June 2009
Lewin contact: Paul Hogan
Expertise Area: Medicaid and CHIP, Medicare
June 2009
Pharmaceutical Research and Manufacturers of America (PhRMA)
PhRMA commissioned an evaluation of the degree to which changes in rebates for Medicare/Medicaid dual eligibles would create "spillover" impacts on the Part D premiums charged to other Medicare beneficiaries. Ingenix Consulting staff conducted modeling of various scenarios and Lewin staff prepared the written report. Our analyses estimate that if dual eligibles' prescriptions are paid for at Medicaid prices, additional costs will be imposed on Part D participants who are not dual eligibles. These increased monthly costs per beneficiary are estimated to range from $8 - $16, which constitutes an increase of 25% - 50% in the Part D premiums paid by non-dual eligibles.
Client Area: Associations
Expertise Area: Medicaid and CHIP, Medicare
December 2008
Pharmaceutical Research and Manufacturers Association (PhRMA)
For the Pharmaceutical Research and Manufacturers of America, The Lewin Group compared the formulary status of drugs commonly used by the Medicare population on the Veterans Affairs National Formulary (VA formulary), the two highest enrollment Medicare Part D plans, and the plan with highest enrollment in the Federal Employee Health Benefit Program (FEHBP). Lewin first completed this analysis in January 2007 using the 2007 versions of the VA formulary, Medicare Part D formularies, and FEHBP formulary. This report provides an update to the 2007 analysis.
Client Area: Associations
Expertise Area: Medicare
October 2007
American Association of Clinical Endocrinologists, International Society for Clinical Densitometry, The Endocrine Society, American College of Rheumatology
Osteoporosis is a disease that is characterized by low bone mass and a deterioration of bone structure that results in bone fragility and an increased risk of fracture. The disease affects 10 million older Americans and is associated with significant mortality and morbidity. An additional 34 million individuals have osteopenia (low bone mass) and are at increased risk of fracture at some time in their lives. Osteoporosis-related fractures represent a serious illness burden and are a major cause of disability among Medicare beneficiaries. Dual-energy X-ray absorptiometry (DXA) is the “gold standard” for diagnosing osteoporosis, using World Health Organization criteria. Amid recent changes in Medicare reimbursement methodology, providers had become concerned that payment for DXA and vertebral fracture assessment (VFA) was below operating costs. However, a systematic study of the cost to perform a DXA procedure had not been conducted. The American Association of Clinical Endocrinologists, the International Society for Clinical Densitometry, The Endocrine Society and the American College of Rheumatology commissioned The Lewin Group to survey office-based providers of DXA, in order to develop estimates of the costs associated with providing DXA services to Medicare beneficiaries. This study should assist policymakers and others to determine whether the current Medicare reimbursement for DXA approximates real world operating costs.
Client Area: Associations
Expertise Area: Evidence-Based Medicine / HTA, Medicare
March 2007
Pharmaceutical Research and Manufacturers of America (PhRMA)
A number of statements have been made about the comprehensiveness of VA formulary coverage in comparison to Part D formulary coverage. The Pharmaceutical Research and Manufacturers of America requested The Lewin Group to look at certain comparisons made of those formularies. This report presents the results of that examination
Client Area: Associations
Expertise Area: Medicare
January 2007
Pharmaceutical Research and Manufacturers of America (PhRMA)
The Lewin Group was asked by The Pharmaceutical Research and Manufacturers of America to compare the formulary status of drugs commonly used by the Medicare population on the Veterans Affairs National Formulary, the two highest enrollment Medicare Part D plans, and the plan with the highest enrollment in the Federal Employee Health Benefit Program. This report presents the findings of that comparison.
Client Area: Associations
Expertise Area: Medicare
September 2006
Pharmaceutical Research and Manufacturers of America (PhRMA)
Lewin contact: Lisa Chimento
This analysis, commissioned by the Pharmaceutical Research and Manufacturers of America, sheds new light on how the Medicare prescription drug program is working by assessing the characteristics of plans chosen by beneficiaries. To date, most studies of the Medicare Part D drug benefit have analyzed overall plan offerings and average characteristics without taking into account the enrollment choices of Medicare beneficiaries. This analysis provides a more complete picture by using beneficiary choice to weight plan characteristics, since beneficiaries have disproportionately chosen to enroll in some plans; 64% of enrollment in concentrated in plans offered by four plan sponsors. The Lewin study finds that, on average, beneficiaries have chosen plans with lower premiums, reduced or zero deductibles, and broader formularies.
