Current Awareness in Aging Research (CAAR) Report #499 -- August 6, 2009

CAAR (Current Awareness in Aging Research) is a weekly email report produced by the Center for Demography of Health and Aging at the University of Wisconsin-Madison that helps researchers keep up to date with the latest developments in the field. For more information, including an archive of back issues and subscription information see:


I. Data:

1. HEALTH AND RETIREMENT SURVEY: The University of Michigan, Institute for Social Research HRS has announced the release of "Prospective Social Security Wealth Measures of Pre-Retirees (Version 2.0)" (Aug. 5, 2009).

Data access:


2. US ADMINISTRATION ON AGING: "AGing Integrated Database, (AGID)," has been updated to include data from 2008. New data includes:

- State Program Reports.

- National Ombudsman Reporting System data.

- National Survey of Older Americans Act Service Recipients.


3. MEDICAL EXPENDITURE PANEL SURVEY: The US Agency for Healthcare Research and Quality has released a new MEPS data file (July 2009, data in .zip or self decompressing [.exe] ASCII text and SAS Transport format, with documentation in HTML and .pdf format, and SAS programming statements in ASCII format).

"MEPS HC-109: 2008 P12R3/P13R1 Population Characteristics"


II. Reports and articles:


A. "Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services," (OEI-09-06-00430, August 2009, .pdf format, 33p.).


In the first 3 months of 2007, when Medicare allowed physicians more than 24 hours of services in a day, nonphysicians performed half of the services and unqualified nonphysicians performed 21 percent of these services. Medicare Part B pays for services that are billed by physicians but are performed by nonphysicians under the "incident to" rule. Little is known about these services because physicians are not required to identify them on their Medicare claims.

To identify the services not personally performed by physicians, we sampled claims from physicians for whom Medicare allowed more than 24 hours of services in a single day in the first 3 months of 2007. Some of the services that were performed by unqualified nonphysicians were invasive services, involving entry into the body by incision or insertion of an instrument. These services, in particular, may represent a risk to Medicare beneficiaries when they are performed by unqualified individuals. We are concerned that the problem of Medicare services performed by unqualified nonphysicians may be more widespread than we can report at this time.

We recommend that CMS seek revisions to the "incident to" rule. The rule should require that physicians who do not personally perform the services they bill to Medicare ensure that no persons except: (1) licensed physicians personally perform the services or (2) nonphysicians who have the necessary training, certification, and/or licensure, pursuant to State laws, State regulations, and Medicare regulations, personally perform the services under the direct supervision of a licensed physician. Further, CMS should require that physicians who bill services to Medicare that they do not personally perform to identify the services on their Medicare claims by using a service code modifier. The modifier would enable CMS to monitor claims to ensure that physicians are billing for services performed by nonphysicians with appropriate qualifications. Finally, CMS should take appropriate action to address the claims for services that we detected that (1) were billed by physicians and performed by nonphysicians that were, by definition, not "incident to" services and (2) were for rehabilitation therapy services performed by nonphysicians who did not have the training of a therapist.

In comments on the draft report, CMS concurred with two of our three recommendations. CMS did not concur with our recommendation to create a service code modifier to identify physicians' claims for services that physicians do not personally perform. We continue to recommend that CMS have the ability to identify and monitor these claims. CMS stated it would study the operational issues involved in implementing the recommendation. We look forward to learning the specific steps CMS plans to take with respect to this issue.

B. "Inappropriate Medicare Payments for Pressure Reducing Support Surfaces," (OEI-02-07-00420, August 2009, .pdf format, 34p.).


Based on a review of medical record documentation and supplier documentation, 86 percent of group 2 support surface claims for the first half of 2007 did not meet Medicare coverage criteria. This amounted to an estimated $33 million in inappropriate payments during that time. We considered a claim as not meeting Medicare coverage criteria if it either (1) did not meet Medicare's clinical coverage requirements or (2) did not meet Medicare's supplier documentation requirements.

