Medicare Part B pays outpatient physicians according to the billed Current Procedural Terminology (CPT) codes, which differ in procedure and intensity. Since many performed services merely differ by intensity, physicians have an incentive to upcode services to increase profitability of a visit. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper explores the effect of Medicare Part B fee differentials on the upcoding of general office visits (i.e. for established patient visits with CPT codes of 99212-99215). It finds strong evidence that these fee differentials influence physician's coding choice for billing purposes across a variety of specialties. For general office visits, Medicare outlays attributable to upcoding may sum to as much as 15% of total expenditures for such visits. Medicare has much to gain financially by clarifying its classification rules. Until the distinctions between types of Medicare visits are redefined in a way that eliminates ambiguity, upcoding under Medicare Part B is likely to continue.

Objective To evaluate physician characteristics associated with pharmaceutical industry transfers and prescribing behavior after public reporting under the Sunshine Act. Data Sources 2014‐2016 secondary data on industry transfers to physicians from the Open Payments Dataset supplemented with Medicare Part D prescription data, Medicare service data, and practice attributes from the Physician Compare Database. Study Design Using regression analysis with county/physician fixed effects, this study examines characteristics associated with the probability/magnitude of transfers and the association between transfers and prescriptions. Data Collection Using an iterative matching approach, this study identifies physicians who delivered outpatient Medicare services in 2014 (n = 409 041) and tracks their annual transfers between 2014 and 2016 (N = 1 227 123) across six transfer categories. In addition, it examines their Medicare Part D prescription behavior between 2014 and 2015 (N = 741 659). Principal Findings Industry transfers dramatically declined in 2015 and 2016. Transfers are significantly associated with increased prescription costs, branded prescribing, and prescribing for High‐Risk Medications (HRMs). Conclusions Industry transfers have declined after public reporting. Transfers are associated with higher prescription costs and incidence of HRMs. Future research is needed to determine the causal impact on quality and cost‐effectiveness of prescribed medications.

Post-acute care provided by skilled nursing facilities (SNFs) is reimbursed by Medicare under a prospective payment system using resource utilization groups (RUGs) that adjust payment intensity on the basis of predefined ranges of weekly therapy minutes provided and the functionality of the patient. Individual RUGs account for differences in the intensity of care provided, but there exists significant regional variation in the payments SNFs receive from Medicare due to the use of geographic adjustment factors. This paper is the first to use this geographic variation in the generosity of Medicare reimbursement to empirically test if SNFs respond to payment differences between RUG categories. The results are highly suggestive that SNFs upcode patients by providing additional therapy minutes to increase revenue, whereas we find no evidence of upcoding related to patient functionality scores. Simulating how different payment differentials affect RUG selection, we predict that reducing the financial incentive to upcode could result in significant savings to Medicare.

Objective. The objective of this study is to examine how nursing homes changed their use of antipsychotic and other psychoactive medications in response to Nursing Home Compare's initiation of publicly reporting antipsychotic use in July 2012. Research Design and Subjects. The study includes all state recertification surveys (n = 40,415) for facilities six quarters prior and post the initiation of public reporting. Using a difference-in-difference framework, the change in use of antipsychotics and other psychoactive medications is compared for facilities subject to public reporting and facilities not subject to reporting. Principal Findings. The percentage of residents using antipsychotics, hypnotics, or any psychoactive medication is found to decline after public reporting. Facilities subject to reporting experienced an additional decline in antipsychotic use (À1.94 vs. À1.40 percentage points) but did not decline as much for hypnotics (À0.60 vs. À1.21 percentage points). Any psychoactive use did not vary with reporting status, and the use of antidepressants and anxiolytics did not change. Conclusion. Public reporting of an antipsychotic quality measure can be an effective policy tool for reducing the use of antipsychotic medications-though the effect many only exist in the short run.

Using 2008 physician survey data, we estimate the relationship between the generosity of fees paid to primary care physicians under Medicaid and Medicare and his/her willingness to accept new patients covered by Medicaid, Medicare, or both programs (i.e., dually enrolled patients). Findings reveal physicians are highly responsive to fee generosity under both programs. Also, their willingness to accept patients under either program is affected by the generosity of fees under the other program, i.e., there are significant spillover effects between Medicare and Medicare fee generosity. We also simulate how physicians in 2008 would have likely responded to Medicaid and Medicare payment reforms similar to those embodied in the 2010 Affordable Care Act, had they been permanently in place in 2008. Our findings suggest that "Medicaid Parity" for primary care physicians would have likely dramatically improved physician willingness to accept new Medicaid patients while only slightly reducing their willingness to accept new Medicare patients. Also, many more primary care physicians would have been willing to treat dually enrolled patients.

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Typically, research on the effect of ownership has considered health care providers in isolation of competitive interaction from other firms. This analysis considers how the selection of Medicare reimbursement codes for skilled nursing facilities varies by ownership and is influenced by the competitive spillovers from market dominance of for-profit institutions. We find evidence that not-for-profits are less likely to code patients into the highest reimbursement categories. Further, as the market becomes dominated by for-profits, both for-profit and not-for-profits increase the share of patients in these high reimbursement categories.

The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor's care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians' ability to balance bill significantly reduce the perceived quality of care under Part B.