Client Area: Associations
Expertise Area: Medicare
June 2006
Healthcare Leadership Council
Lewin contact: Lisa Chimento
The Medicare drug benefit, which went into effect in January 2006, has resulted in an increase in the number of Medicare beneficiaries with comprehensive prescription drug coverage; nine out of ten Medicare beneficiaries now have comprehensive prescription drug coverage. The Lewin Group analyzed how drug coverage has changed for seniors since implementation of the new Medicare drug benefit and developed a set of factsheets indicating what additional coverage is available to seniors in all 50 states and the District of Columbia.
Client Area: Associations
Expertise Area: Medicare
April 2006
Healthcare Leadership Council
Lewin contact: Lisa Chimento
This study, commissioned by the Healthcare Leadership Council, analyzes savings available to Medicare beneficiaries with common chronic conditions who enroll in a Prescription Drug Plan (PDP). The five chronic conditions studied are arthritis, diabetes, hypertension, osteoporosis and respiratory illness. 84 percent of Medicare beneficiaries report having at least one of these most common diagnoses. Lewin finds that, nationwide, beneficiaries can save 43 to 58 percent by enrolling in one of the 5 PDPs with the lowest costs.
The executive summary presents information at a national level by chronic condition. Available in separate files are state level findings for Alabama-Kentucky, Louisiana-North Dakota, and Ohio-Wyoming. Also available in separate files are the appendices which provide additional detailed data for Alabama-Kentucky, Louisiana-North Dakota, and Ohio-Wyoming.
Client Area: Associations
Expertise Area: Chronic Disease / Cost of Illness, Medicare
January 2006
National Health Council
Lewin contact: Lisa Chimento
The purpose of this study is to estimate the potential savings offered throught the new Medicare prescription drug benefit to Medicare beneficiaries living with chronic conditions. For this study, The Lewin Group examined drug spending data for Medicare beneficiaries who face a decision whether to enroll in the Medicare drug benefit. The study focuses primarily on beneficiaries with chronic conditions because these beneficiaries have higher average drug costs than beneficiaries without chronic conditions. The specific chronic conditions included in this study are: Alzheimer's, arthritis, chronic obstructive pulmonary disease, diabetes, heart disease, hypertension, mental disorder, osteoporosis, and Parkinson's.
Client Area: Associations
Expertise Area: Medicare
December 2005
Medicare Payment Advisory Commission (MedPAC)
The Medicare Payment Advisory Commission has expressed concerns about the accuracy and fairness of the current Medicare hospital inpatient and outpatient prospective payment system. Payment rates for these systems are based, to varying degrees, on hospital charges. In order to better understand hospital charge setting practices and the nature of hospital mark-ups across service lines, MedPAC engaged The Lewin Group to conduct a nationwide study of hospital charge practices. This report reviews the charge practices of a purposive sample of hospitals and hospital systems around the U.S.
Client Area: Federal Government
Expertise Area: Medicare
May 2005
American Pharmacists Association
The American Pharmacists Association (APhA) commissioned The Lewin Group to develop a report examining the range of Medication Therapy Management (MTM) programs and practices, and how they are currently being reimbursed. In the final rule implementing the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Centers for Medicare and Medicaid Services (CMS) said that MTMS must "evolve and become a cornerstone of the Medicare Prescription Drug Benefit." The purpose of this report was to identify existing MTMS programs, standards of practice, and compensation models, and to develop a model for payers to consider in compensating pharmacists for MTMS. This report is intended to serve as a resource for pharmacists, health plans, and PDP sponsors charged with designing and implementing a Medicare MTM program.
Client Area: Associations
Expertise Area: Medicare
March 2005
Pharmaceutical Research and Manufacturers of America (PhRMA)
On December 8, 2003, President Bush signed into law the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA). The law modernizes Medicare so that,
beginning in January 2006, seniors and people with disabilities can have coverage for
prescription drugs that have become an important part of quality medical care. This new
benefit improves access to prescription drugs and provides important financial protections to
Medicare beneficiaries. The MMA specified that for the years 2004 and 2005, prior to implementation of the full prescription drug benefit, Medicare beneficiaries would have access to Medicare-approved discount cards, and beneficiaries meeting the low-income thresholds would have access to an additional $600 in annual cash assistance.
In 2002, The Lewin Group conducted a study commissioned by the Healthcare Leadership
Council that examined the potential savings to beneficiaries from using Medicare-approved
discount cards. The Pharmaceutical Research and Manufacturers of America (PhRMA),
engaged The Lewin Group to build upon this prior work to estimate the potential savings
forgone for low-income beneficiaries who do not sign up for Medicare-approved discount cards
in 2005 since these persons have the most to lose by not enrolling in the program.
