WEEKLY E-BULLETIN


Hospital Readmission Penalties Reach Record High; Hospital-Specific List Provided

Over the next year, 2,610 hospitals will lose some of their payments for each Medicare patient they admit, Medicare records show. This is the third year the industry faces these penalties, which were created by the Affordable Care Act. This year potential fines are the highest: up to 3 percent of Medicare bills. Unplanned readmissions have been a longstanding problem for hospitals. Even though rehospitalizations were less common last year, nearly 1 in 5 Medicare patients returned within 30 days, costing taxpayers $26 billion extra. Click here for a hospital-by-hospital penalty chart covering the past three years.

Federal Database: Docs Receive Hundreds of Millions of Dollars from Drug, Device Firms

In the last five months of last year, doctors and other health care professionals made more than $212 million on speaking and consulting engagements for drug and device makers, according to reports analyzing the new data reported to the federal government and required by the Affordable Care Act. At least 130 doctors, out of about 32,000 named in the database, earned more than $100,000. Click here for a detailed Wall Street Journal report. Click here for the New York Times report.

Another Twist in CMS’ RAC Settlement Deal

CMS’ 68 percent RAC settlement offer was the topic of last week’s CMS open door forum and according to one physician participant CMS added another twist to its offer. The CMS deal could mean every claim denial based on patient status that is still in the process of appeal or has been withdrawn and is being processed for Part B rebilling payment (even if it has not actually been paid by a Medicare Administrative Contractor) must be included if a hospital agrees to the 68 percent deal. Click here for the report.

RACs Rake In Almost $4 Billion in 2013

RACs recovered nearly $4 billion in provider payments in FY13, according to a report released by CMS last week. Click here for CMS’ detailed 58-page RAC report.

GAO: Dual Eligible Programs May Not Result in Expected Savings

Integrating Medicaid and Medicare benefits for disabled dual-eligible beneficiaries may not offer the savings CMS had hoped for, said GAO researchers in a report released last week. For dual-eligible beneficiaries deemed “high-expenditure,” meaning they represented the top 20 percent of spending in each state, Medicaid spending drove almost two-thirds of overall spending in 2009, the report found. States that had more Medicaid expenditures spent more overall, even though Medicare costs were lower. Click here for the GAO report.

Generic Drug Prices Skyrocketing; Congress Wants Answers

Members of Congress are criticizing the significant price increases for generic drugs in letters to 14 pharmaceutical companies and are seeking an explanation. The lawmakers cite data from the Healthcare Supply Chain Association that tracked the pricing of 10 generic drugs and found increases in some cases of 20 times or more. For example, a drug used to treat asthma cost about $11 for 100 pills last October. By April, the price had soared to $434. Click here to read the letters sent to each company.

New Hep C Drug As Expensive As Sovaldi

Gilead will price its soon-to-be-approved hepatitis C combination drug, Harvoni, close to the near-$100,000 cost of the current 12-week regimen of Sovaldi plus pegylated interferon and ribavirin. FDA on October 10 is expected to approve Harvoni, which combines Sovaldi and ledipasvir in a once-daily pill. The European Medicines Agency has approved Harvoni. Sovaldi already cures some 95 percent of people with the most common type of hepatitis C, and the new combination drug is expected to work even better and faster. Click here for more.

Supreme Court To Decide Whether Providers Can Force States to Raise Medicaid Rates

The Supreme Court said last week it will decide whether private sector health care providers can force a state to raise its Medicaid reimbursement rates to keep up with the rising cost of services. The justices agreed to hear an appeal from Idaho, which wants to overturn a lower court decision that ordered the state to increase payments. A 2009 lawsuit argued that the state was unfairly keeping Medicaid reimbursement rates at 2006 levels despite studies showing that the cost of providing care had risen. A federal judge agreed, and the 9th U.S. Circuit Court of Appeals affirmed. Click here for more.

CMS Seeking ACO and Other Innovations

CMS is considering letting accountable care organizations combine with drug plans and Medicaid and accept global payments, CMS innovation center (CMMI) chief Patrick Conway said last week in published reports. The agency plans to soon request input from the public on plan designs for CMS to test, and an opportunity to suggest changes to ACOs. CMMI last week issued an RFI to test innovations in stand-alone Medicare Prescription Drug Plans, Medicare Advantage and Medicare Advantage Prescription Drug Plans, Medicaid managed care plans, Medigap plans, and Retiree Supplemental health plans. Click here for the RFI. Meantime, two House members are pushing legislation to test capitated ACOs. Click here for more.

