Posts Tagged ‘Centers for Medicare and Medicaid Services’

Which One Do You Like? Healthcare Insurance Exchanges or Marketplaces?

Wednesday, May 23rd, 2012

If a Medicare staff recommendation is okayed, health insurance exchanges may be re-named.  According to Kaiser Health News , that is because, Medicare officials say consumers understand words like “marketplace” better.  “We are recommending not using the word ‘exchange’” in enrollment materials, said Julie Bataille, director of the CMS Office of Communications.  While Bataille didn’t mention the preferred substitute, she dropped hints.  “Words like ‘marketplace’ resonate much more with the consumer and also tend to be something that is all inclusive,” Bataille said.

According to Bataille, “exchange” can have a number of different meanings to consumers, including the idea that they may have something to trade.  The Patient Protection and Affordable Care Act (ACA) requires the federal government to establish health insurance exchanges in states that refuse to create their own.  They are often described as online marketplaces similar to Travelocity.com or Amazon.com, where consumers can search for insurance policies that fit certain criteria.  Enrollment information will become available in the fall of 2013 and the exchanges — or whatever the ultimate name is – will start operating in 2014, unless the Supreme Court declares the law unconstitutional.

The word “exchange” appears 247 times in the ACA, while “marketplace” is not mentioned once, according to Kaiser Health News.  But that doesn’t mean officials are obligated to use it, said Brenda Cude, a professor of consumer economics at the University of Georgia and a consumer representative for the National Association of Insurance Commissioners.  “I don’t believe that Congress is any kind of expert on how to communicate with consumers,” she said.  But “marketplace” may not be a fool-proof alternative, Cude said.  She is concerned that comparing a health insurance exchange to a shopping website encourages the notion that the lowest price policy is the best choice.  That may be true when looking for a commodity like a cheap airfare to a single destination, but not for healthcare policies offering different benefits.

Bataille said the Medicare staff’s advice to avoid the term “exchange” is supported by external research and the agency’s focus group testing this year in Cleveland, Dallas, Miami, Philadelphia and Phoenix.  CMS “routinely” tests its materials and websites with consumers “to make sure we are serving our beneficiaries as well as possible,” Bataille said.  “So we see our work on the exchanges as an extension of that.”  According to Bataille, CMS will seek public comment on the enrollment materials before finally deciding whether to use the word “exchange” or “marketplace”.

CMS Chooses 27 Medicare Shared Savings Program ACOs

Wednesday, April 25th, 2012

As the nation waits for the Supreme Court to rule on the Patient Protection and Affordable Care Act (ACA), a key provision that will transform the delivery of healthcare is moving ahead.  According to Kaiser Health News, the Obama administration announced that 27 health systems have been designated as Accountable Care Organizations (ACOs) in Medicare’s Shared Savings Program, which offers financial incentives for physicians, hospitals and other healthcare providers to create more integrated healthcare delivery.  The new ACOs will serve an estimated 375,000 individuals in 18 states.

ACO supporters say they improve care for Medicare beneficiaries and slow rising costs by altering the incentives that affect how physicians and hospitals operate.  Experts cite as models such respected health systems as the Mayo Clinic and the Geisinger Health System of Pennsylvania.  Rather than being paid for each service, ACOs reward providers that manage chronic disease and meet certain quality standards, including reducing hospital admissions and emergency room visits.  If they improve care while holding down costs, the systems can share in the savings.

CMS is reviewing another 150 applications seeking to enter the program, suggesting that the Shared Savings Program is succeeding.  The program is “off to a very phenomenal start,” said Jonathan Blum, a CMS deputy administrator.  “We are on track to fundamentally transform the (Medicare) fee-for-service program.”

Late last year, the Department of Health and Human Services (HHS) chose 32 organizations to participate in an advanced version of the Medicare program.  These “pioneers” have made significant progress in developing the ACO model, with many already largely functioning as ACOs.  During their first two years the pioneers will assume more risk, but with a greater potential reward.  Although hospitals were expected to lead the ACO field, Blum noted that the majority of ACOs are physician-led organizations.  He also said many of the organizations are working with private health insurers to serve patients not in the Medicare program.

Chas Roades, chief research officer at the Advisory Board Company in Washington, D.C., warned that as the ACOS take off and “people actually start to deliver care in a different way, it’s messy and complicated.  There will be successes and failures, and it may go slower than policy-makers would like it to.”  According to Roades, it’s important that CMS create some way for the pioneer ACOs to share their data and best practices.  “It’s a slow ramp but everyone will be watching very closely to see how these early ACOs succeed,” Roades said.