Client Area: Associations
Expertise Area: Medicare
August 2004
Healthcare Leadership Council
Lewin contact: Lisa Chimento
The Healthcare Leadership Council commissioned The Lewin Group to examine the savings available to Medicare beneficiaries who elect to participate in the Medicare-endorsed drug discount card program. The study analyzes the 150 drugs most frequently used by seniors and determines the range of savings available to seniors on those medications using their drug discount cards.
The study presents estimated average savings for beneficiaries who shop at retail pharmacies using the drug discount card, including the value of the $600 federal credit available to qualifying low-income beneficiaries. It also provides estimates of aggregate savings based on the number of beneficiaries projected to use the discount cards by the Centers for Medicare and Medicaid Services.
Client Area: Associations
Expertise Area: Medicare
April 2004
Association for Community Affiliated Plans (ACAP)
Lewin contact: Lisa Chimento
The Medicare Modernization Act of 2003 (MMA) has important consequences for dual eligible beneficiaries as well as Medicaid managed care plans. ACAP commissioned this report to provide member health plans with a better understanding of the Act's implications for their current Medicaid business -- as well as a roadmap to explore the possibility of expanding into Medicare managed care.
Client Area: Associations
Expertise Area: Medicaid and CHIP, Medicare
August 2002
American Health Care Association; Alliance for Quality Nursing Home Care
This study builds on an earlier analysis prepared by The Lewin Group that assessed the implications of the expiration of Medicare add-ons for nursing facility margins. It examines the magnitude and implications of reduced Medicare revenue on the industry's ability to generate and access capital in the future.
Client Area: Associations
Expertise Area: Medicare
October 2001
Social Security Administration
Lewin contact: Lisa Alecxih
Over the past two years, the Social Security Administration conducted a demonstration to increase enrollment in the Medicare Part-B Buy-in program, using a variety of outreach methods. This is the final report that evaluates these efforts to increase participation. This report presents key findings that indicate that outreach letters significantly increased enrollment. In addition, it examines whether the outreach made a difference if interested beneficiaries were referred to Medicaid agencies or SSA became actively involved in the application process. Finally, it examines the effect of other means of outreach, such as public service announcements and grass roots information dissemination.
Client Area: Federal Government
Expertise Area: Medicare
September 2001
Social Security Administration
Lewin contact: Lisa Alecxih
SSA was mandated to conduct a demonstration to test outreach and application methods for enrollment in the Medicare Part B Buy-In program. In March 1999, SSA implemented four models in 11 sites around the country and the state of Massachusetts that involve different levels of SSA involvement. This report describes the demonstration, documents the implementation of the four models, and presents findings of the impact of each model on enrollment.
Client Area: Federal Government
Expertise Area: Medicare
August 2001
Social Security Administration
Lewin contact: Lisa Alecxih
SSA was mandated to conduct a demonstration to test outreach and application methods for enrollment in the Medicare Part B Buy-in program. This report provides information on the implementation and early outcomes of three of the six models implemented during fiscal year 2000. This report describes the demonstration, documents its implementation, and presents descriptive analyses of individuals targeted for the program.
Client Area: Federal Government
Expertise Area: Medicare
June 2000
Social Security Administration
Lewin contact: Lisa Alecxih
SSA was mandated to conduct a demonstration to test outreach and application methods for enrollment in Medicare Part B Buy-in programs in which state Medicaid programs pay for Medicare Part B premiums and possibly Medicare copayments and deductibles for low income beneficiaries. The demonstration included mailing letters to all potentially eligible individuals in eleven sites in six states informing them of the benefits and asking them to contact SSA. Of the nearly 240,000 letters mailed, approximately six percent responded and 61 percent appeared to meet the required income and asset limits. Depending upon the site, one of the three models for application referral and intake were employed: 1) Screening Only, where potential eligibles were made an appointment with the local Medicaid or welfare office; 2) Co-location, where a state Medicaid or welfare worker was onsite at the SSA office; and 3) Application, where SSA staff filled out state application forms and forwarded them to the state for processing.
This report describes the demonstration, documents its implementation, presents descriptive analyses of individuals targeted for the program, and discusses our plans for assessing the effectiveness of the models. The key process lessons include the need for clear communication among all parties involved in the demonstration; a well-defined liaison role to resolve implementation problems efficiently; accountability on the part of the central office and the field offices participating in the demonstration; adequate training; local flexibility in implementation strategy; and commitment from major players.