Report: ACOs And Bundled Payments Combined Are the Next Step

According to an analysis from Navigant, the future of ACOs features the marriage of ACOs and bundled payments. It is what payers want. And it is where bigger savings shared by providers can be optimized if implemented effectively. Click here for their 12-page report.

Study: Percentage of Value Payments to Providers Increasing Significantly

40 percent of commercial sector payments to doctors and hospitals now flow through value-oriented payment methods, defined as payment methods designed to improve quality and reduce waste, according to a new report from the Catalyst for Payment Reform. This is a dramatic increase since 2013 when the figure was just 11 percent. Traditional fee-for-service, where we pay for every test and procedure regardless of its value, may rapidly be becoming a relic. Click here for the summary. Click here for the report.

New Hospital Discharge Requirements Law: Coming to a State Near You?

The New Jersey state legislature has passed a bill that will require hospitals to provide designated caregivers with detailed instructions and training on how to carry out their responsibilities. The legislation would let patients admitted to the hospital identify a caregiver who will be providing assistance when the patient is discharged. When the caregiver is identified, the hospital must include that person’s name, address and telephone number in the patient’s medical record, according to the bill. Click here for details.

Proposed HHS Rule Would Help Make Certain Payment Practices Legal

The HHS OIG has issued a proposed rule that would amend the safe harbors to the anti-kickback statute and the civil monetary penalty rules to protect certain payment practices and business arrangements from criminal prosecution or civil sanctions. The rule would revise the definition of “remuneration” added by the Balanced Budget Act of 1997 and ACA, and add a gainsharing provision. Included in the changes are proposals OIG said are “intended to protect certain arrangements that offer beneficiaries incentives to engage in their wellness or treatment regimens or that improve or increase beneficiary access to care, including better care coordination.” Click here to review the proposed rule.

Law Firm: Health Care Execs Now in DOJ Prosecution Sites

In what could be a shift in Justice Department strategy, one major law firm is telling its clients that health care executives could be the target of DOJ prosecution, rather than the corporations that employ them. Now, DOJ has announced it will be targeting corporate executives for prosecution responsible for the misconduct of their companies. Click here for the law firm’s report.

Lawmakers Urge Obama to Suspend Certain Visas for African Countries “Dealing with Ebola”

GOP lawmakers from Arkansas are asking President Obama to suspend thousands of non-immigrant visas for people in “African countries dealing with Ebola.” U.S. Reps. Tom Cotton,Tim Griffin, Rick Crawford and Steve Womack write in a letter that the “quality of our hospitals, as well as our talented doctors, is undoubtedly a draw for people with the means and will to come to the U.S.” Click here for the letter. On the other hand, CDC Chief Tom Frieden said closing the U.S. border will make it worse. Click here.

Dallas Hospital Says There Was No Flaw in EHR for Ebola Patient

There was “no flaw in the EHR in the way the physician and nursing portions interacted related to this event,” according to the latest statement from Texas Health Presbyterian Hospital in Dallas, which issued a clarification of events surrounding its Ebola case. Click here for the hospital’s updated review of events.

CMS Makes Adjustments to EHR Guidance

On the first day of fiscal year 2015, CMS released guidance for hospitals on meeting meaningful use for the new fiscal year. The notice makes clear that all hospitals must use 2014 Edition Certified Electronic Health Record Technology in FY 2015 and report on 365 days of performance. Click here for the 3-page update.

IOM Report Says EHRs Should Be Equipped To Help Identify Infectious Diseases

An Institute of Medicine bioterrorism report in 2010 said that identifying the “index case” of a bioterror attack — or, by extension, any emerging infectious disease — was the “achilles heel” of defense against it because patients may come into an emergency room with common symptoms.  The IOM committee recommended that hospital EHRs be equipped with software that enables quick identification of the index case. Even with a widely publicized epidemic like the Ebola epidemic, specialists say, it’s unreasonable to expect every triage nurse or ER doctor to have it at the top of their minds because of the many other problems a busy ER deals with. Click here for the IOM report.

Coalition Urges Strong Standards for Transporting Contagious Medical Waste

The Healthcare Coalition for Emergency Preparedness urged DOT not to weaken its standards for transporting highly contagious medical waste, complaining that guidance from the CDC are too lax. DOT and CDC are expected to release joint guidance soon on the issue of transporting Ebola waste. Click here for the Coalition’s letter.

CDC: Enterovirus Continues Spreading

The CDC has confirmed 538 people in 43 states and the District of Columbia with respiratory illness caused by Enterovirus D68. This indicates that at least one case has been detected in each state listed but does not indicate how widespread infections are in each state. Click here for the CDC update.

