2117_sejda-DYJ.pdf - TABLE 1 1– 2 The number of Medicare...

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Unformatted text preview: TABLE 1 1– 2 The number of Medicare LTCH cases and users continued to decrease between 2016 and 2017 Average annual change 2017 2012– 2015 2015– 2016 2016– 2017 125,586 116,424 –2.3% –4.2% –7.3% 34.4 32.5 30.2 –3.0 –5.7 –7.0 $141.61 $140.17 $131.94 $115.44 –2.0 –5.9 –12.5 $40,070 $40,015 $40,719 $40,656 $38,253 1.0 –0.2 –5.9 26.2 26.5 26.3 26.6 26.8 26.3 0.4 1.1 –2.2 123,652 121,532 118,288 116,088 111,171 103,322 –2.1 –4.2 –7.1 2012 2013 140,463 137,827 133,984 131,129 37.7 36.6 35.4 Spending per FFS beneficiary $148.78 $146.64 Payment per case $39,493 Cases Cases per 10,000 FFS beneficiaries Average length of stay (in days) Users 2014 2015 2016 Note: LTCH (long-term care hospital), FFS (fee-for-service). Source: MedPAC analysis of Medicare Provider Analysis and Review data from CMS and the annual reports of the Boards of Trustees of the Medicare trust funds. of LTCHs with valid cost reports decreased by about 7 percent from 426 to 398, or about a 1.4 percent average annual decrease, roughly consistent with the 1.3 percent average annual decrease in hospitals paid under the LTCH PPS in the Provider of Services file.10 From 2017 to 2018, the number of LTCHs decreased by another 2.3 percent (data not shown), totaling a nearly 10 percent decline since 2012. Cost report data indicate that the number of LTCH beds nationwide decreased about 2.1 percent annually from 2012 through 2017 (data not shown). Consistent with historical trends, the Commission estimates that, in 2017, more than 75 percent of LTCHs were for profit, and 95 percent were located in urban areas. In our analysis of urban and rural facilities, the data presented in Table 11-1 (p. 287) beginning in 2015 are not comparable with prior years because CMS adopted new core-based statistical area codes based on the 2010 census for LTCHs that year, in addition to the aforementioned anomalous cost reporting trends. This change reclassified as urban several facilities previously classified as rural. Aggregate occupancy rates for LTCHs from 2012 through 2016 remained largely unchanged at 66 percent, and, historically, occupancy rates for for-profit LTCHs have 290 been 1 percentage point to 2 percentage points higher than for nonprofit LTCHs. However, in 2017, occupancy rates dropped to 64 percent, and the difference between occupancy rates at for-profit and nonprofit LTCHs widened. For-profit LTCHs had an occupancy rate of 65 percent compared with 59 percent for nonprofit LTCHs (data not shown). In aggregate, LTCHs with a high share of Medicare cases meeting the criteria had an occupancy rate of 69 percent in 2017. Volume of services: Number of LTCH users decreased Beneficiaries’ use of LTCH services suggests that access is adequate. The volume of services provided by LTCHs has fluctuated in response to payment policy changes. Following a moratorium on new facilities and new beds in existing facilities, from 2012 through 2015, the number of LTCH cases per capita decreased by 3.0 percent (Table 11-2). From 2015 to 2016, as the new dual payment-rate structure was implemented, LTCH cases per 10,000 FFS beneficiaries further dropped by 5.7 percent and by 7.0 percent from 2016 to 2017. These decreases occurred, in part, because LTCHs changed their admitting practices to admit fewer cases that do not meet the criteria to be paid the standard LTCH PPS rate. Long-term care hospital services: Assessing payment adequacy and updating payments Chapter 8 Cumulative Impacts Enhancing genetic resources via genetic modification and improved breeding systems also has great potential to enhance crop resilience (GCRP 2015 citing Jacobsen et al. 2013, Lin 2011). For livestock, adaptive capacity is limited by high costs and competition. Cooling strategies are not always economically feasible due to high infrastructure and energy demands (GCRP 2015). Furthermore, increased shade and moisture can heighten pathogen risk (Fox et al. 2015). Irrigation strategies to improve feed quality and quantity could also be limited by