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Almost One-Third of Hospitals Land on Joint Commissions Top Performers List

The Joint Commission said 31.5% of 3,300 hospitals that submitted quality data won spots on its Top Performers on Key Quality Measures list. To qualify, hospitals had to have a cumulative score of at least 95% across all 49 accountability measures. Joint Commission President Mark Chassin said the overall trend since 2002 is that “everyone has improved dramatically.” Click here for the Top Performer list – it is by state. Click here to read the complete 72-page report.


CMS Releases Final Joint Replacement Rule – Delays Starting Date, Cuts 8 Metro Areas

CMS last week released a final rule that would bundle payments for knee and hip replacements for 67 geographic areas. The Comprehensive Care for Joint Replacement (CCJR) Model for Acute Care Hospitals would bundle all related care for a 90-day episode. After receiving nearly 400 comments on the proposed rule, CMS delayed the implementation of the rule from January 1 to April 1, 2016. CMS also changed the number of geographic areas included in the model from 75 to 67. For a very good and detailed 7-page summary of the rule, click here. Click here to read the 1,018-page rule.

  • The new rule is also granting some of the fraud and abuse waivers providers asked for in their comment letters. Click here for the waivers summary.
  • Medicare providers can use telemedicine much more extensively in this bundled payments program. CMS is waiving many of Medicare’s usually restrictive requirements on telemedicine’s use in the program. The final rule also helps beneficiaries receive technology incentives, for example a monitoring device, without violating federal kickback laws. Providers are limited in their incentives to $1,000 per beneficiary per episode. Under a change in the final rule, providers are allowed to repossess any good valued at more than $100. It was $50 in the rule proposed this summer.
  • The 18-member GOP Doctors Caucus in the House of Representatives is reportedly sending a letter to Speaker Paul Ryan to ask for end-of-year legislation that would further delay the bundled payments program for hip and knee surgeries. The letter is also expected to call for a delay in meaningful use implementation.

HHS Pushes Drug Industry on Prices

The Obama administration’s top health officials said Friday that the nation needs greater clarity about the cost and effectiveness of prescription drugs as part of a strategy to make medicines more affordable without stunting the emergence of new pharmaceuticals. HHS sponsored a broad, day-long forum to discuss rising drug prices, which have become a dominant policy issue, raising the ire of consumers, sparking fights between sectors of the health-care industry and spilling into Congress and presidential campaigns. Recent surveys have shown that making drugs more affordable is the public’s leading health-policy concern. Click here for details.

  • Pfizer Inc. and Allergan PLC are on the cusp of striking a merger deal worth more than $150 billion that would create the world’s biggest drug maker by sales, according to a report yesterday in the Wall Street Journal. Click here.

Daraprim Drug Maker Said To Be Ready To Discount Drug in Certain Circumstances

Turing Pharmaceuticals AG, the small drug maker that gained notoriety for raising the price of an anti-parasite tablet more than 50-fold, is drawing up plans to discount the drug as much as 50% to hospitals, according to a Wall Street Journal report. Even with the discounts, the drug—Daraprim—would still cost hospitals far more than it did before Turing bought the U.S. rights in August and raised the price to $750 a tablet, from $13.50. The amount of the discount will depend on how much of the drug hospitals use, the person said. Click here for the story.


Rx Company-Backed Group Slams Insurance Industry for Health Care Costs

A drug-industry backed group released a report last week blaming insurers for driving up health care costs. The Alliance for the Adoption of Innovation in Medicine document has a laundry list of complaints about insurers’ accounting practices, CEO compensation, and rising premiums and deductibles, among other things. Click here for the full report.

AMA Calls for Ban on Drug Advertising to Consumers

In a provocative move, members of the American Medical Association voted for a ban on drug advertising to consumers, citing it as a chief cause for the rise in prescription drug prices. The new AMA policy also calls for more transparency in drug prices and costs and for the launch of an advocacy campaign around this topic. To read more from the AMA, click here.


FDA OKs First Opioid Fighting Nasal Spray

The FDA last week approved Narcan nasal spray, the first FDA-approved nasal spray version of naloxone hydrochloride, a life-saving medication that can stop or reverse the effects of an opioid overdose. Opioids are a class of drugs that include prescription medications such as oxycodone, hydrocodone, and morphine, as well as the illegal drug heroin. Until this approval, naloxone was only approved in injectable forms, most commonly delivered by syringe or auto-injector. Many first responders and primary caregivers, however, feel a nasal spray formulation of naloxone is easier to deliver, and eliminates the risk of a contaminated needle stick. Click here for the detailed FDA announcement.


