New Scrutiny Targeting Office Visit Medicare Payments
Medicare paid for more than 200 million office visits for established patients in 2012. Overall, health professionals classified only 4 percent as complex enough to command the most expensive rates. But 1,800 providers billed at the top level at least 90 percent of the time, according to a new ProPublica analysis. Experts are questioning whether the charges are legitimate. Click here for the story.
New Physician-Specific Medicare Payment Tracker Released
ProPublica has also produced a physician Medicare payment tracker, allowing users to identify physicians and their Medicare payments, which can also be used to compare physicians. The publication has also delineated office visit payments by physician specialty. Click here for the tracker.
Investigation: Payment Data Identifies Physicians Charging Outside the Norm
CMS’ recent release of raw physician payment data is drawing new scrutiny to practices around the country that appear to be operating well outside the norm. The Washington Post has produced a national map and analysis identifying areas and physicians that are charging the most to administer drugs to patients. They’ve identified areas in Michigan, Florida and Alabama with the highest cost practices. Click here for the map. Click here for the report.
AMA Fighting Back on CMS Data Dump
The American Medical Association reasserted its opposition to CMS’ release of raw Medicare claims data, which it did for the first time last month. AMA sent a letter detailing its issues in a letter last week to CMS Administrator Marilyn Tavenner. For example, the AMA says physicians are not currently able to correct or clarify data in the Provider Enrollment Chain and Ownership System (PECOS) that relates to them. Click here for the AMA letter. Click here for a statement from AMA’s president.
More Insured But Narrow Networks Gaining on Exchanges
Narrow networks, featuring limited groups of providers, have made a big entrance on the newly created state insurance exchanges, where they are a common feature in many of the plans. While the sizes of the networks vary considerably, many plans now exclude at least some large hospitals or doctors’ groups. Smaller networks are also becoming more common in health care coverage offered by employers and in private Medicare Advantage plans. Click here for the New York Times report.
Commercial Insurance Info To Be Made Publicly Available
The Health Care Cost Institute announced last week it will work with three of the nation’s largest health insurance companies, Aetna, Humana and UnitedHealthcare, to develop and provide consumers free access to an online tool that will offer consumers the most comprehensive information about the price and quality of health care services. The independent, not for profit HCCI will create and administer this information portal, which is expected to be available in early 2015. Click here for details.
Analysis: New Transparency Measures Could Save $100 Billion
Several healthcare finance transparency measures could save the sector as much as $100 billion over the next decade, according to a new analysis released last week. Providers have multiple options to expand consumer access to cost information, according to the analysis. For example, they can create an all-claims database where consumers can obtain specific hospital price information for procedures from all commercial and government payers. This alone could save $61 billion over a decade, the analysis suggested. Click here for the analysis.
Study: $10 Billion Spent on Low-Value Services
Despite efforts to increase efficiency in healthcare, a substantial number of Medicare beneficiaries receive low-value services, concludes a new JAMA study. Researchers found between 25 percent and 42 percent of beneficiaries received low-value services that provide little or no benefit to patients. Medicare spent $8.5 billion, or $310 per beneficiary, on services detected by the study’s more sensitive measures of low-value care, while spending on low-value services with more specific definitions totaled $1.9 billion, or $71 per beneficiary. Click here for details.
2-Midnight Rule Guidance Updated
CMS last week updated its 2-midnight guidance. CMS indicates that medical review activities under the Medicare Administrative Contractor Probe & Educate process will be extended through March 31, 2015, as prescribed by law. CMS said it will prohibit recovery auditors from conducting inpatient hospital patient status reviews on claims with dates of admission between Oct. 1, 2013 and March 31, 2015. Click here for the updated guidance from CMS.
Report: Telemedicine Can Expand With Removal of Federal and State Barriers
Federal and state regulatory barriers must be quickly lifted if society is to benefit from telemedicine, according to a report last week by the non-profit Information Technology & Innovation Foundation. The report recommends the federal adoption of a standard definition for telehealth, with a single, national license for providers. It also recommends technology- and location-neutral insurance payment policies, interoperability among state prescription drug-monitoring programs and increased investment in telehealth research, click here.
Medicare Data Being Used to Identify Vulnerable People
For the first time earlier this year, federal officials scoured Medicare health insurance claims to identify potentially vulnerable people facing an powerful storm in New Orleans and shared their names with local public health authorities for outreach during emergencies and disaster drills. The program is just one of a growing number of public and corporate efforts to take health information far beyond the doctor’s office, offering the promise of better care but also raising concerns about patient privacy. Click here for the story.