competition with other water users, especially in arid climates (GCRP 2015 citing Elliott et al. 2014). To enhance resilience against increased pathogen risk, adaptation strategies include no-regrets strategies, disease surveillance and response, disease forecast capacity, animal health service delivery, eradication of priority diseases, increased diversification and integration of livestock with agriculture, breeding resilient animals, and monitoring impacts of land-use change on disease (Grace et al. 2015). Fisheries have developed a number of adaptation practices as well. For example, NOAA’s Climate Science Strategy (2015b) sets forth the objective of designing adaptive decision processes to enable fisheries to enhance fishery resilience. Forest management responses to climate change will be influenced by the changing nature of private forestland ownership, globalization of forestry markets, emerging markets for bioenergy, and climate change policy (Walthall et al. 2013, Joyce et al. 2014). The emerging market for bioenergy—the use of plant-based material to produce energy—has the potential to aid in forest restoration (Joyce et al. 2014). Flexible policies that are not encumbered with legally binding regulatory requirements can facilitate adaptive management where plants, animals, ecosystems, and people are responding to climate change (Joyce et al. 2014 citing Millar and Swanston 2012). Ultimately, maintaining a diversity of tree species could become increasingly important to maintain the adaptive capacity of forests (Duveneck et al. 2014). Carbon sequestration losses can be mitigated using sustainable landmanagement practices (GCRP 2015 citing Branca et al. 2013). In terms of food security, global undernourishment dropped from 19 percent in 1990 through 1992 to 11 percent in 2014 (GCRP 2015). However, it is questionable whether this progress will continue given challenges posed by climate change (GCRP 2015). Developing and implementing new agricultural methods in low-yield regions, reducing waste in the food system, making food distribution systems more resilient to climate risks, protecting food quality and safety at higher temperatures, and policies to ensure food access for disadvantaged populations during extreme events are all adaptation strategies to mitigate the effects of climate change (GCRP 2014 citing Walthall et al. 2013, Ericksen et al. 2009, Misselhorn et al. 2012, Godfray et al. 2010, and FAO 2011; GCRP 2015). Ultimately, adaptation will become more difficult as physiological limits of plants and animal species are exceeded more frequently and the productivity of crop and livestock systems becomes more variable (GCRP 2014). Urban Areas This section defines urban areas and describes the existing conditions and their potential vulnerability to climate change impacts. Urban centers are now home to more than half of the global population, and this percentage continues to increase every year (IPCC 2014a citing UN DESA Population Division 2013, World Bank 2008). In the United States, approximately 80 percent of the population lives in metropolitan areas22 (GCRP 2014). In addition to large numbers of people, urban centers also contain a great concentration of the world’s economic activity, infrastructure, and assets (IPCC 2014a citing UN DESA Population Division 2013, World Bank 2008). However, definitions of urban centers and their 22 Metropolitan areas include urbanized areas of 50,000 or more population, plus adjacent territory that has a high degree of social and economic integration (Office of Management and Budget 2009). 8-50 U.S.-Mexico-Canada Trade Agreement Aggregate Effects of the USMCA from All Simulation Specifications Table E.3 Economy-wide effects of USMCA (percent changes relative to the baseline, unless specified otherwise) Ability of labor to reallocate between industries Impact of provisions reducing policy uncertainty U.S. real GDP U.S. real GDP (billion $) U.S. real output Agriculture Manufacturing and mining Services U.S. employment Agriculture Manufacturing and mining Services U.S. employment (1,000 full-time equivalent jobs) Agriculture Manufacturing and mining Services U.S. wages Agriculture Manufacturing and mining Services Source: USITC estimates. 