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Study asserts insurance marketplaces are healthy

August 12, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , , , , ,

By PHIL GALEWITZ

For Kaiser Health News

Despite dire warnings from Republicans and some large insurers about the stability of the Affordable Care Act exchanges, an Obama administration report released Aug. 11 indicated that the individual health insurance market has steadily added healthier and lower-risk consumers.

Medical costs per enrollee in the exchanges in 2015 were unchanged compared with 2014, according to the Centers for Medicare & Medicaid Services. In contrast, per-member health costs rose between 3 percent and 6 percent in the broader U.S. insurance market, which includes 154 million people who get coverage through their employer and the 55 million people on Medicare, the report said.

Aviva Aron-Dine, senior counselor to U.S. Health and Human Services Secretary Sylvia Burwell, said the data was encouraging when many insurers have announced double-digit rate increases for 2017 and others have pulled back in some states to curtail financial losses.

“What we take from this is that the marketplace is on sound footing,” she said in a phone briefing with reporters. She also said the sharp 2017 rate increases could be intended to help insurers compensate for underpricing their premiums in 2014 and 2015 and not the first in a series of large annual rate hikes. Next year’s phase-out of the Affordable Care Act’s reinsurance programs — which helped insurers cover losses on higher-cost enrollees the past two years — is another reason why some insurers want higher rates for 2017.

Nearly 13 million Americans bought coverage for 2016 on the Obamacare marketplaces. More than 80 percent received federal subsidies that help them afford policies and insulate them from effects of premium increases.

Several insurers, including UnitedHealth Group and Humana, have said they will not sell 2017 individual plans on many state exchanges because they absorbed heavier-than-expected losses in part due to higher medical claims.

Aron-Dine said the administration always expected that rising enrollments would attract younger and healthier enrollees to balance the risk of insuring the older and sicker people who signed up initially. In 10 states with the highest enrollment growth from 2014 to 2015, the government reported, per-member per-month claims costs fell by an average of 5 percent.

Its study was based on claims data collected by CMS to administer the health law’s reinsurance and risk adjustment programs. Insurers submitted their 2015 data earlier this year.

What explains insurers’ losses from Obamacare if health costs have held steady?

Sabrina Corlette, research professor at the Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute, said some insurers priced their coverage too low in 2014 and 2015 — in part to grab market share — and are now trying to make up for it. She said insurers have based most of their 2017 rate increases on their 2015 results.

“This should reassure people that despite the narrative that these markets are going down the toilet, in fact the report shows the opposite … that these markets are generally performing pretty well,” Corlette said.

Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance, said the CMS report is good news for consumers. “This suggests the premium increases that we are seeing going into 2017 is likely to be a one-time adjustment … for pricing too low in the first few years,” she said. (Kaiser Health News is an editorially independent program of the foundation.)

UHC pays $148 million to physicians in value-based program

August 8, 2016by Robert Whitcomb in Uncategorized tagged , , ,

 

HealthcareDive reports that giant UnitedHealthcare paid more than $148 million last year to primary-care physicians for improving  the medical outcomes for patients in Medicare Advantage plans. The insurer said that nearly 1,900 physicians received bonuses for achieving value-based goals in its PATH program, which encourages physicians to promote prevention, including  monitoring of chronic conditions.

Physicians in the program care for about a million Medicare Advantage members.

The Centers for Medicare & Medicaid Services  is trying to shift 50 percent of Medicare payments to value-based payment models by 2018.

To read the whole HealthcareDive story, please hit this link.

CMS to punish over half of U.S. hospitals for readmission rates

August 4, 2016by Robert Whitcomb in Uncategorized tagged , , ,

revolve3

By JORDAN RAU

For Kaiser Health News

The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released this week show.

The government will punish more than half of the nation’s hospitals — a total of 2,597 — having more patients than expected return within a month. While that is about the same number penalized last year, the average penalty will increase by a fifth, according to a Kaiser Health News analysis.

The new penalties, which take effect in October, are based on the rehospitalization rate for patients with six common conditions. Since the Hospital Readmissions Reduction Program began in October 2012, national readmission rates have dropped as many hospitals pay more attention to how patients fare after their release.

The penalties are the subject of a prolonged debate about whether the government should consider the special challenges faced by hospitals that treat large numbers of low-income people. Those patients can have more trouble recuperating, sometimes because they can’t afford their medications or lack social support to follow physician instructions, such as reducing the amount of salt that heart failure patients consume. The Centers for Medicare & Medicaid Services says those hospitals should not be held to a different standard.

