We summarize the Centers for Medicare and Medicaid Services' (CMS's) experience with disease management (DM) in fee-for-service Medicare. Since 1999, the CMS has conducted seven DM demonstrations involving some 300,000 beneficiaries in thirty-five programs. Programs include provider-based, third-party, and hybrid models. Reducing costs sufficient to cover program fees has proved particularly challenging. Final evaluations on twenty programs found three with evidence of quality improvement at or near budget-neutrality, net of fees. Interim monitoring covering at least twenty-one months on the remaining fifteen programs suggests that four are close to covering their fees. Characteristics of the traditional Medicare program present a challenge to these DM models.

The Centers for Medicare & Medicaid Services developed the Oncology Care Model as an episode-based payment model to encourage participating practitioners to provide higher-quality, better-coordinated care at a lower cost to the nearly three-quarter million fee-for-service Medicare beneficiaries with cancer who receive chemotherapy each year. Episode payment models can be complex. They combine into a single benchmark price all payments for services during an episode of illness, many of which may be delivered at different times by different providers in different locations. Policy and technical decisions include the definition of the episode, including its initiation, duration, and included services; the identification of beneficiaries included in the model; and beneficiary attribution to practitioners with overall responsibility for managing their care. In addition, the calculation and risk adjustment of benchmark episode prices for the bundle of services must reflect geographic cost variations and diverse patient populations, including varying disease subtypes, medical comorbidities, changes in standards of care over time, the adoption of expensive new drugs (especially in oncology), as well as diverse practice patterns. Other steps include timely monitoring and intervention as needed to avoid shifting the attribution of beneficiaries on the basis of their expected episode expenditures as well as to ensure the provision of necessary medical services and the development of a meaningful link to quality measurement and improvement through the episode-based payment methodology. The complex and diverse nature of oncology business relationships and the specific rules and requirements of Medicare payment systems for different types of providers intensify these issues. The Centers for Medicare & Medicaid Services believes that by sharing its approach to addressing these decisions and challenges, it may facilitate greater understanding of the model within the oncology community and provide insight to others considering the development of episode-based payment models in the commercial or government sectors.

Pedestrian injury is a significant health problem among urban children. This study is an analysis of the role of population, income, and ecological factors in the occurrence of child pedestrian collisions. One hundred and ninety-eight motor vehicle collisions occurring in Hartford, Connecticut involving pedestrians younger than 15 years old were reported to police during 1986 through 1987. Collision locations were abstracted from police reports and assigned a census tract. Census tracts were classified as "high frequency" (8+ collisions), "moderate frequency" (3 to 7 collisions), or "low frequency" (0 to 2 collisions). High-frequency census tracts had greater proportions of children and of nonwhite residents than moderate- or low-frequency tracts. They also were characterized by high proportions of households headed by females living below the poverty line. High-frequency tracts had a greater number of children per acre than moderate or low tracts. Children per acre had the strongest association with collision frequency (R = .72) and remained the most consistent when other variables were controlled. The number of children per acre is a potentially useful predictor of census tracts at risk for child pedestrian collisions. This may be useful in developing focused prevention strategies within an urban environment.