Physicians Outline Issues with New Doc Payment Formula

Dozens of mostly-physician groups have outlined broad principles they want CMS to follow as it implements MACRA legislation overhauling Medicare physician reimbursement. The groups, led by AMA, called on CMS to eliminate constraints on physicians trying to provide care under alternative payment models and to ensure that providers can choose from an array of APMs. They also called on the agency to streamline various quality reporting requirements and to reduce administrative burdens more broadly. Click here to read the letter.

Families Need to Shop to Avoid Double-Digit Premium Increases

Last year, 47 percent of enrollees from Healthcare.com saw small changes to their plans. That will not always be the case this year, according to a Kaiser Family Foundation analysis. Individuals enrolled in the cheapest silver plan will see average premium increases of 15 percent if they remain in their current plan. However, if they’re willing to switch into the new lowest-cost plan, the average increase drops to 7 percent. Click here for the Kaiser analysis.


25% of Privately Insured Adults Say Health Care Is Unaffordable

A quarter of privately insured working-age adults – mainly with employer plans – say their health care is unaffordable, according to the latest Commonwealth Fund Health Care Affordability Index. That’s not a change from last year’s survey, but the numbers illustrate that affordability is still a barrier to care. Some 40 percent of adults with deductibles that amounted to 5 percent or more of their income said they put off going to the doctor when sick, didn’t take preventive care and recommended follow-up tests or didn’t seek specialist care. Click here for the report.


Analysis: States Have Bad Record Providing Physician Quality Outcome Info

Most states have a dismal record when it comes to providing consumers with information on the quality of the healthcare that physicians provide, according to an annual report card issued by the Health Care Incentives Improvement Institute. For the third year in a row, the scorecard gave failing grades to 43 states, and of those, only three (New Mexico, Missouri and Ohio) managed a D. Among the seven states that passed, three had a C (Oregon, Wisconsin and Massachusetts). California, Washington and Minnesota were at the top with As, and Maine earned the lone B. Click here for the report.

Cancer Group Calls for more Clarity on Drug Coverage

Marketplace plans are not clear enough on their drug coverage and cost sharing requirements to meet the needs of cancer patients, the American Cancer Society Cancer Action Network says in a new report. The study covered six states, including California and Florida, that enrolled nearly half of all exchange customers. It found that: Cost-sharing structures in plans’ formularies didn’t match those available on the exchange websites nearly half the time; Plans continue to place most oral chemotherapy medications on the highest formulary tier, while coverage of newer oral chemotherapies was limited in some states. Click here for the complete report.

House Committee Passes Two Medicaid Reform Bills

The House Energy & Commerce Committee last week passed two Medicaid reform bills. One would require states to provide information to the government about provider terminations (click here to read the bill) and the other would require provider directories in states (click here to read). Both bills passed the Committee by voice vote with bipartisan support.

UnitedHealth May Drop Out of State Health Exchanges; Most Others Plan To Stay

UnitedHealth Group, the country’s largest health insurer says it may scale back its business on state health exchange after cutting earnings projections because of losses on individual plans sold through those exchanges. UnitedHealth is projecting losses of $275 million on the company’s exchange business in 2016. Click here to read the UnitedHealth announcement. Click here for the news story. However, several other major insurers said they plan to stay in the exchanges and their earnings for the year are on track. Click here for that story.

  • Higher premiums and thinner networks threaten the popularity of Obamacare exchange plans, according to the Wall Street Journal. Click here.

CMS Proposes Network Adequacy Requirements, Standardized Health Plans

CMS last week proposed new standardized insurance plans and called for new provider network adequacy standards. The agency also proposed new payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs for health insurers. CMS plans to hold the enrollment period between November 1, 2016 and January 31, 2017. Public comments are due December 21, 2015. Click here for a good 5-page CMS summary. Click here for the 381-page proposed rule.