Medicare said the penalties are expected to total $528 million, about $108 million more than last year, because of changes in how readmissions are measured.

Medicare examined these conditions: heart attacks, heart failure, pneumonia, chronic lung disease, hip and knee replacements and — for the first time this year — coronary artery bypass graft surgery.

The fines are based on Medicare patients who left the hospital from July 2012 through June 2015. For each hospital, the government calculated how many readmissions it expected, given national rates and the health of each hospital’s patients. Hospitals with more unplanned readmissions than expected will receive a reduction in each Medicare case reimbursement for the upcoming fiscal year that runs from Oct. 1 through September 2017.

The payment cuts apply to all Medicare patients, not just those with one of the six conditions Medicare measured. The maximum reduction for any hospital is 3 percent, and it does not affect special Medicare payments for hospitals that treat large numbers of low-income patients or train residents. Forty-nine hospitals received the maximum fine. The average penalty was 0.73 percent of each Medicare payment, up from 0.61 percent last year and higher than in any other year, according to the KHN analysis.

Under the Affordable Care Act, which created the penalties, a variety of hospitals are excluded, including those serving veterans, children and psychiatric patients. Maryland hospitals are exempted as well because Congress has given that state extra leeway in how it distributes Medicare money. Critical-access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, are also exempt.

As a result, more than 1,400 hospitals were automatically exempt from the penalties. Other hospitals did not have enough cases for Medicare to evaluate accurately and were not penalized.  Of the hospitals that Medicare did evaluate, four out of five were penalized.

The KHN analysis found that 1,621 hospitals have been penalized in each of the five years of the program.

Kaiser Health News staff writer Sydney Lupkin contributed to this report.

Study: 30% of pediatric readmissions might be preventable

July 29, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

kids

Boston Children’s Hospital.

By MICHELLE ANDREWS

For Kaiser Health News

One of the key indicators of the quality of a hospital’s care is how frequently its patients are readmitted within a month after being discharged. A study this month examined readmission rates for pediatric patients and found that nearly 30 percent of them may have been preventable.

The study, published online by the journal Pediatrics, reviewed the medical records and conducted interviews with clinicians and parents of 305 children who were readmitted within 30 days to Boston Children’s Hospital between December 2012 and February 2013. It excluded planned readmissions such as those for chemotherapy.

Overall, 6.5 percent of patients were readmitted during the study period.

The study found that 29.5 percent of the pediatric readmissions were potentially preventable. In more than three-quarters of those cases, researchers determined that hospital-related factors played a role. A significantly smaller proportion were related to the patient (39.2 percent), often because of issues that arose after discharge, or the primary care physician (14.5 percent). (Multiple factors played a role in some patients’ readmissions, so the total exceeds 100 percent.)

The most common hospital-related reasons had to do with how patients are assessed, postoperative complications or hospital-acquired conditions.

“One of the things we need to improve upon is engaging families at the time of discharge around how we’re feeling and how they’re feeling about the status of the child at that point in time,” said Sara Toomey,  M.D.,  the study’s lead author, who is the medical director of patient experience at Boston Children’s Hospital and an assistant professor at Harvard Medical School.

Sometimes clinicians and family members may be overly optimistic about a child’s readiness to go home,  Dr. Toomey said.

When policymakers discuss the importance of reducing hospital readmissions, they typically focus on older patients, who make up a much larger proportion of hospital patients than do pediatric patients. The Medicare program, which provides health benefits for Americans age 65 and older, imposes financial penalties on hospitals whose readmission rates are too high.

The federal Centers for Medicare & Medicaid Services doesn’t penalize hospitals for pediatric readmissions, but a growing number of states are doing so, the study found.

Readmissions will never be completely avoidable, Dr. Toomey said. Still, “when you have a child coming home from the hospital, there are things you need to know, and the more active people are in creating a plan and making sure they understand it, the better that will help their children.”

To read the article in Pediatrics, please hit this link

 

 

Some big surprises, complaints in CMS hospital ratings

July 28, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

By JORDAN RAU

For Kaiser Health News

The federal government released its first overall hospital quality rating on July 27, slapping average or below average scores on many of the nation’s best-known hospitals while awarding top scores to dozens of unheralded ones.

