Favorable Selection Risk Adjustment And The Medicare Advantage Program

Intensity Modulated Radiation Therapy Medical Clinical Policy Bulletins. Number 0. 59. 0Policy. Aetna considers intensity modulated radiation therapy IMRT medically necessary where critical structures cannot be adequately protected with standard 3 dimensional 3. D conformal radiotherapy see Appendix. In the United States, Medicare is a singlepayer, national social insurance program administered by the U. S. federal government since 1966, currently when using. Removal of Allocation Rule for Disbursements from Designated Roth Accounts to Multiple Destinations. NH-500x321.jpg' alt='Favorable Selection Risk Adjustment And The Medicare Advantage Program' title='Favorable Selection Risk Adjustment And The Medicare Advantage Program' />Aetna considers placement of fiducial markers medically necessary if the above criteria are met, and the radiation target is not clearly visible, and bony anatomy is not sufficient for adequate target alignment. Aetna considers interfraction image guidance i. Calypso 4. D Localization System, the Ray. Pilot System medically necessary for delivering IMRT and other conformal radiotherapy. Background. Note on Definition of Intensity Modulated Radiation Therapy IMRT For purposes of this policy, to qualify as IMRT, radiation therapy requires highly sophisticated treatment planning utilizing numerous beamlets to generate dosimtery in accordance with assigned dose requirements to the tumor and organs at risk. Note For purposes of this policy, critical structures can not be adequately protected with standard three dimensional 3. D conformal radiotherapy if IMRT would decrease the probability of grade 2 or grade 3 radiation toxicity, as compared to conventional 3. D conformal radiation therapy, in greater than 1. Intensity modulated radiation therapy, also known as tomotherapy, is a type of stereotactic radiosurgery that delivers a highly conformal, 3. D distribution of radiation doses. IMRT uses computercontrolled linear accelerators to deliver precise radiation doses to specific areas within a tumor. This therapy allows for increased precision by the conforming of the radiation to the planned target site while significantly reducing the amount of radiation to surrounding healthy tissues. Favorable Selection Risk Adjustment And The Medicare Advantage Program' title='Favorable Selection Risk Adjustment And The Medicare Advantage Program' />Image guided radiation therapy IGRT may be performed in conjunction with IMRT and includes, but may not be limited to, computed tomography CT, magnetic resonance imaging MRI, ultrasound or Xray. IGRT is utilized to direct and guide the delivery of radiation to maximize accuracy and precision throughout treatment. Different techniques are utilized to control the radiation amount given during IMRT. The most common approach is the use of multileaf collimators MLCs. These devices are attached to the linear accelerator. The MLCs are composed of computer controlled tungsten leaves or panels that move while the radiation beam is directed toward the target. The leaves act as filters that block out certain areas. This modifies the beams intensity so that the radiation is distributed according to the treatment plan. Another delivery approach is compensatorbased IMRT. This approach utilizes custom made based on the 3. D images and the treatment plan high density blocks to control the administration of the radiation. Comprehensive and meticulously documented facts about healthcare. Learn about costs, private insurance, Medicare, Medicaid, politics, and more. In the United States, health insurance is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a social. Original Article. Uninterrupted Dabigatran versus Warfarin for Ablation in Atrial Fibrillation. Hugh Calkins, M. D., Stephan Willems, M. D., Edward P. Gerstenfeld, M. D. The blocks are put into place, the patient is positioned and the radiation is delivered. Fiducial markers are gold seeds or stainless steel screws that are implanted in andor around a soft tissue tumor or within the bony spine, to act as a radiologic landmark, to more precisely define the target lesions position. Fiducial markers may be placed using CT, endoscopic or surgical guidance. The PEACOCK CORVUS system, the Varian system, and the Elekta system are some of the currently available IMRT systems. In contrast to conventional trial and error approach, IMRT uses inverse planning automated optimization, computer controlled radiation deposition, and normal tissue avoidance. In the PEACOCK system, IMRT is delivered through a treatment planning and delivery system called PEACOCK, which shapes or conforms a radiation dose to the contour of the tumor while minimizing the impact on surrounding healthy tissue or organs. The delivery system combines 2 components i the multileaf intensity modulating collimator MIMi. Favorable+Selection+Versus+Selective+Contracting.jpg' alt='Favorable Selection Risk Adjustment And The Medicare Advantage Program' title='Favorable Selection Risk Adjustment And The Medicare Advantage Program' />C that modulates the intensity of thin beams of radiation, and ii the CORVUS planning system, a planning computer that inversely plans the dose of radiation based on the tumor size, shape and