Report No. 84-148 L
Bibliographer, Education and Public Welfare
Library Services Division
T h e Congressional Research Service works exclusively for
the Congress, conducting research, analyzing legislation, and
providing information at the request of committees, Members. and their staffs.
T h e Service makes such research available, without partisan bias, in many forms including studies, reports, compilations, digests, and background briefings. Upon request, CRS
assists committees in analyzing legislative proposals and
issues, and in assessing the possible effects of these proposals
and their alternatives. T h e Service's senior specialists and
subject analysts are also available for personal consultations
in their respective fields of expertise.
This bibliography is a
selected articles, books, and
congressional publications on Medicare
reimbursement, primarily to health facilities and physicians.
cluded focus on the years 1965 to 1 9 8 4 , and are arranged into four sections:
general policies and issues; health facilities; physicians; and effects of
Thanks and appreciation are extended to Subject Specialization Section
Head Richard Gigax and colleague Marsha Cerny for their review of the manuscript
and ongoing support and patience; the Health Section of the Education and Public
Welfare Division for their review and especially to Jennifer OfSullivan for her
invaluable advice and provision of materials; also to Walter Albano of the
Congressional Reference Division for his review. A special note of thanks goes
to bibliographic assistant John M. White for his patience and conscientious
typing of this bibliography.
REIMBURSEMENT: GENERAL POLICIES AND ISSUES
A. Historical Perspectives (1965-1975) ............................
B. Current Outlook (1976-1984) .................................... 2
11. HEALTH FACILITIES AND REIMBURSEMENT .................................
111. PHYSICIANS AND REIMBURSEMENT ........................................ 17
IV. IMPACT/EFFECTS OF REIMBURSEMENT POLICIES
A. Coverage: Services and Programs ................................ 23
(includes drugs, equipment, coinsurance,
testing and treatment)
B. Medical Technology and Devices ................................. 25
C. Beneficiaries .................................................. 26
D. Quality Control and Utilization ............................... 28
This bibliography is a compilation of selected articles, books, and
executive agency and congressional publications on Medicare and Medicaid
reimbursement, mainly to health facilities and physicians.
Materials included focus on the years 1965 to 1984; and are arranged into four sections:
general policies and issues; health facilities; physicians; and effects of
reimbursement policies. To give some perspective on the size and growth of
Medicare and Medicaid since inception, the graph on the next page shows expenditures from 1964 to 1983 and projections to 1989.
References for this bibliography were selected primarily from the bibliographic data base created and maintained by the Library Services Division of
the Congressional Research Service, and from the computerized catalog of the
Library of Congress. Most of the articles, books, and some of the executive
agency publications have been annotated. Books from the Library of Congress'
collections are listed with the Library's call number. The congressional user
may request a book either by calling the Loan Division on 287-5441 (provide
call number as well as author and title) or by placing a request through the
CRS Inquiry Unit.
This bibliography has been compiled for the use of congressional offices
in the Washington metropolitan area. Users of this bibliography in other parts
of the United States may want to contact a nearby public, research or depository
library for assistance in locating these materials.
F I S C A L YEAR
1985 Budget Perspectives: Federal Spending for the Human Resource Programs, by
Richard Rimkunas and Gene Falk. [Washington] Congressional Research Service,
1984. p. 70 (Report no. 84-35 EPW)
HEALTH: MEDICARE AND THE HEALTH FUNCTION
FISCAL YEAR 1964 - FISCAL YEAR 1989
IN MILLIONS OF CONSTANT 1983 DOLLARS
REIMBURSEMENT: GENERAL POLICIES AND ISSUES
A. Historical Perspectives (1965-1975)
National health expenditures,
Cooper, Barbara S., and Nancy L. Worthington.
1929-72. Social security bulletin, v. 36, Jan. 1973: 3-19, 40.
Analyzes health expenditures data for a variety of factors, including
type of expenditure, source of funds, historical trends, and the effect of
the economic stabilization program. Growth rates and trends for Medicare
and Medicaid are also discussed.
Medicare and Medicaid after ten years. [Washington,
Editorial Research Reports] 1975. 525-542 p. (Editorial research reports,
1975, v. 2, no. 3)
Partial contents.--Evaluation of the programs.--History of Medicare
in Congress.--Prospects for national health care.
Medical care in the USA--1932-1972. Problems, proposals and
Falk, I. S.
programs from the Committee on the Costs of Medical Care to the Committee
for National Health Insurance. Milbank Memorial Fund quarterly, v. 51,
winter 1973: 1-39.
Reviews the major events and lessons from the Final Report of the
Committee on Costs of Medical Care (1932) to Medicare and Medicaid (1965)
and their early operational years through 1972.
Hess, Arthur E.
A ten-year perspective on Medicare. Public health reports,
V. 91, July-Au~. 1976: 299-302.
"From the viewpoint of dollars expended, the decade of Medicare
experience suggests that the population has expansive needs for service
providers of care have an insatiable capacity to absorb
Myers, Robert J.
Medicare: the first six years. Pension & welfare news,
v. 9, Apr- 1973: 32, 41-42, 44, 75.
Analyzes the impact of the Medicare program on hospitals, on other
institutional providers of health services, and on physicians.
Significant events in the first decade of Medicare. Employee benefits
journal, v. 1, fall 1975: 36-39.
Discusses several significant features of the Medicare program that
occurred during this first decade of its existence, including cost
Congress- House. Select Committee on Aging.
Medicare: a fifteen-year
perspective. Hearing, 96th Congress, 2nd session. July 30, 1980.
1980. 65 p.
"Comm. pub. no. 96-258"
General Accounting Office.
History of the rising costs of the Medicare
and Medicaid programs and attempts to control these costs, 1966-1975,
Department of Health, Education, and Welfare. Report to the Human
Resources Task Force, House Committee on the Budget, by the Comptroller
General of the United States. [Washington, G.A.O., 19761 126 p.
On cover: "MWD-76-93" "B-164031(3)"
Publication date stamped on
cover: Feb. 11, 1976.
"This report discusses the cost increases that have occurred in the
Medicare and Medicaid programs since their inception and the reasons
for these increases. Information on [H.E.W.] implementation of the
Medicare and Medicaid cost control provisions of 1967 and 1972
of GAO's recommendations to control unnecessary costs is also included."
Performance of the Social Security Administration compared with that of
private fiscal intermediaries in dealing with institutional providers of
Medicare services; report to the House Committee on Ways and Means by the
Comptroller General of the United States. [Washington] 1975. 40 p.
"MWD-76-7, Sept. 30, 1975"
B. Current Outlook (1976-1984)
American Bar Association. Committee on Public Health Care.
control of Federal health care costs. Urban lawyer, v. 15, fall 1983:
"This report presents an analysis of California's earliest experience
with selective contracting. It reports findings in five areas: history
and early expectations, implementation of Medi-Cal contracting for
inpatient hospital services in the first year, impact of contracting on
the hospital sector, impact on the health insurance marketplace, and
impact on the statewide health delivery system."
Analysis of State Medicaid program characteristics 1983; prepared for the
Health Care Financing Administration, U.S. Dept. of Health and Human
Services. [Rockville, Md.] LaJolla Management Corporation, 1983. 196 p.
Barnard, Cynthia, and Truman Esmond.
DRG-based reimbursement: the use of
concurrent and retrospective clinical data. Medical care, v. 19, Nov.
The billing data from a large teaching hospital "are evaluated,
based on the diagnosis and procedure codes and on the groupings (DRGs)
[Diagnosis Related Groups] presently being used by HCFA [Health Care
Financing Administration]; concurrent and retrospective data are found
to be widely divergent on both measures. An apparent difference in
complexity or extent of resource use is noted, suggesting that the data
being used in HCFAfs development effort may not fully represent the level
of complexity of cases being treated and that reimbursement based on this
data may be incorrect."
Can incentives put brake on Federal health costs? Hospital practice, v. 11,
June 1976: 122, 124, 129-130.
Examines S. 3205, the Medicare-Medicaid Administrative and
Reimbursement Reform Act, which proposes a series of cost controls on
Medicare/Medicaid reimbursement, fraud and abuse, and administration.
Conference on the Future of Medicare (1983: Washington, D.C.)
Washington, G.P.O., 1984. 362 p.
At head of title: 98th Congress, 2nd session. [House] Committee
[on Ways and Means. Subcommittee on Health] Print, no. WMCP: 98-23.
"Organized by the staff of the Committee on Ways and Means in conjunction with the Congressional Budget Office (CBO) and the Congressional
Research Service (CRS)."
Cooper, Mary H., and Sandra Stencel.
Rising cost of health care. Washington,
Congressional Quarterly, 1983. 255-272 p. (Editorial research reports,
1983, v. 1, no. 13)
Partial contents.--Reagan's proposal for controlling costs.--Factors
behind health care inflation.--Prospective reimbursement for Medicare.-Rise of third party payment mechanisms.
Diagnosis-related groups: the effect in New Jersey, the potential for the
Nation; conference proceedings. [Baltimore, G.P.O., 19841 225 p.
(HCFA Pub. no. 03170)
"A national conference cosponsored by the New Jersey Department of
Health and the Health Care Financing Administration, U.S. Department of
Health and Human Services."
"Held in Atlantic City, N.J., Nov. 30-Dec. 2, 1983"
Medicaid reform: four studies of case management, by
Freud, Deborah A.
Deborah A. Freund, with Polly Ehrenhaft and Marie Hackbarth. Washington,
American Enterprise Institute, 1984. 83 p.
Calculating reimbursement rates for Medicaid patients.
Grimaldi, Paul L.
American Health Care Association journal, v. 6, July 1980: 24-28.
Provides "an overview of the crucial components of reimbursement
methods such as the types of rates, peer groups, occupancy rates, screening
processes, inflation factors and the appeal process."
DRG update, Medicare's prospective payment plan, by Paul L. Grimaldi
and Julia A. Micheletti. Chicago, Pluribus Press, 1983. 106 p .