The Centers for Medicare & Medicaid Services rated 3,617 hospitals on a one- to five-star scale, angering the hospital industry, which has been pressing the Obama administration and Congress to block the ratings. Hospitals argue that the ratings will make places that treat the toughest cases look bad, but Medicare has held firm, saying that consumers need a simple way to objectively gauge quality. Medicare does factor in the health of patients when comparing hospitals, though not as much as some hospitals would like.

Just 102 hospitals received the top rating of five stars, and few are those considered as the nation’s best by private ratings sources such as U.S. News & World Report or viewed as the most elite within the medical profession.

Medicare awarded five stars to relatively obscure hospitals and at least 40 hospitals that specialize in just a few types of surgery, such as knee replacements. There were more five-star hospitals in Lincoln, Neb., and La Jolla, Calif., than in New York City or Boston. Memorial Hermann Hospital System, in Houston, and Mayo Clinic, in Rochester, Minn., were two of the  nationally known hospitals getting five stars.

Medicare awarded the lowest rating of one star to 129 hospitals. Five hospitals in Washington, D.C., received just one star, including George Washington University Hospital and MedStar Georgetown University Hospital, both of which teach medical residents. Nine hospitals in Brooklyn, four hospitals in Las Vegas and three hospitals in Miami received only one star.

“Consumers can use this trustworthy program to compare hospitals side by side,” said Debra Ness, president of the National Partnership for Women & Families, a Washington nonprofit. “This is a huge step forward.”

Some premier medical centers received the second highest rating of four stars, including Stanford Health Care, in California, Duke University Hospital, in Durham, N.C., New York-Presbyterian Hospital and NYU Langone Medical Center in Manhattan, the Cleveland Clinic, in Ohio, and Penn Presbyterian Medical Center, in Philadelphia. In total, 927 hospitals received four stars.

Medicare gave its below average score of two-star ratings to 707 hospitals. They included the University of Virginia Medical Center, in Charlottesville, Beth Israel Medical Center, in Manhattan, North Shore University Hospital (now known as Northwell Health), in Manhasset, N.Y., Barnes-Jewish Hospital, in St. Louis, Tufts Medical Center, in Boston and MedStar Washington Hospital Center, in D.C. Geisinger Medical Center, in Danville, Pa., which is a favorite example for national health policy experts of a quality hospital, also received two stars.

Nearly half the hospitals — 1,752 — received an average rating of three stars. Another 1,042 hospitals were not rated, either because they did not have enough cases for the government to evaluate accurately, or, as with all Maryland hospitals, Medicare does not collect the necessary data.

Medicare based the star ratings on 64 individual measures that are published on its Hospital Compare website, including death and infection rates and patient reviews. Medicare noted that specialized and “cutting-edge care,” such as the latest techniques to battle cancer, are not reflected in the ratings.

Dr. Elizabeth Mort, chief quality officer at Massachusetts General Hospital, in Boston — which Medicare awarded four stars — said Medicare should have factored in attributes of each hospital, such as what kind of services it offered and how the nursing profession assesses the staff quality.

“On a scale of 1 to 5, a 4 or 5 is not a bad score, but I don’t put any credence in this,” she said. “Don’t clutter it up with measures that have no place being there,” such as infection and readmission measures that she said were not well designed to compare dissimilar hospitals.

Steven Lipstein, the president of BJC HealthCare, which runs Barnes-Jewish Hospital and a 13 others, said that Medicare awarded between two and four stars to the system’s hospitals, even though they all “employ the same standards, the same methodology, the same clinical guidelines.” The major difference, he said, was the comparative affluence of the patients each served, with poorer scoring hospitals located in lower income areas.

“The stars tell you more about the socio-demographics of the population being served than the quality of the hospital,” he said in an interview.

Dr. Kate Goodrich, who oversees Medicare’s quality ratings, said in a statement that it has been using the same type of rating system for other medical facilities, such as nursing homes and dialysis centers, and found them useful to consumers and patients. Those ratings have shown, she said, “that publicly available data drives improvement, better reporting, and more open access to quality information for our Medicare beneficiaries.”

In a statement, Rick Pollack, president of the American Hospital Association, called the new ratings confusing for patients and families. “Healthcare consumers making critical decisions about their care cannot be expected to rely on a rating system that raises far more questions than answers,” he said. “We are especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor.”

A preliminary analysis Medicare released last week found hospitals that treated large numbers of low-income patients tended to do worse. Medicare does not consider patients’ social and financial situations in rating hospitals.

