CMS proposed Monday a new mandatory bundled payment program for heart attacks and bypass surgeries that includes changes to the existing Comprehensive Care for Joint Replacement Model as part of its larger goal to shift Medicare from quantity to quality incentives.
Here are 10 things to know about the proposed rule.
The Medicare Access and CHIP Reauthorization Act final rule is here. As industry experts begin to dig into the 2,400-page document released Friday, a few details are emerging that will be critical for providers who plan to practice fee-for-service medicine in 2017.
Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists who bill more than $30,000 a year or provide care for at least 100 patients under traditional, fee-for-service Medicare will be subject to MACRA’s Merit-Based Incentive Payment System beginning Jan. 1.
Becker’s caught up with two experts who have already started reading — Tom Lee, PhD, founder and CEO of SA Ignite, and Dan Golder, DDS, principal at Impact Advisors — to determine a few details providers should heed in preparation for MIPS next year.
Here are seven takeaways based on the initial findings of Drs. Lee and Golder.
Hillary Clinton and Donald Trump don’t see eye-to-eye on much. But they do agree that drug costs are spiraling out of control at the public’s expense. Both the Democratic and the Republican candidates for president have said that Medicare should be able to negotiate drug prices, something that currently isn’t allowed by law. Letting Medicare do that — which the Department of Veterans Affairs and other countries have been doing for years — has the potential to transform health care.
Most developed nations, including Canada and the United Kingdom, negotiate with pharmaceutical companies to determine how much they will pay for medications. In the US, health care is covered by many different payers, with Medicare being the largest by far. The federal government never gave Medicare the power to negotiate drug prices. Instead, that’s done by the many private insurers that manage Medicare drug plans.
Giving Medicare the power to negotiate drug prices would immediately save billions of dollars. The implications would also reach far beyond the 37 million Americans covered by the Medicare drug benefit (Part D), because commercial insurers often follow Medicare’s lead.
The number of seniors in the United States is projected to nearly double over the next 34 years—from 43 million in 2012 to nearly 84 million by 2050. During that time period, the number of seniors 85 and older is expected to jump from nearly 6 million to 19 million.
“Our Parents, Ourselves: Health Care for an Aging Population,” a report issued by the Dartmouth Atlas Project, a program of The Dartmouth Institute for Health Policy and Clinical Practice, also reveals that the number of seniors in Medicare private health plans such as Medicare Advantage increased from 6.4 million beneficiaries in 1999 to nearly 12 million in 2011—and that number continues to rise.
Because seniors are likely to experience frequent, complex interactions across many providers in the healthcare system, often there’s no single healthcare provider coordinating all of their care, according to the report, which was released in early 2016.
In addition, the American Geriatrics Society’s Choosing Wisely guidelines, which were released in 2013 and updated in 2015, provide geriatrics-specific recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. The campaign advances a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.
Here are four areas of elderly care—highlighted in the report and guidelines—that healthcare systems and health plans should be aware of to ensure that elderly patients aren’t receiving unnecessary care.
California is cracking down on graft in the state’s system of medical care for injured workers with two bills recently signed into law by Gov. Jerry Brown.
The reforms will prohibit medical providers who are felons from billing for workers’ compensation care and rein in a court-governed payment system that gave rise to hundreds of millions of dollars in unsanctioned treatment.
Lawmakers who introduced the bills cited an investigation by Reveal from The Center for Investigative Reporting that examined more than $1 billion in alleged fraud in the medical system for injured workers.
Reviewing more than a dozen prosecutions and analyzing state data, the investigation found that alleged scams affected more than 100,000 injured workers. Many were monolingual Latinos who were targeted in aggressive marketing efforts in Southern California. They encountered everything from kickback-fueled spinal surgeries to fraudulent providers to $1,600 tubes of pain cream.
Alleged scammers included felons and doctors banned from billing Medicare for malfeasance. Many fraud defendants exploited a feature of California’s workers’ compensations system that let them file a “lien,” or a demand for payment, for services after insurers refused to pay. They included therapies like shock wave pain treatments or unwanted drugs, such as the pricey pain creams.
The new laws would ban certain medical providers with troubled pasts from treating injured workers and also aim to limit the avalanche of liens that clog the docket in two dozen workers’ compensation courts throughout the state.
Christine Baker, director of the Department of Industrial Relations, which administers workers’ compensation, said she hopes the laws improve care for people who seek help for an on-the-job injury.
“I think both abuses and fraudulent activities prey on the most vulnerable populations and we’re hopeful that appropriate treatment will be provided to workers when needed,” Baker said. The laws “should reduce costs, because a lot of costs are tied to fraudulent activity, and that frees up dollars for the injured workers.”
Hospitals continue to contest a large proportion of claims denied by recovery audit contractors (RACs) through the multi-level appeals process, and a backlog of claims continue to clog federal administrative law courts.
