Tag Archives: CMS

As ACA enrollment nears, administration keeps cutting federal support of the law

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , • Leave a comment

https://www.washingtonpost.com/politics/as-aca-enrollment-nears-administration-keeps-cutting-federal-support-of-the-law/2017/10/05/cc5995a2-a50e-11e7-b14f-f41773cd5a14_story.html?utm_term=.b9039864660d

Image result for sabotaging ACA

 

For months, officials in Republican-controlled Iowa had sought federal permission to revitalize their ailing health-insurance marketplace. Then President Trump read about the request in a newspaper story and called the federal director weighing the application.

Trump’s message in late August was clear, according to individuals who spoke on the condition of anonymity to discuss private conversations: Tell Iowa no.

Supporters of the Affordable Care Act see the president’s opposition even to changes sought by conservative states as part of a broader campaign by his administration to undermine the 2010 health-care law. In addition to trying to cut funding for the ACA, the Trump administration also is hampering state efforts to control premiums. In the case of Iowa, that involved a highly unusual intervention by the president himself.

And with the fifth enrollment season set to begin Nov. 1, advocates say the Health and Human Services Department has done more to suppress the number of people signing up than to boost it. HHS has slashed grants to groups that help consumers get insurance coverage, for example. It also has cut the enrollment period in half, reduced the advertising budget by 90 percent and announced an outage schedule that would make the HealthCare.gov website less available than last year.

The White House also has yet to commit to funding the cost-sharing reductions that help about 7 million lower-income Americans afford out-of-pocket expenses on their ACA health plans. Trump has regularly threatened to block them and, according to an administration official who was not authorized to speak publicly, officials are considering action to end the payments in November.

The uncertainty has driven premium prices much higher for 2018. A possible move by the Treasury Department to ease the requirement that most Americans obtain coverage could further erode a core element of the law.

On Friday, Sen. Margaret Wood Hassan (D-N.H.) called on the administration to abandon its “attempts to sabotage health care markets and raise health care costs for millions.” Such efforts, warn health advocates as well as state and local officials, will translate into more uninsured Americans.

“In Ohio, the Trump administration has already inflicted the damage,” said Lisa Hamler-Fugitt, executive director of the Ohio Association of Foodbanks. After its nearly $1.7 million enrollment-assistance grant was cut 72 percent last month, the group decided it no longer could effectively participate. “We are past the point of no return on this,” Hamler-Fugitt said.

HHS has told its regional administrators not to even meet with on-the-ground organizations about enrollment. The late decision, which department spokesman Matt Lloyd said was made because such groups organize and implement events “with their own agenda,” left leaders of grass-roots organizations feeling stranded.

“I don’t think it’s too much to ask the agency tasked with outreach and enrollment to be involved with that,” said Roy Mitchell, executive director for the Mississippi Health Advocacy Program, which receives no federal funding for its ACA efforts. “There’s money for HHS to fly around on private jets, but there’s not money and resources to do outreach in Mississippi.”

Administration officials make no apologies for actions scaling back federal support for the ACA, also known as Obamacare. Trump, Vice President Pence and those carrying out the law at different agencies take most every opportunity to claim that it is failing. HHS Secretary Tom Price’s abrupt resignation Friday, prompted by the furor over his use of expensive chartered planes for work trips, is not expected to shift this overall approach.

After failing to repeal and replace the Affordable Care Act, Republican leaders said it will “implode.” Health-care experts disagree, saying the ACA is stable under current law — but President Trump and congressional Republicans could change that. (Daron Taylor/The Washington Post)

“Obamacare has never lived up to enrollment expectations despite the previous administration’s best efforts,” Lloyd said in an email last week. “The American people know a bad deal when they see one, and many won’t be convinced to sign up for ‘Washington-knows-best’ health coverage that they can’t afford.”

Trump and his aides also are looking for ways to loosen the existing law’s requirements, now that the latest congressional attempt to repeal it outright has failed. The Treasury Department may broaden the ACA’s “hardship exemption” so that taxpayers don’t face costly penalties for failing to obtain coverage, a Republican briefed on the plan said. That is sure to depress enrollment among the younger, healthier consumers whom insurers count on to help buffer the health-care costs of sicker customers.