"Explains key features of Medicare's new payment plan and the
implementing regulations." Discussion includes the DRG classification
scheme and assignment process; the "19" coding scheme; calculation of
DRG-specific prospective payment rates; and utilization and quality
DRG--what it is, how it works, and why it will hurt. Medical
economics, v. 60, Sept. 5, 1983: 262-266, 269, 272.
"With Medicare providing about 40 percent of an average hospital's
income, administrators are going to be looking over doctors' shoulders
more than ever before. Admissions, lengths of stay, diagnostic tests,
and requests for new equipment will be closely scrutinized with an eye
toward eliminating everything that isn't absolutely necessary."
Do they finally have the guns to kill fee-for-service? Medical
economics, v. 61, Apr. 2, 1984: 145-152, 154, 157, 160.
Examines the growth of diagnostic related groups, health maintenance
organizations and other health insurance cost control mechanisms,
especially in Medicare, as "the imminent threats to fee-for-service."
Baring costs: how the DRG system works. HealthIPAC
bulletin, v. 15, Mar.-Apr. 1984: 7-12.
Describes the development of diagnosis related groups (DRG1s).
Looks at the consequences for hospital management of DRG1s and their
impact on the quality of care.
Senator Talmadge (D-Ga.) talks about his Medicare reform
bill. Hospitals, v. 50, June 16, 1976: 49-50, 54-55.
Sen. Talmadge answers questions about the proposed Medicare-Medicaid
Administrative and Reimbursement Reform Act which "would streamline and
improve HEW administration of MedicareIMedicaid, would attempt to contain
and would establish a new reimbursement mechanism for
Health care cost containment. [Washington] Congressional
Research Service, i.983. 16 pe (Issue brief ib83172)
Medicare. In U.S. Congress. House. Committee on Ways and Means.
material and data on programs within the jurisdiction of the Committee on
Ways and Means. Feb. 21, 1984. Committee Print, WMCP: 98-22. Washington,
The Medicare and Medicaid data book, 1983, prepared by Darwin Sawyer and others*
Baltimore, Md., U . S e Dept. of Health and Human Services, 1983. 161 p.
(HFCA publication no. 03156; Health care financing program statistics.)
Meyer, Jack A.
Passing the health care buck: who pays the hidden cost?
Washington, American Enterprise Institute for Public Policy Research,
1983. 49 p* (AEI studies, 386)
Partial. contents.--The cost shift compared with the income and
payroll taxes.--Other financing alternatives: a tax-subsidy cap and an
excise tax.--Responses to the cost shift.--A blueprint for reform.
Morrison, Kenneth P.
Medicare reimbursement of financial transactions: do
present policies promote efficiency? American journal of law & medicine,
v. 9, spring 1983: 45-82.
"This Note reviews arguments supporting and opposing reimbursement of
costs that providers incur in the use of equity capital, acquisition of
providers, and loan financingo The Note considers the Secretary [of
Health and Human Services1] regulations in light of the congressional
mandate to encourage efficient delivery of health care and concludes that
current reimbursement policy promotes inefficiency."
OISullivan, Jennifer. Medicare and Medicaid provisions of the Omnibus Budget
Reconciliation Act of 1981 (P.L. 97-35).
Research Service, 1981. 55 p o (Report no. 81-210 EPW)
Medicare and Medicaid provisions of the Tax Equity and Fiscal
Responsibility Act of 1982 (P.L. 97-248), by Jennifer OISullivan and
Glenn Markus. [Washington] Congressional Research Service, 1982. 66 p.
(Report no. 82-173 EPW)
Report on Medicare contracting.
President's Management Improvement Council.
[Washington] 1980. 1 v. (various pagings)
Recommends that Medicare contracting be changed "from its current
non-competitive, cost reimbursement basis to a competitive, fixed price
Federal health care
President's Private Sector Survey on Cost Control (U.S.)
costs. Submitted to the subcommittee for consideration at its meeting on
January 15, 1984. [Washington] The Survey [I9841 65 p.
"Management Office selected issues, volume IX."
Grace Commission report, building on the reports of its Task Forces
on Health and Human Services--Department ManagementIHuman Development
Services/ACTION, Health and Human Services--Public Health ServiceIHealth
Care Financing Administration, and Federal Hospital Management, develops
"recommendations that will generate savings from long-term reforms of
Federal health care financing and reimbursement systems."
Restructuring Medicaid: a survey of State and local initiatives. Edited by
Sean Sullivan and Rosemary Gibson. Washington, American Enterprise
Institute Center for Health Policy Research, 1983. 80 p.
HD7 102.U4R47 1983
Reports on ten "case studies of innovative state and local structural
reforms in Medicaid and other programs for the indigent
the potential to] stimulate evaluation and dissemination of new models of
health care cost containment."
Restructuring Medicaid: an agenda for change: summary report of the National
Study Group on State Medicaid Strategies. Washington, Center for the
Study of Social Policy, 1983. 58 p.
"The National Study Group on State Medicaid Strategies formed in the
fall of 1982 [and] composed of nine state Medicaid, Public Health and
Human Service Administrators, reflects a growing concern about public
support of health care for the poor. The Study Group's mission was to
establish a new agenda for change that offers promise of controlling
rapidly rising costs and improving access to and quality of needed health
care services. "
Rosenberg, Charlotte L.
Fee controls: what Uncle Sam is cooking up now.
Medical economics, v. 57, Aug. 18, 1980: 27-28, 32, 34, 39-40, 42, 47.
Discusses some of the proposals being considered by the Health Care
Financing Administration for changing the Medicare and Medicaid
Title 111 of the Bill. Description of Medicare Prospective Payment Provision.
Congress. Senate. Committee on Finance. Social Security Act
Amendments of 1983; report to accompany S. 1. Mar. 11, 1983. Washington,
G.P.O., 1983. (Report, Senate, 98th Congress, 1st session, no. 98-23)
Congress. Conference Committees, 1983.
Social Security Amendments of 1983; conference report to accompany
H.R. 1900. Mar. 24, 1983. Washington, G.P.O., 1983. (Report, House,
98th Congress, 1st session, no. 98-47) p. 90-114, 179-207.
Congress. Conference Committees, 1984.
[ M e d i c a r e l ~ e d i c a i d ]I n t h e i r
D e f i c i t R e d u c t i o n Act of 1984; c o n f e r e n c e r e p o r t t o accompany H.R. 4170.
June 23, 1984. Washington, G.P.O.,
1984. ( R e p o r t , House, 9 8 t h Congress,
2nd s e s s i o n , no. 98-861)
p. 594-648, 1290-1371.
"Also a p p e a r s i n P a r t I1 of t h e C o n g r e s s i o n a l Record of J u n e 27,
1984 ( v . 130, no. 8 7 , P a r t 11)"
Congress. House. Committee on Energy and Commerce.
Medicaid Budget R e c o n c i l i a t i o n Amendments of 1983; r e p o r t t o accompany
H.R. 4136. Oct. 26, 1983. Washington, G.P.O.,
1983. 133 p. ( R e p o r t ,
House, 9 8 t h Congress, 1 s t s e s s i o n , no. 98-442, p a r t 1)
Congress. House. Committee on Ways and Means.
I n i t s S o c i a l S e c u r i t y Act Amendments of 1983; r e p o r t t o accompany
H.R. 1900. Mar. 0, 1983. Washington, G.P.O.,
1983. ( R e p o r t , House,
9 8 t h C o n g r e s s , 1st s e s s i o n , no. 98-25, p a r t 1 ) p. 132-160, 271-305.
[Medicare/Medicafd] I n i t s Tax Reform Act of 1983; r e p o r t t o accompany
H.R. 4170. Oct. 21, 1983. Washington, G.P.O.,
1983. ( R e p o r t , House,
9 8 t h Congress, 1st s e s s i o n , no. 98-432)
[Medicare/Medicaid] I n i t s Tax Reform Act of 1984; s u p p l e m e n t a l r e p o r t
t o accompany H.R, 4170. Washington, G.P,O., 1984. ( R e p o r t , House, 9 8 t h
Congress, 2nd s e s s i o n , no. 98-432, p a r t 2) p. 835-850, 982-1013, 1661-1663,
Congress. House. Committee on Ways and Means. Subcommittee on H e a l t h .
A d m i n i s t r a t i o n ' s proposed e l i m i n a t i o n of t h e O f f i c e o f D i r e c t Reimbursement
a t t h e H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n . H e a r i n g , 9 8 t h Congress, 1st
s e s s i o n . S e p t . 1 4 , 1983. Washington, G.P.O.,
1984. 106 p.
" S e r i a l 95-42"
Congress. House. S e l e c t Committee on Aging. Subcommittee on H e a l t h
and Long-Term Care.
B r i e f i n g on P r e s i d e n t Reagan's proposed changes i n
t h e Medicare program: Boston, Mass. Washington, G.P.O.,
1984. 37 p.
A t head of t i t l e : Committee p r i n t .
Congress. S e n a t e . Committee on Finance.
Background m a t e r i a l s r e l a t i n g
t o S. 505 and o t h e r h e a l t h c a r e c o s t containment p r o p o s a l s . Washington,
1979. 34 pa
A t head of t i t l e : 9 6 t h Congress, 1st s e s s i o n . Committee p r i n t
Background m a t e r i a l r e l a t e d t o Medicare f i n a n c i n g i s s u e s . Apr. 1984.
1984. 366 p. ( P r i n t , S e n a t e , 9 8 t h Congress, 1 s t
s e s s i o n , committee p r i n t , S. P r t . 98-172)
E x p l a n a t i o n of t h e A d m i n i s t r a t i o n ' s Medicare h o s p i t a l p r o s p e c t i v e
payment p r o p o s a l as compared t o c u r r e n t law. Washington, G.P.O.,
A t head of t i t l e : Committee p r i n t .
