WEEKLY E-BULLETIN


CMS Issues Financial Report on Pioneer ACOs

Of the 32 original Pioneer ACOs, 18 reported gross savings in the first year, according to data released by CMS last week. The best-performing ACO that year was Montefiore ACO in the Bronx, New York, which reported savings of $23.3 million, or 7.1 percent, and $14 million in shared savings. But 14 posted losses in the first year. The highest losses were posted by Fort Worth-based Plus!/North Texas ACO, with a loss of $9.31 million, or 5.2 percent. Click here for the CMS data, which is a 1-page summary. Click here for a detailed look from the Washington Post at Montefiore’s program.

Ebola Update – A Hospital Focus

More details are being published about the management of Ebola cases at Texas Health Resources. The CDC chief said yesterday there was a breach of protocol at the hospital where a health care worker has contracted the virus. Click here. Boston.com has an updated chronology of events regarding the first confirmed Ebola patient. Click here. Click here for a statement from the hospital’s chief clinical officer about the health care worker there that has tested positive for Ebola. For daily updates from Texas Health Resources, click here.

CMS Revising Home Health Regulations

CMS announced last week that it will revise the existing Conditions of Participation (CoPs) that Home Health Agencies must meet to participate in the Medicare program. The CoPs in use today have been in place and essentially unchanged since 1987; the only substantial change being the requirement to use the Outcome and Assessment Information Set (OASIS), which was added in 1999. Click here for our policy team’s 2-page summary. Click here for the rules. In the meantime, the Department of Labor will effectively delay a regulation, previously set to take effect in January, that grants overtime to home health care workers. Click here.

AMA Report: Insurance Market Sees Further Consolidation

WellPoint Inc. has a bigger geographic footprint than any other private health insurer in the United States, according to the new annual study of health insurer competition by the American Medical Association. The study found that WellPoint, soon to be renamed Anthem Inc., was the largest health insurer by market share in 82 of 388 metropolitan areas. Health Care Service Corp. was second with a market share lead in 37 metropolitan areas, followed by UnitedHealth Group with a market share lead in 35 metropolitan areas. Click here to see the 10 most and 10 least competitive states. Click here to access more information from the AMA.

CMS Releases Star Ratings for MA Plans and Drug Plans

CMS on Friday released 2015 star ratings for Medicare Advantage and stand-alone drug plans and published plan ratings on Medicare Plan Finder to help seniors choose plans. About 60 percent of beneficiaries who choose Medicare Advantage enrolled in high-performance plans for 2015, CMS says, and 53 percent of Part D beneficiaries enrolled in stand-alone prescription drug plans with at least a four-star rating on a five-star scale. In 2009, just 17 percent of Medicare Advantage enrollees and 16 percent of Part D enrollees were in high-performance plans. Click here to open the very large file that includes all the results on all the plans.

Nursing Homes to See Changes in Star Ratings

CMS last week announced changes to the rating program for nursing homes. The facilities now have to report quarterly staffing levels, and an auditing program checks if quality measures rating based on patient information is accurate. Click here for the NY Times report. Click here for the CMS announcement.

Major Nursing Home Chain Fined

One of the nation’s biggest nursing home chains, Extendicare, has agreed to pay $38 million to resolve federal claims that it inappropriately billed for physical therapy and provided such poor care to residents that it was effectively worthless, the Justice Department said last week. Click here for the Justice Department announcement.

Full Pricing Disclosure Starts in Massachusetts

In a significant development that started this month, anyone with private health insurance in the state of Massachusetts can now go to his or her health insurer’s website and find the price of everything from an office visit to an MRI to a Cesarean section. For the first time, health care prices are public. However, there some caveats. Click here for the report.

340B Drug Fight Continues; New Suit Filed

The fight over the 340B drug discount program continued last week. The Pharmaceutical Research and Manufacturers of America last week filed suit in federal court to vacate an HHS interpretive rule pertaining to 340B orphan drug discounts. (Click here for a copy of the lawsuit.) PhRMA’s lawsuit challenges a July HHS and Health Resources and Services Administration interpretive rule that continues to allow hospitals subject to the orphan drug exclusion to purchase orphan drugs through the 340B Drug Pricing Program. Click here for the reaction from the 340B coalition.

