Welcome

We are a health care consulting firm working at the intersection of health care and government — widely respected for our expertise in congressional and regulatory matters, health policy analysis and solutions, CMS pilots and demos, federal grants development, managed care contracting and association management. more…

Latest on Regulation, Bills, & Reform

Latest E-Bulletins

07/25/2016

Weekly E-Bulletin


New Hospital Star Ratings Summary Released; Specific Ratings Coming “Soon”

CMS released a breakdown of the upcoming overall hospital star ratings ahead of the highly anticipated facility-by-facility release. Of the 4,600+ hospitals, 102 hospitals earned five stars, 934 four stars, 1,770 three stars, 723 two stars and 133 will only get one star. CMS won’t rate 937 hospitals due to factors such as failure to report or insufficient available data. Disproportionate share hospitals (DSH) received worse ratings on average than non-DSH payment-eligible hospitals, with an average of 2.92 versus 3.47. Critical access hospitals (CAHs) had a higher average rating than non-CAHs, with an average of 3.31 compared to 2.99. CMS said it will soon release facility-specific ratings on its Hospital Compare website. Click here for the CMS fact sheet.

  • About 50 health systems and medical groups across the country have launched their own online star rating programs to give a better picture of how their patients perceive their care in the doctor’s office. Recent adopters include big names like Baystate Health, Spectrum Health, Medstar Health, and the Marshfield Clinic. Click here for more.

DOJ Files Lawsuit To Stop Insurance Mergers

The Justice Department has filed lawsuits against Anthem and Aetna to block their attempted acquisitions of Cigna and Humana, respectively. The Department cites concerns the deals would limit competition in the insurance market and potentially undermine the ACA. In particular, DOJ worries that the mergers would have hurt the Medicare Advantage market. DOJ also cited the effect the potential mergers would have on Obamacare’s exchanges. To read the complaint against Anthem click here and Aetna here.

Humana Will Pull Out of Many ACA Exchanges

Humana announced last week, that it will drastically reduce its exchange presence in 2017 and exit “substantially all” ACA-compliant, off-exchange markets. This decisions means the company will only offer individual plans in 156 counties in 11 states, down from 1,351 counties across 19 states in 2016. The company did not immediately give a breakdown of how many ACA exchanges it was leaving but analysts indicated it was a substantial pullback. Click here for the Humana announcement.

UnitedHealth Has Big ACA Losses

According to the company’s earnings report, UnitedHealth Group lost $200 million more than projected on its ACA-compliant individual plans in the second quarter of 2016. The health insurer had previously announced that it expects to lose $650 million on its Obamacare business for the entire year. UnitedHealth officials attributed the bigger losses to greater enrollment and higher claims than expected and warned that the steeper-than-expected losses in its health exchange business could drive it to exit the three remaining marketplaces the company planned to participate in next year. Click here to read the earnings report.

Most Insurers Had Losses in 1st Year of ACA Exchanges

According to an analysis published by the Commonwealth Fund, insurers underestimated medical claims by 5.7 percent in the individual market in 2014. More than 60 percent of plans lost money in the individual market in 2014, according to the analysis, even after adjusting for reinsurance payments. The reinsurance program was designed to protect insurers from big losses in the early turbulent years of exchange operations, but it expires after this year. Click here to read the Commonwealth Fund study.

Analysis Shows Modest Insurance Premium Growth

Premiums for private health insurance grew modestly between 2014 and 2015 –- 2.2 percent for single coverage and 2.6 percent for employee-plus-one coverage. Those rates were lower than the 4.7 percent growth rate for both categories in the previous 12 months. Meanwhile, the 2014–15 growth rate for family premiums was 4.0 percent, similar to the previous year. This data is according to a new report from the Agency for Healthcare Research and Quality, click here.

LTCHs, IRFs Notified of Reporting Non-Compliance by CMS

CMS notified last week inpatient rehabilitation facilities (IRFs) and Long-Term Care Hospitals (LTCHs) of non-compliance with the Quality Reporting Program (QRP). Facilities that were out of compliance with the program in 2015 will see a cut in their 2017 pay. The agency says those providers who would like to submit a reconsideration request to CMS should do so by Aug. 19. Click here for the IRF reconsideration webpage, and here for the LTCH reconsideration page.

CMS Selects 516 for Cardio Disease Reduction Model

CMS has selected 516 organizations to participate in the Million Hearts Cardiovascular Disease Risk Reduction Model beginning in September. The randomized controlled trial will test whether paying practices to identify and manage cardiovascular risks for Medicare patients reduces heart attacks, strokes and Medicare costs. Half of the participants in the five-year model will serve as a control group. Click here for details and the list of participants.