[MedicareIMedicaidj In its Deficit Reduction Act of 1984.
of the provisions approved by the Committee on Mar. 21, 1984. Apr. 2,
1984. Washington, G.P.O., 1984. (Report, Senate, 98th Congress, 2nd
session, no. 98-169) vol. 1, p. 938-979; vol. 2, p. 1196-1286.
Medicare-Medicaid Administrative and Reimbursement Reform Act; report
to accompany H.R. 5285. Washington, G.P.O., 1978. 95 p. (95th Congress,
2nd session. Senate. Report no. 95-1111)
Medicare-Medicaid Administrative and Reimbursement Reform Act of 1979;
report on H.R. 934. Washington, G.P.O., 1979. 172 p. (96th Congress,
1st session. Senate. Report no. 96-471)
Proposals for Medicare-Medicaid reform and overall hospital revenues
limitation. Washington, G.P.O., 1979. 34 p.
At head of title: Committee print CP 96-10.
Congress. Senate. Committee on Finance. Subcommittee on Health.
Medicare-Medicaid administrative and reimbursement reform. Hearings,
94th Congress, 2nd session, on S. 3205. July 26-30, 1976. Washington,
G.P.O., 1976. 604 p .
Medicare-Medicaid Administrative and Reimbursement Reform Act. Hearings,
95th Congress, 1st session, on S. 1470. June 7-10, 1977. Washington,
G.P.O., 1977. 638 p.
Congress. Senate. Committee on the Budget.
[~edicareIMedicaid] In its
Omnibus Reconciliation Act of 1983; report to accompany S. 2062. Nova 4,
1983. Washington, G.P.O., 1983. (Report, Senate, 98th Congress, 1st
session, no. 98-300) p. 133-164, 178-180.
Congress. Senate. Special Committee on Aging.
The crisis in Medicare:
proposals for reform. Hearing, 98th Congress, 1st session. Washington,
G.P.O., 1984. 120 p. (Hearing, Senate, 98th Congress, 1st session, S.
Hearing held Dec. 13, 1983, Sioux City, Iowa.
Health incentives reform program; message
President (1981- : Reagan)
from the President of the United States transmitting legislative proposals
to restructure the Medicare Hospital Insurance Program; to amend the
Internal Revenue Code of 1954 to provide for the inclusion of certain
employer contributions to health plans in an employee's gross income; to
provide for voluntary private alternative coverage for Medicare beneficiaries, and for other purposes; to make improvements in the Medicare
and Medicaid programs, and for other purposes; and to provide for prospective payment rates under Medicare for inpatient hospital services,
and for other purposes. Washington, G.P.O., 1983. 149 p. (Document,
House, 98th Congress, 1st session, no. 98-24)
Referred to the Committees on Ways and Means and Energy and Commerce.
HEALTH FACILITIES AND REIMBURSEMENT
Health maintenance organizations as
Ashcraft, Marie L. F., and S. E. Berki.
Medicaid providers. In Health care policy in America. Philadelphia,
American Academy of Political and Social Science, 1983. (Annals, v. 468,
July 1983) p. 122-131.
Argues that "as Medicaid programs across the states are cut, resulting
in fewer benefits and more restricted physician payments, beneficiaries
may have greater incentives to enroll in organized systems. Private
physicians may also face greater incentives to develop HMOs [Health
Maintenance Organizations] to serve Medicaid beneficiaries. If that
happens, however, a twoclass system--one for the poor and one for others-will be institutionalized; and to assure minimum standards of care for
the poor, more, not less, regulation will be required."
Bergen, Stanley S., and Amy Conford Roth.
Prospective payment and the
university hospital. New England journal of medicine, v. 310, Feb. 2,
Analyzes how university hospitals have fared in New Jersey since the
introduction of a prospective payment system.
Medicaid cost containment: prospective reimbursement for
Buchanan, Robert J.
long-term care. Inquiry (Chicago), v. 20, winter 1983: 334-342.
Discusses a study which analyzed the impact of prospective, as
compared to retrospective, rate setting by state programs on Medicaid
payment and utilization rates for nursing home care. Recommends prospective rate setting as a means of cost containment because it "does not
adversely affect access of Medicaid patients to care." Also suggests
linkage of payment rate to a "quality-of-care index" to minimize the
dangers of lower quality care for Medicaid patients.
Competition in the health-care marketplace: a beginning in California. New
England journal of medicine, v. 308, Mar. 31, 1983: 788-792.
Describes the legislative package that has been enacted in California
to control hospital costs. This package requires negotiated contracts
with hospitals on a prepaid basis for inpatient services to Medicaid
Corbin, Mildred, and Aaron Krute.
Some aspects of Medicare experience with
group-practice prepayments plans. Social security bulletin, v. 38, Mar.
Reports on a "study of Medicare experience with seven selected grouppractice prepayment plans [which] compares utilization and reimbursement
for members with comparable control groups of beneficiaries who received
services in the fee-for-service delivery system."
Hospital coats and the Medicare program. Social security
bulletin, v. 36, Aug. 1973: 18-36.
"The study findings reveal that many characteristics of hospital
inflation in the pre-Medicare period continued with greater intensity in
the first 2 years of Medicare. The findings tend to support the demandpull view of hospital inflation and the views that emphasize changes in
technology and expansion of the hospital's role."
Demkovich, Linda E.
Verdict is still out on prototype of new hospital costcutting plan. National journal, v. 15, Dec. 10, 1983: 2573-2576.
Looks at the provisions of the New Jersey diagnosis-related group
plan since the Medicare reimbursement plan is based on this State's
regulatory plan. Also, analyzes the effect of this plan on the hospital
industry in the State.
When Medicare tears up the blank check, who will lend hospitals capital?
National journal, v. 16, Jan. 21, 1984: 113-116.
"Congress plans to limit Medicare reimbursements for spending on new
plant and equipment. But hospitals fear the move might jeopardize their
credit on Wall Street."
Doremus, Harvey D., and Elena M. Michenzi.
Data quality: an illustration of
its potential impact upon a diagnosis-related group's case mix index and
reimbursement. Medical care, v. 21, Oct. 1983: 1001-1011.
"Data from the MEDPAR file, the original medical record discharge
order, and a reabstracted record are compared and analyzed for their
effect upon DRG classification and the resultant Medicare reimbursement
ceiling for one large teaching hospital. The study results show widely
divergent diagnostic and surgical data that results in a significant
variation in DRG classification and reimbursement ceilings."
Feder, Judith, and Bruce Spitz. The politics of hospital payment. Journal of
health politics, policy and law, v. 4, fall 1979: 435-463.
"Analyzes the politics of hospital payment over the last decade.
how provider interests and judgments became a
standard for appropriate hospital payment; the impact of that standard on
hospital costs; and the political obstacles to imposing an alternative
standard and controlling hospital costs." Discussion focuses on Medicare,
Medicaid, and private sector reimbursement.
Feuerherd, Kathy M.
New strategies for containing hospital costs under
Medicaid. Forum/Health Care Financing Administration, v. 5, Oct. 1981:
"Explores what states are doing or can do to implement costconstraining ratesetting systems, given recent significant legislative
Friedman, Bernard. Economic aspects of the rationing of nursing home beds.
Journal of human resources, v. 17, winter 1982: 59-71.
"State governments, with federal subsidies under the Medicaid program,
are the source of the largest share of expenditures to support patients
in the long-term institutional nursing care. A major state policy tool
that has been evolving is the authority to approve or deny expansions in
bed capacity. This paper is an analysis of how the behavior of physicians
and nursing home operators, given present reimbursement policies, could
determine the allocation of beds among patients."
Ginsburg, Paul B e
Issues in Medicare hospital reimbursement. National
journal, v. 14, May 22, 1982: 934-937.
"Examines issues associated with revising the manner in which
Medicare pays hospitals. [Reviews] the present reimbursement system,
the general advantage6 and disadvantagee of a prospective payment eyetem
for Medicare, [and] discusses the most controversial issues surrounding
Grimaldi, Paul L.
Medicaid reimbursement of nursing-home care. Washington,
American Enterprise Institute for Public Policy Research [I9821 194 p.
(AEI studies, 333)
Studies in health policy.
Partial contents.--Overview of the nursing-home industry.--Cost
concepts and Medicaid reimbursement.--Computation of Medicaid reimbursement
rates.--Economic models of nursing homes.--The question of profits.--Issues
in cost containment.
The role of profit in a reimbursement plan. American Health Care
Association journal, v. 7, July 1981: 2-6, 8.
"Focuses on relationships between profit and the provision of nursing
home care to MedicareIMedicaid patients. It emphasizes that profits must
be competitive if the supply of nursing home beds is to be sufficient to
Medicaid reimbursement of teaching hospitals. Journal of health
politics, policy and law, v. 7, winter 1983: 911-926.
"Describes current Medicaid policies regarding the reimbursement of
residents' stipends, salaries received by physicians for educational
activities, and services provided by residents or teaching physicians to
Medicaid recipients. Also describes the importance of Medicaid revenues to
teaching hospitals; [and] discusses some of the potential consequences of
Medicaid cuts for teaching hospitals, and some of the effects on Medicaid
services that would result in turn."
Hay, Joel W.
The impact of public health care financing policies on privatesector hospital costs. Journal of health politics, policy and law, v. 7,
winter 1983: 945-952.
"Analyzes the hospital cost-shift issue in the context of a
theoretical economic model of hospital behavior. It shows that, under
plausible assumptions, the MedicareIMedicaid reimbursement policy does
lead to higher private-sector hospital charges, even when the government
pays the full (average or marginal) cost of hospital services. It also
demonstrates that, in contrast to the common view that cost-based
reimbursement policy is inefficient, the current MedicareIMedicaid
reimbursement policy provides certain static optimality characteristics,
so long as hospitals provide at least some services to the private
Hellinger, Fred J.
Hospital charges and Medicare reimbursement. Inquiry
(Chicago) v. 2, Dec. 1975: 313-319.