Hospitals Increasing Competition for Foreign Patients
Hospitals are increasingly competing for one of the most lucrative healthcare demographics: high-income, foreign-born patients with quality insurance coverage or the cash to pay out of pocket, according to an interesting AP report last week. To attract such patients, hospitals are redecorating rooms, adding foreign-language TV channels and changing the color of paperwork in keeping with cultural preferences. Houston’s Memorial Hermann Southwest Hospital gives immigrant patients access to dishes similar to the food prepared in their home countries, such as dumplings, noodles or curry. Click here for the story.
Actuaries Identify Next Year’s Premium Drivers
The American Academy of Actuaries is out with a brief on the key factors that will drive premiums next year. The report cites factors including: the larger health insurer fees in 2015 ($11.3 billion from $8 billion this year) and lower reinsurance payments ($6 billion from $10 billion this year) that will cause an uptick in premiums. State decisions to let carriers renew pre-ACA plans under the Obama administration’s transitional policy will drive them higher, too. Click here for the brief.
Employer Healthcare Costs to Rise about 9% This Year
Employer healthcare costs are expected to rise nearly 9% in 2014, a slight improvement over recent years, according to a new survey. The report released last week found that costs for preferred-provider organization, or PPO, plans are expected to rise 8.7% this year. That’s down from 9% last year. HMO plans should increase 8.6%, down just slightly from the previous year, according to Buck Consultants. Click here for more.
HHS Releases Final 2015 Regs for State Exchanges
HHS released the final rule Friday for health exchanges in 2015. Among other things:
- If states are concerned that allowing employees to choose among multiple insurance companies on the SHOP exchange will lead to higher premiums or adverse selection, they can wait to make the “employee choice” option available until 2016. The option had already been delayed until 2015.
- The rule outlines the state requirements that can prevent navigators and other enrollment assisters from performing their roles as specified by the Affordable Care Act. The rule prohibits navigators from providing cash or gifts to encourage enrollment and clarifies that assisters may not receive payment for their services. It clarifies that targeting specific populations does not violate the law’s broad, non-discrimination requirement.
- The rule requires Insurers to provide enrollees with annual notice of their plan coverage changes, as well as submit data to support the quality ratings of their plans. HHS will give specifics on the quality information required, including how it must be presented and when it will be due, in future technical guidance.
- Starting in 2016, the rule requires that health insurance marketplaces display ratings of their plans’ quality based on a five-star system. They also will need to post results of enrollee satisfaction surveys.
Click here for the 436-page rule.
Senators Want Failed Exchanges to Pay Back Taxpayers
Two leading US Senate Republicans sent a letter to CMS last week urging the agency to recoup its investment into failed state health exchanges. Targeted are Maryland, Massachusetts, Oregon and Nevada. Click here for their letter.
FQHCs See Big Increase in EHR Use
Use of electronic health records increased 133 percent in federally qualified health centers between 2009 and 2013, according to a new Commonwealth Fund survey. Spurred by federal investments and financial incentives to more fully embrace health information technology, 85 percent of FQHCs reported they had achieved advanced HIT capabilities in 2013. The rate in 2009 was just 30 percent. Click here for the report.
AMA Urges Radical Overhaul of EHR Meaningful Use Program
The AMA last week urged the ONC and CMS to radically overhaul the EHR meaningful use program, saying physicians will drop out en masse otherwise. In a letter to CMS and ONC, the AMA charged that the program’s rigid requirements and financial penalties were discouraging physicians despite good faith efforts to incorporate health IT into their practices. It recommended that CMS replace its all-or-nothing approach to achieving meaningful use with a 75 percent pass rate for physicians to receive incentive payments and a threshold of at least 50 percent compliance to avoid penalties. Click here for the letter.
Register for HHS ICD-10 Provider Call
HHS expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. On Wednesday, June 4, at 1:30-3pm EDT, CMS is hosting an ICD-10 Coding Basics National Provider Call. During the call there will be a presentation on more ICD-10 coding basics, along with updates from CMS. Click here to register.