Under the shared savings program, ACOs must meet 33 quality measures relating to care coordination and patient safety, appropriate preventive health services, improved care for at-risk populations and the patient experience of care – while reducing the costs of care.  ACOs that meet the standards will be eligible to share in the program’s savings.

“We are encouraged by this strong start and confident that by the end of this year, we will have a robust program in place, benefitting millions of seniors and people with disabilities across the country,” said CMS Acting Administrator Marilyn Tavenner.

Regarding the anticipated Supreme Court ruling, Emily Brower, an executive director with Atrius Health, operator of a pioneer ACO in Massachusetts, said “It’s not changing anything for us.  This is a model of care we’ve been trying to evolve into since before the pioneer program existed.  We’ll continue making investments, and if the law is overturned, we’ll be asking where the return on investment is for us, if not in shared savings.”

Writing for the e-Care Management blog, Vince Kuraitis is unimpressed.  “I had been anticipating this announcement as a defining moment for Medicare’s thrust into accountable care.  My expectations had been that we would see either:  Boom — a big splash of new Medicare shared savings ACOs announced, including big name hospitals and medical groups that were starting large scale ACOs, perhaps with hundreds of thousands of patients.  Bust — no one showed up at the party.  Providers would have concluded that Medicare ACOs were too risky, bureaucratic, and high effort.  This isn’t the defining moment I thought it would be.  But that defining moment might be just around the corner.  Medicare’s announcement included a mention that they have 150 more Shared Savings ACO applications waiting in the wings.  Is the boom around the corner?”

Medicare to Tie Physician Pay to Quality, Cost

Tuesday, April 24th, 2012

Approximately 20,000 physicians in four Midwest states recently had a sneak peak at their financial future. According to Kaiser Health News, they were e-mailed links to Medicare reports detailing the amount their patients cost on average as well as the quality of the care they provided.  Additionally, the reports showed how Medicare spending on each doctor’s patients compared to their peers in Kansas, Iowa, Missouri and Nebraska.

The so-called “resource use” reports, which Medicare eventually plans to distribute to doctors nationally, are one of the most visible phases of the government’s efforts to enact a complex and delicate although little-known proviso of the Patient Protection and Affordable Care Act (ACA): paying more to doctors who provide quality care at lower cost to Medicare, and cutting payments to physicians who add to Medicare’s costs without improved results.

Requiring providers to pay closer attention to cost and quality is seen as crucial if the nation is to succeed at controlling its healthcare spending — currently more than $2.5 trillion a year.  It’s also vital to Medicare’s solvency.  Efforts are already underway to transform the way Medicare pays hospitals, physicians and other providers who agree to work together in accountable care organizations.  This fall, Medicare – which covers 47 million seniors and disabled people — will fine-tune hospital reimbursements based on quality of care.  It plans to take cost into account as early as next year.

But applying these same precepts to doctors is much more difficult, experts agree. Doctors see far fewer patients than do hospitals, so making statistically accurate assessments of doctors’ care is much harder. Comparing specialists is tricky, since some focus on particular kinds of patients that tend to be more costly.  Properly assessing how a physician impacts costs must include not just the specific services provided, but also care other providers may give.

“It may be the most difficult measurement challenge in the whole world of value-based purchasing,” said Dr. Donald Berwick, the former administrator of the federal Centers for Medicare and Medicaid Services (CMS).  “We do have to be cautious in this case.  It could lead to levels of gaming and misunderstanding and incorrect signals to physicians that might not be best for everyone.”

Dr. Michael Kitchell, a neurologist and chairman of the McFarland Clinic in Ames, IA, predicted that the Medicare reports “will be a huge surprise to almost every physician.”  That’s because the calculations of how much those doctors’ patients cost Medicare not only include the services of the individual doctor but of all the physicians who provided any treatment to the patient.  Kitchell said his own patients typically saw 13 other physicians.  “You’re a victim or a beneficiary of your medical neighborhood,” Kitchell said.  “If the primary-care doctors are doing the preventative screening tests, you’ll get credit for that, but if you’re in a community where the community doctors are doing a poor job, you’re going to look bad.”

Medicare officials are attempting to improve the way they measure physicians as they follow the ACA’s directive to phase in the new payment system, called a Physician Value-Based Payment Modifier, which is scheduled to begin in 2015.  At first, it will apply solely to physician groups and some specialists selected by the government; by 2017, the payment change is intended to apply to most if not all doctors.  The assessment “is a very important change we’re putting into place, one where we’re going to need a lot of feedback and deliberation,” said Jonathan Blum, CMS’s deputy administrator. “We’re not blind to the challenges that are coming toward us.”  Although the program is still being worked out, it will become reality for many doctors in January, because CMS wants to base its 2015 bonuses or penalties on a doctor’s patients’ outcomes during 2013.