“We should fully expect the Trump administration to take a more activist route to deal with Obamacare, given the inability of Congress to move through with a repeal-and-replace bill,” said Lanhee Chen, a research fellow at Stanford University’s Hoover Institution.

While the law’s open enrollment period has attracted the most public attention, a more obscure battle within the administration over several states’ proposed changes for their marketplaces speaks volumes about the president’s approach to the law.

It was a Wall Street Journal article about Iowa’s request that provoked Trump’s ire, according to an individual briefed on the exchange. The story detailed how officials had just submitted the application for a Section 1332 waiver — a provision that allows states to adjust how they are implementing the ACA as long as they can prove it would not translate into lost or less-affordable coverage.

Iowa’s aim was to foster more competition and better prices. The story said other states hoping to stabilize their situations were watching closely.

Trump first tried to reach Price, the individual recounted, but the secretary was traveling in Asia and unavailable. The president then called Seema Verma, administrator of the Centers for Medicare and Medicaid Services, the agency charged with authorizing or rejecting Section 1332 applications. CMS had been working closely with Iowa as it fine-tuned its submission.

State Insurance Commissioner Doug Ommen has repeatedly described the “Iowa Stopgap Measure” as critical to expanding marketplace options there. The plan would abolish the ACA exchange there and convert consumer subsidies into a type of GOP-styled tax credit. New financial buffers would help insurers handle customers with particularly high medical expenses.

Without the measure, “over 20,000 middle class farmers, early retirees and self-employed Iowans will likely either go uninsured or leave Iowa,” Ommen warned in a Sept. 19 statement. Those who sign up for 2018 exchange coverage face premium rate increases of 57 percent on average from the single insurer participating.

Some administration officials are still pressing for the waiver to be granted, according to interviews with several Republicans. The HHS spokesman confirmed last week that Iowa’s application “has been deemed complete and is currently under review” but did not address the president’s directive on the matter.

Eliot Fishman oversaw such waivers at CMS during the previous administration and said in an interview that President Barack Obama weighed in on those decisions only in “unusual” cases” toward the end of the process.

“Things that are tough calls typically go to the president, but they go with a [staff] recommendation that often carries a great deal of weight,” said Fishman, now senior director of health policy for the liberal health-care advocacy group Families USA.

Iowa is not the only red state to chafe at the administration’s unwillingness to allow more flexibility.

On Friday, Oklahoma sent a letter to Price and Treasury Secretary Steven Mnuchin saying it was withdrawing its federal waiver request because administration officials had not provided an answer “after months of development, negotiation, and near daily communication over the past six weeks.”

“While we appreciate the work of your staff, the lack of timely waiver approval will prevent thousands of Oklahomans from realizing the benefits of significantly lower insurance premiums in 2018,” wrote Terry Cline, the state’s health secretary.

In at least one case, CMS has approved a waiver in a way that upended a state’s plan to maximize health coverage for its residents. Minnesota applied to CMS for permission to establish a reinsurance program, which can lower premiums by giving insurers a guarantee that they will have limited financial exposure for customers with particularly high medical expenses. The agency informed Gov. Mark Dayton (D) on Sept. 22 that it would provide $323 million for the program since the lower premiums would mean savings to the federal government on subsidies to Minnesotans with ACA health plans.

But, Verma added, the federal government also would cut $369 million in funding for a separate program aimed at residents who earn between 138 percent and 200 percent of the federal poverty level and don’t qualify for the same subsidies.

Minnesota’s entire congressional delegation, Democrats and Republicans alike, issued a joint statement saying they were “disappointed that our state is facing a last-minute penalty” and “exploring possible paths forward.”

Sen. Patty Murray (Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee, said Trump should devote time to forging a bipartisan agreement to stabilize the ACA marketplaces.

“If he is only interested in sabotaging the market, that is a dangerous road for him to ride, because he will own it,” she said.

Gene therapies save lives, but how to pay for them?