Senators Introduce MACRA Relief Legislation

Prior to leaving for the summer recess, Sens. John Thune (R-S.D.), Lamar Alexander (R-Tenn.), Mike Enzi (R-Wyo.), Pat Roberts (R-Kans.), Richard Burr (R-N.C.), and Bill Cassidy (R-La.) introduced the Electronic Health Record (EHR) Regulatory Relief Act (S. 3173). The legislation, backed by the American Hospital Association (AHA), would:

  • Codify the previously proposed 90-day reporting period for eligible hospitals and providers to attest for 2016 the way they did last year,
  • Remove the “100 percent-is-passing” approach to meaningful use,
  • Return the threshold for providers to meet certain criteria from 75 percent to 70 percent of the metrics and,
  • Extend the existing hardship exceptions for 2016 and 2017 to accommodate providers that cannot attest because of insufficient web connectivity, natural disasters, vendor certification issues and other problems.

Click here to view the legislation, here for the summary, and here for the endorsement letter from AHA.

CDC Announces $60 Million in Zika Grants

The Centers for Disease Control and Prevention announced that on August 1 it will start distributing grants totaling $60 million to states and territories to fight the Zika virus. The money is designated for surveillance, mosquito control, strengthening lab capacity and related activities to track and fight the virus. An additional $10 million will go to quickly identify cases of microcephaly and other Zika-related birth defects and help refer those families to services. Click here for details.

  • Three more infants with Zika-related birth defects were born in the last week, according to new CDC data. The agency has been tracking births and pregnancy losses to mothers infected with the Zika virus on a weekly basis as part of the agency’s pregnancy registry. Click here.

Studies: Generic Rx Competition Low; Drug Costs in Medicaid are High

More than one-third of drugs eligible for generic competition had three or fewer generic competitors; of the 210 drugs approved in the last 30 years that were eligible for generic competition, 17 had no generic competitor, 84 percent had at least one generic and 63 percent had at least four, a new JAMA analysis found. Additionally, according to the Kaiser Family Foundation, the antipsychotic Abilify was the most expensive drug for state Medicaid programs from January 2014 through June 2015, followed by Sovaldi, ADHD drug Vyvanse, Harvoni and HIV drug Truvada. 45 of the 50 costliest drugs fall into the high-cost category in part or primarily because they are frequently prescribed. Click here for the JAMA study, and here for the KFF study.

HRSA Awards $149 Million for Workforce Development

The Health Resources and Services Administration announced more than $149 million in new awards through 12 workforce programs to prepare the next generation of skilled, diverse primary care providers to serve communities in need across the country. HRSA’s education and training grants support the development of a workforce through an emphasis on diversity, distribution of clinicians, and quality services that encourage innovative team-based and interprofessional approaches. Click here for details.

CMS Claims $42 Billion in Savings from Fraud, Integrity Programs

CMS has released a report showing that investments made in program integrity activities – which include stamping out fraud and deterring and reducing other improper payments – have saved $42 billion. In fiscal year 2013, savings from prevention activities represented about 68 percent of total savings. In fiscal year 2014, the portion of savings from preventing potentially fraudulent and improper payments rose to nearly 74 percent. From October 1, 2012 through September 30, 2014, every dollar invested in CMS’ Medicare program integrity efforts saved $12.40 for the Medicare program, the report said. Click here for more.

Precision Medicine May Be Years Away: Analysis

The goal of precision medicine is to provide drugs and therapies that are uniquely suited to individual patients based on their genetics and other distinguishing health information. Some of that is already happening. Dozens of targeted drugs have gotten approval from the FDA, and there are particularly successful examples in oncology. But despite the early successes, we are many years from realizing a “new era of medicine.” Click here for the brief from the MIT Technology Review.

Efforts Intensify to Increase Home Births in More States

22 states do not license midwives who deliver babies outside of hospitals. The state regulatory terrain for midwives poses a problem for consumers when the nation is experiencing an increase in the number of births taking place outside hospitals, usually in homes or freestanding birthing centers. The percentage of out-of-hospital births crept up from 0.87 percent of all births in 2004 to 1.36 percent in 2012, according to the CDC. Click here for details on the efforts to expand the number of states that will license midwives.

Researchers Find Stress Coping Circuits in the Brain

NIH researchers have identified brain patterns in humans that appear to underlie “resilient coping,” the healthy emotional and behavioral responses to stress that help some people handle stressful situations better than others. The study of human volunteers used a brain scanning technique called functional magnetic resonance imaging (fMRI) to measure localized changes in brain activation during stress and revealed a sequence of three distinct patterns of response to stress, compared to non-stress exposure. Researchers suggest that this could lead to predictions of stress responses that contribute to excessive drinking, anger, and other unhealthy reactions to stress. Click here to view more on the study.

View all ebulletins