Client Area: Federal Government
Expertise Area: Medicare
May 2000
Alliance for Quality Nursing Home Care, American Health Care Association
A new Lewin study shows that Medicare's funding of skilled nursing care has been significantly reduced by nearly twice as much as Congress intended. Currently, CBO budget figures show Medicare spending for SNF services from 1998 to 2002 will be $12.2 billion less than originally projected when the Balance Budget Act (BBA) was enacted in 1997; and $15.8 billion less when extended to 2004. Due to BBA payment reductions, the current low inflation rate, provider concerns about fraud and abuse, etc., Medicare SNF spending actually decreased from $13.6 billion in 1998 to $12.3 billion in 1999. These funding reductions have forced approximately 1600 SNFs that participate in Medicare into bankruptcy, and have markedly diminished the industry's ability to attract capital financing.
Client Area: Associations
Expertise Area: Medicare
February 2000
American Hospital Association
In May of 1999, The Lewin Group prepared a report for the American Hospital Association (AHA) showing the impact of the Balanced Budget Act of 1997 (BBA) Medicare provisions on America's hospitals and health systems. The BBA reduced payments for most hospital-based services, e.g. inpatient acute care, outpatient care, home health care, skilled nursing care, medical education, indigent care, and many other services.
Client Area: Associations
Expertise Area: Medicare
November 1999
Institute of Medicine
The Lewin Group was commissioned by the Institute of Medicine (IOM) Committee on Medicare Coverage Extensions to prepare cost estimates for selected expanded Medicare benefits. Congress in the Balanced Budget Act of 1997 mandated that the IOM examine Medicare coverage for certain preventive benefits. The Lewin Group prepared cost estimates for the following services:
Skin cancer screening
Medically necessary dental services (in connection with treatment of specific diagnoses)
Elimination of the three-year limit on immunosuppressive therapy. The purpose of these cost estimates is to support the Committee's analysis of their efficacy based upon the clinical evidence available. The following sections summarize our cost estimates for these services, the data sources used for these estimates, and the key assumptions that underlie these estimates. Congressional Budget Office (CBO) type budget-neutral procedures ("pay as you go") apply to each of these extended benefits. Under these congressional budget scoring rules, additional Medicare benefits must be estimated to at least break even over a five-year time period, or funding must be reappropriated from an existing budgetary source.
Our analytic process required estimations of both gross and net costs to Medicare for the five- year period of 2000 through 2004. Gross costs are the direct costs to Medicare of the services, and net costs are the gross costs minus the potential cost offsets Medicare would realize as a result of covering these services. We also reduced our cost estimates to account for cost sharing offsets of 20% and premium offsets of 25% per CBO standards. Cost offsets are derived from the Committee's analysis of the research evidence available and expert judgement.
Projections of the Medicare Part B population for the years 2000 through 2004, as well as other sources of Medicare Part A and Part B population statistics (such as race and sex) were provided by the HCFA Office of the Actuary.
Client Area: Federal Government
Expertise Area: Medicare
August 1999
American Association of Retired Persons
AARP's Public Policy Institute published a Lewin Group report on the potential impacts of jointly raising the Normal Age of Retirement (NAR) and Medicare Eligibilty Age (MEA) from age 65 to 67. Under this proposed policy, a significant portion of peopled aged 65 to 66 would lose their Social Security benefits and Medicare coverage. Some portion of these individuals, however, could potentially retain both their Social Security benefits and Medicare eligiblity by meeting the qualifications for the Social Security Disability Insurance (DI) program. Using data from the Survey of Income and Program Participation and Medicare Current Beneficiary Survey, we estimate that 11.7 percent of the population aged 65 to 66 would have retained their benefits under DI if the NAR and MEA were increased in 1993 to age 67. We also estimated that 11.4 percent of the population aged 65 to 66 would have retained their Medicare coverage under this policy change.
Client Area: Associations
Expertise Area: Medicare
May 1999
National Association for Home Care
Lewin contact: Lisa Alecxih
The Medicare Home Health Interim Payment System (IPS) raises concerns for beneficiaries and providers. A temporary plan proposed until HCFA develops a home care PPS, the IPS may cause the number of home health agencies (HHAs) exceeding the Medicare cost limits to more than double and the published cost limits to decrease 21% on average overall. HHAs may operate without knowing the per-beneficiary limits for up to 6 months of the initial IPS cost reporting period. Strategies developed by HHAs to cope with this reduction may include increasing the proportion of low-end users with fewer visits and restraining costs per visit and number of visits per beneficiary. Some of these strategies could have considerable consequences for high-use home health clients.