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

http://www.sandiegouniontribune.com/business/biotech/sd-me-drug-price-20171005-story.html

Image result for gene therapy

 

Stem cell and gene therapies for cancer and other diseases used to be considered exotic. But stunning successes are fast moving them into the medical mainstream.

While only a few of these therapies have yet been approved, many more are being tested experimentally. In addition to treating otherwise fatal cancers, they may relieve sickle cell disease, restore failing hearts and even cure HIV infection.

And with mainstream success comes a mainstream worry: How will patients pay for these expensive treatments? Or to look at it another way, how much is it worth to save a life?

Drug company representatives discussed these issues Wednesday at Cell & Gene Meeting on the Mesa, an annual event in La Jolla devoted to stem cell and gene therapy.

At the end of August, drug giant Novartis marked a milestone by receiving U.S. approval for a blood cancer treatment made from the patient’s own genetically modified immune cells. The treatment, Kymriah, has rescued children and young adults who were gravely ill with acute lymphoblastic leukemia and placed them into remission.

Kymriah costs $475,000. But Novartis made an unusual guarantee: If patients don’t respond in a month, the company won’t charge for it.

However, these arrangements, like the therapies themselves, are so new that federal regulators are hesitant, said Pascal Touchon, a senior vice president with Novartis Oncology.

“The system is not organized for that,” Touchon said at a morning panel. “So when you ask for the first time whether we can do that, the answer is no. That’s the starting point.”

Novartis eventually reached agreement with the Centers for Medicare and Medicaid Services, or CMS.

The challenge now is to make general rules for such therapies, instead of making rules case-by-case, said Bob Azelby, chief commercial officer of Juno Therapeutics. Juno is developing a cancer immune therapy similar to Novartis’.

“They’re getting value for the dollars they’re spending,” Azelby said of CMS.

Cell & Gene Meeting in La Jolla began more than a decade ago as a purely scientific conference on stem cells. But it has grown as stem cell technology has been augmented with gene therapy, the delivery of disease-fighting genes.

Genetically modifying stem cells provides a virtually unlimited source of cells with useful properties. These could fight cancer, or perhaps correct a disease caused by a faulty gene.

Many of these therapies, such as Kymriah, are made from a patient’s own cells, collected, modified, grown and re-infused into the body. Such custom-made treatments are extremely expensive. They belong to a class of treatments called CAR T cell therapy.

Bluebird Bio, also represented on the panel, is developing its own version of CAR T cell therapy, in its case for another blood cancer called multiple myeloma.

In addition, Bluebird is developing gene therapies for a rare disease called cerebral adrenoleukodystrophy, and the blood disorders sickle cell disease and beta-thalassemia.

“For Bluebird … it’s ultimately putting together a value story, that allows for a dialogue” about pay-for-performance, said Jeffrey Walsh, chief financial and strategy officer.

Vericel, which grows replacement skin from a burn patient’s own skin cells, also makes such a value pitch, said Nick Colangelo, president and CEO.

“When we treat a catastrophic burn patient, an order of our skin grafts can cost a couple hundred thousand dollars,” Colangelo said. “But it’s a one-time treatment.”

Moreover, treated patients have nearly a 90 percent survival rate, he said.

“That clearly is a product that has a lot of value,” Colangelo said.

Besides helping patients and the companies that make successful therapies, treatments like Kymriah also benefit companies that supply their research tools. One of them is Thermo Fisher Scientific, which had an early collaboration with Carl June, the physician who pioneered the therapy at the University of Pennsylvania.

Thermo Fisher supplied its Dynabeads, microscopic magnetic beads that attach to specified cells using an antibody linker, said Mark Stevenson, the company’s chief operating officer.

“They help extract and amplify the cells prior to the therapy … to actually enrich the cells that you want to pull out, also that you’re able to develop and expand the correct CAR T cells,” Stevenson said. “And for Novartis we scaled up that therapy to make a successful launch.”

“It’s a very exciting time for cell therapy,” Stevenson said. “We’ve been involved in it for 10 years and we’re finally seeing the benefits coming to patients.”

