Most Hospitals NOT Meeting Target C-Section Rate: Leapfrog Group

After championing a drastic reduction in the occurrence of early elective deliveries at hospitals, The Leapfrog Group last week released new information on hospital rates of C-sections. Of the hospitals analyzed this year, less than half (39.1 percent) met Leapfrog’s target rate. Among reporting rural hospitals, 49.7 percent achieved the target rate of 23.9 percent or lower, whereas only 36.8 percent of urban hospitals met the target. States like Utah and Idaho excelled with average rates less than 20 percent, whereas others like Kentucky and Florida failed to achieve the target, with average rates over 32 percent. Click here for a summary. Click here for the hospital-specific list – about half the hospitals declined to respond.

  • The U.S. birth rate rose 0.6% in 2014 to 62.9 per 1,000 women, the first increase since 2007, according to a new report by the CDC. The Cesarean delivery rate declined 1.5% in 2014 to 32.2% of all births. Cesarean rates for African American, Hispanic and Asian/Pacific Islander women fell for the first time since 1996, by about 1%. Click here for more from the CDC.

Medicare Advantage Plans Showing Improvement with Star Ratings

The 2016 Medicare Advantage Star Ratings were released last week by CMS and the results show an improvement year over year in the number of high-performing plans. About 49 percent of Medicare Advantage plans with Part D prescription drug coverage (MA-PDs) earned four stars or higher for their 2016 rating, up from 40 percent of MA-PDs that did so for the 2015 ratings. Seventeen MA plans this year earned the highest rating–five stars–seven of which are new to the top ranks: Cigna Healthcare of Arizona Inc., Tufts Associated Health Maintenance Organizations, Group Health Plan Inc., Essence Healthcare Inc., Medical Associates Clinic Health Plan, Sierra Health and Life Insurance Company Inc. and Tufts Insurance Company. Last year, 16 plans earned a five-star rating. Click here for details from CMS. Click here for all the CMS ratings (zip file).


Seniors Using High-Cost Services Leaving MA Plans

Seniors who used high-cost medical services are more likely to leave Medicare Advantage plans in favor of traditional Medicare, according to a new study in Health Affairs. In particular, patients who use nursing home or home health care are much more likely to abandon their MA plans. The authors noted, “Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.” Click here for the study abstract (subscription required for complete study.)


Consumers Union Releases Names of 12 Hospitals with Lowest Infection Scores

Consumers Union is out with a new report that identifies what they believe are the 12 hospitals with the lowest scores for avoiding five infections. The consumer’s organization is also posting the hospital scores on Twitter. The hospital ratings provide a snapshot of how hospitals performed in a given time period, and they say they use the best and most relevant data available to them. Note that if the hospitals provide a written response it is posted to the website. Click here for the hospital list and further details. Click here on how the media wrote about a hospital on the list in its area.


MedPAC Reviews New Payment Options for Rural Hospitals

The Medicare advisory commission to Congress last week discussed payment reforms intended to preserve access to emergency services in rural America and professional staffers proposed moving away from inpatient-centric payment models and cost-based payments towards a combination of PPS payments and fixed grants. Two new models for rural emergency care were presented:

– Model 1: Rural hospitals can convert to freestanding 24/7 emergency departments that do not offer inpatient services; paid at PPS rate and receive fixed grant for standby services, SNFs paid at PPS rates

– Model 2: Rural hospitals can convert to a primary care clinic and ambulance – similar to the FQHC model; paid at PPS rate and receive fixed grant to pay for ambulance stand by costs.

Commissioners from rural areas considered how these models would affect facilities’ ability to recruit physicians, cover uncompensated care, and provide hospitals with the flexibility to revert back to a hospital if the community’s health care needs were not met under the new model. Click here to review MedPAC’s slide presentation.


Feds Seeking Solutions to Hold Down Medicare Premiums

Congress and the Obama administration are frantically seeking ways to hold down Medicare premiums that could rise by roughly 50 percent for some beneficiaries next year, according to lawmakers and Medicare officials.The administration has criticized commercial insurance companies for seeking rate increases much smaller than that. The cost of avoiding such big premium increases, $7.5 billion by some estimates, could be a problem for conservative Republicans. Click here for the NY Times report.