Private insurers may decide to use a formula similar to Medicare’s, said Paul Ginsburg, president of the Center for Studying Health System Change.  Medicare’s ultimate method of judging and paying physicians could become “a valuable asset for private insurers, with a tool that will be somewhat bulletproof, that physicians won’t attack because they’ve been part of the process of developing them.”

Getting physician support might not be a peace of cake, said Margaret O’Kane, president of the National Committee for Quality Assurance.  “Doctors are a very powerful political segment,” she said. Additionally, “Patients are not behind this agenda.  The public is very scared about managing costs.”

Dana Gelb Safran, who measures quality for Blue Cross Blue Shield of Massachusetts, doubts it will be possible for the government to judge individual doctors.  “There really are very few measures that we can reliably evaluate on the individual doctor level,” she said.  “When they move forward with the value-based modifier, there is going to have to be a way to allow physicians to identify other physicians with whom they say they practice and who they say they share clinical risk for performance.”

CMS Chooses 27 Medicare Shared Savings Program ACOs

Wednesday, April 18th, 2012

As the nation waits for the Supreme Court to rule on the Patient Protection and Affordable Care Act (ACA), a key provision that will transform the delivery of healthcare is moving ahead.  According to Kaiser Health News, the Obama administration announced that 27 health systems have been designated as Accountable Care Organizations (ACOs) in Medicare’s Shared Savings Program, which offers financial incentives for physicians, hospitals and other healthcare providers to create more integrated healthcare delivery.  The new ACOs will serve an estimated 375,000 individuals in 18 states.

ACO supporters say they improve care for Medicare beneficiaries and slow rising costs by altering the incentives that affect how physicians and hospitals operate.  Experts cite as models such respected health systems as the Mayo Clinic and the Geisinger Health System of Pennsylvania.  Rather than being paid for each service, ACOs reward providers that manage chronic disease and meet certain quality standards, including reducing hospital admissions and emergency room visits.  If they improve care while holding down costs, the systems can share in the savings.

CMS is reviewing another 150 applications seeking to enter the program, suggesting that the Shared Savings Program is succeeding.  The program is “off to a very phenomenal start,” said Jonathan Blum, a CMS deputy administrator.  “We are on track to fundamentally transform the (Medicare) fee-for-service program.”

Late last year, the Department of Health and Human Services (HHS) chose 32 organizations to participate in an advanced version of the Medicare program.  These “pioneers” have made significant progress in developing the ACO model, with many already largely functioning as ACOs.  During their first two years the pioneers will assume more risk, but with a greater potential reward.  Although hospitals were expected to lead the ACO field, Blum noted that the majority of ACOs are physician-led organizations.  He also said many of the organizations are working with private health insurers to serve patients not in the Medicare program.

Chas Roades, chief research officer at the Advisory Board Company in Washington, D.C., warned that as the ACOS take off and “people actually start to deliver care in a different way, it’s messy and complicated.  There will be successes and failures, and it may go slower than policy-makers would like it to.”  According to Roades, it’s important that CMS create some way for the pioneer ACOs to share their data and best practices.  “It’s a slow ramp but everyone will be watching very closely to see how these early ACOs succeed,” Roades said.

Under the shared savings program, ACOs must meet 33 quality measures relating to care coordination and patient safety, appropriate preventive health services, improved care for at-risk populations and the patient experience of care – while reducing the costs of care.  ACOs that meet the standards will be eligible to share in the program’s savings.

“We are encouraged by this strong start and confident that by the end of this year, we will have a robust program in place, benefitting millions of seniors and people with disabilities across the country,” said CMS Acting Administrator Marilyn Tavenner.

Regarding the anticipated Supreme Court ruling, Emily Brower, an executive director with Atrius Health, operator of a pioneer ACO in Massachusetts, said “It’s not changing anything for us.  This is a model of care we’ve been trying to evolve into since before the pioneer program existed.  We’ll continue making investments, and if the law is overturned, we’ll be asking where the return on investment is for us, if not in shared savings.”

Writing for the e-Care Management blog, Vince Kuraitis is unimpressed.  “I had been anticipating this announcement as a defining moment for Medicare’s thrust into accountable care.  My expectations had been that we would see either:  Boom — a big splash of new Medicare shared savings ACOs announced, including big name hospitals and medical groups that were starting large scale ACOs, perhaps with hundreds of thousands of patients.  Bust — no one showed up at the party.  Providers would have concluded that Medicare ACOs were too risky, bureaucratic, and high effort.  This isn’t the defining moment I thought it would be.  But that defining moment might be just around the corner.  Medicare’s announcement included a mention that they have 150 more Shared Savings ACO applications waiting in the wings.  Is the boom around the corner?”