Moody’s: Proposed changes to 340B program will hurt the finances of nonprofit hospitals

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , • Leave a comment

http://www.fiercehealthcare.com/finance/moody-s-proposed-changes-to-340b-program-will-hurt-finances-nonprofit-hospitals?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTURSbU5qazJZbU5sWlRKayIsInQiOiJJTnUxcUsyUm42Y3FjKzBZZXkzQytVR09NYzB0TzNZXC9rXC9YNnBFNXowa0duZGM1SU4yRGJYM2EraXk2TitOa3lwODlWVFNEXC9rc001WUJvcXNjc1U5ZDlYb3FWclNEUjBwbnNlNHc4RVwvc3dGWDVQclJtMDYyZXU4ZmJBNU1lcVkifQ%3D%3D

drugs

Inpatient drug costs will continue to rise for nonprofit and public U.S. hospitals, but the pace of drug price increases will likely slow down amid growing scrutiny of drug manufacturers’ pricing practices.

But even with the slowing rate of price increases, the rising drug costs and potential changes to Medicare 340B payments for outpatient drugs would further reduce hospital margins, according to a new report from Moody’s Investors Service.

Pharmaceutical costs have outpaced hospital revenue growth in recent years, contributing to weaker operating margins, Moody’s finds. “Price increases in recent years were extraordinarily high for certain branded hospital inpatient drugs, but drug manufacturers are pulling back on these increases,” said Diana Lee, a Moody’s vice president. “On the generic drug side, we expect that some of the pressure will ease as the U.S. Food and Drug Administration approves more generic drugs for the first time.”

However, the government’s proposed reduction of Medicare Part B outpatient drug reimbursement to 340B hospitals by roughly 30% would hurt hospital margins.

“Hospitals and health systems of varying size and across the rating spectrum have noted anecdotally that they have benefited from cost savings from this discount drug program,” Lee says. “In some instances, the savings and income gained from this program can be meaningful relative to total operating cash flow. While about half of hospitals in the nation are 340B providers, those that have limited financial flexibility would be most exposed to possible changes to the 340B program.”

Hospitals and industry trade groups have urged the Centers for Medicare & Medicaid Services to withdraw its proposal to cut the drug payments to hospitals in the federal drug discount program. Hospitals use the savings to waive copays and provide drugs and other services for free or reduced costs to low-income patients.

Last week a bipartisan group of more than 220 members of the House of Representatives also told CMS in a letter (PDF) they oppose the proposal.

“This program is a lifeline for the hospitals that serve our most vulnerable patients. These arbitrary cuts will do nothing to improve patient care, or address rising costs in the Medicare program. Instead they simply jeopardize access to the treatments and services that 340B hospitals provide,” said Rep. Mike Thompson (D-Calif.) in an announcement. “There is robust bipartisan agreement that CMS should go back to the drawing board to prevent harm to patients across the country.”

Rep. David P. McKinley (R-W.Va.) said CMS’ proposal was “misguided.” “Our letter shows strong bipartisan opposition to this proposed rule, and hopefully will convince CMS to change course. We must address the high costs of drugs, but this is not the way to do it,” he said.

Meanwhile, the Health Resources and Services Administration has once again delayed (PDF) the effective date of a different 340B final rule that would set drug price ceilings and penalties for drug manufacturers that knowingly overcharge hospitals for drugs purchased under the program. The Department of Health and Human Services said it has delayed the effective date to July 1, 2018, to give more time to make changes to facilitate compliance. “After reviewing the comments received from stakeholders regarding objections on the timing of the effective date and challenges associated with the complying with the final rule, HHS has determined that delaying the effective date to July 1, 2018, is necessary to consider some of the issues raised.”

Population Health Advisors

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , • Leave a comment

Click to access Translating_Data_Analytics_into_Population_Health_Insights_BSW.pdf

Related image

 

Health insurers working the system to pad their profits

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

https://www.publicintegrity.org/2015/08/17/17863/health-insurers-working-system-pad-their-profits

Image result for Health insurers working the system to pad their profits

Commentary: taking advantage of Medicare Advantage

One of the reasons the health insurance industry worked behind the scenes in 2009 and 2010 to derail Obamacare was the fear that changes mandated by the law would cut their Medicare Advantage profits. Medicare Advantage plans are federally funded but privately run alternatives to traditional fee-for-service Medicare.

