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ACA exchanges’ navigators are hitting roadblocks


— Photo by HurwiczRocks


For Kaiser Health News

While healthcare uncertainty roils Washington, the rest of the country is coasting toward  signup season on the Affordable Care Act insurance exchanges.

Open enrollment is just about a month away. But the current landscape is marked by funding cuts and other White House efforts to pull back on ACA outreach, which has led some people to brace for what they foresee as the toughest season yet.

And the latest wrinkle? In states that use the federal marketplace,, many navigators — nonprofit groups and workers who receive federal funding to help consumers enroll — are hitting snags completing a mandatory certification course. Those credentials are required before they can formally advise consumers or organize educational events about getting coverage.

To be sure, the training — which involves buggy, not-so-user-friendly software — has never been a smooth process.

But this year, many say they’re experiencing more technical glitches and — in a critical shift — getting less help from the Centers for Medicare & Medicaid Services, the federal agency tasked with supporting them.

“It used to be … you got the impression they were trying to help you,” said Randal Serr, director of Take Care Utah, a navigator organization based in Salt Lake City. “Now it seems, passively, this is not their priority.” He reports that he has experienced firsthand the slow responses to these technical difficulties.

CMS did not provide comment for this story.CMS

Chief among the complaints are repeated error messages and lost or unsaved work after sections of the training are completed.

Based on interviews with navigators as well as advocates and experts who work with their organizations, when these problems arise, they compound an already uphill climb to sign people up for ACA health coverage.

“I don’t know how much icing we need on this cake, but it’s more icing on the cake,” said Shelli Quenga, director of programs for the Palmetto Project, in South Carolina, whose federal grant was cut by more than 50 percent.

Software problems are occurring more frequently than in the past at her organization, Quenga said. Meanwhile, she added, it can take weeks before CMS resolves the issue — a delay she didn’t recall experiencing in previous years. On top of the funding cuts and administration’s messages that undermine enrollment, it’s “a new circle of Dante’s hell,” she said.

But even as navigators from a number of states report problems, others say their experiences haven’t differed from other years.

Adam VanSpankeren, a Wisconsin-based navigator, said he faced a few bugs in completing his training, but nothing unusual. When he sought technical support, he added, he received quick and thorough help. Amalia Benvenutti, a Georgia-based insurer, reported a similar encounter.

“There has always been the occasional odd bug with a particular module not saving or the site crashing — the interface is a bit clunky — but nothing that I would describe as more restrictive or onerous than previous years,” VanSpankeren said.

Daniel Bouton, who organizes the marketplace program at a Dallas-based navigator group and has already experienced some of these problems, sees a larger pattern. He worries that will almost certainly affect how many consumers can both access information about their insurance options and how many actually get covered.

Together, these challenges underscore the impact of the Trump administration’s broader disinterest in maintaining much of Obamacare’s vast apparatus.

“Local organizations are feeling the cut on funding. Then you move to, ‘OK, I’m not going to have enough funds for a strong marketing campaign. I’ll utilize my navigators, and go back to grass roots, and do door-to-door marketing.’ But then you go back to, ‘I can’t send my navigators out because they’re not certified,’” Bouton said. “I have this feeling of having our hands tied.”

And there are other potential delays. Many navigator groups saw their federal funding cut this year — a change that required them to submit new working budget proposals to CMS by last Wednesday. It’s unclear if or when they will receive federal approval, which some said could further cut into planning and outreach efforts.

Meanwhile, these challenges come as open enrollment — which starts Nov. 1 — for the first time lasts only six weeks compared with three months in previous seasons. CMS also indicated it will for the first time be shutting down the website on most Sundays of open enrollment, which officials say is for maintenance. Sundays, though, have typically been a prime time for consumers to sign up.

And at the same time, the learning curve is steeper. Many consumers aren’t aware that the enrollment period is shorter, Quenga said. Because of congressional back-and-forth, she added, some aren’t even sure if Obamacare is still in effect.

“People need that in-person assistance to understand the subtleties and nuances of a very complicated system,” she said. “You’re cutting these people off at the knees.”

Moody’s see stable finances for for-profit hospitals

Moody’s Investors Service sees the financial outlook for U.S. for-profit hospitals as stable.