"Determine[s] whether hospitals set their charges for laboratory,
radiology and operating room services in order to maximize their Medicare
Hitchner, Carl H.
Medicare and Medicaid reimbursement of teaching hospitals
and faculty physicians. Journal of college and university law, v. 10,
Article warns that "as Federal and state budgets become more
constrained, the reimbursement of teaching physicians on a reasonable
charge basis by Medicare and the state Medicaid programs will be targeted
for future change. In addition, an increased emphasis on a more competitive system of financing the cost of health care is likely to mean
more trouble for the nation's teaching hospitals and teaching physicians."
Medicare begins prospective payment of hospitals. New
Iglehart, John K.
England journal of medicine, v. 308, June 9, 1983: 1428-1432.
"Summarizes the major features of the prospective-payment legisAlso notes that looming ahead for Medicare, despite the
savings projected from prospective payment, are massive long-range
financial problems, indeed bankruptcy, unless the program's income and
its expenses can be brought more nearly in balance before the end of the
The new era of prospective payment for hospitals. New England journal
of medicine, v. 307, Nov. 11, 1982: 1288-1292.
Focuses on Federal and State changes to force hospitals to become
better managers of the resources they expend. These changes include an
interim program of tighter Medicare controls on hospitals, and a Health
and Human Services Department directive to develop a prospective payment
system that would impose a ceiling on Medicare payments to hospitals.
Kinney, Eleanor D., and Bonnie Lefkowitz.
Capital cost reimbursement to
community hospitals under Federal health insurance programs. Journal of
health politics, policy and law, v. 7, fall 1982: 648-666.
"Explores the issues of capital cost reimbursement under Medicare and
Medicaid and some of the ways current policies could be changed."
Hospital insurance under Medicare: the financing problem.
[Washington] Congressional Research Service, 1983. 15 p. (Issue brief
Prospective payments for Medicare inpatient hospital services.
[Washington] Congressional Research Service, 1983. 16 p. (Issue brief
Reagan Administration health legislation: the emergence
Michaelson, Michael G.
of a hidden agenda. Harvard journal on legislation, v. 20, summer 1983:
Comment "reviews the development and changing definition of the
health-care crisis and of the government's response to that crisis.
Identifies and discusses the ways in which the provisions of TEFRA operate
to impose limits on hospital reimbursement under Medicare, summarizes and
analyzes in detail the report on prospective reimbursement under Medicare
Concludes that the Reagan [Health Care Incentives
Reform Package] initiatives may begin to reduce the growth of federal
health-care expenditures, but suggests changes to reinforce their strengths
and to mitigate their weaknesses."
Reform Medicaid? The view from a coumunity hospital.
Paseett, Barry A.
Forum/Health Care Financing Administration, v. 5, Oct. 1981: 30-340
Discusses the problems of the Medicaid program and examines some
proposals for addressing the problems of the health care industry. These
include "using lower cost alternatives to hospital and nursing home care,
paying providers according to care given, reforming l o n g term care, and
introducing price competition."
Progress report on hospital cos2 control in California:
Petersdorf, Robert G.
more regulation than competition. New England journcl af medicine,
V. 309, July 28, 1983: 254-256.
Comments on the effectiveness of the introduction of competition into
the health care industry through the use of Medicaid contracts.
The Propriety of reimbursement by Medicare for Hill-Burton E;ez care.
University of Pennsylvania law review, v. 130, A p r ; 1 9 5 2 : 892-918.
"Comment addresses the propriety of reimbursemenC under Medicare
principles. The two theories of reimbursement--as an interest expense
on construction loans or as an indirect cost of service---[are] examined.
The conflict between these theories of reimbursement and the current
regulations, the statutory provisions, and the basic cost principles and
overall purposes of Medicare [are] discussed."
U-SO Congress. House. Committee on Energy and Commerce. Subcommittee on
Health and the Environment.
Prospective reimbursement for hospitals.
Hearing, 97th Congress, 2nd session. Nov. 22, 1982. Washington, G.P.O.,
1983. 324 pe
Congress. House. Committee on Interstate and Foreign Comnerce.
Subcommittee on Health and the Environment.
Reimbursement of rural
clinics under Medicare and Medicaid. Hearing, 9 5 t h Congress, 1st session,
on H.R. 8543, H.R. 791, H.R. 8459, H.R. 6259, B.Ra 2504 and H.R. 8422.
July 29, 1977. Washington, G.PcO., 1977. 147 p.
"Serial no. 95-45"
Congress. House. Committee on Ways
Cost-based reimbursement of hospitals
issues. Washington, G.P.O., 1976. 8
At head of title: 94th Congress,
and Means. Subcomimttee on Health,
under Medicare; alternatives and
2nd session* Committee print.
Medicare coverage and reimbursement of skilled nursing facility services.
Hearing, 97th Congress, 2nd session. Feb. 2, 1982, Washington, G.P.O.,
Medicare hospital prospective payment system. Hearings, 98th Congress,
1st sessiono Feb. 14 and 15, 1983. Washington, G.P.O., 1983. 310 p.
Medicare reimbursement issues. Hearings, 94th Congress, 2nd session.
Aug. 3 and Sept. 15-16, 1976. Washington, G.F.O., 1976. 610 p.
Congress. House. Select Committee on Aging.
payment system for hospice care. Hearing, 98th Congress, 1st session.
May 25, 1983. Washington, G.P.O., 1983. 195 p.
"Comm. pub. no. 98-394"
Congress. Senate. Committee on Agriculture, Nutrition, and Forestry.
Subcommittee on Rural Development. Medicare reimbursement for rural
health care clinics. Hearing, 95th Congress, 1st session. Mar. 29, 1977.
Washington, G.P.O., 1977. 429 p.
Congress. Senate. Committee on Finance.
Materials relating to health
care cost containment and other proposals. Washington, G.P.O., 1979.
At head of title: 96th Congress, 1st session. Committee print
Staff data and materials related to Medicaid and long-term care.
Washington, G.P.O., 1984. 32 p. (Print, Senate, 98th Congress, 1st
session, committee print, S, Prt. 98-112)
U-SO Congress. Senate. Committee on Finance. Subcommittee on Health.
Hospital prospective payment system. Hearing, 98th Congress, 1st session.
Parts 1-2. Feb. 2 and 17, 1983. Washington, G.P.O., 1983. 2 v.
(Hearings, Senate, 98th Congress, 1st session, S. Hrg. 98-60, parts 1-2)
Hospital reimbursement systems used by private third-party payors.
Hearing, 97th Congress, 2nd session. Sept. 16, 1982. Washington, G.P.O.,
1983. 291 pe
Medicare reimbursement of HMO's.
July 30, 1981. Washington, G.P.O.,
Hearing, 97th Congress, 1st session.
1981. 256 p.
State hospital payment systems. Hearings, 97th Congress, 2nd session.
June 23, 1982. Washington, G.P.O., 1982. 249 p.
Congress. Senate. Special Committee on Aging.
care costs: State, local, and private sector initiatives. Hearing, 98th
Congress, 1st session. Oct. 26, 1983. Washington, G.P.O., 1984. 103 p.
(Hearing, Senate, 98th Congress, 1st session, S. Hrg. 98-529)
Current developments in prospective reimbursement systems for financing
hospital care; an information paper. Washington, G.P.O., 1983. 23 p.
(Print, Senate, 98th Congress, 1st session, committee print, S. Prt.
Medicare reimbursement to competitive medical plans. Hearing, 97th
Congress, 1st session. July 29, 1981. Washington, G.P.O., 1981. 127 p.
Problems associated with the Medicare reimbursement system for hospitals.
Hearing, 97th Congress, 2nd session. Mar. 10, 1982. Washington, G.P.O.,
1982. 189 p.
General Accounting Office.
Impact of Medicare reimbursement limits on
small rural hospitals. Washington, 1982. 13, 9 p.
"GAO/HRD-82-109, Aug. 6, 1982"
I n f o r m a t i o n on u s e of Medicare reimbursement method t o d e t e r m i n e
h o s p i t a l payments under t h e c i v i l i a n h e a l t h and m e d i c a l program o f t h e
uniformed s e r v i c e s , Department of Defense; r e p o r t of t h e C o m p t r o l l e r
G e n e r a l of t h e United S t a t e s . [Washington] 1977. 17 p.
"HRD-77-128, J u l y 27, 1977"
Need t o more c o n s i s t e n t l y
and Medicaid, Department of
Congress by t h e C o m p t r o l l e r
1974. 5 0 pe
"B-164031(4), Aug. 16,
r e i m b u r s e h e a l t h f a c i l i t i e s u n d e r Medicare
H e a l t h , E d u c a t i o n , and W e l f a r e ; r e p o r t t o t h e
General of t h e United S t a t e s .
Problems a s s o c i a t e d w i t h reimbursements t o h o s p i t a l s f o r s e r v i c e s
f u r n i s h e d under Medicare, S o c i a l S e c u r i t y A d m i n i s t r a t i o n , Department o f
H e a l t h , E d u c a t i o n , and W e l f a r e ; r e p o r t t o t h e Congress by t h e C o m p t r o l l e r
G e n e r a l of t h e United S t a t e s .
[Washington] 1972. 65 p.
"B-164031(4), Aug. 3 , 1972"
H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n .
Medicare program; c h a n g e s t o t h e
i n p a t i e n t h o s p i t a l p r o s p e c t i v e payment s y s t e m ; proposed f i s c a l y e a r 1985
r a t e s ; F i n a l r u l e . F e d e r a l r e g i s t e r , v. 49, Aug. 31, 1984: 34728-34797.
P e r s p e c t i v e s on Medicaid and Medicare management. B a l t i m o r e , Md., U e S :
Dept. o f H e a l t h and Human S e r v i c e s  79 p.