Hospital Workers Exposes 850 Infants to TB

An El Paso, Texas hospital worker, who exposed more than 850 infants to tuberculosis, was allowed to return to work despite showing symptoms of the disease and coughing up blood at a hospital health screening, a federal report shows. The report from CMS said that the nurse assistant on July 2 told others at Providence Memorial Hospital that she was fatigued and coughing up blood. After a private doctor diagnosed her with TB, she continued to work six more weeks. Click here for the story.

Incidence of Deadly Hospital Virus Levels Off

It’s not all bad news for hospitals on the infection front. The incidence of the potentially deadly bacterial infection known as Clostridium difficile doubled in hospitals between 2001 and 2010, researchers report, and leveled off between 2008 and 2010. C. difficile is a hospital-acquired infection linked to 14,000 deaths a year. According to the CDC, the main cause is the overuse of antibiotics. Click here for the story.

Insurers Will Notify Thousands of Loss of Health Insurance

Tens of thousands of consumers across the country are set to receive notices this fall from their insurers canceling their health plans in the latest sign of how the Affordable Care Act is reshaping the insurance market, according to a Wall Street Journal report. The cancellations are far less widespread than last fall, when millions of people were told their individual insurance plans didn’t meet the law’s more-stringent coverage requirements. Click here for the story.

One Year Since Start of Exchanges – What Are the Results?

It has been one year since the disastrous rollout of the federal and state health insurance exchanges and senior Obama Administration officials are promising a better rollout in year two. Click here for an LA Times review of what the impact of the new law has been in the past year.

Consumer Reports: Americans Angry Over High Cost of Health Care

Americans have become angry over rising healthcare costs, Consumer Reports reported. Twelve percent of nearly 1,100 American adults surveyed said they spent more than $5,000 of their own money on medical bills in the past year, and 11 percent said they had trouble paying their medical bills. Click here for their story.

Publicly Available Physician Quality Data Not Helpful

The Affordable Care Act requires CMS to provide physician quality data, but that database offers only the most basic information. It’s so limited, health care experts say, as to be useless to many consumers. Click here for the USA Today story.

Insurer Business Models Moving to be Consumer Focused

Insurers need to update their business models if they want to thrive amid “a fast growing wave of consumerism,” according to a new report from healthcare investment firm Psilos Group. The report pointed out that 40 percent of the health insurance market now consists of individual plans, a large jump from the 10 percent share of the market before implementation of the Affordable Care Act. Click here for details.

HHS To Strengthen Medicaid Managed Care Access Rules

The HHS OIG is urging CMS to strengthen its oversight of Medicaid managed care access after finding that state requirements vary widely. The agency, which is preparing for its first major update of Medicaid managed care regulations, agreed with the OIG’s recommendations and said it is working to develop guidance for states. The report — which looked at 33 states that have comprehensive, “full risk” Medicaid managed care plans — found that states’ standards can vary widely from requiring one primary care provider for every 100 enrollees to one primary care provider for 2,500 enrollees. Click here for the OIG report. In another development, CMS released a new rate-setting consultation guide for Medicaid managed care programs. Click here.

GAO: Insurance Risk Corridor Funding In Question

The Affordable Care Act did not properly authorize spending on so-called risk corridors intended to shield health insurers from heavy losses, but there may be other sources of funding for the program, the GAO reported last week. The GAO’s report joins an opinion earlier this year from the nonpartisan Congressional Research Service in finding that the ACA directed regulators to spend money on risk corridors but failed to officially supply a source of revenue. Click here for the GAO report.

Study: Too Many Hospice Patients Get Late Admission

One in six terminal cancer patients enroll in hospice only during their last three days of life, according to a new study from a team from the Perelman School of Medicine at the University of Pennsylvania. Their findings, published online in the Journal of Clinical Oncology, also reveal a profile of patients who may be most at risk of these late admissions. Click here for the story.

Heroin Related Deaths Doubled

Heroin-related deaths across 28 states doubled between 2010 and 2012, according to a new survey from the CDC. However, despite the sharp increase, more than twice as many people in those states died of prescription opioid overdoses in 2012. CDC researchers reviewed death certificate data in 28 states representing 56% of the U.S. population. Click here for the CDC report.

NIH Released First BRAIN Grants

The National Institutes of Health has issued the initial $46 million in research grants under President Obama’s Brain Initiative, kick-starting projects such as classifying cell types in the brain and creating futuristic human brain imaging technology. The goal is to develop better treatments of illnesses like Alzheimer’s and epilepsy, or simply develop a deeper scientific understanding of how the human brain functions. Click here for the NIH announcement. Click here for the WSJ story.