Client Area: Associations
Expertise Area: Medicare
May 1999
American Hospital Association
The Balanced Budget Act (BBA) of 1997 is projected to cut $71 billion in Medicare payments to hospitals, which may cause 7 out of 10 hospitals to have negative total Medicare margins by the year 2002. For all hospitals, total Medicare margins are projected to be around negative 4.4 percent, and margins for outpatient, hospital-based home health, and PPS-exempt services will all be negative under the BBA. The BBA reduced payments for most hospital services, including inpatient acute care, outpatient care, home health care, skilled-nursing care, medical education, and indigent care.
The study included hospital specific analyses for inpatient PPS and PPS-exempt hospital services, hospital-based home health services, and outpatient hospital services. The findings report Medicare payments and margins for these services, as well as total Medicare payments and margins.
Client Area: Associations
Expertise Area: Medicare
February 1999
Pharmaceutical Research and Manufacturers of America (PhRMA)
Lewin contact: Lisa Alecxih
Elderly patients paid for more than half (52%) the cost of their prescriptions out of their own pockets, according to a recent study for the Pharmaceutical Research and Manufacturers of America. This is not surprising since Medicare does not, for the most part, cover outpatient prescribed medications.
The study reviewed third party coverage options for pharmacy coverage (total average per beneficiary spending of $571 per person) as based on 1995 data. It showed that employers were the second largest source of payment (26%) through supplemental insurance. Beneficiaries with employer supplemental insurance drug coverage spent 31% out-of-pocket, while those with Medigap spent 60%, and those with Medicare HMO coverage spent 37% out-of-pocket. Additionally, only about 36% of beneficiaries with less than $10,000 in income had drug coverage, compared to 71% among those with $50,000 or more in income.
The study also showed that Medicare beneficiaries at the extreme ends of the income spectrum (that is, those poor enough to qualify for full dual Medicare/ Medicaid coverage or those with full coverage from employer-provided supplemental health plans) had the most extensive coverage. Those at greatest risk were the middle group: beneficiaries with individually purchased Medigap coverage have no or limited drug benefits.
Client Area: Associations
Expertise Area: Medicare
February 1999
National Coalition on Health Care
Lewin contact: John Sheils
The Health Care Financing Administration (HCFA) should promote "best practice" methods and educate providers. This study outlines ways in which the government can improve the quality of health care in Medicare programs. The cause for concern is due to the large gaps between the care that people should receive and the care they do receive. Medicare reforms must affect the whole system, and should not be tacked on as an afterthought.
Client Area: Associations
Expertise Area: Medicare
March 1998
National Association for Home Care
Lewin contact: Lisa Alecxih
The Medicare Home Health Interim Payment System (IPS) raises concerns for beneficiaries and providers. A temporary plan proposed until HCFA develops a home care PPS, the IPS may cause the number of home health agencies (HHAs) exceeding the Medicare cost limits to more than double and the published cost limits to decrease 21% on average overall. HHAs may operate without knowing the per-beneficiary limits for up to 6 months of the initial IPS cost reporting period. Strategies developed by HHAs to cope with this reduction may include increasing the proportion of low-end users with fewer visits and restraining costs per visit and number of visits per beneficiary. Some of these strategies could have considerable consequences for high-use home health clients.
Client Area: Associations
Expertise Area: Aging and Disability, Medicare
December 1997
American Association of Retired Persons
Lewin contact: Lisa Alecxih
This study found that Medicare beneficiaries spend on average two out of every ten dollars in income on out-of-pocket health expenses, excluding the costs of home health and nursing home care. In addition, the report found that older Medicare beneficiaries living below the poverty line spend on average more than one-third of their yearly income on out-of-pocket health care costs. A first-time look at the magnitude of out-of-pocket spending for the nearly 60 percent of poor Medicare beneficiaries who do not receive Medicaid, the study provides the first comparison of out-of-pocket costs paid by beneficiaries enrolled in HMOs versus those in traditional fee-for-service programs.
Client Area: Associations
Expertise Area: Medicare
April 1997
American Dietetic Association
Analysis of data from a Northwestern HMO shows that the use of dietition services under Medicare Part B as specified in the Medical Nutrition Therapy Act of 1995 can reduce inpatient and physician service use for patients with diabetes and/or cardiovascular disease. Utilization savings appeared within the first calendar quarter and increased over time. Authors found also that the program could produce net savings to Medicare over the period analyzed (1998 to 2000) if coverage is limited to those with diseases demonstrated to show savings.
Client Area: Associations
Expertise Area: Chronic Disease / Cost of Illness, Medicare
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