CMS Sweetens Medicare ACO Regs

CMS last week finalized a Medicare Shared Savings Program (MSSP) rule that is designed to encourage more participation in the model and better reward participants for providing quality care. CMS revised its benchmarking methodology with a series of changes phased in over time, including regional rather than national measures. The rule would also allow ACOs participating in Track 1 – the only track in which providers don’t face financial penalties for missing their performance targets – to extend their Track 1 participation for an additional year if they renew for a second period if the plan to participate in Track 2 or Track 3. Tracks 2 and 3 have an up-and-down side risk component. Click here for the rule, and here for the CMS fact sheet.

CMS Home Health Demo Requires Pre-Claim Review in 5 States

Despite pushback from the home health industry and lawmakers, CMS announced last week it will move forward with a pre-claim review requirement demonstration. CMS’ demo will be rolled out in Illinois after Aug. 1; Florida after Oct. 1; Texas after Dec. 1; Michigan and Massachusetts after Jan.1. Under the program, home health agencies in select states will be required to perform a pre-claim review before processing claims for services. CMS says that under the demonstration, home health services can begin as soon as a physician orders them and providers should submit documentation to CMS for review within the first 30 days that services are provided. Click herefor the CMS fact sheet on the demonstration.

One in Five Hospitals Don’t have “Never Event” Policies

A new report from the Leapfrog Group found that 20 percent of U.S. hospitals don’t have a policy for “never events”–serious medical errors or adverse events that should never happen to a patient. Never events include wrong-site surgeries, objects left inside patients after surgery, deaths from medication errors or death or serious injuries from falls. The report found broad variation in compliance by state, with 100 percent of reporting hospitals in Washington, Maine and Massachusetts meeting the standards, compared to only 10 percent in Arizona. Click herefor the report.

HHS OIG: CMS Didn’t Disclose Payment Issues with Several Pioneer ACOs

CMS helped five Pioneer ACOs in their first year to avoid nearly $6.8 million in losses – and didn’t reveal that to the public or other providers interested in the program, according to the agency’s inspector general. The Pioneer ACOs had originally chosen to be held accountable for penalties as well as bonus payments, but after a year of participation, data showed they’d be hit with huge penalties instead of bonuses. CMS let them switch, retroactively, to a penalty-free track. Four would have been on the hook collectively to repay CMS a combined total of $6.8 million; the fifth did not lose enough to trigger the penalties. The OIG said what CMS did wasn’t illegal, but that CMS should have been more transparent. Click herefor the OIG report.

CMS to Offer Physician Payment System Support Grants

CMS said last week it will provide $10 million over three years to support networks to help doctors transition under Medicare’s new physician payment system – the Quality Payment Program. The Transforming Clinical Practice Initiative supports 39 national and regional care networks for doctors. They will provide peer-to-peer support to help doctors be more successful within the new program with the goal of accelerating the adoption of Alternative Payment Models at very large scale and with very low cost. CMS will award cooperative agreement funding to successful applicants that may include health care delivery systems. Click here for the announcement and herefor the program website.

Study Questions CMS’ 5-Star Hospital Rating System

CMS’ star-rating system has raised questions about its usefulness, prompting the agency to break down exactly how it arrives at the ratings. But a look at the data shows it’s unclear how much the system actually helps consumers choose the best care, according to a new report.  Researchers analyzed data to determine whether the star ratings steer patients in the direction of safer hospitals. Their analysis determined that for every 70 patients transferred from a one-star facility to a five-star facility, one life would be saved. However, holding all other factors constant, star ratings became a much less reliable predictor of patient safety and mortality when comparing different types of hospitals, such as urban teaching hospitals and small rural providers.  Click herefor the JAMA article.

Key House Committee Holds Hearing on ACA Reform Bills

The Energy & Commerce committee held a hearing last week on a several bills that would make changes to the Affordable Care Act, including adjusting the age-rating band, aligning the grace period for non-payment with state law, and requiring verification before allowing enrollment through a special enrollment periods. The package also includes bills that would align pediatric dental benefits sold on and off the exchange, and require states with failed exchanges to conduct an audit and return funds to the federal government. To view the hearing, read the legislation, or read witness testimony, click here.

Larger Subsidies Lead to Higher Health Exchange Enrollments

Of the Americans with incomes between 300 and 400 percent of the poverty who were also eligible to enroll in a health exchange, 17 percent actually enrolled, according to a new study. Those individuals are generally eligible for subsidies, but the financial assistance is much less generous than what’s available for lower income households. Among those with incomes below 150 percent of the poverty level, 80 percent signed up for coverage. Half of Americans eligible to enroll in exchange coverage in 2016 were under the age of 34; however, only 37 percent of those who actually signed up for coverage this year were in that age group. By contrast, just over a quarter of exchange enrollees were 55 and over. Click herefor the study.