314 | Somewhat restricted None -0.12 -22.6 Somewhat restricted Moderate 0.35 68.2 Somewhat restricted High 1.21 235.0 Free Moderate 0.36 70.6 -0.22 0.37 -0.13 -0.04 -0.15 0.28 -0.07 -53.9 -2.3 36.9 -88.5 -0.06 -0.18 0.25 -0.10 0.18 0.57 0.17 0.12 0.12 0.37 0.09 175.7 1.7 49.7 124.3 0.27 0.23 0.50 0.23 0.88 0.88 0.71 0.40 0.58 0.51 0.38 588.9 8.6 68.6 511.7 0.86 0.94 0.94 0.84 0.19 0.65 0.18 0.11 0.09 0.45 0.08 169.3 1.3 60.9 107.1 0.27 0.26 0.27 0.27 TABLE 1 1– 3 The volume and share of cases meeting the criteria for the standard LTCH PPS rate increased from 2016 to 2017 Percent change Cases meeting the criteria Share of all LTCH cases 2015 2016 2017 72,429 72,318 74,666 55% 58% 2015–2016 2016–2017 –0.2% 3.2% 64% Cases per 10,000 FFS beneficiaries 19.0 18.7 19.4 –1.7 3.6 Spending (in billions) $3.3 $3.3 $3.4 –0.1 3.0 $87.90 $86.40 $89.30 –1.7 3.4 $46,217 $46,223 $46,127 0.0 –0.2 28.5 27.9 27.9 –2.0 –0.1 Spending per FFS beneficiary Payment per case Length of stay (in days) Note: LTCH (long-term care hospital), PPS (prospective payment system), FFS (fee for service). “Cases meeting the criteria” refers to Medicare discharges that meet the criteria specified in the Pathway for SGR Reform Act of 2013 to be paid the standard LTCH PPS rate. Source: MedPAC analysis of Medicare Provider Analysis and Review data from CMS and the annual reports of the Boards of Trustees of the Medicare trust funds. Since 2015, the share of Medicare cases in LTCHs meeting the criteria increased by 9 percentage points to 64 percent in 2017, driven primarily by a reduction in volume of cases not meeting the criteria (Table 11-3). From 2012 through 2017, the total number of cases meeting the criteria in LTCHs remained stable, with a decrease occurring between 2014 and 2015 but an increase between 2016 and 2017. Controlling for changes in the number of FFS beneficiaries, we found the number of LTCH cases meeting the criteria increased by 3.6 percent from 2016 to 2017. The higher rate of LTCH use by African American beneficiaries may be due to the concentration of LTCHs in areas of the country with larger African American populations (Dalton et al. 2012, Kahn et al. 2010). Another contributing factor may be a greater incidence of critical illness in this population (Mayr et al. 2010). At the same time, African American Medicare beneficiaries may be more likely to opt for LTCH care since they are less likely than White beneficiaries to elect hospice care (Medicare Payment Advisory Commission 2017b). In 2017, Medicare FFS beneficiaries accounted for 63 percent of LTCH discharges and just over half of patient days in aggregate, representing a slight decline in the share of Medicare FFS discharges and patient days following a period of relative stability since 2010. In 2016, dual-eligible beneficiaries (enrolled in both Medicare and Medicaid) accounted for about 45 percent of FFS Medicare days (data not shown). LTCH patient discharges are concentrated in a relatively small number of diagnosis groups. In fiscal year 2017, the top 20 LTCH diagnoses made up 63 percent of all LTCH discharges. The most frequently occurring diagnosis was pulmonary edema and respiratory failure (Medicare severity–long-term care diagnosis related group (MS– LTC–DRG) 189). Over 35 percent of LTCH cases were diagnoses that included respiratory conditions, an increase from 2016.11 Compared with all Medicare beneficiaries, those admitted to LTCHs are disproportionately disabled (under age 65), over age 85, or diagnosed with end-stage renal disease. They are also more likely to be African American. Not unexpectedly, the patient diagnoses become even more concentrated when we consider cases from the cohort of LTCHs with the highest share of cases (85 percent or more) meeting the criteria for the standard Report to the Congress: Medicare Payment Policy  |  March 2019 291 ...
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  • Fall '19
  • 2010s, Percentage point, Years in the future, LTCHs

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