HHS Issues New Rules on Healthcare Insurance Exchanges

Wednesday, April 4th, 2012

The Department of Health and Human Services (HHS) has issued its final rule aimed at implementing state health insurance exchange provisions of the federal healthcare law.  The rule becomes effective 60 days after it is published in the Federal Register.  The regulation outlines details of the exchanges, which are scheduled to launch on January 1, 2014, and offer insurance plan options for individuals and small businesses, as well as federal subsidies for premiums.

The final rule outlines the minimum standards states must meet in establishing and operating their exchanges, such as individual and employer eligibility for enrollment.  The rule also outlines minimum standards that health insurers must meet to participate in an exchange and the standards employers must meet to participate in the exchange.  The regulation offers states “substantial discretion” in how to design and operate their exchanges.  HHS will accept comment on nine sections of the exchange rule, including provisions regarding the ability of a state to allow agents and brokers to assist qualified individuals in applying for advance payments of the premium tax credit and cost-sharing reductions for qualified health plans; Medicaid and CHIP regulations; options for conducting eligibility determinations; and verification for applicants.  This final rule does not address all of the insurance exchange provisions of the Patient Protection and Affordable Care Act (ACA).

“These policies give states the flexibility they need to design an exchange that works for them,” said HHS Secretary Kathleen Sebelius. “These new marketplaces will offer Americans one-stop shopping for health insurance, where insurers will compete for your business.  More competition will drive down costs and Exchanges will give individuals and small businesses the same purchasing power big businesses have today.”

Among the regulations are a guide to set standards for establishing exchanges; setting up a Small Business Health Options Program (SHOP); performing the basic functions of the exchange; and certifying health plans for participation in the exchange; as well as setting up a streamlined, web-based system for consumers to apply for and enroll in qualified health plans and insurance affordability programs.  The announcement is the culmination of more than two years’ work with states, small businesses, consumers, and health insurance plans.  The administration examined models of exchanges; convened numerous meetings and regional listening sessions across the country with stakeholders; and consulted closely with state leaders, consumer advocates, employers and insurers.  To finalize the rules, HHS accepted public comment to learn from states, consumers, and other stakeholders on how to improve the rules; HHS adapted the proposals based on feedback from the American people.

Unfortunately, many state lawmakers are hesitant to move forward with creating the exchanges until the Supreme Court has ruled on the ACA’s constitutionality, according to Joy Johnson Wilson, federal affairs counsel and health policy director at the National Conference of State Legislatures.  “It’s fair to say that legislation has kind of slowed,” Johnson Wilson said, noting that many lawmakers are taking a “wait-and-see approach” in anticipation of the high court’s oral arguments this month.  Legislators do not want to make plans that have to be revisited and revised, Johnson Wilson said.

Despite the ambivalence of some states, they will be given great flexibility in setting up the exchanges. The concept is the eligibility for determining the premium tax credit is going to be done by the exchange…but also in the state-based exchange to allow — whether it’s a web-based broker or a small-business broker or agent — to interact with the exchange in an automated way,” Tim Hill, deputy director in the Centers for Medicare and Medicaid Services insurance-regulation office, said.

“Those are all relationships that are regulated on the state level…to determine the fee structure for how agents or brokers can be compensated for bringing business to the exchange,” Hill said.  “That’s something we’re going to leave to the state.”  Hill said allowing third-party companies or brokers access the exchanges will help inform people about the insurance exchanges.  “There are lots of folks out there who can generate interest and marketing…it’s a source of leverage that we want to leverage if the states choose to,” Hill said.

Writing on The Hill’s Healthwatch blog, Julian Pecquet notes that “States will have ‘substantial flexibility’ to operate a key provision of President Obama’s healthcare reform law.  The long-awaited final rules expand states’ ability to craft insurance marketplaces that meet their residents’ needs.  This includes allowing states to structure their health insurance exchange in a variety of ways — for example, as a nonprofit entity established by the state, as an independent public agency or as part of an existing state agency.  The final rules also offer each state more time to set up its exchange.  The law requires states to ‘demonstrate complete readiness’ to guarantee they’ll be operational 12 months later.  If states don’t meet the deadline, a federal exchange will take over.  The final rule, however, allows for ‘conditional approval’ if a state is ‘advanced in its preparation’ by January 1, 2013.  In addition, states that aren’t deemed ready for 2014 can apply to operate their own exchange in 2015 or any subsequent year.  ‘HHS may conditionally approve a state-based exchange upon demonstration that it is likely to be fully operationally ready by October 1, 2013, which provides States with flexibility in meeting exchange development timelines,’ according to the regulation.  ‘HHS will provide additional details in future guidance.’”

