美国Medicare临床检验费用支付方式的变革

本文对美国老年医疗照顾计划 ( Medicare)临床检验费用支付系统进行了全面的描述。它以当前费用支付系统发展之前的支付政策的简单历史作为开始 ,讨论了当前的费用支付系统如何发展进化 ,并详细地解释了美国老年医疗照顾计划中临床检验费用支付系统的各个组成部分。对完善我国医疗保险模式具有重要的参考与借鉴意义。

美国Medicare支付互联网+医疗服务的政策分析与启示

互联网+医疗服务是我国“互联网+”战略在医疗健康领域的重要布局,也是医疗服务的重要发展方向。为促进我国互联网+医疗服务良好发展,完善基本医疗保险对互联网+医疗服务的支付政策,文章梳理并分析了美国Medicare关于互联网+医疗服务支付的地理条件、服务范围、支付方式与利益分配,并从准入和监管两方面提出了我国互联网+医疗服务的医保支付的完善策略。

美国以Medicare为主导的综合性初级卫生保健改革概述

初级卫生保健在有效的卫生服务体系中处于基、础性地位,其重要性已经成为共识。但近十年来,初级卫生保健体系处于较为不利的地位。一方面,初级卫生保健医生相比于大部分专科医生而言获得较少的收入,却肩负着艰巨的控费和提高医疗服务质量的重任;另一方面,初级卫生保健机构与医院相比,每年新入职的医生更少。

Persistence in health behaviors among Medicare beneficiaries

We examined persistence in seven common preventive health practices for a nationally representative sample of Medicare beneficiaries over 4-year observation periods. Six panels from the 1997-2005 Medicare Current Beneficiary Survey (MCBS) were used resulting in 13,913 unique individuals with ages ranging from below 65 (disabled) to over 80 years old. Persistence in behavior was defined as the proportion of the observation period beneficiaries participated in each activity. We estimated behavioral persistence as a function of baseline demographic, socioeconomic, and health characteristics using multivariate regression analysis. Beneficiaries were most persistent in smoking abstinence (81% reported not smoking) and least persistent with routine exercise (47% reporting none). From multivariate regression results, there was greater persistence among beneficiaries who were married when compared to those living alone (p 300% FPL compared to <100% FPL all p < 0.01). Increasing age (greater than 80 compared to 65 - 69) was associated with increased compliance in influenza vaccination and smoking cessation (p < 0.01) while negatively associated with weekly exercise and cancer screenings (p < 0.01). Medicare beneficiaries are inconsistently persistent with common preventive health practices.

Medical Costs by Disease Stage in Medicare Patients with Metastatic Melanoma

Background: Melanoma is a rare but serious skin cancer that is responsible for >90% of skin cancer-related deaths. This retrospective data analysis quantifies the direct cost of medical care by disease stage at diagnosis for patients with metastatic melanoma. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was queried for patients diagnosed between 2004-2009 with stage IIIB/C and stage IV (M1a, M1b, M1c) melanoma. The primary outcome was overall medical utilization and associated costs from diagnosis to death, the end of Medicare enrolment, or 12/31/2010. Results are stratified by disease stage at diagnosis and presented as per-patient per-month (PPPM) costs. Results: Of the 1263 patients meeting the study criteria (mean age: 75 years;64% male, 92% white, mean duration of follow up: 37.5 months), 66.6% were diagnosed at stage IIIB/C and 33.4% at stage IV. Cost of care increased with disease stage. Total PPPM costs ranged from $1966 for patients diagnosed with stage IIIB to $4585 among patients diagnosed with stage M1c. Outpatient costs accounted 48.9% of total medical costs among stage IIIB patients, and 38.7% of total medical costs for stage M1c patients. Inpatient costs accounted for 37.1% (stage M1b) - 40.9% (stage M1c) of total medical costs. Conclusions: Healthcare costs for treating patients with metastatic melanoma increase by disease stage. The cost of care was more than double among patients with late stage compared to those with early stage. Treatments demonstrating ability to prevent disease progression from early stage to late stage may confer an economic benefit among other clinical advantages.

