WEEKLY E-BULLETIN


60 Percent of Hospitals in CJR Could Face Penalties

60 percent of hospitals in CMS’ Comprehensive Care for Joint Replacement (CJR) model (that started Friday) could face penalties based on their cost performance, and that one way for those hospitals to cut costs is by improving post-acute care — this is according to a new analysis released by Avalere last week.  The CJR model includes hospitals in 67 metropolitan statistical areas that will be required to participate in bundled payments for hip and knee replacements and the 90-day episode of care following the replacement. The analysis says that because 39 percent of total spending for hip and knee replacements is tied to care after a patient is discharged, hospitals can achieve savings by making sure patient care is provided in the lowest-cost setting that is clinically appropriate. To read the analysis, click here.

  • CMS leaders are hoping the 800 hospitals impacted by the new mandatory CJR program will be improving quality and efficiency. Click here to read what CMS hopes to achieve.
  • Perhaps the most powerful doc in America, Patrick Conway at CMS is profiled by the NYTimes.  Click here.

Physician, Provider Groups Want Numerous Changes To Medicare ACO Program

Maintaining and growing the ACO program remains a top priority for the Obama administration as it works to expand value-based payments. However, warning signs continue.  More than 30 percent of the ACOs that joined the program in its first two years have now left. Enrollment in the program keeps growing, but departures from ACO programs have left lingering questions about their viability. The latest CMS proposal, which will affect about 430 ACOs in the agency’s Medicare Shared Savings Program, will rely more heavily on regional benchmarks. Provider groups have welcomed the broad outlines of the plan but have made numerous recommendations to improve the program.  Click here for a letter from nearly two dozen physician groups and other provider organizations.

  • Some hospitals are putting their own employees into ACOs and disease management programs in an effort to reduce their benefits costs.  Click here.

$250 Million in Improper Hospice Charges: OIG

Hospices inappropriately billed over $250 million, or one-third of their inpatient stays, in incorrect Medicare payments, according to an HHS OIG report released last week. The providers billed for inpatient stays in situations that should have been handled at home were the most frequent problem, according to the report. Most of the problematic episodes involved stays in nursing homes, and for-profit hospice facilities. Additionally, Medicare paid twice for drugs in some cases, both through the hospice daily payment rate and through Medicare Part D. OIG recommended that HHS ramp up its oversight of hospice claims as well as Part D claims for hospice beneficiaries and that it ensure a doctor is involved in a decision to use an inpatient stay for those patients. To read the report, click here.

Justice Department Pursues Nursing Homes Providing Substandard Care

The Justice Department last week announced the launch of 10 regional Elder Justice Task Forces.  These teams will bring together federal, state and local prosecutors, law enforcement, and agencies that provide services to the elderly, to coordinate and enhance efforts to pursue nursing homes that provide grossly substandard care to their residents. The 10 Elder Justice Task Forces will be launched in the following Districts: Northern District of California, Northern District of Georgia, District of Kansas, Western District of Kentucky, Northern District of Iowa, District of Maryland, Southern District of Ohio, Eastern District of Pennsylvania, Middle District of Tennessee and the Western District of Washington. Click here for more from DOJ.

  • Recovery Audit Contractors are also going after nursing homes.  Click here for the report.

 VA Commission Considers Closing VA Hospitals, Shifting Care To Private Sector

The VA’s Commission on Care is “floating” the idea of gradually closing VA facilities and giving veterans immediate access to private health services, according to a report last week. The Commission was created by the Veterans Access, Choice, and Accountability Act (VACAA) of 2014 to examine veterans’ access to VA health care and how to strategically best to organize the Veterans Health Administration (VHA), locate health resources, and deliver health care to veterans. The proposal would make VA the primary payer similar to Medicare. Click here for more from Military Times.

Major Physician Group Issues Recommendations To Lower Rx Costs

One of the country’s largest physician groups is calling for sweeping new policies to curb the rising cost of prescription drugs in recommendations released last week (click here). The American College of Physicians proposes giving Medicare and other public health programs more authority to negotiate drug discounts.  The group’s position paper, published in the Annals of Internal Medicine, also recommends exploring policies to allow the reimportation of certain drugs where they’re sold at lower prices. It also wants to eliminate the prohibition on the Patient Center Outcomes Research Institute from considering cost effectiveness in its work.