ACA’s Future Unclear As It Celebrates Its 2nd Birthday

Tuesday, April 3rd, 2012

As the Patient Protection and Affordable Care Act (ACA) celebrates its second birthday, the Obama administration reminded senior citizens – one of the most reliable voter blocs — exactly how much healthcare reform has helped them.  Coverage of the “donut hole” in prescription drug plans saved five million seniors and disabled people $3.2 billion.  According to data from the Centers for Medicare and Medicaid Services (CMS), through the first two months of 2012, roughly 103,000 Americans saved $93 million in the donut hole.  “Without the healthcare law, more than 5.1 million seniors would have faced $3.2 billion in higher drug costs,” Health and Human Services Secretary Kathleen Sebelius said.  The donut hole is a gap in coverage for prescription drugs under what is called Medicare Part D.  Part D covers 75 percent of the cost of prescription drugs until total medication spending for the patient hits $2,800.  Then the hole opens, and seniors must pay out of pocket until they have spent $4,550.  After that, Medicare pays about 95 percent of drug costs.

The ACA sent all seniors who hit the prescription drug donut hole a one-time $250 check.  In 2011 and 2012, seniors in the donut hole receive a 50 percent discount on brand-name drugs.  Additionally seniors covered by traditional Medicare received wellness check-ups and screenings for diseases like cancer and diabetes without paying anything out of pocket.  Under the law, the donut hole phases out in 2020.

The seniors’ lobby AARP launched its largest-ever outreach effort with ads and town-hall meetings aimed at defending Medicare and Social Security.  “We’re not leaving it up to chance” that the public hears about the law’s benefits, congressional Seniors Task Force co-chairwoman Jan Schakowsky (D-Ill.) said.  Democrats, Schakowsky said, have made it a “primary organization effort”…”to tell the truth (about the law) over the next several months.”

Writing in The Hill, Julian Pecquet says that “Democrats see the Ryan budget, which is expected to propose replacing Medicare with subsidies for people to buy insurance, as political gold ahead of the November election.  Republicans for their part will spend the week hammering the law’s ‘broken promises’ — higher premiums, employers dropping coverage and the soaring cost of insurance subsidies when compared to the earlier budget window Democrats highlighted when they were debating the law two years ago.  They’re also arguing that the healthcare law hastens Medicare’s insolvency by removing $500 billion from the program to pay for what they call an unsustainable new entitlements.”

In terms of implementing the law to meet the 2014 deadline, the ACA leaves it up to the states to set up health insurance exchanges.  In states that refuse to do that, HHS has the authority to create a federal exchange as a backup — but it could be stretched thin if it has to cover too many states.  At the moment, a number of states are not making plans and the federal exchange could end up covering as many as 15 to 25 states.

Other states are biding their time depending on the outcome of the Supreme Court case — and the elections — to decide what to do next.  There’s an excellent possibility that many of them won’t be far enough along by January of 2013, when HHS has to either certify the states’ exchanges or prepare to run a federal exchange in those states.  HHS has already extended the deadline for states to apply for the grants that will help them run exchanges.  And it’s taking other steps to help states that won’t be ready in time.  But if a lot of states refuse to create the exchanges –and more time won’t help them — HHS will be forced to act.

White House spokesman Jay Carney told reporters that President Obama is looking beyond past battles. “He is focused on a forward agenda right now, and working with Congress and doing the things he can through executive action to grow the economy and create jobs,” Carney said.

Republican leaders, who once accused the president of focusing too much on healthcare and not enough on jobs, now say the White House is moving away from the ACA because of uncertainty over whether or not its individual mandate is constitutional.  In terms of the upcoming Supreme Court oral arguments, Senator Roy Blunt (R-MO) said “I think we’ll win in the end.  Now the question is how long is it until the end.  There’s no question that the president’s plan will not work.”

A differing opinion was offered by Democratic Caucus Vice-Chairman Xavier Becerra (D-CA).  “I think as time goes by more and more people are beginning to support the reform because it starts to apply to them.  The more people see what the ACA does, the more they’re going to like it.”

CMS’ Value-Based Purchasing Program Is In the Works

Wednesday, March 28th, 2012

The Department of Health and Human Services (HHS) is formulating a new initiative to reward hospitals for the quality of care they provide to Medicare patients and reduce healthcare costs.  Authorized by the Patient Protection and Affordable Care Act (ACA), the Hospital Value-Based Purchasing program marks an historic change in how Medicare pays healthcare providers and facilities — for the first time, 3,500 hospitals nationwide will be paid for inpatient acute-care services based on care quality, not just the quantity of the services they provide.

This initiative supports the objectives of the Partnership for Patients, a public-private partnership that will help improve the quality, safety and affordability of health care for all Americans.  The partnership has the potential to save 60,000 lives and up to $35 billion in U.S. healthcare costs over the next three years, including up to $10 billion for Medicare.  Over the next ten years, the Partnership for Patients could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.

“Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us,” said HHS Secretary Kathleen Sebelius.  “Under this initiative, Medicare will reward hospitals that provide high-quality care and keep their patients healthy. It’s an important part of our work to improve the health of our nation and drive down costs.  As hospitals work to improve their performance on these measures, all patients – not just Medicare patients – will benefit.”

The Hospital Value-Based Purchasing initiative is just one part of a broad effort by the Obama Administration to improve the quality of health care for all Americans, using important new tools provided by the ACA.  The Partnership for Patients brings together hospitals, doctors, nurses, pharmacists, employers, unions, and state and federal government committed to keeping patients from getting injured or sicker in the health care system and improving transitions between care settings.  The Centers for Medicare and Medicaid Services (CMS) is investing up to $1 billion to drive these changes.  Additionally, proposed rules allowing Medicare to pay new Accountable Care Organizations (ACOs) to improve coordination of patient care are also expected to result in better care and lower costs.

In essence, the program rewards hospitals that perform well on quality measures relating both to clinical process of care and to patient experience of care, or those making improvements in their performance on those measures.  Hospitals that meet performance criteria will receive higher compensation.  The hospital value-based purchasing program, which is expected to become effective in fiscal 2013 for payments for discharges occurring on or after October 1, 2012, would make value-based incentive payments based on how much the hospitals’ performance improves certain quality measures during a baseline timeframe.  The better a hospital’s performance or improvement during the performance period, the higher the hospital’s value-based incentive payment would be, according to CMS.

According to CMS estimates, approximately 50 percent of the facilities participating in this Hospital Inpatient Value-Based Purchasing program will receive a net increase in their Medicare payments.  The other half will see a net decrease.  Neither the increase nor the decrease will exceed one percent in the first year, CMS said.  The better-performing hospitals in the first year have the potential to receive value-based incentive payments totaling as much as two percent of Medicare reimbursement, or a net one percent extra,  CMS sees the program as “the next step in promoting higher quality care for Medicare beneficiaries.”  When the program gets underway, CMS said, the government will reward hospitals on the basis of “actual quality performance,” and not just data.

Jean Moody-Williams, director of the Quality Improvement Group within CMS’ Office of Clinical Standards and Quality, said the Hospital VBP Program is funded by a one percent withholding from participating hospitals’ diagnosis-related group (DRG) payments; hospitals excluded from the program will not have that one percent withheld from their DRG payments.  “The goal of CMS through the Hospital Value-Based Purchasing Program is to link payments to quality outcomes,” Williams said.  “We really are starting to get away from asking, ‘How much did you do?’ to ‘How well did you do and how was it for the patient?'”

The American Hospital Association (AHA) has serious reservations about the program, noting that “CMS has not met its requirements with respect to certain measures.  This failure will unfairly and adversely impact the hospital field and even undermine the intent of the law, which is to provide opportunities for hospitals to improve their performance.”

According to the AHA, the problem “is exacerbated in the outpatient PPS (prospective payment system) rulemaking cycle because it builds on policies that fail to comply with the law’s requirements.” AHA also expressed concern with how the agency handled the notice and comment process for the hospital VBP program, which “made significant changes to this program in three separate regulations,” and suggested that the agency choose a single regulation in which it will make any future changes to the program.

Mitt Romney Says “No” to Medicare on His 65th Birthday

Monday, March 19th, 2012

Even though he just celebrated his 65th birthday, GOP presidential hopeful Mitt Romney isn’t signing up for Medicare or Social Security.  According to an aide, Romney plans to keep his private health insurance plan although there is no word on whether he accessed that plan through a former employer or bought it on the individual market.  Ironically, if elected, Romney wants to offer senior citizens the choice of enrolling in the traditional program or purchasing private insurance with some financial help from the government.

Romney’s decision puts him in a tiny minority. The vast majority of seniors participate in Medicare.  Nearly all seniors are automatically enrolled in Medicare Part A, which covers hospital care, although they can opt not to use it.  Another 95 percent enroll in Medicare Part B, which covers physician services, according to the Kaiser Family Foundation.

“It was personally meaningful in me to be enrolling in the program I ran.  It made me feel one step closer to the beneficiaries,” Dr. Donald Berwick, who left his post at the Centers for Medicare and Medicaid Services (CMS) at the end of 2011, said.  “It validated what I had thought — which was that it was remarkably easy [to sign up].  Any president, at any age, should be committed to these important programs,” Berwick said.