Medicare等医疗保障名词的译法

医疗保障研究领域存在对国外保障制度的翻译不统一的现象。作者对Medicare、Medicaid、Socialized Medicine等名词的翻译进行分析,根据不同名词的历史背景和主要内容提出更贴切的译法,并希望能够在医疗保障研究领域达成共识。

Health Technology and U.S. Medicare Policy in the Late 20th Century

Much of the history of the American Social Welfare movement has been directed to the identification and development of entitlement programs needed to strengthen the health and economy of even the neediest members of the society. The emergence of health technologies have precipitated and supported policy advances. The Medicare Act （Title XVIII the United States Social Security Act of 1935） as such an entitlement program, was originally directed to resolving the health coverage concerns of the elderly without families or finances to afford coverage. The program entered crises periods over rising costs and continuity of funding concerns. Many have been assisted, in the U.S., in addition to the aged population, by the development of Medicare entitlements. These entitlements have emerged during periods of social need often accompanied by health technology or service delivery innovation. The program benefits more than its constituents and contributes to the health of the overall society. This paper will provide both a historical overview of the conflicts and uncertainties weathered by the Medicare Act in the later quarter of the 20th Century in the U.S. （United States of America）. The paper will also explore the implications of changes in the technology of federal and state funding mechanisms along with demographic changes that offered the greatest challenges to the continuation of the Medicare Act as a mainstay of stable health coverage to millions of needy Americans, into the 21st century.

Medicare Hospital Readmissions at the Community Level

The Medicare Hospital Readmissions Reduction Program has been implemented in the United States for a five-year period. This study reviewed data associated with Medicare readmissions in the metropolitan area of Syracuse, New York during 2015 and 2016, the latest years available. The study data demonstrated that the total number of annual Medicare readmissions for the Syracuse hospitals increased from 2132 to 2202, while chain readmission rates declined from 8.30 to 7.65 as the at-risk population increased. The data also demonstrated that readmissions for diagnosis and procedure categories used in the Medicare program accounted for only 15 - 21 percent of total Medicare readmissions. The study suggested that the program should be expanded by including all Medicare readmissions and that it should employ more current data.

Venous thromboembolism among Medicare acute ischaemic stroke patients with and without COVID-19

background COVID-19 is associated with an increased risk of venous thromboembolism(VTE).This study examined the prevalence of VTE among acute ischaemic stroke(AIS)patients with and without a history of COVID-19.Methods We identified AIS hospitalisations of Medicare fee-for-service(FFS)beneficiaries aged≥65 years from 1 April 2020 to 31 March 2022.We compared the prevalence and adjusted prevalence ratio of VTE among AIS patients with and without a history of COVID-19.results Among 283034 Medicare FFS beneficiaries with AIS hospitalisations,the prevalence of VTE was 4.51%,2.96%and 2.61%among those with a history of hospitalised COVID-19,non-hospitalised COVID-19 and without COVID-19,respectively.As compared with patients without a history of COVID-19,the prevalence of VTE among patients with a history of hospitalised or non-hospitalised COVID-19 were 1.62(95%CI 1.54 to 1.70)and 1.13(95%CI 1.03 to 1.23)times greater,respectively.Conclusions There appeared to be a notably higher prevalence of VTE among Medicare beneficiaries with AIS accompanied by a current or prior COVID-19.Early recognition of coagulation abnormalities and appropriate interventions may help improve patients’clinical outcomes.