Key to this forecast is the expectation that outpatient services will drive revenue and earnings growth. The ratings company sees outpatient service growth fueling a 2.5-3 percent earnings growth for for-profit hospitals over the next 18 months as much of American healthcare, under pressure from consumers and public and private insurers, seeks lower-cost settings. At the same time, Moody’s predicted,  higher patient costs and an increase in the number of uninsured Americans may lead to more bad debt for hospitals.

Moody’s noted that patients with high-deductible health plans will seek less costly settings than hospitals to save money. Also, the company said, the CMS’s proposal to let more orthopedic procedures be done on an outpatient basis could do more financial damage to hospitals.

Moody’s warned:

“Higher patient responsibility and fewer insured patients will lead to lower volumes, but also higher costs of uncompensated care. Even with strong cost controls, given the high fixed costs of operating hospitals, it will be difficult to expand margins in an environment of weak patient volumes and rising bad debt expense. At the same time, nursing shortages and rising fees associated with medical specialists (including outsourced emergency departments) will also pressure margins.’’

Still, profit margins of some for-profit systems may well widen in the coming months, Moody’s said. citing Quorum Health and Community Health Systems (CHS) benefiting from selling off less profitable facilities and LifePoint Health and HCA Healthcare improving efficiencies at recently acquired facilities.

Moody’s expects for-profit hospitals in Texas and Florida will recover quickly from losses associated with recent hurricane damage.

To read more, please hit this link.


Value-based care is a ‘bipartisan movement’


Shannon Muchmore writes in Healthcare Dive that CMS’s scaling back of bundled-payment programs won’t stop the shift to alternative models. The agency’s changes to such programs could have “immediate and long-term effects,” she writes, “but value-based care remains a bipartisan movement that won’t be easily stopped.”

She concludes:

“The changes from CMS may hinder the broader movement and set back bundled models because of less reliable results from the government programs, but they aren’t going to put an end to reform efforts.”

To read her article, please hit this link.



Looking at Medicare’s ‘skeletal’ site for hospice comparison shopping


For Kaiser Health News 

Medicare has launched a web site aimed at helping families choose a hospice — but experts say it doesn’t help very much.

The Centers for Medicare & Medicaid Services this week released Hospice Compare, a consumer-focused site that lets families compare up to three hospice agencies at a time, among 3,876 nationwide. Following similar Web sites for hospitals and nursing homes, the site aims to improve transparency and empower families to “take ownership of their health,” according to a press release.

Through the website, families can see how hospices performed in seven categories, including how many patients were screened for pain and breathing difficulties, and how many patients on opioids were offered treatment for constipation.

But the measurements of quality, which are self-reported by hospices, have limited utility, some experts say. Over three-quarters of hospices scored at least 91 percent out of 100 on six of the seven categories, a recent paper in Health Affairs found. Because so many hospices reported high marks, there is “little room” for using these metrics to measure hospice quality, argued the authors, led by Dr. Joan Teno at the University of Washington.

The Hospice Compare grades are based on hospices reporting whether they followed a specific process, such as screening for pain when the patient arrives. This type of metric may lead staff to just check a box to indicate they completed the desired process, resulting in high grades for everyone, which is not helpful for consumers or for quality improvement, the authors wrote.

Meanwhile, Teno’s other research has found troubling variation in hospice quality, measured by how often hospice staff visit a patient when death is imminent.

“It’s nice that they’re at least beginning to be concerned about hospice quality,” said Dr. Joanne Lynn of the Altarum Institute, a longtime hospice physician  and researcher, of CMS’s new Web site. But “at the present time, it’s of pretty limited value.”

Lynn said people trying to choose a hospice would be better helped by other kinds of information, such as the average caseload for hospice staff; what percentage of patients are discharged alive; and whether the hospice predominantly serves nursing home patients or devotes significant resources to at-home care.

The Hospice Compare site also doesn’t say how often hospices run awry of federal regulations: Inspection reports, which contain verified consumer complaints as well as problems uncovered during routine inspections, are not part of the website, as they are for nursing homes.

Recent hospice inspection reports may be hard to find. Until a recent federal rule change, hospices could go as long as six years without being inspected. By 2018, CMS requires states to increase the frequency to once every three years.

Common quality measures for hospitals and nursing homes, such as mortality rates, don’t translate well to the hospice setting, where people are expected to die, Lynn noted.