By contrast, two of Romney’s competitors — Newt Gingrich and Ron Paul — are already 65, the age at which most Americans become eligible to enroll in Medicare’s coverage of hospital treatment, physician visits and other medical care, including prescription drugs.  Gingrich has a Medicare Advantage plan, administered by Blue Cross Blue Shield, according to his campaign.  Medicare Advantage plans are run by private insurance companies, who receive a fixed monthly payment from the federal government.  Gingrich frequently plugs Medicare Advantage and wants to expand the proportion of seniors who enroll in it from the current 25 percent.  Congressman Paul has a federal government-sponsored Blue Cross Blue Shield employee health insurance plan.  He has said that he would not change any aspect of Medicare for current beneficiaries but would let younger people opt out of the program and use medical savings accounts or other ways to pay their own healthcare costs.

According to NPR’s Julie Rovner, “Romney is clearly making a political point.  Wealthy people like him ought to pay more for their Medicare benefits (if they get them at all) and that perhaps 65 is a little young to qualify, too.  ‘Wealthier seniors will receive less support,’ under the changes Romney has proposed for Medicare, according to his website. http://www.mittromney.com/issues/medicare At the same time, he is proposing to ‘gradually raise the retirement age to reflect increases in longevity.’  But could his political point cost him more down the road if he changes his mind?  Maybe.  Medicare charges penalties for those who wait to sign up.  It’s the program’s way of ensuring that people don’t wait until they get sick to enroll.”

Beneficiaries currently have a seven-month window to sign up for Medicare: three months before their birth month, the month of their birthday, and three months after their birthday.  That means that Romney has through June to enroll if he changes his mind.  The majority of adults use the Social Security Administration website to enroll for their benefits, while others go to local district offices.

Writing for the Huffington Post, Ethan Rome, Executive Director of Health Care for America Now, says that “I’m not sure what Romney’s trying to prove, but what his action says is clear: I’m not like the Americans who enroll in Medicare.  I’m special.  I’m rich.  I’m better than you.  Ask yourself: If Romney doesn’t need or want Medicare for himself, will he protect it for the rest of us who do?  Of course not.  Instead, he’ll continue to support the Republican plan to eliminate Medicare as we know it.  He’ll work to turn Medicare into a voucher program that will saddle seniors with thousands of dollars in out-of-pocket health care costs.  Because, after all, what senior can’t afford to spend an extra $6,400 a year on doctors and hospitals?  Before Medicare, seniors were left at the mercy of the private market and therefore virtually uninsurable.  Without insurance, even brief hospital stays could impoverish them.  The result was that the elderly went without the care they needed — unless their families were rich.  Most seniors were one illness away from bankruptcy.”

EHR Adoption Moving Forward

Wednesday, March 14th, 2012

The nation’s hospitals must demonstrate that they have collected the vital statistics of more than 80 percent of their patients in digital form if they want to continue receiving as much as $14.6 billion in federal grants for installing electronic health records (EHR) technology.  Awards as large as $11.5 million are available to hospitals that can prove “meaningful use” of the equipment, under preliminary rules issued by the Obama administration.  Physicians can apply for grants of $44,000 or $64,000, depending on whether they treat patients in Medicare or Medicaid.

The rules continue carrying out an initiative in the American Recovery and Reinvestment Act (ARRA) as a step toward overhauling the nation’s healthcare system, specifically in the Health Information Technology for Economic and Clinical Health (HITECH) Act.  Hospitals and doctors should achieve “substantial benefits” from adopting digital records, including lower record-keeping costs, fewer pointless tests, shorter hospital stays and reduced medical errors.

The percentage of U.S. hospitals that have adopted electronic records more than doubled between 2009 and 2011, to 35 percent, according to the American Hospital Association.  Approximately 85 percent of hospitals told the association that they plan to take advantage of government incentives by 2015.  The government expects that by 2019, 96 percent of hospitals will adopt electronic records and at least 36 percent of doctors’ practices.

In this second stage of adoption of EHR, the government is emphasizing making sure that electronic systems can talk to one another – or are “interoperable.”  According to Kaiser Health News, it’s “a real push ahead,” said Farzad Mostashari, the national coordinator for health information technology.  The rules require systems be able to transfer patient information across platforms.  A “summary of care” — including past diagnoses, procedures and test results – must be able to follow patients across referrals and changes in health care provider.  Additionally, the information should be available to some patients, who under Stage 2 requirements must be allowed to view their records online, as well as download and transfer information.  Finally, some patients must be able to communicate with their doctors through a secure, online system.