美国Medicare住院支付改革的经验借鉴及对中国的启示

文章从美国Medicare住院支付制度改革的缘起、立法和管理体系、设计实施过程的一系列关键问题等方面探讨了美国医院住院支付制度改革中的一些经验和教训,并从制度设计、宏观监管等多个角度对中国支付制度改革提出了一些意见和建议。

中国社会医疗保险管理应谨慎私有化——基于美国Medicare私人计划改革的经验

随着我国进入快速人口老龄化和高龄化阶段,医疗费用支出压力将日益增大。本文采用文献分析法,对美国Medicare医疗保险私有化改革及其成效进行分析,探究市场机制在医疗费用控制中的作用,以为我国医疗费用控制改革提供经验借鉴。研究发现,在待遇确定型的条件下,市场竞争并不比政府更能有效地控制医疗费用,但是,私人计划的发展对医疗费用控制也具有一定的积极意义。我国社会医疗保险部门应谨慎引入商业保险公司来控制医疗费用支出。

Association between baseline levels of muscular strength and risk of stroke in later life:The Cooper Center Longitudinal Study

Background:Muscular strength is an important component of physical fitness.We evaluated the relationship between baseline muscular strength and risk of stroke among adults who were aged≥65 years during follow-up.Methods:We included 7627 healthy adults(mean age=43.9 years,86.0%male)underwent a baseline physical examination between 1980 and 1989.Muscular strength was determined by 1-repetition maximum measures for bench press and leg press and categorized into age-and sex-specific tertiles for each measure.Cardiorespiratory fitness(CRF)was assessed via a maximal treadmill exercise test.Those enrolled in fee-for-service Medicare from 1999 to 2019 were included in the analyses.Associations between baseline strength and stroke outcomes were estimated using a modified Cox proportional hazards model.In a secondary analysis,we examined stroke risk by categories of CRF where Quintile 1=low,Quintiles 2-3=moderate,and Quintiles 4-5=high CRF based on age and sex.Results:After 70,072 person-years of Medicare follow-up,there were 1211 earliest indications of incident stroke.In multivariable analyses,the hazard ratio(95%confidence interval(95%CI))for stroke across bench press categories were 1.0(referent),0.96(0.83-1.11),and 0.89(0.77-1.04),respectively(p trend=0.14).The trend across categories of leg press was also non-significant(p trend=0.79).Adjusted hazard ratio(95%CI)for stroke across ordered CRF categories were 1.0(referent),0.90(0.71-1.13),and 0.72(0.57-0.92)(p trend<0.01).Conclusion:While meeting public health guidelines for muscular strengthening activities is likely to improve muscular strength as well as many health outcomes in older adults,performing such activities may not be helpful in preventing stroke.Conversely,meeting guidelines for aerobic activity is likely to improve CRF and lower stroke risk.

CAR-T细胞治疗产品医保支付政策研究——基于美国Medicare的实证分析

嵌合抗原受体T细胞(CAR-T)疗法作为一种新型的肿瘤免疫疗法,在血液肿瘤治疗领域具有突破性的疗效,但是CAR-T细胞治疗产品价格高昂。为减轻患者的医药费用,部分发达国家已将CAR-T细胞治疗产品纳入医保支付。本文基于美国Medicare Part A和Part B,对CAR-T细胞治疗产品的医保支付政策进行实证分析,以期为我国未来CAR-T产品的医保支付提供借鉴,提出未来可探索“产品准入+DRG/DIP医保打包支付”相结合的方式,以及为高值创新药物建立疾病诊断相关分组(DRG)临时分组、临时补偿机制等。

美国Medicare社商合作模式对我国"惠民保"发展的启示

"惠民保"作为我国推进多层次医疗保障体系建设、社商融合发展的一次有力尝试, 在发展之初存在政企边界不清、保障范围及力度有限等问题亟待解决。作者在厘清"惠民保"现状及问题的基础上, 通过梳理美国公共医疗保险Medicare Part C计划的社商合作管理经验, 提出我国应发挥有为政府与有效市场相结合优势、引导进行差异化产品设计、建立市场准入及评价机制, 以推动我国商业健康保险与基本医疗保险的有效衔接, 进一步降低人民群众就医负担。