Feds Move To Limit Short-Term Health Policies

The Obama administration is seeking to limit short-term health policies that include features largely banned under the Affordable Care Act.  Under a proposed rule released last week, insurers would only be able to offer short-term health policies that last less than three months, and the coverage couldn’t be renewed at the end of that period. The proposal seeks to close a gap that has let healthier consumers purchase short-term plans that could last for nearly a year, sometimes using them as a cheaper substitute for ACA plans. Click here for the WSJ report.

  • The country’s largest health insurance lobbying group, AHIP, has moved to restructure.  Click here for more.

Geisinger Health Plan Deals with Higher Costs of the Newly Insured

Geisinger Health Plan foresees health costs rising 7.5 percent next year, but requested a 40 percent rate increase. The plan, which is run by one of the nation’s top-rated health organizations, underestimated the cost of covering the newly insured under the Affordable Care Act.  Click herefor the NY Times report.

Rx Monitoring Databases Curb Opioid Prescribing: Study

Doctors in states that adopted prescription drug monitoring databases to help prevent doctor-shopping were 30 percent less likely to prescribe the most powerful opioids after having access to the data, according to a new study.  The study examined data on doctor visits by patients who complained of pain in 24 states that started such databases from 2001 to 2010. Before prescribers had access to the data, they wrote prescriptions for Schedule II opioids, such as OxyContin, in 5.5 percent of visits. Once the databases became available, the likelihood of doctors prescribing the powerful painkillers in such visits fell by almost a third to 3.7 percent. Click here for the news report.  Click herefor the Health Affairs abstract.

CDC, AHA Partner on Opioid Use Guidance

 The American Hospital Association and the Center for Disease Control are partnering to provide guidance to both patients and providers on opioid usage. The two-page fact sheet stresses the risks of taking addictive prescription drugs and suggests alternatives for treating pain, such as physical therapy or non-prescription medications like acetaminophen. It also points out best practices for safely taking opioids. Click here for the fact sheet and herefor the detailed advisory from AHA.

Some Hospital EDs Are Taking an Aggressive Approach on Opioid Use

One hospital emergency department in New Jersey has taken the lead in using opioids as a last resort, according to a NYTimes article last week.  St. Joseph’s Regional Medical Center is taking on a challenge that is even more daunting than teaching new protocols to 79 doctors and 150 nurses. It must shake loose a longstanding conviction that opioids are the fastest, most surefire response to pain, an attitude held tightly not only by emergency department personnel, but by patients, too. Pain is the chief reason nearly 75 percent of patients seek emergency treatment. Click herefor the story.

House Passes Pro-Hospital Bill with HOPD, Socio-Economic Provisions

The House last week passed, H.R. 5273, the Helping Hospitals Improve Patient Care Act by voice vote. The legislation would allow certain off-campus Hospital Outpatient Departments that were in “mid-build” prior to Nov. 2, 2015, to be grandfathered and receive the higher HOPD payment rate, under certain circumstances. The legislation also changes the hospital readmission penalty program to account for the socioeconomic status of patients. The Senate Finance Committee has no immediate plans to act on the package leaving its fate in the Senate uncertain. Click here for the House legislation, herefor a summary.

Some States Tackling Physician Shortages in Rural Areas

The United States is projected to face a shortage of as many as 94,700 physicians by the year 2025, according to the most recent analysis by the Association of American Medical Colleges.  The shortage is especially dire in parts of the South, with its many rural areas and minority communities. And in some states, tight budgets and projected deficits have exacerbated the problem.  States are now working to combat the problem by opening new schools and creating branches in underserved areas.  Click herefor more.

Rural Areas have Big Gains in Coverage Because of Affordable Care Act

According to a new HHS report released last, health coverage in rural counties increased an average 8 percent between late 2013 and early 2015. The analysis found that the share of rural Americans unable to afford care fell nearly 6 points in the time period. HHS asserts that rural Americans are more likely to live in a state that did not expand Medicaid, but their coverage gains are on par with residents of large cities. For the HHS report, click here.

  • States that expanded Medicaid are seeing less debt go to collections agencies, according to a new report from researchers at the Federal Reserve Bank of New York.  Click here.


  • Hospital costs for uncompensated care have decreased in states that opted to expand Medicaid under the Affordable Care Act, but have remained stagnant in the states that have not, according to a report released last week by the Kaiser Family Foundation. Click here.