According to a survey of 302 hospital IT executives, more than one-quarter said they had already proven to the Centers for Medicare and Medicaid Services (CMS) that they have met the government’s standard for the first stage of meaningful use of health IT.  That means they have demonstrated that they have the baseline capabilities in their CMS-approved health IT system to collect and submit data.  Stage 2 also deals with security of exchanging patient information electronically, particularly the risk of a doctor mistakenly leaving his laptop or iPad accessible to the public.  “A huge, huge, huge portion of all breaches don’t occur because someone hacked into the system; they occur because people left their laptop on the train and they didn’t encrypt it,” Mostashari said.

Writing on the practicefusion.com website, Robert Rowley, M.D., says that “Stage 2 is about connectivity.  So let us take a step back and re-assess the larger picture.  Stage 1 Meaningful Use is about adoption of EHRs into the daily practice of clinicians and hospitals.  It is about moving the documentation of healthcare away from paper, and onto a digital platform.  The platform didn’t really have to connect with anything, though the capability to connect needs to be built for the technology to be Certified.  Stage 2 is about connectivity.  Now that EHRs are adopted, implemented and used meaningfully, the next stage is intended to be about connecting the silos together.  Stage 3, to come later, will be about inserting Decision Support between the connections, so that best practices (as well as authorizations) become part of the daily fabric of healthcare.”

A little-known fact is that EHR adoption is having a positive impact on healthcare IT job creation.  According to job resource Medzilla, an estimated 50,000 new jobs have been created in the health IT field since 2009, when the government passed the HITECH Act, which authorized funding for the EHR incentive program.  “The statistics over the past few months have been more than encouraging,” said Del Johnson, director of client relations at Medzilla.  “Here you have two, previously separate industries that are rapidly growing into one another.  Where the two meet you have an opportunity to explore a completely new labor pool.”

Hospitals, CMS Butt Heads Over Too Many Readmissions

Tuesday, February 14th, 2012

Medicare has plans to penalize hospitals that frequently readmit patients who really don’t need hospitalization. According to one estimate, this practice costs the federal government $12 billion every year.  Medicare’s goal is to persuade hospitals to be certain that patients get the care they need following their discharge.  This new policy is likely to excessively impact hospitals, particularly those that treat low-income patients, according to a Kaiser Health News analysis of data provided by the Centers for Medicare & Medicaid Services.  Hospitals that admitted the most underprivileged Medicare patients were approximately 60 percent as likely to have significantly higher readmission rates for heart failure.  At these hospitals, lower-income people comprise a larger share of the patients than they do at 80 percent of hospitals.

“When some of our patients get home, their lights and gas are shut off,” said Roland Abellera, vice president of quality and corporate compliance at St. Bernard Hospital in Chicago’s blighted Englewood neighborhood.  “So what ends up happening is that the ambulance brings them back to us and we have to house them until our staff can help them get the utilities turned on.  We have a community in need.”

Within 30 days of discharge, 25 percent of Medicare patients with heart failure are readmitted to the hospital.  The Patient Protection and Affordable Care Act (ACA) has ruled that beginning next October, Medicare will fine hospitals whose patients who have had heart attacks, heart failure or pneumonia return to the hospital too soon.  By 2014, hospitals with high readmission rates can potentially lose up to three percent of their Medicare reimbursements.

Medicare has set aside funds so hospitals can more effectively plan patients’ post-discharge care.  According to Patrick Conway, Medicare’s chief medical officer, some funds will be targeted to hospitals that serve significant numbers of poorer people.  “We especially are concerned about safety-net hospitals that take care of a high portion of patients in poverty and racial and ethnic minorities,” he said.  At the same time, his agency is committed to the readmission penalties, in part because it is the law and because it believes the penalties will persuade hospitals to be certain that patients get the follow-up care they need.

Some hospital administrators are concerned that the new policy is too harsh.  “In essence, they are penalizing those hospitals and areas that need the most help and the most money to address these issues because we have the sickest, most noncompliant and vulnerable patient population,” said Guy Alton, chief financial officer at St. Bernard.  According to Abellera, St. Bernard’s heart failure patients usually have more than one serious conditions, such as kidney failure, hypertension and diabetes.  “A patient does not come here for heart failure alone,” he said.  “They have no less than six or seven diagnoses — we’ve had many with more than that.”

Dr. Ashish Jha, in the latest New England Journal of Medicine, makes the case that readmissions aren’t the best gauge of unnecessary care — even though they’re a natural target for budget-cutters.  The Harvard University professor points out that many hospitals with the highest readmission rates serve the poorest areas with the biggest health problems.  “Readmissions are caused by what hospitals do, who the patients are, and what’s happening in the community,” he says. “You want hospitals to fix the things they can, but you don’t want to punish them for taking care of poor people, and you don’t want to punish them for being located in a poor area.”

Two of the most frequent reasons for hospital readmissions are medication errors and failure to see a physician – both of which could be reduced if patients were supervised through home care visits following discharge.