ICD-10 To Start This Week – On the Same Day the Government Could Be Shut Down

The Federal government may shut down Thursday unless Congress passes legislation by then to keep the money flowing – and there is some concern about what could happen to the transition to ICD-10 on that same day. Click here for details. A shutdown won’t stop ICD-10 from starting and claims will be paid, according to CMS’ Deputy Administrator. Click here. CMS has conducted extensive testing of the systems implemented to support transitions to ICD-10, but the true functionality of those systems will not be fully known until code processing begins October 1, according to a GAO study. The report details CMS’ claims processing systems updates, the testing and validating of those system changes in order to minimize the impact of system errors, the technical support CMS will offer stakeholders in processing claims and the estimated cost of updating CMS’ systems — approximately $116 million thus far. Click here for the GAO report.


Aetna, Anthem CEOs on the Congressional Hot Seat

Senators took swipes at the CEOs of Anthem and Aetna last week at the first of two hearings on the proposed mega-deals that could combine Anthem and Cigna and Aetna and Humana. The two deals together would shrink the top five U.S. health insurers to a big three, each with annual revenue of more than $100 billion. The third player would be UnitedHealth Group Inc. Click here for the WSJ story. Click here for Anthem’s CEO testimony. Click here for Aetna’s CEO testimony. The House takes up the issue this week (click here), and if last week offered any indication, insurers should expect some hard hitting questions from Democrats especially. Public Integrity is out with a report on how the insurers are using lobbying muscle and campaign cash to get the mergers done. Click here.


High Cost of Drugs Fuels Public Outcry and Political Campaigns

The high cost of pharmaceuticals is fueling renewed attention on the issue. Little known Turing Pharmaceuticals acquired the rights to Daraprim, a drug to treat life-threatening parasitic infections, in August and increased the price from $13.50 a tablet to $750. The outrage caused by the dramatic price escalation has cause the young new CEO to change his mind. Click here. Drug boss Martin Shkreli, 32, reportedly was previously accused of a “bizarre campaign of employee harassment.” Click here. Meantime, another new report says Americans are overpaying hugely for cancer drugs. Click here. And presidential candidate Hillary Clinton released a controversial proposal to reign in Rx prices. Click here.


Members of Congress Pushing CMS To Change Reg Proposals on Joint Replacements, Home Health and More…

60 House Members Want Changes to Mandatory Joint Replacement Regs

  • 60 Members of Congress, including six Democrats, signed onto a letter lead by House Budget Committee Chairman Tom Price (R-GA) requesting CMS to delay the proposed Comprehensive Care for Joint Replacement (CCJR) Payment Model for 1 year. The letter states that providers need more time to prepare for implementation since this will be CMS’ first mandatory bundled payment model. The signers have posed a series of questions to CMS asking what protections and safeguards are in place to ensure quality and access to patients as well as providers across the continuum of care. Click here for the letter and to see if your Rep. signed on.

Representatives Concerned About Value-Based System for Home Health

  • 133 bi-partisan Members of Congress expressed their concern over CMS’ proposed value-based payment system for home health agencies. The letter states the proposed cuts in this system are based on a case mix that’s out of date and that this would drive reimbursements to “unsustainable levels” for home health providers, particularly small and rural providers. Click here for the signed letter.

Stark Law Focus of Congressional Letter to CMS

  • Reps. Charles Boustany (R-LA) and Ron Kind (D-WI) have sent a letter asking CMS to consider including aspects of their Stark Administrative Simplification Act (H.R. 776) in the final CY2016 Physician Fee Schedule Rule. The Congressmen state that while CMS has attempted to address concerns with technical violations of the Physician Self-Referral, or Stark, law, the proposed rule doesn’t give providers enough certainty. The Stark Administrative Simplification Act would create an expedited process for resolving technical violations under the self-referral law and has been endorsed by the American Hospital Association, Federation of American Hospitals, National Rural Health Association and the Healthcare Financial Management Association. Click here for the letter.

Advanced Imaging Rule Focus of House Letter to CMS

  • 29 Members of Congress led by Rep. Michael Burgess (R-TX) sent a letter to HHS expressing support for the framework that CMS has taken in proposing a definition that would let provider groups like the American College of Radiology or the American Association of Family Physicians be the arbiters of the Appropriate Use Criteria for patients seeking imaging services like MRIs and CTs. Click here for the letter.