Although the industry’s biggest trade group, America’s Health Insurance Plans, said repeatedly that insurers supported Obamacare, the group was secretly financing the U.S. Chamber of Commerce’s TV campaign against reform. Among the companies most concerned about the law were those benefiting from overpayments the federal government had been making to their Medicare Advantage plans since George W. Bush was in the White House.

Bush and other Republicans saw the Medicare Advantage program as a way to incrementally privatize Medicare. To entice insurers to participate in the program, the federal government devised a payment scheme that resulted in taxpayers paying far more for people enrolled in the Medicare Advantage plans than those who remained in the traditional program. The extra cash enables insurers to offer benefits traditional Medicare doesn’t, like coverage for glasses and hearing aids, and to cap enrollees’ out-of-pocket expenses.

When the Affordable Care Act became law in 2010, the payments to Medicare Advantage plans exceeded traditional Medicare payments by 14 percent. To end what they considered an unfair advantage for private insurers, and to reduce overall spending on Medicare, Democrats who wrote the reform law included language to gradually eliminate the over-payments.  So far, the 14 percent disparity has been reduced to 2 percent.  The final reductions are scheduled to be made next year.

Despite that decrease, the fears by Republicans and insurance company executives that the reductions would lead to a steady decline in Medicare Advantage enrollees have proved to be completely unfounded. In fact, the plans have continued to grow at a fast clip.

In March 2010, the month Obamacare became law, 11.1 million people were enrolled in Medicare Advantage plans—one of every four people eligible for Medicare. That was an increase from the 10.5 million Medicare Advantage enrollees in March 2009. Since then, Medicare Advantage membership has grown by more than 8 percent annually. Now 17.3 million—one in three people eligible for Medicare—are enrolled in private plans.

As Center for Public Integrity senior reporter Fred Schulte has written over the past year, many insurers have discovered that even though the overpayments are being reduced, they can boost profits another way: by manipulating a provision of a 2003 law that allows them to get additional cash for enrollees deemed to be sicker than average.

A risk-coding program was put in place by the government primarily because insurers were targeting their marketing efforts to attract younger and healthier—and thus cheaper— beneficiaries. Under the risk-coding program, insurers are paid more to cover patients who are older and sicker; the idea was to encourage the firms to cover those folks by offering a financial incentive. They get more money, for example, to cover someone with a history of heart disease than they do for someone with no such risk.  Last week Schulte uncovered whistleblower accusations that a medical consulting firm and more than two dozen Medicare Advantage plans have been ripping taxpayers off by conducting in-home patient exams that allegedly overstated how much the plans should be paid.

The Center for Medicare and Medicaid Services has refused to provide information that would enable taxpayers to know just how widespread fraud and abuse in the Medicare Advantage program might be. But CMS announced earlier this year that it will implement plans designed to make it harder for insurers to manipulate the risk scores. As you can imagine, insurers have howled and have put on a full court press to get CMS to scuttle those plans, but so far the agency says it intends to go forward. We’ll see.

This all matters to insurers because more and more of their revenue and profits are coming from the Medicare and Medicaid programs. When Aetna announced a few weeks ago that it planned to buy Humana, which has more than three million Medicare Advantage members—second only to UnitedHealthcare—Aetna and Humana executives said 56 percent of revenues from the combined company would come from the government programs.

Indeed, some of the firms would not be growing at all if it weren’t for their government business. When Aetna announced second quarter earnings earlier this month, the company noted that its membership in Medicare and Medicaid programs was up 8 percent over the same period last year. By contrast, its commercial membership was down from last year.

Despite that dip in commercial membership, Aetna surprised Wall Street with stronger profits than financial analysts had expected.

So don’t expect the Medicare Advantage program to wither on the vine because of Obamacare. If anything, it will continue to grow—as will the profits of the private insurers that participate in the program.