According to the most recent data from the American Hospital Association’s RACTrac Survey of 676 hospitals nationwide, 45 percent of denials were appealed through the second quarter of 2016, with 56 percent of those appeals related to inpatient coding denials. That’s down slightlyfrom the first quarter, where 47 percent of denied claims were appealed.
The average dollar value of an automated denial–which are caught through computer algorithms–is $741. Complex denials involve far more money, with an average dollar value of $5,418.
Meanwhile, the appeals process remains sluggish. Nationwide, three-quarters of survey respondents said that administrative law courts have taken longer than the mandated 90 days under federal statutes. In the Upper Midwest, 93 percent of hospitals say the process has taken longer than 90 days. Altogether, 27 percent of all appeals ever filed by hospitals since the RAC program began in 2010 continue to be sitting in the appeals process. In 2014, the feds briefly suspended the program after the number of claims being appealed topped 350,000.
Last year, the Centers for Medicare & Medicaid Services (CMS) offered to settle the backlog of appeals involving disputed short-stay hospital stay for 68 cents on the dollar, for a total settlement of about $1.6 billion.
Nevertheless, hospitals have enjoyed considerable success in the appeals process, with 60 percent of appeals leading to a denial being overturned.
Still, the financial burden of appealing a RAC denial is fairly costly. Twenty-percent of hospital said during the second quarter they spent at least $10,000 on administrative costs related to addressing RAC issues; 12 percent spent more than $25,000, 7 percent spent more than $50,000, and 5 percent spent more than $100,000.
http://www.gallup.com/poll/196193/uninsured-rate-new-low-third-quarter.aspx
In the third quarter of 2016, 10.9% of U.S. adults were without health insurance, representing a new low in Gallup’s and Healthways’ nearly nine years of trending the rate of uninsured. This is down from 11.9% in the fourth quarter of 2015, before the 2016 open enrollment period that allowed U.S. adults to obtain insurance through the government health insurance exchanges.
The uninsured rate has declined 6.2 percentage points from 17.1% in the fourth quarter of 2013, right before the Affordable Care Act’s requirement that Americans carry health insurance took effect in early 2014.
Results for the third quarter are based on approximately 44,000 interviews with U.S. adults aged 18 and older from July 1- Sept. 30, 2016, conducted as part of the Gallup-Healthways Well-Being Index. Gallup asks 500 U.S. adults each day whether they have health insurance, which, on an aggregated basis, allows for precise and ongoing measurement of the percentage of Americans with and without health insurance.
Turning 65 soon? Your mailbox probably is stuffed with ads from health care companies eager to sign you up for Medicare coverage.
Be aware, though: buried in there may be a notice that you are about to be automatically enrolled in an HMO-style, private Medicare Advantage plan by your current insurance company. If you never see that letter, or if you ignore it, you could find yourself locked into coverage that doesn’t cover your doctors or costs you more.
Some insurance companies serving South Florida seniors are considering, or have started, a little-known policy called seamless conversion. Insurers granted approval by the federal Centers for Medicare and Medicaid Services can automatically shift existing members into their Advantage plans when those members become eligible for Medicare.
While CMS requires that beneficiaries be notified in writing at least 60 days in advance, insurers do not need confirmation that the member wants the new coverage before making the switch. Medicare advocates say that blocks seniors from making informed choices.
Seamless conversion was created by Congress almost 20 years ago, as part of the Social Security Act of 1997, but rarely used over the years, said Stacy Sanders, federal policy director for the Medicare Rights Center in New York City. That changed in the 2016 plan year, she said, when CMS sent Medicare Advantage providers letters suggesting conversion was a good option for transitioning low-income seniors and nursing home residents into new state Medicaid managed care programs once their members were eligible for Medicare.
Sanders is concerned that seniors usually will receive seamless conversion notices when they’re most likely to be flooded with Medicare Advantage pitches: during annual open enrollment in October and right before their 65th birthdays.
Despite the singular nature of this year’s presidential campaign, there is plenty of continuity with past elections when it comes to health care, argue David Blumenthal, M.D., and James A. Morone in their New England Journal of Medicine “Perspective.”
In “Past as Prologue—Presidential Politics and Health Policy,” Blumenthal, The Commonwealth Fund’s president, and Morone, director of Brown University’s Taubman Center for American Politics and Policy, discuss the “deep underlying political forces and historical experiences with health care politics and policy” that are reflected in the platforms of Hillary Clinton and Donald Trump.
The authors previously collaborated on the book The Heart of Power: Health and Politics in the Oval Office (University of California Press, 2009).
A growing proportion of Medicare beneficiaries are opting out of the government-run insurance program. They are instead choosing a private plan alternative, one of the Medicare Advantage plans. The strength of this trend defies predictions from the Congressional Budget Office, and nobody can fully explain it.
Here’s another mystery. Traditional Medicare spending growth has slowed, bucking historical trends and expectations. Though there are theories, we don’t fully know what’s causing that either.
Pinning down explanations for these two mysteries is important. Doing so could help us understand the structure and cost of Medicare in the future.
HENRY KOTULA 