Dept. o f H e a l t h
and Human S e r v i c e s . DHHS (HCFA) 80-20021)
P a r t i a l contentso--Teaching c o s t containment t o medical s t u d e n t s :
t h e U n i v e r s i t y of Oregon experience.--The
Iowa e x p e r i m e n t : c a p i t a t i o n
reimbursement of pharmacists.--Supplementary i n s u r a n c e t o Medicare--two
a n a l y s i s o f Medicare reimbursement p o l i c y f o r p r o v i d e r
based p h y s i c i a n s .
A national costVolk, L a u r a , J e a n n e B. H u t c h i n s , and J e a n S. Doremus.
c o n t a i n m e n t s t r a t e g y f o r long-term c a r e . P u b l i c a d m i n i s t r a t i o n r e v i e w ,
v. 40, S e p t a - O c t . 1980: 474-479.
Analyzes how "a dominant f u n c t i o n o f m e d i c a l i n f l a t i o n , Medicaid
reimbursement c o s t s r e f l e c t t h e s y s t e m s f a i l u r e t o c r e a t e a c o s t - e f f e c t i v e
b a l a n c e between s u p p l y and demand, government and t h e p r i v a t e s e c t o r ,
q u a l i t y and p r i c e , f l e x i b i l i t y and c o n t r o l . A l s o d e s c r i b e s CAREPLAN which
combines ' a c o s t c o n t r a 1 mechanism w i t h a c e n t r a l i z e d s e r v i c e d e l i v e r y
s y s t e m w h i l e p r o v i d i n g f o r consumer c h o i c e . ' "
Wennberg, John E.
Should t h e c o s t o f i n s u r a n c e r e f l e c t t h e c o s t o f u s e i n
l o c a l h o s p i t a l m a r k e t s ? New England j o u r n a l o f m e d i c i n e , v. 307, Nove
25, 1982: 1374-1381.
"Examines v a r i a t i o n s i n h o s p i t a l e x p e n d i t u r e s and reimbursements
Th3 q u e s t i o n of
under t h e Medicare and Blue C r o s s programs.
f a i r n e s s t h a t a r i s e s when p u b l i c r e g u l a t i o n imposes l i m i t s on m a r k e t
growth b u t d o e s n o t t a k e l o c a l h e a l t h r e s o u r c e s o r e x p e n d i t u r e s i n t o
a c c o u n t i s i l l u s t r a t e d by examining t h e numbers o f h o s p i t a l beds and t h e
r a t e s of e x p e n d i t u r e and Medicare reirnhursement i n two a d j a c e n t market
a r e a s i n Rhode Island--a s t a t e where t h e h o s p i t a l i n d u s L r y i s r e g u l a t e d
by s t r o n g cert:iffcate-of-np.;.d
and prospeetjve-rejmbursetrent programs.
The a r t i c l e also r o n e i d e r n nnme o f t h e economic l n p l l r n f i l o n a of the
vnl-rmtary vn:tcl:rr b ~ l ~ which
IIRR been p r o p i s e ~ d a s one appr'nec:~ f o r
fntroducinp cornnot-i t i o n j n t n I > c . q 1 - h - - , - ? r , - *?.irb
111. PHYSICIANS AND REIMBURSEMENT
Boyles, William R.
Why don't physicians like assignment? ~orum/HealthCare
Financing Administration, v. 5, June 1981: 5-9.
Tries to "identify what factors increase physician acceptance of the
Medicare payment over time."
Burney, Ira L., and otherso Geographic variation in physicianss fees:
payments to physicians under Medicare and Medicaid. JAMA [Journal of t h e
American Medical Association] v o 240, Sept, 22, 1978: 1368-13?ie
Analyzes physician reimbursement in the Medicaid and Medicare
programs at the national, regional, State, and county levels during f i s c i l
year 1975. Results show a wide range in fees and "indicate that under
national health insurance, fees set at national or statewide levels could
have notable effects on physician renumeration in some localities."
Cantwell, James R.
Implications of reimbursement policies for the location of
physicians. Agricultural economics research, v. 31, Apr, 1979: 25-35"A simple model of physician migration predicts a positive relarlonship between physician fees and the number of physicians in an area and a
negative relationship between physician fees and area population-physician
ratios. The strong empirical support for this model suggests that Government health insurance programs could be used to encourage physicians to
locate in scarcity areas."
A court takes a hand in fee-setting. Medical economics,
v. 58, Mar. 2, 1981: 25, 28, 32, 34, 36, 41.
"Setting Medicare reimbursement according to epecialty is illegal, e
federal judge in one state has declared*"
These doctors forced Medicaid to shape up. Medical economics, ve 57,
A u ~ .4 , 1980: 23, 26, 28, 30, 32.
"Missouri's Medicaid bureaucracy had to be turned upside down before
doctors' reimbursement rates were raised to acceptable levels."
Dalessio, Donald J.
The hospital bill that Medicare won't pay. JAMA [Journal
of the American Medical Association] v. 233, July 14, 1975: 179-187e
Contends that "denial of payment for hospital service [provided by
physicians] for Medicare patients is retrospective and arbitrary
[and] could be ameliorated if fiscal intermediaries for the Medicare
program would accept the decisions of the local Utilization Review
Committees regarding the necessity for the admission of the patient."
Demkovich, Linda E.
Congress eyes limits
Medicare costs. National journal, v.
Explains why "a move by Congress
helps the elderly defray doctor bills
American Medical Association."
on doctorss fees to remedy runaway
16, Apr. 7, 1984: 652-656.
to rescue the Medicare program that
would mean a showdown with the
E t h e r e d g e , Lynn.
Medicare: paying t h e p h y s i c a n - - h i s t o r y , i s s u e s , and o p t i o n s ;
an i n f o r m a t i o n paper p r e p a r e d f o r u s e by t h e S p e c i a l Committee on Aging,
United S t a t e s S e n a t e . Washington, G.P.O.,
1984. 37 p.
( P r i n t , Senate,
9 8 t h Congress, 2nd s e s s i o n , committee p r i n t , S. P r t . 98-153)
The Medicare f e e index--everyone l o s e s . Medical economics,
F e l t s , W i l l i a m R.
V. 52, NOY. 24, 1975: 86-88,
S t a t e s t h a t " s i d e e f f e c t s t r i g g e r e d by t h e l a t e s t F e d e r a l c u r b on
d o c t o r s ' e a r n i n g s w i l l v i c t i m i z e p a t i e n t s and dim any chance f o r r a t i o n a l
improvement of t h e h e a l t h - c a r e system."
F e r r y , Thomas P., and o t h e r s .
P h y s i c i a n s ' c h a r g e s under Medicare: a s s i g n m e n t
r a t e s and b e n e f i c i a r y l i a b i l i t y . H e a l t h c a r e f i n a n c i n g r e v i e w , v . 1,
w i n t e r 1980: 49-73.
"Under M e d i c a r e ' s P a r t B program, t h e p h y s i c i a n d e c i d e s w h e t h e r t o
P h y s i c i a n s ' a c c e p t a n c e of a s s i g n m e n t
a c c e p t assignment of c l a i m s o
i s of c o n s i d e r a b l e i m p o r t a n c e i n r e l i e v i n g t h e b e n e f i c i a r i e s of t h e burden
of t h e c o s t s o f m e d i c a l c a r e s e r v i c e s o T h i s f a c t o r and t h e b e n e f i c i a r i e s '
l i a b i l i t i e s f o r premiums, t h e a n n u a l d e d u c t i b l e , and c o i n s u r a n c e a r e
a n a l y z e d i n c o n s i d e r a b l e d e t a i l i n t h i s report.,"
Hadley, J a c k .
Can f e e - f o r - s e r v i c e reimbursement c o e x i s t w i t h demand c r e a t i o n ?
By J a c k Hadley, John Holahan, and William Scanlon. I n q u i r y ( C h i c a g o ) ,
v. 16, f a l l 1979: 247-258.
" P r e s e n t s some e v i d e n c e t h a t p h y s i c i a n s respond b o t h t o changes i n
r e l a t i v e p r i c e s and t o a b s o l u t e c o n t r o l s on t h e i r f e e s . "
Toward a p h y s i c i a n payment p o l i c y : e v i d e n c e from t h e Economic S t a b i l i z a t i o n Program, by J a c k Hadley and Robert Lee. P o l i c y s c i e n c e s , v. 10,
Dec. 1978-1979: 105-12Qo
Examines t h e e x p e r i e n c e w i t h c o n s t r a i n t s on p h y s i c i a n s ' p r i v a t e
c h a r g e s and p u b l i c payments i n C a l i f o r n i a under t h e Economic S t a b i l i z a t i o n
Program. Concludes " t h a t c o n t r o l s o v e r b o t h p u b l i c and p r i v a t e f e e s a r e
needed i n o r d e r t o s i m u l t a n e o u s l y c o n t a i n c o s t s o f and m a i n t a i n a c c e s s
t o p h y s i c i a n s ' s e r v i c e s by Medicare and Medicaid b e n e f i c i a r i e s . "
How much you c a n c h a r g e . Medical economics, v. 52,
H e n d r i c k s , James D.
S e p t . 29, 1975: 10-18.
S t a t e s t h a t t h e r e i s no p o s s i b i l i t y t h a t t h e F e d e r a l Government w i l l
d i c t a t e how much a d o c t o r c a n e a r n from p r i v a t e p r a c t i c e .
H i l l , David B e
P h y s i c i a n p a r t i c i p a t i o n i n h e a l t h c a r e programs: b i b l i o g r a p h i c
e s s a y . P o l i c y s t u d i e s j o u r n a l , v. 9 , summer 1981: 1092-1096.
I d e n t i f i e s f a c t o r s which i n f l u e n c e p h y s i c i a n p a r t i c i p a t i o n i n
Medicare and Medicaid programs.
Holahan, John, and o t h e r s .
Paying f o r p h y s i c i a n s e r v i c e s u n d e r Medicare and
Medicaid. Milbank Memorial Fund q u a r t e r l y , v o 57, no. 2, 1979: 183-211.