Major Health Insurers on a Nurse Hiring Spree

Health insurers have taken the trend of payer-provider collaboration a step further, adding more nurses to their ranks than ever before. Cigna, for instance, employs six times the number of nurses than in did a decade ago, with about 2,000 currently on staff. Humana, meanwhile, has 10,500 nurses, or seven times the number it had in 2010. And Health Care Service Corp., which owns five Blue Cross and Blue Shield plans, plans to increase its hiring of nurses by 15 percent each of the next six years. The nation’s largest insurer beats them all: UnitedHealth currently has more than 15,000 nurses on staff. Click here for this interesting story from Forbes.


BCBS Launching Nation’s Largest Health Care Database

The Blue Cross Blue Shield Association announced last week that all of its 36 member companies will contribute healthcare quality and cost information to BCBS Axis, which the company bills as the “largest database in the healthcare industry.” Axis will aggregate secure cost data from more than 2.3 billion procedures each year, from 96 percent of all hospitals in the country and 92 percent of doctors. That data will also reflect more than $350 billion in annual claims, 36 million provider records and information from every ZIP code in the country. Click here for details.


Hospitals Urge Labor Board Not To Change Key Employee Bargaining Rule

Two national hospital groups have asked the National Labor Relations Board to keep a rule in place that excludes jointly employed workers from bargaining unless both of their employers consent to doing so. Such workers include traveling nurses, who regularly fill in at hospitals during vacations and work stoppages. Demand for traveling nurses recently hit a 20-year high due to rising hospital admissions since the implementation of the Affordable Care Act. In protest to potential changes to the rule, the American Hospital Association (AHA) and the Federation of American Hospital Systems (FAH) filed an amicus brief that says the new rule could force hospitals to bargain with these groups of employees even though the organizations may not have any actual control over the contingent workers’ terms and conditions of employment. Click here to read their brief.


OIG Says Oklahoma, Texas, Louisiana, Massachusetts Were Overpaid on EHR Incentives

HHS’s Inspector General is going after states, hospitals and physicians on EHR incentive payments – or overpayments. In a report released last week the OIG said Oklahoma Medicaid mispaid $888,000 to 47 hospital-based doctors and recommended the state refund the federal government $127,500 in incorrect EHR incentive payments. Click here for that report. In a report on Texas (click here), the OIG said the State overpaid 26 hospitals a total of $13.9 million and underpaid 12 hospitals a total of $1.4 million, for a net overpayment of $12.5 million. Click here. For Massachusetts, the OIG said the state overpaid 13 hospitals a total of $2.7 million and underpaid 6 hospitals a total of $564,000, for a net overpayment of $2.1 million (click here). And in Louisiana, the OIG said the state overpaid 13 hospitals a total of $3.1 million and underpaid 6 hospitals a total of $1.3 million, for a net overpayment of $1.8 million (click here).


Largest Catholic Hospital System CEO Encouraged by Pope To Do More

On the heels of the visit by Pope Francis to the United States, Anthony Tersigni, CEO of the Catholic health system Ascension, is looking for new ways to expand the care to the poor already provided by hospitals. Ascension, based in St. Louis, is the largest Catholic hospital system in the world and the largest non-profit health system in the USA, Tersigni, who chairs the International Association of Catholic Hospitals, will meet with Francis in the Vatican in November to discuss the pope’s push to get Catholic-owned health care providers to do more to help the poor. Click here for the USA Today story.


Report: We Must Improve Diagnosis in Health Care

The National Academy of Medicine is out with a landmark report on improving diagnosis in health care. The report concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors—inaccurate or delayed diagnoses—persist throughout all settings of care and continue to harm an unacceptable number of patients. For example: A conservative estimate found that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error. Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths. Medical record reviews suggest that diagnostic errors account for 6 to 17 percent of hospital adverse events. Click here for their report.


ACA Enrollment Season Focuses on Four States

With the third open enrollment season under the Affordable Care Act beginning in about six weeks, Obama administration officials said last week that they would focus efforts to expand health coverage to the uninsured in Dallas, Houston, northern New Jersey, Chicago and Miami. The administration plans to focus on 10.5 million uninsured Americans who were eligible for coverage through the public insurance exchanges, also known as marketplaces. The enrollment period runs from Nov. 1 through Jan. 31, 2016. Click here for details. Meanwhile, the Administration said last week that Obamacare enrollment had swelled to more than 17 million. Click here.

