenital anomalies, severe physical disabilities, severe asthma, complex organ system diseases (e.g. cystic fibrosis, sickle cell anemia), major depression, and the devastating effects of physical...
Under the new Medicare prescription drug benefit, drug plans will have a fair amount of discretion in setting formularies. The idea is to encourage competition among drug plans and offer Medicare beneficiaries choice. The Centers for Medicare & Medicaid Services (CMS) will review the benefit designs of drug plan...
Prescription drug utilization varies dramatically among individuals. To make sure Medicare payments to Prescription Drug Plans (PDPs) reflect the health status of enrollees, the Centers for Medicare & Medicaid Services (CMS) is developing a risk adjustment methodology. Risk adjustment is a statistical process used to identify and adjust for...
Adjusted for cost-of-living differences, rural physicians have 13 percent more purchasing power than urban physicians. And while there are fewer physicians per capita in rural areas, the overall urban-rural disparity is likely due to an over supply of physicians (particularly specialists) in urban areas. So says a new study by...
When the Medicare prescription drug benefit begins on January 1, 2006, about seven million beneficiaries face more restricted drug formularies. Currently, these "dual eligible" individuals receive their drug benefit through state Medicaid programs, which offer more liberal formularies than what will be expected of the new Medicare drug plans. In...
In 2005, state Medicaid programs will pay for over 18 percent of the nation's quarter trillion dollar pharmaceutical market. Thanks to an excellent new analysis by Jim Verdier and colleagues at Mathematica Policy Research, we have new insights into cost and use patterns in Medicaid. Some highlights: ● Average monthly Medicaid...
Many Americans living with HIV/AIDS receive critically important prescription drug coverage from state Medicaid programs. For these beneficiaries, Medicaid typically offers broad formularies, low cost sharing, and access to a large network of pharmacies. However, about 50,000 to 60,000 persons with HIV/AIDS will be losing Medicaid drug coverage on January...
The new Medicare prescription drug benefit presents many challenges to the nation's seven million dual Medicare-Medicaid eligibles. On January 1, 2006 they must move from broader, more flexible Medicaid drug coverage to the narrower, extraordinarily complex Medicare drug benefit. Among those in jepordy are about a half million frail...

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