" R e p o r t s t h e r e s u l t s of r e s e a r c h on Medicare and Medicaid reimbursement f o r p h y s i c i a n s v s e r v i c e s i n C a l i f o r n i a [which i n v e s t i g a t e d ] t h e
r e l a t i o n s h i p s between p h y s i c i a n s ' b e h a v i o r and two c r i t i c a l h e a l t h p o l i c y
g o a l s : c o n t r o l l i n g t h e r a t e of i n c r e a s e i n t h e c o s t s of p h y s i c i a n s '
s e r v i c e s ; and a s s u r i n g an a d e q u a t e s u p p l y o f c a r e t o b e n e f i c i a r i e s o f
p u b l i c l y f i n a n c e d h e a l t h programs."
Physician pricing in California: executive summary. [Washington, U.S.
Health Care Financing Administration, 19791 41 p. (U.S. Dept. of Health,
Education, and Welfare. DHEW publication no. (HCFA) 03005 9-79)
"The primary focus has been on the determinants of the level and rate
of change in physicians' charges and Medicare and Medicaid reimbursement
Also analyzes changes in the quantities of services supplied
to inpatients in response to variations in private and program reimbursement levels."
Controlling inflation of Medicare physicians' feess Policy
analysis, v. 3, summer 1977: 325-339.
"This study shows that the stringency with which Medicare carriers
screen 'customary, prevailing, and reasonable chargess (C.P.R*) inhibits
significantly the inflation of Medicare physicians' fees."
Congress draws a fresh bead on your fees. Medical ecsnonics,
V. 60, July 11, 1983: 43, 47, 51.
"Congress is looking to save Medicare money any way it can and as
soon as it can. Not surprisingly, doctors' fees are a prime target."
Washington's 1984 game plan for physicians. Medical economics, v. 61,
Jan. 9, 1984: 35, 38, 42, 47, 49, 52, 54, 57.
Looks at actions that might be taken by Congress to reform physician
payments. "The options include freezing Medicare fee reimbursements,
shifting physician payment to the same diagnosis-related system imposed on
hospitals since last October, denying hospital privileges to physicians
who don't accept Medicare assignment, and offering no-fault malpractice
insurance coverage to induce those physicians to take assignment."
Institute of Medicine.
Medicare-Medicaid reimbursement policies; social
security studies final report. Washington, G.P.O., 1976. 382 p.
At head of title: 94th Congress, 2nd session. House Committee on
Ways and Means print.
Medicaid participation by medical and surgical specialists.
Mitchell, Janet B.
Medical care, v. 21, Sept. 1983: 929-938.
Findings emphasize that "state Medicaid programs that streamline the
billing and collection process or employ liberal eligibility criteria
reap the rewards in terms of higher participation levels [of ph~sicians]~
If Federal policy in the future will allow states even greater discretion
in setting reimbursement limits and in denying payment, then two
unambiguous outcomes will be reduced physician participation in Medicaid
and restricted access to specialist services for the poor."
Muller, Charlotte, and Jonah Otelsberg.
Carrier discretionary practices and
physician payment under Medicare Part B: a preliminary report. Medical
care, v. 17, June 1979: 650-666.
"Reviews preliminary findings from a study which examines carrier
differences in discretionary practices as to specialties, localities and
other claims data that may be merged or compared with Medicare data in
determining customary and prevailing prices used to set llmits on Medicare
payments, and other practices reported in an official questionnaire to
Study of physician reimbursement under Medicare and Medicaid.
[Washington, U.S. Health Care Financing Administration, 19791 2 v.
(U.S. Dept. of Health, Education, and Welfare. DHEW publication no.
(HCFA) 03008 9-79)
"Presents background material on the economics of aging and the
Medicare market, including a review of literature and a summary of Medicare regulations; reports on national findings about Medicare practices
and fees; describes a two-county micro study of carrier practices and
experience of providers and beneficiaries under Medicare as well as a
comparison with Medicaid in one of the counties; discusses methodological
problems, summarizes findings, and presents a consideration of policy
implications and recommendations for research."
How they've perverted the Medicare payment system. Medical
Myers, Robert J.
economics, Y. 50, Feb. 19, 1973: 229, 233, 235, 239-240.
"Describing past Medicare cutbacks in physician reimbursement as
'contrary to both the letter of the law and its intent,' an insider says
the latest changes open the door to uniform payment schedules."
OISullivan, Jennifer, and Glenn Markus.
How Medicare pays doctors.
Washington, Congressional Research Service, 1984. 34 p. (Report no.
Medicare assignment rates of physicians: their responses to
changes in reimbursement policy. Health care financing review, v. 1,
winter 1980: 75-89.
"Examines the effect of changes in Medicare reimbursement on the
assignment rates of physicians.
Also predicts Medicare assignment
rates under a policy option which would increase Medicare reasonable fees
to the level of prevailing fees."
Peck, Richard L.
H.E.W. launches a new move to control doctors' fees.
Medical economics, v. 55, Sept. 18, 1978: 35, 38, 42, 46, 50, 55.
"National health insurance has been delayed again. But physicians
now face a threat of Federally imposed Mediplan fee schedules."
Physician's guide to DRGs, edited by Robert J. Shakno. Chicago, Ill.,
Pluribus Press, 1984. 232 p.
Partial contents.--How DRGs are supposed to work.--Doctors and
hospitals--a new era of cooperation.--Financial considerations that won't
go awayo--The New Jersey experience.--Using DRG data.
Reynolds, James A.
The new index they'll use to hold down Medicare fees.
Medical economics, v. 50, May 14, 1973: 35, 39, 43-44.
Contends that the index developed by Congress to control medical
fees "could lead to further erosion of the doctrine of usual-and-customary
fees, if not an outright curb on the doctor's right to charge what he
Rice, Thomas H.
The impact of changing Medicare reimbursement rates on
physician-induced demand. Medical care, v. 21, Aug. 1983: 803-815.
"The results show that declining medical reimbursement rates result
in increase in the intensity of medical services provided, and that
declining surgical reimbursement rates result in increases in the
intensity of surgical services provided."
Rosenberg, Charlatte L o As theZr proklems spread, so will yours. Medical
economics, v. 60, Oct. 3, 1903: 112, 114-115, 118, 121, 124, 129, 133,
With new payment schemes wfch built-in incentives to deliver health
care a c lower c m t , hospitals will not only be pressing physicians to be
more cost-effective b u t will a l s o be competing for patients. Looks at
the n@w payment schemes that m i g h t be used to do this.
Shwartz, Michael, and o t h e r s .
T h e e f f e c t s f a t h i r t y p e r c e n t redaction in
physicnaa fees o n Medicaid s u ~ - g p r pr a t e s in Massachusetts. American
journal of p u b l i c health, v, 71, hpr. 19Slr 370-375.
Foncicdes that -'with t h e eycrptfon of tonsiEPectomies/adenoideet~mie~~
a very Large reduction f n t h e r s i m b u - r s e ~ e w cfee f o r Medicaid surgery had
only a small impact on & h e race a t which eight elective % u r g k d
procedures were performed '
Congress. Rouse. Commietee o n Ways and Means. Subcommittee on Health.
Physician reimbursement under Xedicare: current policy, trends, and issues:
Washington, G.P.O., 1880, 58 p~
A t head of titles 96th Congress, 2nd session. Committee print
Prepared with the assistance of the Congressional Research Servicee
U. S O Congresso Senate. Committee on Finance.
Rackground data on physician
reimbursement under Medicare; prepared by the staffs for the use of the
Committee on Finance, United States Senate, Robert J. Dole, Chairman, and
the Committee on Ways snd Means, Dan Rostenkowski, Chairman, and Committee
on Energy and Commerce, John D. Dingell, Chairman, House of Representatives. Washington, GaP:Ge9 19830 109 p a (Print, Senate, 98th
Congress, 1st session, -Joint committee print, S o Prt 98-106)
"Serial noo 98-P"
General Accounting Office,
Study of the application of reasonable
charge provisions far paying physicians9 fees under Medicare, Social
Security Administration, Department of Health, Education, and Welfare;
report to the Special Committee on Aging, United States Senate by the
Comptrol.ler General of the United States. [Washington] 1973. 56 P "B-l64031(4), Decn 20, 1973'"
Warner, Judith S I
Trends in t h e Federal rcg~~latian
of physicims' fees.
Inquiry (Chicago), v 13, B e c , 1976: 364--370.
"Traces the development in the Federal regulation of physiciansv fees
over the past 10 y e a r s , " Emphasis is on the impact of Medicare and
MedCcaid reimbursement and the control mechandsmn of t h e Economic Stabilization Program.
IV. IMPACTIEFFECTs OF REIMBURSEMENT POLICIES
A. Coverage: Services and Programs
Reimbursement for durable medical equipment;
Exotech Research & Analysis, inc.
[Baltimore] Health Care Financing Administration,
volume I (final report)
1980. 210 p. (U.S. Dept. of Health, Education, and Welfare. DHEW
publication no. (HCFA) 03018)
"This document is the Final Report of a research and demonstration
project entitled 'An Experiment in Alternative Methods of Reimbursing for
Durable Medical Equipment (DME) Acquired by Medicare Beneficiaries.'
This report describes the implementation, operation and results of the
experiment; and [the] tabulation and interpretation of a large database
of DME claims is presented."
Evaluation of the maximum
Lee, A. James, Dennis Hefner, and Ralph Hardy, Jr.
allowable cost (MAC) for drugs program: phase I report: final design
report and report of pilot study analysis. [~altimore]Health Care
Financing Administration, 1980. 239, 20, 45 p.
At head of title: Health care financing grants and contracts report.
Partial contents.--Background on the MAC/EAC [Estimated Acquisition
Cost] program.--An overview of the pharmaceutical marketplace.--A review
of literature relevant to MAC-EAC evaluation,--The hypotheses and conceptual perspective for MAC evaluation.--Survey of Medicaid drug programs.