States Now Using Medicaid for Housing

Several months ago, CMS told state Medicaid offices around the country that Medicaid dollars, usually reserved for clinical services and medications, could be used to help chronically homeless people and others with long-term disabilities to find and maintain permanent housing. That means a fresh source of funds for everything from helping homeless people apply for housing and understand the terms of their lease to teaching them how to get along with neighbors and make healthy food choices. Click here for an update on this development.


RN Survey Says Nurses Make Most in California, Least in Southeast

RNs make the money in California, averaging about $105,000 a year, while RNs in the southeastern United States earn the least on average at about $74,000 a year, according the annual Medscape survey of nursing professionals across the country. Asked if they had to do it all over again, 60 percent of nurses said they would take the same path. More than 8,200 nurses participated in the survey. Click here for all the survey results.

Here’s a Surprise: Expanded Medicaid Leads to Less Charity Care

According to a new Crowe Horwath report, hospitals in states that expanded Medicaid are spending much less on charity care. The report found hospitals in expansion states experienced a 36 percent decline in charity expenditures since the start of 2014. Due to the decrease in uncompensated care in these states, the report found uninsured self-payers decreased 31 percent during the same time. Interestingly, from September 2014 to September 2015, inpatient admissions increased 3.6 percent for non-expansion states while decreasing 1.4 percent for expansion states. Click here for the report.

Premium Increases Reflect Higher Spending for Services

Insurance premium increases in 2016 largely follow health plans’ spending in different areas, with hospital services taking up the largest share at 53 percent, according to an Avalere analysis. 17 percent of premium increases were from prescription drugs and professional services accounted for 21.5 percent. Overall, premiums are rising an average of $25.26 per month. Click here for the complete analysis.


The Check’s in the Mail…No, Really!

About 5.5 million individuals will receive refunds totaling $470 million because insurers failed to spend enough of their premiums payments on medical costs in 2014, CMS announced late last week. Under the Affordable Care Act, insurers in the individual and small group markets are required to spend at least 80 percent of premiums on medical claims. In the large group market that threshold is 85 percent.If insurers fail to meet the requirement — known as a medical loss ratio — they must return the extra money to consumers through refunds or reduced future premiums. Insurers have now paid out more than $2.4 billion in refunds to customers. Click here for details.

CMS Announces $32 Million in Grants to Get Children Enrolled in Health Coverage

CMS announced that it has $32 million in available funds to be used for activities to get eligible children enrolled in CHIP or Medicaid. Proposals are due January 20. The funds will support activities aimed at notifying families of the availability of coverage, identifying children likely to be eligible, and assisting families with the application and renewal process. Health care providers, community and faith-based groups, and schools are among those eligible to apply. Click here for more information and to apply.


$200 Million Targeted in Precision Medicine Research Grants

In an effort to support creation of a national research cohort of one million Americans as part of the Precision Medicine Initiative, the National Institutes of Health on Nov. 17 released the first set of funding opportunities that will lay the foundation for the study. Depending on the outcome of this year’s congressional appropriations process, the initiative could receive $200 million. Click here for details from NIH.

90% of Industries Have Experienced a Health Data Breach

Verizon announced last week that 90 percent of industries have experienced a data breach of personal health information. This information, within the company’s inaugural Protected Health Information Data Breach Report, set for full release in December, highlights the threat to health data outside traditional healthcare settings and industries. Of 20 industries studied, only the utilities and management industries reported no breaches of protected health information. Click here to read the Verizon report.


Internal Medicine Docs Have Highest Reported Use of Quality Performance Measures: Analysis

About one in three healthcare organizations considered “ahead of the curve” in incorporating quality measures into provider incentive plans have more than 10 percent of physician compensation tied to value- and quality-based performance measures, according to a report from Sullivan, Cotter and Associates. Based on the survey, here are the top five specialties with the highest reported use of quality-based performance measures: Internal medicine — 94 percent; Hospitalist, internal medicine — 93 percent;Family medicine — 90 percent; Anesthesiology — 88 percent;Diagnostic radiology, interventional — 88 percent. Click here to get the complete report.


Hope the Best Cardiologists Are Out of Town When You Have a Heart Attack?

Here’s a scary notion: if you’re having a heart attack, going to the best cardiologists may not be in your best interest…this is according to a recent JAMA Internal Medicine study and commented on by noted Dr. Ezekiel Emanuel. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away. Click here for the story.


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