CMS OKs $1000 Per Pill Hep C Drug for One Patient
An Arizona man denied access to new drugs to cure his hepatitis C infection, will get the costly medications after all, according to news reports last week. The real question is whether this sets a precedent for CMS. After NPR and Kaiser Health News reported his plight, federal Medicare officials said they would investigate. Bianco’s appeal of an earlier denial had been rejected by WellCare, a private insurer that contracts with the federal program to provide drug coverage. New hepatitis C drugs can cost as much as $1,000 per pill. Click here for the story.
CDC Recommending New, Costly Drug to Prevent HIV
The CDC is broadly recommending the use of the $13,000-a-year drug Truvada to prevent HIV infection in at-risk populations, the New York Times reported last week. Click here for the story.
Study: Drugs on Popular Exchange Plans Cost Consumers More
The most popular plans on the Obamacare exchanges are about four times as likely to have a “combined deductible” than employer-sponsored policies, according to a report issued this week for the drug industry. Silver plans with the combined deductibles will cover on average about 54 percent of a consumer’s drug costs, while employer plans with separate deductibles cover about 80 percent, the report says. Almost half of silver plans have the combined deductible, but only 12 percent of employer plans do. Click here for the report.
CDC: Half of Americans on Prescription Drugs
Nearly half of all Americans said they had taken one or more prescription drugs over the past 30 days and 10% had taken at least five, a 2007-2010 CDC survey found. Among adults 65 and older, 90% had taken at least one prescription drug over the past 30 days, nearly 47% had taken a cholesterol-lowering drug and more than 70% had taken a cardiovascular drug. Among adults younger than 65, nearly 18% had taken a cardiovascular drug, and the use of cholesterol-lowering drugs increased more than sixfold since the 1988-1994 survey. Click here for a summary and a link to the CDC’s full report.
Spinal Infusion Procedures to Drop
Scrutiny of overuse of spinal fusion procedures and changing reimbursement policies means the spinal fusion market will suffer — or at least stop growing so fast, the London-based GlobalData consulting firm says. US government data shows the procedures increased by 77 percent from 2002 to 2011 as the surgery began to be used for 14 conditions, not the original two. The report predicts there will still be growth — but instead of the current 10 percent rate it will drop to around 5. Click here for the report.
Medicare Anti-Fraud Effort Nets 90, Including 27 Docs
The Attorney General and HHS announced last week that a nationwide takedown by Medicare Fraud Strike Force operations in six cities — Houston, Miami, Tampa, Brooklyn, Detroit, Los Angeles — has resulted in charges against 90 individuals, including 27 doctors, nurses and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $260 million in false billings. Click here for details.
Lawmakers’ Bill Would Make Colonoscopies Free for Some
Lawmakers in both chambers of Congress have introduced legislation (S 2348) introduced last week by Senator Sherrod Brown, D-OH, and previously by Rep. Charlie Dent, R-PA in the House (HR 1070) that would require Medicare to fully cover the cost of the colonoscopies when they reveal something that necessitates treatment. Click here to read the legislation.
About a Third of California Hospital Patients Have Diabetes
Almost a third of hospital patients in California have diabetes, according to a study released last week. The joint study from the UCLA Center for Health Policy Research and the not-for-profit California Center for Public Health Advocacy, has some other compelling findings: Hospitalizations of diabetics cost nearly $2,200 more per patient than hospitalizations of non-diabetics; Extra costs, when totted up, hit $1.6 billion a year; The rate of diabetes was higher among some minority groups, with African-American and Asian-American patients at 39% and Latino patients at 43%. Click here for the study.
Women Still Face Health Care Access Obstacles
While the Affordable Care Act will expand women’s access to health care and help with the cost of that, several structural obstacles to obtaining care remain, according to a report released last week by the Kaiser Family Foundation. In the fall and early winter of 2013, about one in five women ages 18-64 were uninsured. Just 7 percent had individual plans, and 9 percent were on Medicaid. Low-income women went without coverage at a higher rate, as did black women (22 percent) and Hispanic women (36 percent). Women in states choosing not to expand Medicaid will still have no coverage, the report notes, click here for more.
Medicaid Enrollment Increasing in Non-Expansion States
A number of states that did not expand their Medicaid programs under the Affordable Care Act are seeing an enrollment expansion anyway, according to reports last week. Montana, Idaho and New Hampshire are leading the way, click here for more.
New Study Questions Premise of Fish Oil Benefits
Does fish oil help prevent heart disease? The original study that identified the health value of fish oil — which fuels the $1.1 billion fish oil industry — is being called into question in a new study. Click here for the story.