Although Hospice Compare is “skeletal” at the moment, Lynn said, it does enable families to search which hospices are near them, and find the hospice’s phone number to start asking questions.

“I’m hoping that it continues to improve over time,” as CMS’s other consumer-focused sites have, she said.

Next year, CMS plans to add family ratings of hospices, including how timely hospice staff were when a patient needed help. CMS is also collecting data on the number of staff visits a patient received in the final week before death. That information should be made public in late 2018, a CMS spokesman said.

CMS wants more power to review MA provider networks

The CMS wants more review power over  Medicare Advantage (MA) provider networks to ensure that they “provide adequate access to covered services to meet the needs of the population served.” Next month, it will formally request that the Office of Management and Budget (OMB) approve the plan.

Currently, CMS only reviews MA plans’ networks when there is a triggering event – e.g., when an insurer starts in a Medicare Advantage plan, when it expands its MA coverage or after a complaint about network issues. Translation: If an MA payer doesn’t expand its offerings or the CMS doesn’t receive any complaints, an MA plan’s provider directory might never get reviewed after first entering the market.

Assuming that the OMB approves the proposal, the CMS could act against MA payers that have incorrect information, including fining the insurers or freezing their enrollments.

Healthcare Dive notes that the Government Accounting Office (GAO)  has expressed concerns “about the size of MA provider networks and incorrect online provider directories, including having providers listed as accepting new patients who had left the network, moved or even died. GAO suggested the CMS have more oversight over MA provider networks. ‘’

“In January, the CMS found that 45% of MA provider directories had incorrect information, including which providers were taking new patients, wrong phone numbers and wrong addresses.’’



Despite CMS delays, bundled payments seen here to stay


Despite another delay  in CMS-led bundled-payment programs, bundled payments are likely to continue as providers’ favorite  value-based reimbursement model.

As Healthcare Dive notes: “Bundled payments serve as an entry to value-based care because of the relatively low risk providers take on. And while these programs aren’t yet proven to be successful, there is enough positive data to excite those who champion paying for healthcare based on value.”

S0, “although CMS under the current administration is less enthused for bundled payments {than the Obama administration}, the industry trend isn’t likely to stop.”

“Private payers are getting in the game, too, so hospitals should invest in EHRs that allow real-time care coordination, and should consider trying voluntary programs as an onramp to the process.”

The American Hospital Association  has spoken out against  against additional delays and thus burdens on providers. “As it exists, the {current} rule places too much risk on providers with little opportunity for reward in the form of shared savings, especially in light of the significant upfront investments required,” said AHA Executive Vice President Tom Nickels.

To read more, please hit this link.












Bill seeks to ease Meaningful Use demands on hospitals


bipartisan group has introduced a bill in the U.S. House that would apparently let the U.S. Department of Health and Human Services (HHS)  ease the burden on hospitals (apparently hospitals only) of Meaningful Use rules involving Medicare recipients.

Called an effort to “amend title XVIII of the Social Security Act to reduce the volume of future electronic health-related significant hardship requests,” the bill would  only affect  providers  still subject to the government’s electronic health record (EHR) incentive program, known as ‘Meaningful Use,”’  Robert Tennant, senior policy adviser to the Medical Group Management Association, told Medscape.

CMS no longer requires individual physicians to participate in the Meaningful Use program, which for them has been subsumed by the Quality Payment Program (QPP) of the Centers for Medicare and Medicaid Services. And, Mr. Tennant said, physicians   eligible to participate in the Medicaid portion of Meaningful Use are not penalized if they don’t participate.

He explained that the legislation might ease their Meaningful Use reporting, but any hardship exceptions would not affect them.

To read more, please hit this link.

CMS further lightens the MACRA load.



CMS is continuing to lighten the MACRA load after smaller and rural providers  complained that their paucity of capital and other resources make complying with the reporting requirements too difficult.

Its latest proposed move would permit  the exemption of small providers participating in the program by increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or fewer Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients. The agency believes  that the move would let about 134,000 clinicians stay out of  MIPS.

The proposal follows more than 800,000 clinicians in May being told that  they will not be evaluated under the MIPS program

MACRA will replace Medicare’s Sustainable Growth Formula with a 0.5% annual rate increase through 2019. After that, CMS says, physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).

Most physicians are expected to enter the MIPS.

“We’ve heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps toward alleviating burdens and improving health outcomes for all Americans that we serve.”