Lawmakers Urge CMS To Increase OPPS Payments, Not Cut Them

A bipartisan group of 95 House lawmakers last week urged CMS to scrap its proposed payment cut for hospital outpatient services and provide a positive update in its final outpatient prospective payment system rule for 2016. “Prescribing a negative update to OPPS payment rates will only make it more difficult for hospitals to serve their patients and their communities, particularly as they move to adopt delivery system reforms.” Reps. Pat Tiberi (R-OH) and Richard Neal (D-MA) led the House effort. Click here to see if your representative signed on.


Stage 3 Meaningful Use Regs Released

Despite efforts from Congress to get CMS to delay its release and implementation, the agency last week released the rule to finalize changes to stage two of the meaningful use program and set up stage three of the program. An outline of the final rule is contained in this CMS fact sheet. The 752-page rule finalizes requirements for the meaningful use program for 2015 through 2017 and for 2018 and beyond. Click here for the rule. There is a 60-day public comment period. Click here to see the mixed response of health care organizations – it also includes a good, brief summary. Click here for another brief summary.


OIG Issues Alert for Questionable EHR Donations

HHS’s Office of the Inspector General is out with a new alert that it is keeping an eye out for Stark and anti-kickback problems with EHR donations. Stark and anti-kickback exemptions allow hospitals to subsidize purchases of EHRs, to help defray the large capital costs associated with starting up the typical EHR. Critics charge that they are doing this to use limited interoperability to trap referrals inside the system, or to inspect the donor’s data to determine when they could be capturing more referrals. Click here for the OIG’s alert.


Price Guarantees Coming for Rx and Medical Devices

Value-based purchasing is not only impacting providers, but now payors and providers want a similar system for drug and device manufacturers. For example, St. Jude Medical is offering all its hospital customers a guarantee on one of its products, an implantable cardiac resynchronization device called the Quadra CRT system that it introduced in 2011. St. Jude will refund hospitals 45 percent of the Quadra’s cost if a patient needs corrective surgery within a year. Click here for the Bloomberg report.

  • Cancer doctors are increasingly declining to prescribe medicines that have little or no effect, even as a last resort. Click here for the story.
  • The Wall Street Journal is out with a report on how Rx price increases are driving Rx company profitability. Click here.

Federal Government May Need To Act To Reign In Rx Prices: MedPAC

Federal officials and lawmakers soon may face tough decisions on whether to peg payments for new medicines to the value they deliver for patients, with the aging of the population and ads directed at consumers set to increase Medicare’s pharmaceutical costs, MedPAC reported last week. The Medicare Payment Advisory Commission engaged in a broad preliminary discussion of potential approaches to managing the future cost of buying drugs for the nation’s elderly and disabled. There appeared to be broad consensus about a need to make Medicare, the nation’s single biggest purchaser of health care, a much more demanding customer when it comes to drugs for the more than 50 million people for whom it provides health care. Click here for the MedPAC slides used during the staff presentation.

  • With Medicare Part D nearing the end of its tenth year, the program — which now provides drug coverage to 72 percent of all Medicare beneficiaries — has experienced no growth in average premiums in recent years but some notable increases in cost-sharing, according to a new report. Click here.


New Analysis Shows Wide Price Variations Nationally for Mammograms and Other Screenings

Nationwide for a mammogram, a woman could pay anywhere from $43 to $1,898 for the test, a 44x difference, according to a new analysis released last week by Castlight Health. With some of the country’s largest cities, the clear indication is that women in larger metropolitan areas are being charged wildly varying amounts for a critical preventative test. For example: In Dallas, which has the nation’s widest range, a woman could pay anywhere from $50 to $1045, roughly a 21x difference. In New York City, the price can vary between $130 to $1,898, roughly a 15x difference. New York also has the most expensive mammograms in the entire country. Click here for details on the study. Click here for the LA Times report.


U.S. Number One Again – In Health Care Costs

The latest Commonwealth Fund international comparison study was published last week and once again the U.S. ranked far above its peers in health care spending, despite having the lowest life expectancy. According to the report, the U.S. spent about $9,086 per person on health care in 2013 – the highest of the 13 countries included in the report – while maintaining the lowest life expectancy of 78.8 years. Switzerland, the second highest spending country – spent $6,325 per person on health care and had a life expectancy of 82.9 years. Click here for the report.