--Econometric analysis--a cross section/time series model of Medicaid
drug reimbursement experience in the States.
Lowrie, Edmund G., and C. L. Hampers,
The success of Medicare's end-stage
renal-disease program: the case for profits and the private marketplace.
New England journal of medicine, v. 305, Aug. 20, 1981: 434-438.
"The success of the ESRD [End Stage Renal Disease program] program
in expanding services to meet demand while controlling costs and maintaining quality has been due primarily to the combined effect of setting
a price and creating a system of incentives that involves physicians in
the medical marketplace."
Changing the structure of Medicare benefits: issues and
options. Washington, U.S. Congressional Budget Office, 1983. 82 p.
Report "explores potential changes in Medicare's benefit structure.
It examines options for increasing the share of medical care costs paid by
beneficiaries and changes that would improve the protection of the elderly
and disabled against catastrophic medical expenditures. In addition to
calculating the federal savings from each options, the paper estimates
the impact of such changes on individual enrollees."
Sawyer, Darwin 0.
Pharmaceutical reimbursement and drug cost control: the MAC
experience in Maryland. Inquiry (Chicago), v. 20, spring 1983: 76-87.
Focusss "on economic benefits to the government resulting from
reduced levels of Medicaid spending for outpatient drugs" in Maryland.
Smith, Michael Ira, and Albert I. Wertheimer.
Maximum allowable cost: can the
Government control drug costs? Journal of health politics, policy and
law, v. 5, summer 1979: 155-175.
"In I973 the federal government moved to limit drug reimbursement
to providers in federally sponsored or supported programs, to the lowest
cost at which the drug is generally and consistently available unless a
difference in therapeutic effect can be demonstrated between the brand
name and generic drug. This paper examines the political evolution and
rationale for this program and explores the issues surrounding the ongoing
controversy regarding publicly financed programs offering drug benefits."
Bureau of Health Insurance.
Review of Medicare payments to renal
physicians under the alternative method of reimbursement. Washington,
G.P.O., 1977. 20 p.
At head of title: 95th Congress, 1st session. Committee print
Printed for the use of the Subcommittee on Oversight and Subcommittee
on Health of the Committee on Ways and Means, 1J.S. House of Representatives.
Bureau of Health Manpower. Division of Associated Health Professions.
Report to the Congress: reimbursement under part B of Medicare for certain
services provided by optometrists; as required by title I, section 109, of
P.L. 94-182. [Washington] U.S. Bureau of Health Manpower, 1976. 132 p.
"Expert consultants to the study concluded that steps should be taken
immediately to extend reimbursement under Part B for services provided
by optometrists to both aphakic and cataract patients. It was their
collective judgement that referral delivery patterns, costs, and administrative features of the program, would not be significantly affected if
reimbursement of optometrists were extended to cataract, as well as
Congress. House. Committee on Ways and Means. Subcommittee on Health.
Medicare coverage of emergency response systems and direct reimbursement
of mental health specialists. Hearing, 97th Congress, 2nd session, on
H.R. 3921 and H.R. 6092. Dec. 14, 1982. Washington, G.P.O., 1983.
Medicare reimbursement for physician extenders practicing in rural health
clinics. Hearing, 95th Congress, 1st session, on H.R. 2504. Feb. 28,
1977. Washington, G.P.O., 1977. 203 p.
"Serial no. 95-8"
Congress. Senate. Committee on Finance.
reimbursement rates for the end-stage renal disease (ESRD) program under
Medicare. Washington, G.P.O., 1982. 62 p.
At head of title: 97th Congress, 2nd session. Committee print
Congress. Senate. Committee on Finance. Subcommittee on Health.
Proposed prospective reimbursement rates for the end-stage renal disease
program. Hearing, 97th Congress, 2nd session. Mar. 15, 1982. Washington,
G.P.O., 1982- 406 p*
General Accounting Office. Home health care services--tighter fiscal
controls needed; report to the Congress by the Comptroller General of the
United States. [Washington] 1979. 48 p.
"HRD-79-17, May 15, 1979"
"Discusses the need for improvements in Medicare's cost reimbursement
procedures for home health care services and makes recommendations for
Medicarevs reimbursement policies for durable medical equipment should
be modified and made more consistent; report to the Honorable Russell B e
Long, United States Senate. [Washington] 1981. 32 p.
"HRD-81-140, Sept. 10, 1981"
"Evaluates allegations to the effect that suppliers of durable
medical equipment to Medicare beneficiaries in certain southeastern States
were being subjected to discriminatory reimbursement and coverage
Programs tc control prescription drug costs under Medicaid and Medicare
could be strengthened; report by the Comptroller General of the United
States. [Washington] 1980. 55 p.
"HRD-81-36, Dec. 31, 1980"
"Concludes that MAC has resulted in savings under the State-operated
Medicaid outpatient drug programs. This savings could have been greater,
however, if States had implemented the limits in a more timely manner, HHS
had systematically updated the limits, and HHS had encouraged States to
implement or expand their own MAC programs."
Nurse practitioner reimbursement. Journal of health politics,
policy and law, v o 6, fall 1981: 444-462.
"Addresses problems related to nurse practitioner reimbursement and
the Rural Health Clinic Services Act of 1977. An overview of payor
policies prior to the passage of P.L. 95-210 is presented, followed by a
discussion of some of the difficulties in implementing the statute."
B. Medical Technology and Devices
Demkovich, Linda E,
Technological medical breakthroughs may collide with new
cost controls. National journal, v. 15, Apr. 30, 1983: 892-893.
"Medicare's new payment system will force hospitals to be conscious
of costs, but it may also discourage their investing in important medical
agnosis related groups (DRGs) and the Medicare program: implications for
medical technology. Washington, Congress of the U.S., Office of Technology
Assessment, for sale by the Supt. of Docs., G.P.O., 1983. 82 p.
Reviews the use of Diagnosis Related Groups (DRGs) to measure
hospital care mix. "Beginning in October 1983, Medicare will phase in a
per-case payment system using DRGs as the case-mix measure."
Greenberg, B a r b a r a , and R o b e r t A . Derzon.
Determining h e a l t h i n s u r a n c e
c o v e r a g e o f t e c h n o l o g y : problems and o p t i o n s . Medical c a r e , v. 1 9 , O c t .
Examines t h e c o v e r a g e p r o c e s s o f Medicare and Blue Cross-Blue S h i e l d
and t h e p o l i c y c h a n g e s t h a t b o t h programs a r e c o n s i d e r i n g .
i t d i s c u s s e s t h e s t r e n g t h s and drawbacks o f f o u r c o v e r a g e p o l i c y o p t i o n s :
r e s t r i c t i n g i n s u r a n c e c o v e r a g e o f unproven p r o c e d u r e s , i n t r o d u c i n g c o s t e f f e c t i v e n e s s c r i t e r i a , e d u c a t i n g p h y s i c i a n s and e d u c a t i n g consumers."
Medical t e c h n o l o g y and c o s t s o f t h e Medicare program. Washington, Congress o f
t h e U.S. O f f i c e o f Technology Assessment, f o r s a l e by t h e S u p t . o f Docs.,
1984. 2 ve
"OTA-H-227 and 228, J u l y 1984"
"Reviews s p e c i f i c Medicare p o l i c i e s t h a t have had a n i n f l u e n c e on
t h e a d o p t i o n and u s e o f m e d i c a l t e c h n o l o g y and a l s o a n a l y z e s t h e c o n t r i b u t i o n of m e d i c a l t e c h n o l o g i e s t o i n c r e a s e s i n Medicare c o s t s . The
r e p o r t i d e n t i f i e s s e v e r a l p o s s i b l e c h a n g e s i n Medicare c o v e r a g e , payment,
and o t h e r p o l i c i e s t h a t c o u l d be used t o i n f l u e n c e m e d i c a l t e c h n o l o g y
a d o p t i o n and u s e and t o r e s t r a i n Medicare program c o s t s . "
Volume two i s
a summary o f t h e r e p o r t .
P o t t e r , Dave.
Health c a r e : t h e high p r i c e of technology.
V. 1 2 , Octe 1982: 26-31.
" I n f l a t i o n a r y p r e s s u r e s have t a k e n t h e i r t o l l , b u t t h e m a j o r f a c t o r
behind s p i r a l i n g c o s t s i s t e c h n o l o g y : who u s e s i t and who pays f o r i t . "
S t e i n , Jane.
Keeping a n eye on t h e m e d i c a l t e c h n o l o g y s t o r e . N a t i o n a l
j o u r n a l , v. 11, J u n e 9, 1979: 958-961e
"Congress e s t a b l i s h e d t h e N a t i o n a l C e n t e r f o r H e a l t h Care Technology
t o h e l p d e t e r m i n e which o f t h e b e w i l d e r i n g a r r a y of m e d i c a l equipment and
t e c h n i q u e s s h o u l d be p a i d f o r by m e d i c a r e .
So f a r , t h e new c e n t e r h a s had
t o o p e r a t e w i t h o n l y $175,000--not even enough t o s e t up shop. But i t h a s
a l r e a d y begun t o c o n s i d e r whether m e d i c a r e s h o u l d pay t h e b i l l s when t h e
e l d e r l y r e c e i v e s u c h new-fangled s e r v i c e s a s e l e c t r o m a g n e t i c t r e a t m e n t of
f r a c t u r e s and e l e c t r i c p a i n - r e l i e v i n g t e c h n i q u e s . "
C. B e n e f i c i a r i e s
H e a l t h c a r e f o r t h e poor.
I n H e a l t h c a r e p o l i c y i n America.
P h i l a d e l p h i a , American Academy of P o l i t i c a l and S o c i a l S c i e n c e , 1983.
(Annals, v . 468, J u l y 1983) p. 103-121.