OIG: Acute care hospitals owe Medicare $51.6M, CMS agrees to provider clawbacks

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

http://www.fiercehealthcare.com/finance/oig-medicare-overpayment-acute-care-hospitals-audit?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWmpSaVpqZGxPREF5TlRBMiIsInQiOiJCamZSYmt6YkZzc0FcL2J1NWFyaFBTRHdtT2Rwd3BKbnI0OGQ5RW1jWXhEcklUa2RYcjVOU2JhWEJXTFBuRlJEcnJRWXVXd0ROT0drZmF5WG00dkVYNFY2QmtMWk1BTUFXRmVtcmUwWVhHdnNKejA2dlZBMmhYbGVyVW9EazZtZTUifQ%3D%3D

money

A new government report finds that Medicare improperly paid acute care hospitals for outpatient services they provided to patients who were inpatients at other facilities. And now Medicare wants the money back

The Centers for Medicare and Medicaid Services has agreed to claw back the $51.6 million and require hospitals to refund patient copays and deductibles.

The Department of Health and Human Services Office of Inspector General audited (PDF) Medicare payments made between Jan. 1, 2013, and Aug. 31, 2016, and found that in that window CMS made $51.6 million in improper payments to hospitals for outpatient services provided to patients who were inpatients at long-term care facilities, critical access hospitals, inpatient rehabilitation facilities and inpatient psychiatric facilities.

Medicare typically would not pay an acute care hospital for outpatient treatments for a patient who is an inpatient at a different facility, according to the OIG, and instead the services should be rendered through an agreement between the two facilities, with payments going to the inpatient provider.

In addition, Medicare beneficiaries were responsible for $14.4 million in coinsurance and unnecessary deductibles paid to the acute care hospitals, the OIG found.

“Medicare overpaid the acute care hospitals because the system edits that should have prevented or detected the overpayments were not working properly,” the OIG concluded.

“If the system edits had been working properly since 2006, Medicare could have saved almost $100 million, and beneficiaries could have saved $28.9 million in deductibles and coinsurance that may have been incorrectly collected from them or someone on their behalf.”

OIG made three recommendations to CMS to resolve this issue:

  1. Recover the $51.6 million in inappropriate payments.
  2. Have the acute care hospitals refund the patients’ $14.4 million in coinsurance and deductibles.
  3. Identify improper payments outside of the audit window, and recover those as well.

CMS has agreed to these recommendations, OIG said.

OIG conducted the audit as previous investigations showed Medicare made inappropriate payments for outpatient services for people who were inpatients at acute care hospitals, and the organization wanted to see whether the trend extended to other types of facilities.

Moody’s maintains for-profit hospitals’ stable outlook

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

http://www.healthcaredive.com/news/moodys-maintains-for-profit-hospitals-stable-outlook/505680/

Image result for hospital credit ratings

Dive Brief:

  • Moody’s Investors Service announced in a recently released report that the outlook for U.S. for-profit hospitals is stable.
  • Outpatient services will drive revenue growth. Moody’s said outpatient service growth will result in EBITDA growth of 2.5-3% for for-profit hospitals over the next 18 months. That growth will be offset somewhat by higher patient costs and more uninsured Americans, which may lead to more bad debt for hospitals.
  • Moody’s warned that recent hurricanes in Florida and Texas, which are the two largest states by revenue among for-profit hospitals, may cause short-term financial issues, but Moody’s expects those hospitals will recover quickly.

Dive Insight:

Payers, both private and public, continue to squeeze hospital margins as they push patients to outpatient services. Moody’s said volumes to lower-cost settings will continue. Revenue growth from outpatient services will rise faster than inpatient services.

Moody’s said patients with high-deductible health plans, who pay more out-of-pocket costs, are going to seek less costly settings than hospitals to save money. Also, the CMS’ proposal to allow several orthopedic procedures on an outpatient basis could cause more financial harm for hospitals. “If finalized, this will further push surgeries out of the inpatient setting.”

For-profit hospitals will capture some of the added outpatient volume through their own outpatient departments and associated ambulatory surgery centers. However, some volume will go to competitors, Moody’s warned.