340B Study Questioned

Fighting back on 340B, a blog post in Health Affairs last week raised serious questions about a study that had been previously published by the journal that concluded that some hospitals are being enriched by the program well beyond its intent. Click here to read the rebuttal.

New Hep C Drug Is a “Deal” at $94,500

The new hepatitis C drug, Harvoni, approved last week by the FDA, will cost $94,500 for a 12-week treatment course — compared to $84,000 for Sovaldi, the drug on which it is based. Insurers and a coalition of hospitals, employer and consumer groups have pressured manufacturer Gilead to bring Sovaldi’s cost down, saying it is unsustainable because of the large population that potentially needs it. CDC estimates that 3 million Americans have the viral liver disease. Patients who have never been treated for hepatitis C can be cured with an 8-week course, which will cost about $63,000. Click here for more from the FDA.

Exchange Customers More Likely to Use Specialty Drugs

Consumers who enrolled in plans sold on the health insurance exchanges are 59 percent more likely to use pricey specialty drugs, particularly medications that treat HIV and hepatitis C, than people with employer-based coverage, according to a new study from Express Scripts. Of all specialty drug prescriptions, about 57 percent were for HIV drugs, compared to just 20 percent of specialty medications filled for members in employer-based plans. Click here for the study.

More States Requiring “Observation” Notification

3 states have it and at least 3 more are now considering it: a law that requires hospitals to inform patients whether they have been admitted or are on observation status. Connecticut’s new law started last week. Click here for details.

CMS Extends Hardship Exemptions for Meaningful Use

CMS last week reopened the period to request hardship exemptions from so-called Meaningful Use requirements for electronic health records, giving some doctors and hospitals another opportunity to avoid penalties in 2015. The move follows stakeholders’ calls earlier this year for more time to submit hardship requests and lawmakers’ requests that some providers attesting to Meaningful Use for the first time in 2014 be allowed to avoid penalties in 2015. Click here for the info from CMS.

HHS Report Says EHR Adoption Continues Growth

59 percent of hospitals and 48 percent of physicians had at least a basic EHR system, up 47 percent and 26 percent respectively since 2009, the year that the HITECH Act was enacted – according to a new report submitted to Congress last week. As of June, 75 percent of eligible professionals and 92 percent of eligible hospitals and critical access hospitals have received incentive payments pursuant to the Meaningful Use program. Click here to read the HHS report.

Report Recommends Improvements to Digit Health Strategies

The Commonwealth Fund is out with a report making recommendations on what it will take to move digit health strategies into meaningful, long-term innovations. Click here for the 20-page report.

Analyst: RAC Numbers Aren’t Truthful

The federal government is lying about certain aspects of the Recovery Audit Contractor program, according to an analyst who closely follows RACs. The government’s recently released RAC report for 2013 (click here) says that only 18.1 percent of hospital challenged claims were actually overturned. Not so, says Frank Cohen, who outlines his arguments here.

Next Exchange Enrollment Expected to be Smoother

The second round of open enrollment for health insurance on the federal marketplace begins Nov. 15 and continues for three months, half the length of the first enrollment period. The Obama administration officials said last week that consumers would have a much easier time this fall, and although they promised that HealthCare.gov would not crash, they provided few operational details to back up their confidence in the revamped website. Click here for the NY Times report.

One in Four Latinos Have No Health Insurance

A year after open enrollment for the ACA began, one in four Latinos living in the U.S. does not have health insurance, according to new census data, more than any other ethnic population in the country—and most states have few backups in place to help those in the coverage gap. Click here for the story from Pew Charitable Trusts.

CMS Announces 2015 Part A, Part B Copays, Deductibles

The Medicare Part A deductible – for inpatient hospital, skilled nursing facility and home health services – will increase by $44 in calendar year 2015, to $1,260, CMS has announced. The daily coinsurance amounts will be $315 for days 61-90 of hospitalization in a benefit period; $630 for lifetime reserve days; and $157.50 for days 21-100 of extended care services in a skilled nursing facility in a benefit period. The base Part B monthly premium and annual deductible will be unchanged for CY 2015 at $104.90 and $147, respectively. The base Part B premium is adjusted upward for higher income beneficiaries. Click here for the 11-page CMS.