A sizable proportion of the nation’s major academic medical centers, which train doctors, scored poorly, according to a Kaiser Health News analysis. Out of 288 hospitals that teach significant numbers of residents, six in 10 received below-average scores, the analysis found. Teaching hospitals comprised one-third of the facilities receiving one-star. A number were in high poverty areas, including two in Newark, N.J., and three in Detroit.

“Hospitals cannot be rated like movies,” Dr. Darrell Kirch, president of the Association of American Medical Colleges, said in a statement. “We are extremely concerned about the potential consequences for patients that could result from portraying an overly simplistic picture of hospital quality with a star rating system that combines many complex factors and ignores the socio-demographic factors that have a real impact on health.”

 

Feds to press on with hospital-rating program

July 22, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , ,

marching

By JORDAN RAU

For Kaiser Health News

Despite objections from Congress and the hospital industry, the Obama administration said it will soon publish star ratings summing up the quality of 3,662 hospitals. Nearly half will be rated as average, and hospitals that serve the poor will not score as well overall as will other hospitals, according to government figures released July 21.

The government says the ratings, which will award one to five stars to each hospital, will be more useful to consumers than its current mishmash of more than 100 individual metrics, many of which deal with technical matters. The hospital industry, however, fears that the ratings will be misleading and oversimplify the many types of care at the institutions.

The Centers for Medicare & Medicaid Services said it would release the ratings “shortly.” In a preemptive effort to rebut criticisms, it noted its analysis showed “hospitals of all types are capable of performing well on star ratings and also have opportunities for improvement.”

The stars are based on 64 individual measures of hospitals that are already public on the government’s Hospital Compare Web site. Those include mortality rates, the number of readmissions, patient opinions, infection rates and frequency of medical scans like MRIs.

Medicare said that based on its current data, 102 hospitals would receive the best rating of five stars, 934 would get four stars, 1,770 would receive three stars, 723 would be awarded two-stars and 133 would get the lowest rating of one star. Another 937 hospitals would not be rated because the government did not have enough data to properly evaluate them.

“The star ratings provide people a broader picture,” Medicare officials said in a statement. “CMS used a similar approach to simplify complex quality information on other healthcare quality reporting websites, such as Nursing Home Compare, Home Health Compare, Dialysis Facility Compare and Medicare Plan Finder.”

The ratings factor in the mix of patients at a hospital, so those with a high proportion of sicker patients are not supposed to rate lower than those that handle more run-of-the-mill cases. The analysis showed hospitals of different sizes also did about the same, and critical access hospitals — small, mostly rural facilities — performed slightly better overall.

Medicare did not consider the relative wealth of patients. Its analysis showed hospitals serving large swaths of low-income people tended to receive lower star ratings. An analysis by Kaiser Health News of the hospitals that CMS rates shows 22 percent of safety-net hospitals were rated above average — four or five stars — compared with 30 percent of hospitals overall. Twenty-nine percent of safety-net hospitals were rated as below average, with just one or two stars, while 22 percent of other hospitals received those lower ratings.

Teaching hospitals also received lower scores on average. A third were rated with only one or two stars, while only a fifth of other hospitals received fewer than three stars, according to the KHN analysis. The teaching hospitals include large academic medical centers that often top the lists of best hospitals put together by groups such as Healthgrades and U.S. News & World Report.

Janis Orlowski, M.D., an executive at the Association of American Medical Colleges, said the fact that so many prestigious hospitals fare poorly in the star ratings is a signal that Medicare’s methods are flawed.

“These are hospitals that everyone in the know tries to get into, so we need to be careful about the consequences, that this star rating can be misleading,” Orlowski said. “Putting the information out at this time is not in the patient’s interest.”

The American Hospital Association also expressed continued concerns.

The government originally planned to release the star ratings in April but postponed it after a majority of members of Congress echoed the industry’s concerns. Debra Ness, the president of the National Partnership for Women & Families, a nonprofit in Washington, urged Medicare to post the ratings before the end of the month.

“We believe great thought and care went into development of the Hospital Star Ratings Program,” she wrote on the group’s Web site.  “If needed, the program can be adjusted over time. But now is the time to move forward and give consumers a tool that will allow them to assess which hospitals do the best job of providing the care they need.”

Proposed CMS changes would be boon for primary-care clinicians

July 14, 2016by Robert Whitcomb in Uncategorized tagged , , , , ,

primary

The Centers for Medicare & Medicaid Services plans to make a renewed push over the next year to boost primary care with new incentive programs.