Pressure reducing support surfaces are used for the care or prevention of pressure ulcers. Pressure ulcers, also known as bedsores or decubitus ulcers, commonly occur among the elderly and among individuals with spinal cord injuries. Support surfaces are covered under Medicare Part B as durable medical equipment (DME). CMS categorizes support surfaces into three groups based on the complexity of their features. Group 2 is the largest group.

Based on an independent medical review, we found that 80 percent of group 2 support surface claims did not meet Medicare's clinical coverage requirements. In addition, we found that 33 percent of claims did not meet supplier documentation requirements. Over three-quarters of the claims that did not meet supplier documentation requirements also did not meet Medicare's clinical coverage requirements.

More specifically, 38 percent of the claims were undocumented, 22 percent were medically unnecessary, 17 percent had insufficient documentation, and 3 percent had other billing errors. For the claims that did not meet supplier documentation requirements, the supplier delivered the support surface before obtaining the physician order, the supplier did not have a physician order, the supplier was missing proof of delivery, or the physician order was not dated.

Lastly, we found that CMS contractors had limited safeguards in place to prevent improper payments for group 2 support surfaces. In particular, contractors' use of the KX modifier, which a supplier uses to indicate that a claim meets Medicare coverage criteria and that adequate documentation exists, was not successful in flagging inappropriate claims. In addition, none of the CMS contractors conducted any widespread medical reviews of support surface claims. Moreover, only half of the CMS contractors responsible for supplier education conducted any educational activities in recent years that focused on group 2 support surfaces.

Based on the findings of this report, we recommend that CMS ensure that claims for group 2 support surfaces meet Medicare coverage criteria and are paid appropriately. Accordingly, CMS should: (1) conduct additional prepayment and postpayment medical reviews of group 2 support surface claims; (2) educate suppliers and health care providers, such as home health agencies, about Medicare coverage criteria for support surfaces; (3) review the use of the KX modifier as a program safeguard; (4) conduct additional statistical analyses to monitor payments for group 2 support surfaces; and (5) take appropriate action regarding the claims in our sample that were inappropriate. CMS concurred with all five of our recommendations.



A. "CMS Proposes Payment Changes For Home Health Services to Protect Beneficiaries and Medicare," (July 30, 2009).

B. "CMS Announces Policy and Payment Rate Changes For Inpatient Stays in Acute Care and Long-Term Care Hospitals in Fiscal 2010," (July 31, 2009).

C. "CMS Announces Fiscal 2010 Payment and Policy Updates for Inpatient Rehabilitation Facilities," (July 31, 2009).

D. "Supplier Bidding To Start In October For Medicares Competitive Bidding Program For Certain Medical Equipment And Supplies," (August 3, 2009).

E. "Decision Memorandum for Pharmacogenomic Testing to Predict Warfarin Responsiveness," (August 3, 2009).


6. US ADMINISTRATION ON AGING NEWSLETTER: AoA eNews (August 2009, Word format).


7. UK DEPARTMENT OF HEALTH WORKING MANUEL: "Working with Older Prisoners," (August 2009, .pdf format). There is a resource pack (55p.) and workshop pack (68p.).


8. MINNESOTA DEPARTMENT OF ADMINISTRATION, OFFICE OF GEOGRAPHIC AND DEMOGRAPHIC ANALYSIS REPORT: "Life expectancy in Minnesota varies by region," (August 2009, .pdf format, 10p.).


9. ILLINOIS DEPARTMENT OF PUBLIC HEALTH REPORT: "Prostate and Testicular Cancer Program Report to the Illinois General Assembly: 2008" (2009, .pdf format, 11p.).



A. "Is Latin America Retreating From Individual Retirement Accounts?" by Fabio Bertranou, Esteban Calvo, and Evelina Bertranou (IB No. 9-14, July 2009, .pdf format, 18p.).

B. "Should Social Security Rely Solely on the Payroll Tax?" by Alicia H. Munnell (IB No. 9-16, July 2009, .pdf format, 7p.).