成本-效果分析中药物成本测量的良好研究规范:Medicare和Medicaid计划以及其他美国政府支持者角度——ISPOR药物成本工作组报告之四

目的:公共项目为美国的药物支出提供了大部分的财政支持。截至目前,仍然没有相关指南来估算由美国公共项目资助的药物的成本。本研究的目的是为估算由美国公共项目支持的药物的成本提供标准,以便将其用于药物经济学评价。方法:本报告由国际药物经济学与结果研究协会(ISPOR)的专项计划——成本-效果分析中药物成本测量的良好研究规范工作组中的美国政府角度即美国医疗保险计划(Medicare)和医疗补助计划(Medicaid)以及其他美国政府支付者角度的专门小组撰写。该小组的任务是对研究者在估算由美国公共项目资助药物的成本时所遇到的方法学及实际问题进行评价,以便提出适用于更透明、更准确和更具一致性的成本计算的标准。结果:该小组提出了以下建议:(1)研究者必须考虑会对由公共项目所支付的药物成本产生影响的管理要求;(2)药物成本必须反映真实的购置成本,包括所有的回扣和折扣;(3)必须确保成本投入的相关透明度;(4)推荐包括公共项目的视角;(5)需要特别关注高成本药物,尤其当某一特殊疾病所用药物占卫生保健支出很大比例时;(6)由于公共项目之间的差异,必须对实际购置成本、实际依从性以及仿制药的可获得性进行敏感性分析。此外还对Medicare和Medicaid提出了特别建议。结论:随着对美国公共项目覆盖政策而进行的药物经济学评价越来越多,必须保证药物成本估算的准确性和一致性。以上建议的执行将允许研究者在药物经济学评价当中使用准确、无偏倚的成本估算。

Use of prostate-specific antigen testing in Medicare beneficiaries:Association with previous evaluation

Objective:Determine uptake of prostate-specific antigen(PSA)testing in Medicare benefi-ciaries according to previous receipt of PSA testing.Methods:A 5%random sample of men aged 67 years or older without a previous diagnosis of prostate cancer was identified through 2009-2012 Medicare claims.We measured the annualized frequency of PSA screening among men due for PSA testing,stratified by PSA testing use in the previous 2 years,and clustered by ordering provider.Results:Throughout the study period,PSA testing use was consistently higher for men with previous screening than for men without previous screening.For men without previous screening,there was a decline in testing that was most pronounced in 2012.Compared with 2009,the cor-responding odds ratios were 0.98[95%confidence interval(CI)(0.96-1.00)]in 2010,0.94[95%CI(0.92-0.95)]in 2011,and 0.66[95%CI(0.65-0.68)]in 2012.In contrast,for men with previous screening,PSA testing frequency was stable from 2009 to 2011,and declined to a lesser extent in 2012[odds ratio 0.80,95%CI(0.79-0.81)].Conclusion:Receipt of PSA testing is highly dependent on whether an individual was tested in the recent past.In previously unscreened men,the largest decrease occurred in 2012,which may reflect in part the publication of US Preventive Services Task Force guidelines,but there was much less impact among men already being screened.

Health minister promises reform of medicare system

In a New Year＇s message China＇s Minister of Health, GAO Qiang, promises to hammer out reform of the country＇s medical care system in 2007.

Medicare in Australia

Australia, once a British Colony and now still a member state of the British Commonwealth, is a large country with rich resource and thin population of 18 milion.MedicarE in Australia began in 1938, in that year a newly established parliament adopted the proposal on Medicare, yet it was not put into practice.