location. When IMRT is used for head and neck tumors, it allows for the treatment of multiple targets with different doses, while simultaneously minimizing radiation to uninvolved critical structures such as the major salivary glands e. Collimator based IMRT uses computers to modify the intensity of the beam across each individual field with the use of moving collimators. Conventional treatment with multi leaf collimation MLC uses static positions of the collimator leaves whereas IMRT allows the dynamic motion of the various collimator leaves during each session of therapy. With compensator based IMRT, a pre shaped piece of material the compensator or modulator is used to modulate the beam. The amount of modulation of the beam is based on the thickness of material through which the beam is attenuated. This modulation requires the fabrication and the manual insertion of the modulator into the tray mount of a linear accelerator. Intensity modulated radiation therapy typically involves inverse treatment planning, although forward treatment planning has been used. Forward treatment planning involves estimating the radiation delivery profile based on the number, directions and shape of the beams. In inverse treatment planning, the radiation oncologist and physicist determine the treatment target, the normal structures that should be protected, the required radiation dose for the tumor and the tolerated doses for the surrounding normal tissues the computer then computes the beam profiles needed to yield those results. The outlined objectives for radiation dose distribution are in prescribed dose volume histograms. The histograms are translated into beam configurations that will deliver tumor and normal tissue doses prescribed. Intensity modulated radiation therapy optimizes the treatment plan based on the physicians dose instructions, the specific dose constraints for planned treatment volume PTV and information about tumor size, shape and location in the body. A medical linear accelerator equipped with a dynamic MLC shapes the radiation beams wrapping around the tumor, conforming to its shape and delivers the radiation. Intensity modulated radiation therapy involves at least 5 separate ports. The beam angle or gantry position is what determines a port or entry point of the beam. Segments are part of the individual beam profile and there may be many per port or beam angle. If the segment is truly an independent port within a port often called en field and can be demonstrated to provide sufficient beam profiling, then it may be considered a separate port within the same beam angle and be considered a port for purposed of defining IMRT. An evidence review by ANAES 2. IMRT remain to be established, clinical interest in IMRT is greatest for cancers of the head and neck and for prostate cancer. In addition, ANAES found that there is some emerging interest in use of IMRT for cancers of the lung and central nervous system CNS. An assessment by the Belgian Health Care Knowledge Centre KCE Van den Steen et al, 2. IMRT compared with 2. D RT or 3. D CRT for head and neck cancer, prostate cancer and breast cancer. The assessment found that current reports do no allow for a good comparison of relapse or survival data between IMRT and conventional techniques. Healthcare Just Facts During 2. U. S. spent 1. 5 trillion on health and healthcare programs. This amounted to 7. U. S. gross domestic product, 2. U. S. 1. 521. 53Relative to other types of government spending in 2. Social Security, unemployment, and cash welfare. Between 1. 95. 9 and 2. Mandatory Spending. Mandatory programs are those that can spend taxpayer money without Congress passing annual spending bills. The four major federal mandatory healthcare programs are Medicare, Medicaid, the Childrens Health Insurance Program, and the Affordable Care Act i. Obamacare exchange subsidies. In 2. 01. 4, 2. 7 of all federal government spending except interest on the national debt and 2. Under the federal governments current policies,1. Congressional Budget Office estimates that the share of federal revenues spent on mandatory healthcare programs will increase from 5 in 1. Data from the graph above Year. Portion of. Federal Revenues. Portion of Federal Spending. Except Interest on the Debt. The Medicare program was founded in 1. It was later expanded to cover younger people who are permanently disabled. In 2. 01. 3, Medicare provided health insurance for almost all Americans aged 6. In total, these Medicare enrollees represent about 1. U. S. population. Medicare provides coverage for. Part A component. Part B component. Winrar X84. Part C component commonly called Medicare Advantage. Part D component. In 2. 01. 1 latest available data, Medicare covered 6. Medicare beneficiaries not living in institutions such as nursing homes. The remainder of beneficiaries healthcare expenses were paid by private supplemental insurance 1. Medicaid and the Department of Veterans Affairs 6. In 2. 01. 4, Medicare spent about 6. This amounts to 1. Medicare expenditures in 2. Portion1. 74Category. Source. 