Moody’s expects payer rates will rise, but lower than usual — 1.5-2% net revenue per adjusted admission over the next 18 months. Some factors that will affect the slower growth include the CMS changing disproportionate share payments and proposing 1.75% rates for hospital outpatient procedures, and private payers implementing cost-controlling policies. These policies include Anthem’s plan to no longer pay for MRIs and CTs scans in hospital outpatient departments. Instead, patients will need to get the services at lower-cost, freestanding imaging centers.

Moody’s also warned that rising bad debt and expenses are pressuring margins.

“Higher patient responsibility and fewer insured patients will lead to lower volumes, but also higher costs of uncompensated care. Even with strong cost controls, given the high fixed costs of operating hospitals, it will be difficult to expand margins in an environment of weak patient volumes and rising bad debt expense. At the same time, nursing shortages and rising fees associated with medical specialists (including outsourced emergency departments) will also pressure margins,” said Moody’s.

However, some for-profit systems may see improved margins in the coming months. Moody’s said Quorum Health and Community Health Systems (CHS) will benefit from shedding less profitable facilities, while LifePoint Health and HCA Healthcare will improve margins over time as they improve efficiencies at recently acquired facilities.

Moody’s also warned that Hurricanes Harvey and Irma, which destroyed portions of Texas and Florida, will affect the largest for-profit hospitals: HCA Healthcare, Tenet Healthcare and CHS, which all have “significant presence” in those areas. For those states, Moody’s expects “incremental expenses,” such as cleanup and remediation, staffing and overtime, as well as transporting critically ill patients to other facilities, will play a financial role for those systems in the next two quarters.

Shared Savings Program ACOs Reduced Medicare Spending by $1 Billion

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , • Leave a comment

http://www.healthleadersmedia.com/quality/shared-savings-program-acos-reduced-medicare-spending-1-billion?spMailingID=11861186&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1240498373&spReportId=MTI0MDQ5ODM3MwS2

Image result for Medicare ACO

 

ACOs under CMS’ largest alternative payment model outperformed fee-for-service providers in quality and cost savings within the first three years of program.

According to findings reported by the Department of Health and Human Services Office of Inspector General (OIG), accountable care organizations (ACOs) participating in the Shared Savings Program are learning how to achieve greater cost savings over time. The Medicare Shared Savings Program is one of the largest alternative payment models implemented by CMS to reward providers for the quality and value of their services in order to keep patients healthy and lower costs.

The OIG’s report suggests many positive outcomes of the program, including that one-third of the ACOs that reduced their spending lowered costs enough to receive a portion of the savings. CMS data on quality measures also shows that ACOs generally improved the quality of care they provided, with a rate of 82% performance improvement on the individual quality measures within the first three years of the program. ACOs also outperformed fee-for-service providers on 81% of the quality measures.

A small portion of ACOs are reported to have gone above expectations, reducing Medicare spending by an average of $673 per beneficiary, including spending reductions for high-cost services such as inpatient hospital care and skilled nursing facility care. The OIG reports that these high-performing ACOs’ frequent use of primary care services, which can lower utilization and costs for other care, and cost reductions for services such as emergency department visits, was a factor in their cost savings. These strategies are compared to other Shared Savings Program ACOs and the national average for fee‐for‐service providers, who showed an increase in per beneficiary spending for key Medicare services.

The OIG concluded that ACOs show promise in reducing Medicare spending while also improving quality. These improvements come at a critical time, as Medicare spending is predicted to grow to $1.4 trillion by 2027. A large portion of Medicare spending has been attributed to overbilling, with the Medicare program losing more money to this error than any other program government-wide.

Swedish Health’s Cherry Hill campus at risk of losing Medicare, Medicaid funding

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , • Leave a comment

http://www.beckershospitalreview.com/quality/swedish-health-s-cherry-hill-campus-at-risk-of-losing-medicare-medicaid-funding.html

Image result for Swedish Health's Cherry Hill campus at risk of losing Medicare, Medicaid funding

CMS is threatening to cut off Medicare and Medicaid funding to Seattle-based Swedish Health’s Cherry Hill campus in 90 days unless it resolves patient safety issues, according to The Seattle Times.