Estimation of economic burden throughout course of cervical squamous intraepithelial lesion and cervical cancer in China:A nationwide multicenter cross-sectional study

Objective: Cervical squamous intraepithelial lesion(SIL) and cervical cancer are major threats to females' health and life in China, and we aimed to estimate the economic burden associated with their diagnosis and treatment.Methods: A nationwide multicenter, cross-sectional, hospital-based survey was conducted in 26 qualified hospitals across seven administrative regions of China. We investigated females who had been pathologically diagnosed with SIL and cervical cancer, and included five disease courses(“diagnosis”, “initial treatment”,“chemoradiotherapy”, “follow-up” and “recurrence/progression/metastasis”) to estimate the total costs. The median and interquartile range(IQR) of total costs(including direct medical, direct non-medical, and indirect costs), reimbursement rate by medical insurance, and catastrophic health expenditures in every clinical stage were calculated.Results: A total of 3,471 patients in different clinical stages were analyzed, including low-grade SIL(LSIL)(n=549), high-grade SIL(HSIL)(n=803), cervical cancer stage ⅠA(n=226), ⅠB(n=610), ⅡA(n=487), ⅡB(n=282), Ⅲ(n=452) and Ⅳ(n=62). In urban areas, the estimated total costs of LSIL and HSIL were $1,637.7(IQR:$956.4-$2,669.2) and $2,467.1(IQR:$1,579.1-$3,762.3), while in rural areas the costs were $459.0(IQR:$167.7-$1,330.3) and $1,230.5(IQR:$560.6-$2,104.5), respectively. For patients with cervical cancer stage ⅠA,ⅠB, ⅡA, ⅡB, and Ⅲ-Ⅳ, the total costs were $15,034.9(IQR:$11,083.4-$21,632.4), $19,438.6(IQR:$14,060.0-$26,505.9), $22,968.8(IQR:$16,068.8-$34,615.9), $26,936.0(IQR:$18,176.6-$41,386.0) and $27,332.6(IQR:$17,538.7-$44,897.0), respectively. Medical insurance covered 43%-55% of direct medical costs for cervical cancer patients, while the coverage for SIL patients was 19%-43%. For most cervical cancer patients, the expense was catastrophic, and the extent of catastrophic health expenditure was about twice large for rural patients than that for urban patients in each stage.Conclusions: The economic burden of SIL and cervical cancer in China is substantial, with a significant proportion of the costs being avoidable for patients with LSIL. Even for those with medical insurance, catastrophic health expenditures are also a major concern for patients with cervical cancer, particularly for those living in rural areas.

Patient Quality-of-Life, Providers with Incentive Payments, Real-World Evidence, and Reducing Healthcare Costs through New Innovations

Background: Value-Based Care is a program that was created by Professor Michael E. PORTER and Elizabeth O. TEISBERG which has been modified for implementation over the last seventeen years. This new program is paid by Commercial Health Insurers (Insurance Companies) and Centers for Medicare and Medicaid Services (Medicare). This program incorporates the patients, doctors, Life Sciences Companies, Insurance Companies, Holistic practice, traditional Chinese medicine, etc. with alternative traditional treatments and therapies for Real-World Evidence based and value-based treatment customized to patients’ needs and the patients benefit. Methods: The program was proposed to achieve value for patients and an improved healthcare system which is especially needed to provide treatment for patients in Serious or Life-threatening conditions or diseases. The program will accurately measure the outcomes of patients and provide a wider choice of treatments that matter to patients, also to measure the cost that successful alternative treatments provide which may lower the cost to Medicare and Insurance Companies. Conclusion: The proposed and now implemented program is to achieve value for patients. Golden Sunrise Nutraceutical (Golden Sunrise) provides a New Medical Innovation and treatment alternative to patients suffering from Serious or Life-threatening illnesses. By using Golden Sunrise Innovation and with the incorporation of Value-based Care patients will become the drivers or it could be said the patient Ambassadors of their own health. By incorporating Golden Sunrise Innovation, the doctors will have more diversity of treatments available for their patients. Payment should reflect value not volume, and the New Medical Innovation Golden Sunrise offers will help in reducing the costs to Insurance Companies accelerating the adoption of Value-Based Care.