41General revenues1. Federal income, corporate, excise, and other taxes. In total, these taxes are progressive so that higher income households pay higher effective tax rates. Payroll taxes. A 2. Obamacare on wages above 2. Insurance premiums. Premiums paid by Medicare beneficiaries who receive Part B or Part D benefits. These premiums are indexed so that wealthier beneficiaries pay greater amounts. Trust fund redemptions1. Primarily Medicare payroll taxes that were previously loaned to the general fund of the U. S. Treasury. 1. 851. Taxes on Social Security benefits. Taxes paid by Social Security beneficiaries whose incomes exceed certain thresholds. Transfers. State governments. Miscellaneous. Fines, penalties, and gifts. In 2. 01. 3, Medicare payment rates for inpatient hospital services were 6. Medicare paid hospitals an average of 1. Medicare patients. When Medicare began funding healthcare for seniors in 1. Americans in their primary working years for every American aged 6. By 2. 01. 4, this ratio had declined by 2. As the baby boom generation matures and projected life expectancy increases,1. Social Security Administration projects that this ratio will decline by 3. When Medicare was established in 1. Americans was 1. 2. By 2. 01. 4, these figures had risen to 1. This amounts to a 4. Medicare benefits for males and a 2. As these life expectancies have increased, the age at which people become eligible for Medicare has not increased. According to Social Security Administration projections, by 2. Americans will rise to 1. This would amount to a 5. Medicare benefits for males and a 3. The 2. 01. 5 Medicare Trustees Report projects the future finances of the Medicare program based upon high, low, and intermediate cost assumptions. Per the intermediate assumptions, the Medicare program faces a 2. The report states that the resources needed to cover this deficit would be in addition to the payroll taxes, benefit taxes, and premium payments. This actuarial deficit approximates how much money must be immediately added to the Medicare program to cover the projected shortfall between the programs dedicated funding sources and its costs for the next 7. It is equivalent to 4. Medicare in 2. 01. The Medicare Trustees have stated that measures such as the actuarial deficit can. One way to account for the last of these concerns is to calculate how much money must be immediately added to the Medicare program in order to cover the projected shortfall for all current participants in the program both taxpayers and beneficiaries. This amounts to 2. U. S. resident aged 1. This measure approximates the method by which publicly traded companies are required by law to report the finances of their pension and retirement plans. The annual Medicare Trustees Report makes financial projections based primarily on current law. Per the 2. 01. 5 report. Medicare projections could be substantially understated as a result of other potentially unsustainable elements of current law. Medicares payments are not expected to keep up with underlying physician costs, resulting in a large and growing problem over the long range. Because of cuts in the 2. Affordable Care Act i. Obamacare, the prices paid by Medicare for most health services will fall increasingly short of the cost of providing such services. If this issue is not addressed by subsequent legislation, it is likely that access to, and quality of, physicians services would deteriorate over time for beneficiaries. Overriding these cuts would lead to substantially higher costs for Medicare in the long range than those projected in this report. In 2. 01. 5, U. S. Centers for Medicare and Medicaid Services published an alternative projection to estimate the potential costs of Medicare given the practical realities listed above. Per this estimate, actual Medicare costs will exceed the costs shown in the Trustees Report by 3 per year by 2. In 2. 01. 5, the U. S. Treasury published a financial analysis of the alternative projection described above. These calculations show that Medicares 7. The Medicaid program was founded in 1. United States and its Territories. Twilight Dancer Torrent. In 2. 01. 3, about 7. U. S. and its territories received Medicaid benefits at some point in the year. This represents about 2. In 2. 01. 3, an average of 5. U. S. were enrolled in Medicaid during the entire year. This represents about 1. U. S. population. In 2. 01. 3, Medicaid enrollment and spending was divided as follows Category. Portion of. Beneficiaries. Cost Per Full Year. Enrollee. Portion of. Medicaid Spending. Children. 482,8. Adults. Disabled. 171. 7,3. Aged. 91. 5,4. 83. In 2. 01. 3, an average of one million people in five U. S. territories Puerto Rico, the U. S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands were enrolled in Medicaid over the course of the entire year. This represents about 2. States are not required to participate in the Medicaid program, but all choose to do so. Within certain federal guidelines, states have latitude in setting eligibility criteria, deciding which healthcare services to cover, and regulating payments to doctors and other healthcare providers. An example of a federal guideline is that all participating states must provide Medicaid coverage for pregnant women and children in families with income below a certain level. Starting in 2. 01. Affordable Care Act a. Obamacare required all states to provide Medicaid coverage for all individuals under the age of 6. In 2. 01. 6, 1. 38 of the federal poverty guideline was 3.