11. URBAN INSTITUTE/AARP REPORT: "Increasing Health Insurance Coverage for High-Cost Older Adults," by Linda J. Blumberg and Timothy A. Waidmann (2009-10, July 2009, pdf format, 20p).


12. EMPLOYEE BENEFIT RESEARCH INSTITUTE ISSUE BRIEF: "Individual Account Retirement Plans: An Analysis of the 2007 Survey of Consumer Finances, With Market Adjustments to June 2009," by Craig Copeland (EBRI Issue Brief No. 333, August 2009, .pdf format, 36p.).


13. CENTER FOR HEALTH CARE STRATEGIES REPORT: "Case Study: Rhode Island Pilots Innovative, Cross-Payer Patient-Centered Medical Home Model," (July 2009, pdf format, 6p).


14. FINANCIAL SERVICES CONSUMER PANEL [UK] REPORT: "Financial Services and Later Life: A Scoping Project," by Jackie Wells and Mary Gostelow (July 2009, .pdf format, 14p.).


15. MICHIGAN RETIREMENT RESEARCH CENTER PERIODICAL: MRRC Newsletter (Vol. 10, No. 3, July 2009, HTML and .pdf format, 10p.).





A. "Induction of cerebral {beta}-amyloidosis: Intracerebral versus systemic A{beta] inoculation," by Yvonne S. Eisele, Tristan Bolmont, Mathias Heikenwalder, Franziska Langer, Laura H. Jacobson, Zheng-Xin Yan, Klaus Roth, Adriano Aguzzi, Matthias Staufenbiel, Lary C. Walker, and Mathias Jucker (Vol. 106, No. 31, August 4, 2009, p. 12926-12931).

B. "Repression of {alpha}-synuclein expression and toxicity by microRNA-7," by Eunsung Junn, Kang-Woo Lee, Byeong Seon Jeong, Teresa W. Chan, Joo-Young Im, and M. Maral Mouradian (Vol. 106, No. 31, August 4, 2009, p. 13052-13057).

C. "Inclusion formation and neuronal cell death through neuron-to-neuron transmission of {alpha}-synuclein," by Paula Desplats, He-Jin Lee, Eun-Jin Bae, Christina Patrick, Edward Rockenstein, Leslie Crews, Brian Spencer, Eliezer Masliah, and Seung-Jae Lee (Vol. 106, No. 31, August 4, 2009, p. 13010-13015).

D. "Simultaneous inactivation of Par-4 and PTEN in vivo leads to synergistic NF-{kappa}B activation and invasive prostate carcinoma," by Pablo J. Fernandez-Marcos, Shadi Abu-Baker, Jayashree Joshi, Anita Galvez, Elias A. Castilla, Marta Canamero, Manuel Collado, Carmen Saez, Gema Moreno-Bueno, Jose Palacios, Michael Leitges, Manuel Serrano, Jorge Moscat, and Maria T. Diaz-Meco (Vol. 106, No. 31, August 4, 2009, p. 12962-12967).


17. NATURE LETTER ABSTRACT: "Advances in development reverse fertility declines," by Mikko Myrskyl Hans-Peter Kohler & Francesco C. Billari (Vol. 460, No. 7256, August 6, 2009, p. 741-744).



A. "ExStroke Pilot Trial of the effect of repeated instructions to improve physical activity after ischaemic stroke: a multinational randomised controlled clinical trial," by Gudrun Boysen, Lars-Henrik Krarup, Xianrong Zeng, Adam Oskedra, Janika Korv, Grethe Andersen, Christian Gluud, Anders Pedersen, Marianne Lindahl, Lotte Hansen, Per Winkel, Thomas Truelsen, for the ExStroke Pilot Trial Group (BMJ 2009;339:b2810, August 1, 2009, .pdf and HTML format).

