I was cleaning out my office and I found a stack of folders that were "airplane reading" for 2019. One of them had the intriguing title, "The Accidental Administrative Law of the Medicare Program," by Eleanor Kinney of Indiana University (2015). Legal articles - this one is is about 30 pages, 12000 words - dive right in with an introduction and close with "conclusions," but don't have a built-in abstract.
I asked ChatGPT 3.5 to summarize the paper. I've learned not just to ask for "a detailed summary" (which can fizzle) but to give ChatGPT a target summary word count, in this case "500 words or more," to avoid a summary that is too short to be useful for me. Summary below; the original is worth reading.
The legal article is available here. It's Pubmed 25876376. The long article is abridged into a shorter essay, by the author, in Health Affairs in 2014, here. McKinney died at age 71 in 2018.
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Summary of the Essay "The Accidental Administrative Law of the Medicare Program"
"The Accidental Administrative Law of the Medicare Program" is a detailed analysis of the evolution of the Medicare program in the United States, focusing on its regulatory framework and the changing relationship between the Centers for Medicare and Medicaid Services (CMS) and the providers of healthcare services. The essay highlights how the Medicare program unintentionally transformed into a model of collaborative regulation, departing from the traditional command and control approach.
The essay starts by tracing the historical development of the Medicare program, from its establishment in 1965 under Title XVIII of the Social Security Act to subsequent legislative amendments. It examines the early years when the program was heavily focused on cost containment and the adversarial relationship between CMS and providers. It also discusses key legislation, such as the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, which introduced the Medicare Prospective Payment System (PPS) and established a new framework for hospital reimbursement.
A turning point in the Medicare program's regulatory approach came in the late 1990s when CMS initiated experiments in provider collaboration, signaling a shift away from strict control over healthcare providers. This collaborative model gained traction with the introduction of the Medicare Part C program, allowing private managed care plans to participate, and the establishment of Quality Improvement Organizations (QIOs) to improve healthcare quality.
The essay delves into the concept of collaborative regulation and how it differs from traditional regulatory models. Collaborative regulation involves engaging providers in policy-making, giving them more flexibility, and focusing on shared goals, such as improving patient outcomes and reducing costs. This approach is driven by factors like the growing influence of business-trained executives in healthcare organizations, advances in health services research, and changing attitudes of younger physicians.
A significant example of this shift is the development of Accountable Care Organizations (ACOs) under the Affordable Care Act (ACA). ACOs foster coordination and cooperation among providers, incentivizing them to deliver high-quality care at lower costs for Medicare beneficiaries. CMS exhibited a willingness to negotiate with providers during the rule-making process for the Shared Savings Program, showcasing the collaborative nature of the program.
The essay also discusses how CMS has become more responsive to provider concerns, demonstrated through modifications to the Shared Savings Program based on feedback from program participants and stakeholders. CMS' openness to experimentation and innovation is seen as critical to the program's success.
Additionally, the essay examines the impact of collaborative regulation on the appeals process for Medicare beneficiaries and providers. It advocates for alternative dispute resolution (ADR) procedures to expedite appeals and resolve issues more collaboratively. The collaborative approach has resulted in reduced wait times for beneficiaries appealing CMS decisions.
In conclusion, "The Accidental Administrative Law of the Medicare Program" showcases the transformation of the Medicare program from a command and control regulatory model to a collaborative and flexible approach. The shift has been driven by various factors, including changes in healthcare leadership and attitudes, the introduction of ACOs, and the ACA's emphasis on innovation and provider engagement. The essay suggests that the collaborative model may have broader implications for future regulatory efforts in the healthcare sector, promoting quality-driven care and cost containment through cooperation between CMS and healthcare providers.