The Washington Department of Health inspected Swedish’s Cherry Hill campus after a February Seattle Times investigative report exposed troubles, including staff members feeling intimidated, patient care concerns and surgeons performing overlapping surgeries.

The state surveyors identified numerous patient safety issues at the Cherry Hill campus, including failure to outline the roles of medical fellows, failure to address behavioral concerns, failure to document surgical tasks of medical residents, failure to listen to staff concerns and failure to track when the attending physician was in the operating room.

“Staff members feared punishment and retaliation for voicing concerns,” the regulators wrote, according to the Seattle Times. “Staff members stated they were frequently bullied and intimidated for voicing concerns about the working conditions in the neurosurgical operating area.”

To keep federal funding for the Cherry Hill campus, Swedish Health must submit a corrective action plan to CMS. Regulators will conduct another survey to ensure the hospital is in compliance with Medicare and Medicaid rules.

Swedish Health said that many of the deficiencies cited have been addressed, according to the report. The system implemented a new policy to ban overlapping surgeries. Additionally, Swedish Health CEO Guy Hudson, MD, insured that the culture of intimidation will be addressed

“We are sorry for what occurred at Swedish Cherry Hill on our watch,” Swedish Health board members told the Seattle Times. “As volunteers, we continue to be deeply committed to our critical governance role in overseeing patient quality and safety, as well as physician credentialing.”

Fitch: States will take the lead on Medicaid reform despite ACA repeal and replace failure

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

http://www.healthcarefinancenews.com/news/fitch-states-will-take-lead-medicaid-reform-despite-aca-repeal-and-replace-failure?mkt_tok=eyJpIjoiWVdGallqTTBZVGRoTVdKaSIsInQiOiI4UXRNZDB6VUZ2MEtTbGhNbm9zZ3dnQys3Z2dkS2VYWDQyZlwvbkxtNEIxRlwvT085a056VlwvbjhweFlxOEFWUktZOGVMeWRTMm5BbCtCaE44T0VlOUNDdkRIQ1ZCRFpBd2NhK1NjZTJOaGFteHJjWEZDOTN5R2pDK3oxb2w4d0xvZSJ9

Some states had already begun negotiations with the Centers for Medicare and Medicaid Services on securing Medicaid waivers, Fitch said.

Despite the Senate’s failure to pass an ACA repeal and replace bill, state governments are moving ahead with their own efforts to revamp Medicaid, especially through waivers, according to a Fitch Ratings report.

Some states had already begun negotiations with the Centers for Medicare and Medicaid Services on securing Medicaid waivers granting them more flexibility. State waiver proposals could affect both Medicaid expansion beneficiaries and the traditional enrollees, the report said.

Arkansas, Indiana and Kentucky have submitted proposals to CMS asking to add work requirements to their Medicaid expansions. Other states including Arizona, Maine, Pennsylvania and Wisconsin are considering work requirements for at least some traditional Medicaid enrollees as well, Fitch said.

Fitch ratings agency said the Trump administration has indicated they are in favor of such measures.

Overall, Fitch said states have indicated their proposed Medicaid changes could reduce costs and also “support key policy goals.”

The states proposing these measures suggested they support “key policy goals” and could yield cost savings. “However, the actual amount of cost savings could be low as some health policy experts have raised questions about the efficacy of such work requirements given characteristics of the current Medicaid population. Adding work requirements could also add to state administrative burdens for oversight of the Medicaid program,” the agency said.

Fitch also projects states will continue to focus on controlling Medicaid spending as they look at their budgets. CMS predicted long-term rises in Medicaid spending due to growth in higher-cost traditional Medicaid-eligible populations, especially the elderly and disabled, and their most recent 10-year forecast for National Health Expenditures showed state and local government Medicaid spending will rise an average of 6.1 percent annually between 2017 and 2025.

“This is far ahead of Fitch’s expectations for national economic growth and state tax revenue growth, signaling continued pressure on states to manage their budgets accordingly,” Fitch said.