Newly Insured on Exchanges Appear To Be Less Healthy

People who acquired health insurance through the Affordable Care Act exchanges seem less healthy than people who previously bought coverage on their own, according to a new report by the Blue Cross Blue Shield Association. However, newly insured individuals are only slightly less healthy than workers with job-based coverage. The largest assumed difference is that previously, people with pre-existing conditions, if not covered through an employer’s plan, often had trouble finding or affording health insurance on their own. The ACA banned this practice. To read the full report, click here.

33 Percent of Exchange Enrollees Kept Same Plans

3.2 million of the 9.6 million customers on HealthCare.gov in 2016 stuck with the same plan as they had the prior year, according to a new analysis. 2.4 million health plan shoppers switched to a new plan through the federal enrollment portal, and 4 million enrollees were new to the marketplace in 2016. This is the second straight year that only one-third of exchange customers kept their plan. Some enrollees likely left the market for other sources of coverage, like Medicaid or employer coverage. Click here to read the report from Avalere.

New CMS Final Rule Improves Mental Health Access for Medicaid Patients

CMS last week finalized a rule to strengthen access to mental health and substance use services for people with Medicaid or Children’s Health Insurance Program coverage, aligning with protections already required of private health plans. The Mental Health Parity and Addiction Equity Act of 2008 generally requires that health insurance plans treat mental health and substance use disorder benefits on equal footing as medical and surgical benefits. Click here for a CMS summary. Click here for the rule.

Expanded Medicaid Increases Behavioral and Substance Abuse Program Access

Expanding Medicaid programs would dramatically improve access to behavioral health care and also boost states’ efforts to curtail the substance abuse epidemic according to an HHS report published last week. The HHS report found about 1.9 million uninsured adults with mental illness or substance use disorders are eligible for Medicaid under the Affordable Care Act but live in states that have not expanded coverage. For low-income individuals with a serious mental illness, the chance of getting mental health treatment was 30 percent greater for individuals enrolled in Medicaid. Click here to read the report.

Hospitals Are the New Cyber Attack Targets

DC-based hospital system MedStar Health is recovering from a hit by a ransomware attack, the latest in a string of malware attacks afflicting U.S. hospitals. In the weeks before the attack on MedStar, hackers hit Hollywood Presbyterian Medical Center in Los Angeles, extorting $17,000 in bitcoin out of the leadership, and Kentucky-based Methodist Hospital, which declared a state of emergency after an attack. Two southern California hospitals, part of Prime Healthcare Services, were attacked in March. Click here for the story.

More Powerful than Heroin, Fentanyl Is the New Killer Epidemic

Fentanyl, used in its legal pharmaceutical form to treat severe pain, represents the latest evolution of an epidemic of opioid addiction that began with prescription painkillers and moved to heroin, as users demanded cheaper drugs and greater highs.  At least 28,000 people died of opioid overdoses in 2014, the highest number of deaths in U.S. history. Of those, fentanyl was involved in 5,554 fatalities, a 79 percent increase over 2013, according to a December CDC report.  Unpublished data for the first half of 2015 indicate an even steeper spike in fentanyl deaths.  Click here for more.

  • The results of a new poll indicating 99 percent of physicians are prescribing opioid painkillers for longer than the three-day period recommended by the CDC suggests doctors need more education and training, according to an announcement from the National Safety Council. Click here.
  • A CDC study of data from death certificates found that deaths caused by hepatitis C rose at a rate of 6% per year from 2003 to 2013. In 2013, 51% of people who died due to hepatitis C were between the age of 55 and 64.  Click here for details.

9 Percent of Jobs Are in Health Care

That’s according to a Bureau of Labor Statistics report on employment and wage data released on Friday, which found that 12 million people worked in health care as of May 2015. That number has gone up by about 400,000 jobs in the past 11 months. Registered nurses alone accounted for more than 2.7 million jobs last year. Mean hourly wages:· Surgeon: $119.00 · Family and general practitioners: $92.36· Registered nurse: $34.14· Home health aide: $11.00.  Click here for more employment info.

Consumer Reports Details Physician Discipline Issues

In a detailed report out last week, Consumer Reports finds that thousands of doctors are on probation for drug abuse, sexual misconduct or other violations that are almost impossible for patients to discover.  Click here.

Do You Think Health Plans Really Work Like This?

Catalyst Solutions, a health plan consulting firm, has released a fun video parody  on You Tube looking inside of operations at “Dynamite Health Plan” — it’s good for a chuckle or two!  Click here.