CMS announced last week the first suite of accountable care organization models specifically geared toward treatment of end-stage renal disease. More than 600,000 people in the U.S. live with the condition, which requires patients to undergo costly, but life-sustaining dialysis treatments each week that account for nearly 6% of Medicare spending. The 13 ESRD seamless care organizations, called ESCOs, began to share this month the financial risks for treating Medicare beneficiaries with kidney failure in 11 U.S. states. DaVita and Fresenius, the nation’s two largest dialysis providers, both won bids to participate. Click here for details from CMS.

  • Two health care experts are touting the ACO model of the future. Click here for their interesting proposal in Health Affairs.

CMS Details Results of Primary Care Initiative

CMS last week announced results of the first shared savings performance year for the Comprehensive Primary Care (CPC) initiative. In 2014, CPC practices showed positive quality results, with hospital readmissions lower than national benchmarks and high performance on patient experience measures, particularly on provider communication with patients and timely access to care. CPC practices that demonstrated high quality care and reduced spending above a threshold shared in savings generated for Medicare. Click here for a summary from CMS’ Chief Medical Officer.


Kentucky Co-Op Fails

Kentucky Health Cooperative last week became the first co-op to drop out of its health insurance exchange for 2016 following the release of federal risk corridor data, and blamed the lower-than-expected return to insurers for its decision not to offer plans next year. The Kentucky co-op asked for $77 million from the risk corridor program but came away with $9.7 million, according to interim CEO Glenn Jennings, a death blow despite almost entirely reversing a $50 million shortfall to come up only $4 million in the red by the end of the first half of 2015. Click here for more.


Hospital Wound Care Company Targeted for Fraud

Jacksonville-based Healogics, which runs wound care centers across the U.S. and 504 hospitals across the country, has been accused of performing unnecessary hyperbaric oxygen therapy on patients in an apparent scheme to defraud Medicare, former employees said in a False Claims Act suit unsealed last week in a federal court. Willie and Michelle Arnold, a former hyperbaric technologist and a former hyperbaric safety director at Healogics respectively, allege that more than half the hyperbaric treatments the company billed to Medicare were fraudulent, according to the suit, which was first filed in July 2014. Click here for the story.


Suit Filed in Patient Stealing Case Involving EHRs

Here’s a novel use for EHRs. Valley Children’s Hospital in Madera, California, has filed a suit against three pediatric lung specialists and two medical groups, claiming they wrongfully accessed patient records in order to lure them away.

Records of at least 164 patients were accessed by the doctors while they were working at Valley Children’s, Michael Goldring, interim chief legal officer and administrative officer, told local news media. Click here for the lawsuit. Click here for the news report.


House GOP Moving Bill To Cut Obamacare Provisions

House Republicans last week moved a budget reconciliation package that would repeal both key and never-implemented parts of the Affordable Care Act through the House Budget Committee, passing the legislative package in a 21-11 vote. Budget committee members combined three separate bills that would cut federal spending by $79.8 billion. ACA provisions on the chopping block include the individual and employer mandates and their related penalties, the 40-percent “Cadillac” excise tax and medical device tax, the Independent Payment Advisory Board, the Prevention and Public Health Fund and the large employer auto-enrollment requirement that was indefinitely delayed. Click here for a 2-page CBO summary. Click here for a Washington Times summary.


New Bill Would Allow HHS To OK Health Insurance Rate Increases

Sen. Diane Feinstein (D-CA) and Rep. Jan Schakowsky (D-IL) last week introduced legislation (S. 2172 and HR 3727) that would build on the Affordable Care Act by granting HHS the ability to reject or modify proposed rate increases. The ACA requires plans to publish and provide a justification for rate increases of 10 percent or more, and the administration published those materials for the first time June 1. Some state regulators are being publicly criticized for approving premium increases of up to 50 percent, while policymakers defend the hikes as smaller than those before the ACA was enacted. Click here for the story.


FDA Acts on Duodenoscope Safety Issue

The FDA has ordered the three manufacturers of duodenoscopes marketed in the U.S. to conduct postmarket surveillance studies to better understand how the devices are reprocessed in real-world settings. Click here for the announcement.


CMS Releases New DME Data Base

As part of CMS’ efforts to make the healthcare system more transparent, affordable, and accountable, the agency has posted a new data set as part of the Provider Utilization and Payment files. This data set, called Referring Provider Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Public Use File (PUF), provides information on physicians and other healthcare professionals who referred DMEPOS products and services, such as wheelchairs, walkers, and diabetes supplies for Medicare beneficiaries. Click here for more from CMS.