American Medical Association President David Barbe, M.D., praised  CMS.   “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country.”

To read more, please hit this link.

CMS rule would force more transparency by private hospital accreditors


The Centers for Medicare & Medicaid Services (CMS) has published a draft rule meant to   increase transparency and address critical patient-safety issues at hospitals. The proposed rule would require private hospital accreditation organizations to publicly release details about problems found in hospital inspections. The problems and the steps that the facilities would need to take to address them would have to be posted within 90 days of a report to the facility.

Rita E. Numerof, Ph.D.,  president of Numerof & Associates, a  healthcare sector consultancy writes:  “Healthcare consumers have a right to this information. Almost 90% of hospitals are overseen by private accreditors—not directly by government regulators. And medical errors remain a leading cause of death and injuries in U.S. hospitals, with estimates starting at nearly 100,000 people a year dying due to such mistakes.”

She adds:

“Each year, CMS does its own inspection of healthcare facilities to validate the work of the private accreditation organizations. The agency has reported that state inspectors frequently found ‘serious deficiencies’ that were not reported by private reviewers. In the agency’s language: ‘This continued trend of high disparity rates from FY 2012 to FY 2015 raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies during the survey process.’

“For more than a decade, industry executives from leading facilities have acknowledged behind closed doors that they know their organizations are unsafe. But they have not taken the actions required to fix the issues—largely because they haven’t felt pressure from CMS or the market to do so. This kind of transparency is likely to change that.”

To read more, please hit this link.


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5 building blocks for successful bundling

“Baby at Play,” by Thomas Eakins (1876).

Win Whitcomb, M.D., writing in Hospitals & Health Networks, presents what he calls five “building blocks of success” in bundled payments. He is chief medical officer at Remedy Partners, in Darien, Conn.; an assistant professor of medicine at the University of Massachusetts Medical School,  and a founder and a past president of the Society of Hospital Medicine.

Here are his building blocks, in abbreviated form:

1. Data

“For the first time, we are able to view cost data over the entire span of an episode, including acute care and the post-acute recovery period… Administrators and clinicians can identify variation in costs or quality, analyze processes underlying the variation and then implement new processes designed to mitigate such variation.”

“In addition, information systems are emerging that provide access to a patient’s location and clinical status over the entire course of an episode (something most electronic health records cannot do).”

2. Incentives

“Bundled payments disrupt the fee-for-service incentive to increase utilization. Medicare’s Bundled Payments for Care Improvement program enables hospitals, physician groups, post-acute facilities and home health agencies to bear first-dollar risk for an episode. The risk-bearing entity’s monetary reward for lowering costs can be invested in human resources (e.g., patient navigators) and technological resources (e.g., performance reporting and patient tracking software) that help the program succeed.”

“Gainsharing, most often offered to physicians, but also possible with hospitals, nursing facilities and other providers, can ensure that the risk-bearing entity and physicians or other providers have the same goal. Gainsharing in these programs can reward either internal cost savings (derived from, for example, bulk purchasing of implantable devices) or the net payment reconciliation amount (derived from, for example, lower post-acute facility utilization or fewer readmissions).”

3. Post-acute performance networks

“Successful risk-bearing entities build networks of post-acute facilities and home health agencies to ensure efficient and high-quality care for patients after an episode. Inclusion in such a network can be based on costs, readmissions or quality — such as star ratings, the availability of on-site providers and disease specialty programs. ”

4. Care redesign

“CMS promotes care redesign, or improving quality while cutting costs, as the defining feature of bundled payments. Successful organizations have redesigned care for specific bundles like joint replacement; others have redesigned care in an across-the-board fashion agnostic to bundle type.”

“Examples of across-the-board care redesign include deploying an early mobility program, using a decision-support tool to determine an optimal post-discharge location, applying rules to identify candidates for palliative care, having a structured goals-of-care conversation or using protocols to avoid unnecessary acute care transfers of skilled nursing patients. ”

5. Pooling knowledge

“BPCI  supports the role of a ‘convener,’ working with ‘episode initiators’ (providers) to deploy the program. Conveners can provide crucial support for healthcare organizations that aren’t able to go it alone because of a shortage of resources or expertise in data analytics, information technology, care redesign and, in some cases, the assumption of a portion of financial risk.”

To read more, please hit this link.

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