"Government h a s been r e t h i n k i n g i t s c a p a c i t y t o f i n a n c e h e a l t h
s e r v i c e s f o r t h e p o o r , and new and sometimes c o n t r o v e r s i a l a r r a n g e m e n t s
f o r d e l i v e r i n g t h e s e s e r v i c e s a r e b e i n g d e v e l o p e d . The dilemma government
o f f i c i a l s f a c e now i s how t o c u t c o s t s w h i l e s t i l l a s s u r i n g t h a t q u a l i t y
m e d i c a l s e r v i c e s a r e a v a i l a b l e . T h i s a r t i c l e f o c u s e s on what t h e s e new
p o l i c y developments and a r r a n g e m e n t s a r e and w h e t h e r t h e s i g n i f i c a n t g a i n s
i n a c c e s s and i n h e a l t h a c h i e v e d o v e r t h e p a s t 2 0 y e a r s w i l l be s u s t a i n e d . "
Financing h e a l t h c a r e f o r t h e e l d e r l y :
F e d e r , J u d i t h , and John Holahan.
Medicare, Medicaid, and p r i v a t e h e a l t h i n s u r a n c e . Washington, Urban
I n s t i t u t e , 1979. 106 p o
" I d e n t i f i e s c u r r e n t g a p s i n Medicare c o v e r a g e and a t t e m p t s t o
d e t e r m i n e t h e e x t e n t t o which c o n t i n u e d l i a b i l i t y f o r m e d i c a l e x p e n s e s
c r e a t e s a burden f o r e l d e r l y c i t i z e n s . " D e s c r i b e s " e x p e n s e s f o r m e d i c a l
c a r e t h a t a r e e x p l i c i t l y e x c l u d e d from Medicare c o v e r a g e , n o t a b l y
c u s t o d i a l c a r e i n a n u r s i n g home o r a p l a c e of r e s i d e n c e , o u t - o f - h o s p i t a l
p r e s c r i p t i o n d r u g s , n o n p r e s c r i p t i o n d r u g s , d e n t a l c a r e , e y e g l a s s e s , and
h e a r i n g a i d s . " Also p r o v i d e s a " d e t a i l e d e x a m i n a t i o n o f p r i v a t e h e a l t h
insurance policies f o r t h e e l d e r l y o "
L i n k , C h a r l e s R . , Stephen H. Long, and R u s s e l l F. S e t t l e .
Cost s h a r i n g ,
s u p p l e m e n t a r y i n s u r a n c e , and h e a l t h s e r v i c e s u t i l i z a t i o n among t h e
Medicare e l d e r l y o H e a l t h c a r e f i n a n c i n g r e v i e w , v. 2 , f a l l 1980: 25-31.
" I n v e s t i g a t e s t h e e x t e n t t o which p r i v a t e s u p p l e m e n t a r y i n s u r a n c e and
Medicaid, which v i t i a t e t h e e f f e c t o f Medicare c o s t - s h a r i n g , e n c o u r a g e
e l d e r l y b e n e f i c i a r i e s t o seek a d d i t i o n a l medical care."
What a i l s Medicare. Money, v. 5, May 1976: 44-470
Contends t h a t "Congress s e t up t h e [Medicare] p l a n t o pay o n l y a
s e v e r e l y r e s t r i c t e d p o r t i o n of m e d i c a l e x p e n s e s . Many o f t h e most common
h e a l t h n e e d s of t h e e l d e r l y - - r o u t i n e c h e c k u p s , f a l s e t e e t h , e y e g l a s s e s ,
d r u g s , p r i v a t e n u r s e s , long-term c u s t o d i a l c a r e i n n u r s i n g homes--are
Soroka, Mordachai, and Robert D. Newcomb. V i s i o n c a r e f o r t h e n a t i o n ' s
e l d e r l y : a plea f o r policy d i r e c t i o n . Journal of h e a l t h p o l i t i c s , p o l i c y
and law, v. 6, s p r i n g 1981: 73-86A r t i c l e examines t h e impact of e y e c a r e b e n e f i t e x c l u s i o n s and
r e s t r i c t i o n s and t h e i r e f f e c t upon t h e u s e o f o p h t h a l m o l o g i c a l and
o p t o m e t r i c s e r v i c e s by t h e e l d e r l y . "
Congress. House. S e l e c t Committee on Aging.
h a s i t become a broken promise t o t h e e l d e r l y ?
views. Washington, G.P.O., 1980. 112 p.
A t head of t i t l e : Committee p r i n t .
Medicare a f t e r 1 5 y e a r s :
Report w i t h s u p p l e m e n t a l
R i s i n g h e a l t h c a r e c o s t s and t h e e l d e r l y . H e a r i n g , 9 8 t h C o n g r e s s , 2nd
s e s s i o n . Washington, G.P.O.,
1984. 130 p.
"Comm. pub. no. 98-427"
Hearing h e l d J a n . 20, 1984, P e t e r s b u r g , Va.
Congress. S e n a t e . Committee on F i n a n c e .
New a p p r o a c h e s t o p r o v i d i n g
h e a l t h c a r e t o t h e poor: Medicaid freedom of c h o i c e w a i v e r a c t i v i t i e s .
Mar. 1984. Washington, G.P.O.,
1984. 20 p.
( P r i n t , Senate, 98th Congress,
1st s e s s i o n , committee p r i n t , S. P r t . 98-162)
Congress. S e n a t e . S p e c i a l Committee on Aging.
Medicare and t h e h e a l t h
c o s t s of o l d e r Americans: t h e e x t e n t and e f f e c t s of c o s t s h a r i n g .
1984. 3 8 p.
( P r i n t , S e n a t e , 9 8 t h C o n g r e s s , 1st
s e s s i o n , committee p r i n t , S. P r t . 98-166)
Health Care Financing Administration. Office of Policy, Planning, and
Medicare: health insurance for the aged and disabled, 1976;
section 1.1: reimbursement by State and county. [Washington] 1978.
"Provides figures on the number of persons enrolled under Medicare
as of July 1, 1976, and the amounts reimbursed during calendar year 1976,
to, or on behalf of, insured persons. The data are further subdivided
into the two types of coverage available under the Medicare program-hospital insurance and supplementary medical insurance."
Social Security Administration. Office of Research and Statistics.
Medicare: health insurance for the aged: geographic index of reimbursement
by State and county, 1971. Washington, G.P.O., 1974. 47 p. (U.S. Dept.
of Health, Education, and Welfare. DHEW publication no. (SSA) 74-11710)
"This ratio, a 'geographic index,' provides a comparison of per
capita county reimbursements under Medicare with the national average."
D. Quality Control and Utilization
Quality and cost control: Medicare and beyond. Medical
care, v. 12, Feb. 1974: 95-114.
"Documentary history of Medicare reveals serious flaws in regard to
cost and quality controlem
Chao, Cedric C.
Cost and quality control in the Medicare/Medicaid program;
concurrent review. Harvard civil rights-civil liberties law review,
v. 11, summer 1976: 664-700.
Comment "analyzes the possible policy objections to concurrent
review [of Professional Standards Review Organizations or PSROs]; the
statutory objecti~nthat utilization review
[interferes] with the
physician's practice of medicine and mandates a treatment process not
in the patient's best interest; [and] the argument that concurrent
intrudes upon a constitutionally protected right to privacy
[in the doctor-patient relationship]."
Demkovich, Linda E.
The physiciansP peer review program--does it cost more
than it saves? National journal, v, 12, May 3, 1980: 733-736.
"Nobody argues that the eight-year-old Professional Standards Review
Organizations (PSROs) have not reduced the federal government's expenditures for medicare--and probably for medicaid as well. But critics say
that the savings have been outpaced by the costs of the physicians' peer
review program and that some savings have been accomplished by shifting
the costs to privately insured patients."
Medical necessity in Medicare and Medicaid: the impliGosfield, Alice G.
cations of Professional Standards Review Organizations. Temple law
quarterly, v. 51, no. 2, 1978: 229-280.
Article contends "that regardless of the cost or quality results
achieved by PSROs [Professional Standards Review Organizations], the PSRO
law provides the opportunity to expand the availability of medical care
to the populations affected by it."
Federally imposed self-regulation of medical practice: a
critique of the Professional Standards Review Organization. George
Washington law review, v. 42, May 1974: 822-849.
Case note written by a physician examines three methods provided by
PSRO legislation to eliminate unnecessary services and enhance the quality
of care: "review with denial of payment; review with sanctions against
the physician or provider; and malpractice immunity for the physician
relying on PSRO standards."
Medicare: health insurance for the aged and disabled, 1975;
summary-utilization and reimbursement by person. [Washington] Health Care
Financing Administration [I9811 134 p. (U.S. Dept. of Health and Human
Services. DHHS publication no. (HCFA) 03084)
"This report contains information on the use of reimbursed services
by Medicare beneficiaries. It profiles amounts reimbursed, services paid
for, variations in utilization and reimbursement by age, race, and sex of
the beneficiaries, and beneficiary place of residence in 1975."
Physician fee patterns under Medicare: a
Schieber, George J., and others.
descriptive analysis. New England journal of medicine, v. 294, May 13,
Describes physiciansP fee patterns by analyzing physician reimbursement rates according to local Medicare reimbursement areas. "The results
generally ranged from
indicate that the maximum prevailing charge
three to ten times the minimum charge
meann in most cases.
Congress. House. Committee on Ways and Means. Subcommittee on
Professional standards review organizations. Hearing, 95th
Congress, 2nd session. June 15, 1978. Washington, G.P.O., 1978. 69 p.
Congress. Senate. Special Committee on Aging.
Quality assurance under
prospective reimbursement programs. Hearing, 98th Congress, 1st session.
Feb. 4, 1983. Washington, G.P.O., 1983. 176 p. (Hearing, Senate, 98th
Congress, 1st session, So Hrg. 98-168)
Health Care Financing Administration. Health Standards and Quality
Legislative history of Professional Standards Review Organizations: provisions of the Social Security Act amendments. Washington,
1978. 86 p .
Legislation through Oct. 25, 1977.