B. "Changes in white matter as determinant of global functional decline in older independent outpatients: three year follow-up of LADIS (leukoaraiosis and disability) study cohort," by Domenico Inzitari, Giovanni Pracucci, Anna Poggesi, Giovanna Carlucci, Frederik Barkhof, Hugues Chabriat, Timo Erkinjuntti, Franz Fazekas, Jose M Ferro, Michael Hennerici, Peter Langhorne, John O'Brien, Philip Scheltens, Marieke C Visser, Lars-Olof Wahlund, Gunhild Waldemar, Anders Wallin, Leonardo Pantoni, on behalf of the LADIS Study Group (BMJ 2009;339:b2477, August 1, 2009, .pdf and HTML format).



A. "Elder Self-neglect and Abuse and Mortality Risk in a Community-Dwelling Population," by XinQi Dong, Melissa Simon, Carlos Mendes de Leon, Terry Fulmer, Todd Beck, Liesi Hebert, Carmel Dyer, Gregory Paveza, and Denis Evans (Vol. 302, No. 5, August 5, 2009, p. 517-526).

B. "Elder Self-neglect: Medical Emergency or Marker of Extreme Vulnerability?" by Thomas M. Gill (Vol. 302, No. 5, August 5, 2009, p. 570-571).


20. PUBLIC LIBRARY OF SCIENCE (PLoS) ONE ARTICLE: "Genetic Polymorphisms of Estrogen Receptors alpha and beta and the Risk of Developing Prostate Cancer," by Young Kwang Chae, Han-Yao Huang, Paul Strickland, Sandra C. Hoffman, and Kathy Helzlsouer (PLoS ONE 4(8): e6523. doi:10.1371/journal.pone.0006523, .pdf, XML, and HTML format, 11p.).


21. NATURE MEDICINE ARTICLE ABSTRACT: "Pivotal role of cerebral interleukin-17-producing {gamma}{delta} T cells in the delayed phase of ischemic brain injury," by Takashi Shichita, Yuki Sugiyama, Hiroaki Ooboshi, Hiroshi Sugimori, Ryusuke Nakagawa, Ichiro Takada, Toru Iwaki, Yasunori Okada, Mitsuo Iida, Daniel J Cua, Yoichiro Iwakura & Akihiko Yoshimura (Vol. 15, No. 8, August 2009, p. 946-950).



A. "A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fracture," by Rachelle Buchbinder, Richard H. Osborne, Peter R. Ebeling, John D. Wark, Peter Mitchell, Chris Wriedt, Stephen Graves, Margaret P. Staples, and Bridie Murphy (Vol. 361, No. 6, August 6, 2009, p. 557-568).

B. "A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures," by David F. Kallmes, Bryan A. Comstock, Patrick J. Heagerty, Judith A. Turner, David J. Wilson, Terry H. Diamond, Richard Edwards, Leigh A. Gray, Lydia Stout, Sara Owen, William Hollingworth, Basavaraj Ghdoke, Deborah J. Annesley-Williams, Stuart H. Ralston, and Jeffrey G. Jarvik (Vol. 361, No. 6, August 6, 2009, p. 569-579).

C. "Apixaban or Enoxaparin for Thromboprophylaxis after Knee Replacement," by Michael Rud Lassen, Gary E. Raskob, Alexander Gallus, Graham Pineo, Dalei Chen, and Ronald J. Portman (Vol. 361, No. 6, August 6, 2009, p. 594-604).


III. Working Papers:

23. NATIONAL BUREAU OF ECONOMIC RESEARCH: "Low Life Expectancy in the United States: Is the Health Care System at Fault?" by Samuel H. Preston and Jessica Y. Ho (w15213, August 2009, .pdf format, 46p.). Links to the abstract and full-text can be found at:


24. CALIFORNIA CENTER FOR POPULATION RESEARCH [UNIVERSITY OF CALIFORNIA-LOS ANGELES]: "Take Me 'Home': Determinants of Return Migration Among Germany's Elderly Immigrants," by Jenjira Yahirun (CCPR-2009-019, July 2009, .pdf format, 44p.).