Report: Reference Pricing Won’t Decrease Health Spending

Although the practice of reference pricing helps emphasize the wide variation in medical costs, it doesn’t actually decrease healthcare spending, according to a new report from the National Institute for Health Care Reform. The analysis simulated the impact of reference pricing for claims data on 528,000 consumers in 2011 by applying the price capping method to about one-third of those claims. It determined that reference pricing would only decrease costs by 5 percent, excluding the amount of money needed to actually operate the system. Click here for the study.

FQHCs Struggling Financially

Although Medicare increased payments to FQHCs by as much as 32 percent under a new payment system in the Affordable Care Act, the centers still lack funding for operational necessities, according to a physician researcher who posted a new report last week. And the increasing popularity of Medicare and Medicaid plans means states are enrolling more members than FQHCs can handle. Click here for the blog.

$238 Million Invested in National Health Service Corp in FY14

HHS announced last week that $283 million has been invested in the National Health Service Corps in fiscal year 2014 to increase access to primary care services in communities that need it most. Now, more than 9,200 Corps clinicians are providing care to approximately 9.7 million patients across the country. Click here for more from HHS.

Hospital-Led Hunger Summit in Atlanta

Health systems, regulators, legislators, and business leaders are coming together for a half-day summit to address hunger and other social determinants of health in a Friday, November 14 Come to the Table Summit at the Carter Center in Atlanta. The event will run from 8:30am to 2:00pm and feature a keynote address by Audrey Rowe, Administrator for the Food and Nutrition Service at the USDA. Click here to register for the Nov. 14 Summit and more information about the summit can be found here.

HRSA Awards $1.4 Million to Help Rural Enrollment

The Health Resources and Services Administration has awarded $1.4 million in grants to help hospitals, rural health centers, health departments and community health centers in 57 rural communities enroll Americans in health insurance coverage. The non-profit and public entities received up to $25,000 each under three Office of Rural Health Policy programs. Click here to see who got the money.

CBO Says FY14 Deficit Lowest in Six Years

In what could have a significant impact on what next year’s Congress could change in health care spending, rising tax receipts and slower spending growth propelled a reduction of the fiscal 2014 deficit to an estimated $486 billion, the lowest since the $459 billion deficit in fiscal 2008, the Congressional Budget Office said last week. The deficit for the fiscal year that ended Sept. 30 is $195 billion, far less than the $680 billion deficit in fiscal 2013, according to the CBO estimate. Click here for the full CBO report.

NIH Awards $32 Million for Biomedical Data Sets

The National Institutes of Health yesterday awarded $32 million to develop new strategies to analyze and leverage an “explosion of increasingly complex biomedical data sets.” The awards will support the development of new approaches, software, tools and training to help researchers access and use large data sets to improve human health. Click here to see the organizations that were funded, which include several hospitals, but mostly major universities.

Motor Vehicle Crashes Send 200,000 to ED in 2012

More than 2.5 million Americans went to the emergency department, and nearly 200,000 of them were hospitalized, for motor vehicle crash injuries in 2012, according to a new Vital Signs report from the CDC. CDC estimates their lifetime medical costs at $18.4 billion and the lifetime cost of their work loss at $32.9 billion. Click here for more from the CDC.

SAMHSA, NIMH Release Mental Health, Substance Abuse Report

An estimated 22.5% of American adults, or 51.2 million people, reported at least one mental health or substance use disorder in the past year when interviewed during 2008-2012, according to a report released by the Substance Abuse and Mental Health Services Administration and National Institute of Mental Health. Click here for the report.

AHA PAC Airs Ad for Kansas Senator

I don’t normally report on political campaigns, but thought it was worth noting that the political action committee of the American Hospital Association is up with a new TV ad in the Kansas Senate race and warns voters not to replace GOP Sen. Pat Roberts. The AHA has reportedly reserved about $200,000 worth of air time in Topeka and Wichita markets for the next two weeks. Click here to see the 30-second spot.