Medicare: Quality and Access to Care

Monitoring Quality in Medicare

We are at the forefront of quality improvement efforts in health care, developing the first Medicare Quality Monitoring System (MQMS). MQMS is a surveillance system designed to give the Centers for Medicare & Medicaid Services (CMS) an early warning about declines in any aspect of quality. We are analyzing a variety of indicators of health care quality, including:

• Utilization, readmission, and mortality after treatment for acute myocardial infarction, heart failure, pneumonia, and stroke
• Preventive services and outcomes for Medicare beneficiaries with diabetes
• Readmission and mortality rates for 14 high-risk surgeries
• Patient safety events
• Preventable hospitalizations

We are also working with CMS on methods for developing a hospital-level public reporting system for CMS to post on the internet. This includes developing quality outcome measures and risk-adjustment models for acute myocardial infarction and heart failure mortality.

Click here to view MQMS publications.

Mathematica has also investigated how health care quality standards in Medicare managed care can be used to provide a framework for implementing quality standards in the traditional Medicare fee-for-service program. We developed a concept paper on this issue for the Medicare Payment Advisory Commission.

Access to Skilled Nursing Facility Care

The Balanced Budget Act of 1997 mandated that a prospective payment system be implemented for Medicare-funded skilled nursing facility care. Mathematica assisted the Medicare Payment Advisory Commission in assessing the feasibility of monitoring Medicare beneficiaries' use of skilled nursing facility care in a clinically meaningful way, using routinely collected administrative data. The feasibility analysis included a review of the clinical and health services literature and of existing standards and protocols for patient care. It also examined previous use of administrative data to analyze the use of necessary skilled nursing facility care. Our staff interviewed clinicians, researchers, and others whose work places them at the acute/post-acute care interface and integrated their feedback into a conceptual framework of necessary care. The study found that progress in measuring access to necessary care will require greater professional consensus and richness of administrative data than are now available.

Access to Physician Services

Decreases in Medicare payment rates in both Medicare Advantage (formerly Medicare+Choice) and traditional Medicare, as well as cost pressures external to Medicare such as rising malpractice premiums, have raised concerns about physicians' participation in the program. To inform policy decisions on access to physician services, we designed and fielded a timely survey to measure the incidence of access problems. In addition, we analyzed this data to help CMS determine whether problems in given areas are more extensive than in the past.

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