This paper examines the determinants of return migration as foreign-born individuals approach old age in Germany. Return migration in later life engages a different set of conditions than return migration earlier on, including framing return as a possible retirement strategy. Using data from the German Socioeconomic Panel, results suggest that later-life emigrants are "negatively selected" on the basis of economic resources. However, family resources such as spousal characteristics and ties to kin in "home" and "host" countries also shape decisions to return. Results from this paper highlight the broader importance of framing return migration within the processes of international migration and immigrant incorporation.


25. US DEPARTMENT OF JUSTICE, ANTITRUST DIVISION: "Does Competition Among Medicare Advantage Plans Matter?: An Empirical Analysis of the Effects of Local Competition in a Regulated Environment," by Abe Dunn (EAG 09-5, July 2009, .pdf format, 25p.). Links to the abstract and full-text can be found at:


IV. Journal Tables of Contents (check your library for availability):

26. American Journal of Alzheimer's Disease and Other Dementia (Vol. 24, No. 4, August/September 2009).

27. Canadian Journal on Aging / La Revue canadienne du vieillissement (Vol. 28, No. 2, Summer 2009).

28. Omega: Journal of Death and Dying (Vol. 59, No. 3, 2009).


29. AMEDEO MEDICAL LITERATURE: Note: "AMEDEO has been created to serve the needs of healthcare professionals, including physicians, nurses, pharmacists, administrators, other members of the health professions, and patients and their friends. They can easily access timely, relevant information within their respective fields... All AMEDEO services are free of charge. This policy was made possible thanks to generous unrestricted educational grants provided by AMGEN, Berlex, Eisai, Glaxo Wellcome, Novartis, Pfizer, Roche, and Schering AG."

A. Osteoporosis: Literature for the week of Aug. 3, 2009:

B. Alzheimer's Disease: Literature for the week of Aug. 3, 2009:

C. Parkinson's Disease: Literature for the week of Aug. 3, 2009:

D. Prostate Cancer: Literature for the week of Aug. 3, 2009:

E. Stem Cell Research: Literature for the week of Aug. 3, 2009:

F. Ophthalmology: Literature for the week of Aug. 3, 2009:

AMEDEO Literature Guide:


V. Books:

30. UNIVERSITY OF CHICAGO PRESS: Social Security Policy in a Changing Environment, edited by Jeffrey R. Brown, Jeffrey B. Liebman, and David A. Wise (2009, ISBN: 9780226076485, 472p.).


VI. Funding Opportunities:


A. "Limited Competition: The National Institute on Aging Multicenter Study on Exceptional Survival in Families: The Long Life Family Study (LLFS) (U01)," (RFA-AG-10-005, a reissue of RFA-AG-03-004, National Institute on Aging, July 29, 2009).

B. "Innovations in Biomedical Computational Science and Technology (R01)," (PAR-09-218, a reissue of PAR-07-344, National Institute on Aging, in conjunction with other agencies, August 5, 2009).

C. "Innovations in Biomedical Computational Science and Technology Initiative (SBIR [R43/R44])," (PAR-09-220, a reissue of PAR-07-160, National Institute on Aging, in conjunction with other agencies, August 5, 2009).

D. "Innovations in Biomedical Computational Science and Technology Initiative (STTR [R41/R42])," (PAR-09-221, a reissue of PAR-07-161, National Institute on Aging, in conjunction with other agencies, August 5, 2009).


VII. Conferences:

32. UNIVERSITY OF WISCONSIN INSTITUTE ON AGING: "21st Annual Colloquium on Aging," (October 1, 2009, Madison, Wisconsin).


33. WORLD DEMOGRAPHIC AND AGEING FORUM: "World Ageing & Generations Congress 2009," (Sept. 3-5, 2009, University of St. Gallen).


34. EUROPEAN CENTRE FOR SOCIAL WELFARE POLICY AND RESEARCH: "Monitoring Long-Term Care for the Elderly," (Sept. 6-10, 2009; Jerusalem, Israel).


VIII. Websites of Interest:

35. US CENTER FOR MEDICARE AND MEDICAID SERVICES MEDICARE.GOV UPDATES: The following site was updated Jul. 30, 2009: "Nursing Home Compare", "Supplier Directory", and "Helpful Contact".




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