“In the United States, we have historically invested far more in treating sickness than we do in maintaining health,” CMS acting Administrator Andy Slavitt said in a blog post. “The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals, and nursing homes.”

“The road to a better healthcare system means correcting this imbalance. We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients.”
“Today, we are proposing significant actions to improve how we pay primary-care physicians, mental-health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well.”

The proposed changes include:

  • Increasing  payments to primary-care providers for routine office visits of  patients with mobility-related disabilities to $119 from $73 a visit.
  • Increasing payments to geriatricians and family physicians. “We anticipate that these clinicians could receive a 2 percent increase in their payments for providing the care we propose to recognize under the Physician Fee Schedule,” Mr. Slavitt said. “Over time, if all of the practitioners that can provide these services provide them to all eligible patients, we estimate that the payment increase could be as much as 30 percent and 37 percent, respectively, to these specialties.”
  • Paying for mental-health care using the Collaborative Care Model, which “supports mental and behavioral health through a team-based coordinated approach involving a psychiatric consultant, a behavioral healthcare manager, and the primary care clinician, and which extends beyond the scope of an office visit,” he said.

To read a longer story in this, please hit this link.

CMS wants to expand diabetes-prevention program

July 8, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

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The Centers for Medicare & Medicaid Services has proposed expanding a program to help people avoid diabetes.

Beneficiaries receive  lifestyle intervention, including boosting their  physical activity,  with the goal of preventing diabetes in prediabetic individuals..

People with higher than normal blood-sugar levels are enrolled and attend weekly training sessions on nutrition, exercise and other aspects of healthy living.

Providers are paid based on the number of sessions attended by patients and patients’ ability to achieve and maintain a minimum weight loss.

The CMS suggests expanding the program in 2018. The agency seeks public comment on whether to launch the effort nationally or in additional select markets.

The program, begun in 2013, has so far  enrolled beneficiaries in Arizona, Delaware, Florida, Indiana, Minnesota, New York, Ohio and Texas. It is the first such program of  the CMS Innovation Center,  created by the Affordable Care Act, to be seen as successful enough to be upgraded from a demonstration project and integrated into the full Medicare program. The ACA lets the CMS expand successful programs  without  Congress’s approval.

Providers are paid   based on the number of sessions attended by patients and patients’ ability to achieve and maintain a minimum weight loss.

For the full Modern Healthcare article on this, please hit this link.

Medicaid overpayment problem threatens some W.Va. hospitals

June 16, 2016by Robert Whitcomb in Uncategorized tagged , , , , , ,

wva

The Charleston (W.Va.) Gazette Mail reports that some rural hospitals in that state might go bankrupt if the Feds try to force them to pay millions  of dollars in possible Medicaid overpayments.

The paper reported that Boone Memorial Hospital, Minnie Hamilton Health System, Roane General Hospital, Grafton City Hospital, Jackson General Hospital, Pocahontas Memorial Hospital and Sistersville General Hospital–might be compelled to repay Medicaid payments from the Disproportionate Share Hospital program (DSH). The DSH program is being phased out under the Affordable Care Act.

The problem is that all these hospitals have also runat least one rural health clinic. The Centers for Medicare & Medicaid Services is apparently taking back clinic-related DSH payments made to the hospitals from 2011 to 2015. The repayments would total $8 million, with repayments from individual hospitals  ranging from $28,000 to $1.8 million.

West Virginia is a poor state and so more than three-quarters of the patients are enrolled in Medicaid or lack insurance.

To read the article, please hit this link.

 

AMA moves further to address physician-burnout issue

June 15, 2016by Robert Whitcomb in Uncategorized tagged , , , , ,

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MedPage Today reports that the “American Medical Association wants physician work-life balance added to provider-experience measures for evaluating how well alternative payment models function” address what is seen as the growing  incidence of physician burnout under the stress of ever more complicated work, including vast quantities of red tape and record-keeping.
The new AMA policy, approved following the annual meeting of its House of Delegates, also changed  its support of the “Triple Aim” to  support of the “Quadruple Aim”. As originally conceived in the development of healthcare reform in recent years, the Triple Aim seeks to improve patient experience and the health of populations and to cut per-capita costs.

The AMA will ask the Centers for Medicare & Medicaid Services to use the Quadruple Aim when evaluating Accountable Care Organizations and other practice

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