  • Average Medicare Advantage premiums will decline by 31 cents next year to $32.60, and 59 percent of enrollees won’t see any price increases, CMS said last week. Next year, roughly 17.4 million seniors are expected to be enrolled in MA plans. Click here for more from CMS.

Judge Says Hospitals Can Fight 2-Midnight Payment Cuts

A federal judge has ruled that hospitals should get another chance to fight a 2013 rule that cut payments for inpatient services as part of CMS’s controversial “two-midnights” policy. The cut will stand while CMS provides additional information and considers comments. The American Hospital Association and several individual hospitals sued HHS over the rule when it was finalized, arguing that the agency lacked the authority to cut payments and had failed to explain its reasoning in time for public comment. The court disagreed with that first argument but agreed with the latter. Click here for the judge’s ruling.


CMS Proposes New Medicare Clinical Diagnostic Laboratory Tests Fee Schedule

CMS late last week announced its next step in implementing the Protecting Access to Medicare Act of 2014 (PAMA), requiring clinical laboratories to report on private insurance payment amounts and volumes for lab tests. This data will be used to determine Medicare’s payment for lab tests beginning January 1, 2017. Medicare pays approximately $8 billion a year for clinical diagnostic laboratory tests. The new system will be updated every three years for clinical diagnostic laboratory tests and every year for ADLTs to reflect market rates paid by private payers. Click here for more from CMS.


Fourth Co-Op Insurer Shutting Down

Health Republic Insurance of New York, which attracted more than 200,000 customers during its first two years of operations, is being forced to shut down at the end of the year by state and federal regulators. The co-op plan attracted more customers than any other nonprofit startup seeded with Affordable Care Act loans. But it also lost the most money, with roughly $130 million in losses during its first 18 months of operations, according to financial filings. Health Republic becomes the fourth Obamacare co-op plan to collapse. Previously, startup insurers based in Iowa, Louisiana and Nevada have shut down or announced plans to cease operations at the end of the year. Click here for more information.


Analysis: States Have Avenue of Fundamentally Changing Affordable Care Act

With current financing of U.S. health care highly dependent on federal health spending and tax subsidies for private insurance, state leaders seeking to take health reform to the next level face the quandary of losing federal funding flows if they act unilaterally to control health care spending, according to a new analysis from the nonpartisan, nonprofit National Institute for Health Care Reform. However, Section 1332 of the Affordable Care Act opens the door for states to fundamentally rearrange state and federal government roles in regulating and financing health care by allowing states to request federal waivers of many key ACA provisions. The catch, however, is that alternate state reforms must achieve the same or better health coverage and affordability for state residents and be budget-neutral for the federal government. Click here for the analysis.


House To Vote on Planned Parenthood Bill This Week

The House is expected to vote this week on a bill to allow states to exclude Planned Parenthood from their Medicaid programs. The bill, sponsored by Rep. Sean Duffy (R-WI), would allow states to exclude parties from Medicaid based on their “involvement with abortions.” Three Republican-led states that have moved to cut Planned Parenthood clinics from their Medicaid programs in the past month are facing lawsuits. The Obama administration has warned those states their moves are likely illegal because Medicaid law allows enrollees to see providers of their choosing. Click here to see the 2-page legislation.


Government Issues 5-Year Health IT Strategic Plan

The ONC has finalized the Health IT Strategic Plan for the next five years, which focuses on advancing health IT use in the US. The 35-office plan promotes four overall objectives: person-centered and self-managed health, research and science, the transformation of health care delivery and better health IT infrastructure. Click here for the ONC’s report.


CDC: 10 Percent of Pregnant Women Report Drinking Alcohol

One in 10 (10.2 percent) pregnant women in the United States ages 18 to 44 years reports drinking alcohol in the past 30 days. In addition, 3.1 percent of pregnant women report binge drinking – defined as 4 or more alcoholic beverages on one occasion. This means that about a third of women who consume alcohol during pregnancy engage in binge drinking according to a report in CDC’s Morbidity and Mortality Weekly Report release last week. Click here.