The CMS has awarded a contract to HealthInsight to improve care quality at the Indian Health Service’s hospitals, first by fixing alarming deficiencies there that have attracted federal scrutiny. HealthInsight, a nonprofit, community-based organization, is charged with “supporting, building and redesigning if needed” the infrastructure of IHS hospitals.
“IHS hospitals—and our staff members across the country—are focused on continuous improvement. (HealthInsight) will provide training for our staff and access to experts to strengthen IHS capacity to deliver quality health care for American Indian and Alaska Native patients,” said Mary L. Smith, IHS’s principal deputy director.
HealthInsight operates in Nevada, New Mexico, Oregon and Utah, which have large populations of Native Americans. It serves as the CMS’s quality-innovation network-quality improvement organization for those states under a five-year contract that began July 2014 .
“HealthInsight works with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, engage patients and families, and improve clinical care locally and across our region,” the organization’s Web site explains. That involves “transforming physician practices, employing lean methodology, assisting with value-based purchasing programs and developing innovative approaches to quality improvement.”
Although the contract particularly targets Medicare beneficiaries, the CMS said that the work involved would “result in systemic change that improves all of the care provided at these facilities.”
Stressed healthcare providers are pleading with the CMS to slow its flood of new payment models that the agency is pushing in order to move healthcare from fee-for-service to value-based care.
Modern Healthcare reports that “Since the start of the year, the agency has introduced or expanded nine pay models and announced selected markets for another three. In comments on a July proposed rule that would make 98 markets financially accountable for the cost and quality of all care associated with bypass surgery and heart attacks, industry stakeholders ask the agency to step on the brakes.”
The Federation of American Hospitals said its members “have become increasingly concerned about the pace of change proposed by the CMS and the unreasonable expectations and burden that such rapid and multiple changes in the delivery system and related payment structure place on hospitals and their work forces….Simply put, this is too fast and too soon.”
The publication reported that “The trade group said it believes that the CMS first needs to evaluate and learn from hospitals’ Comprehensive Care for Joint Replacement Model, or CJR experience, which is less than 6 months old, and from the results of the Bundled Payments for Care Improvement initiative.”
The American Hospital Association said: “In failing to take the time to learn from CJR, the agency has missed a critical opportunity to move bundled-payment models forward in a meaningful way. This proposed rule {in July} raises serious concerns about the agency’s pace of change, as well as its ability to accurately track and process the outcomes of its myriad, increasingly complex alternative payment models.”
Hospitals have been pushing back against the CMS’s proposal to expand the CJR program to include surgical hip and femur fracture treatment episodes, or to make certain CJR hospitals implement the cardiac bundled-payment model. Providers complain that neither the CMS nor participating hospitals have had the time or the data to to properly analyze lessons learned from the model as it is.
A new report from Aledade, a company that helps physicians form and run Accountable Care Organizations (ACOs), says its ACOs have increased primary-care use (which should help boost prevention and reduce the need for expensive specialty care) and revenue, cut lab and imaging costs, and reduced emergency department and hospital use and readmissions in Medicare’s Shared Savings Program (MSSP) for ACOs.
Importantly, the CMS and Aledade both emphasized that more time in the program tends to result in more savings – e.g., CMS noted that 42 percent of ACOs that entered the program in 2012 generated savings above their minimum savings rate, compared to just 21 percent of those who entered in 2015.
The company cited problems involving benchmarking, hospital coding, risk adjustment and information flows/information blocking from EHR vendors and hospitals. Aledade also noted the importance of importance of scale, and said that that MSSP policies can be improved to shorten ACOs’ timeline to financial success.
Healthcare leaders at the Geisel School of Medicine at Dartmouth College and the affiliated Dartmouth-Hitchcock Medical Center have been busily explaining to the national news media their decision to scrap their Accountable Care Organization — a model mostly invented at Dartmouth.
A New York Times story said that Dartmouth’s ACO cut Medicare costs on hospital stays, tests, imaging and other procedures. But although it met its goal for quality of care, the Feds still penalized Dartmouth’s ACO for not reaching cost-savings benchmarks, which prompted it to exit the program last fall.
Robert A. Greene, M.D., an executive vice president in the Dartmouth-Hitchcock Health System, told The New York Times that that the cost-cutting, in combination with federal penalties, was not sustainable for the system. Elliot S. Fisher, M.D., director of Dartmouth Institute for Health Policy and Clinical Practice and one of the designers of the ACO model, noted the disappointment of himself and his colleagues.
“It’s hard to achieve savings if, like Dartmouth, you are a low-cost provider to begin with,” Dr. Fisher told The Times.
A Health Affairs blog post said that the Centers for Medicare & Medicaid Services data suggest that while more ACOs are finding success, financial performance and health outcomes can vary widely across America. In late August, CMS reported that that fewer than a third of ACOs qualified for Medicare bonuses.
The Centers for Medicare & Medicaid Services has announced that it will let providers choose the level and speed at which they comply with the new payment-reform model that emphasizes the medical value/outcomes of patient care over the volume of procedures. In the current, predominately “fee for service” system, the more procedures that providers order, the more they get paid. That is one reason that America’s physicians are by far the highest paid in the world.
Healthcare industry stakeholders have put the CMS under intense pressure to ease implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017. Two months ago, CMS Acting Administrator Andy Slavitt said the agency was considering delaying the start date.
And so eligible physicians and other clinicians next year will be given four options to comply with such new payment schemes such as the Merit-based Incentive Payment System (MIPS) or an alternative payment model (APM), such as Accountable Care Organizations.
Modern Healthcare reported that under MIPS, physician payments “will be based on a compilation of quality measures and the use of electronic health records. About 90 percent of physicians are expected to pursue MIPS because a qualifying APM requires a hefty amount of risk.
“In the first option offered Sept. 8, any data reported will allow providers to avoid a negative payment adjustment. The goal is to ease providers into broader participation in the following two years, ” the publication reported.
The second option lets providers submit data for a reduced number of days. “This means their first performance period could begin later than Jan. 1 and that practice could still qualify for a small payment if it submits data on how the practice is using technology and how it’s improving,” Modern Healthcare reported.
The third option is for practices that are ready to go in 2017.
Anthem Blue Cross and Blue Shield plans in Ohio and 13 other states have become the nation’s first health-insurance plans to offer providers incentives for obtaining integrated-care certification (ICC) from the Joint Commission, Healthcare Dive reports.
“The certification will help Anthem meet its care coordination measure under its Quality-In-Sights hospital incentive program, its performance-based reimbursement program for hospitals,” the news service reported.
So far only one Florida hospital, Parrish Medical Center, has attained integrated-care certification from the Joint Commission. “Anthem hopes its recognition of the standard will prompt hospitals to do so,” Healthcare Dive said.
The decision is part of a broader effort by CMS to reimburse based on quality, not quantity of procedures. Among CMS’s initiatives is a proposed bundled- payment model for heart attacks and bypass surgeries, with a demonstration project to be launched at 98 sites next year.
“The Joint Commission launched the ICC a year ago to recognize providers that excel at communication, information sharing and other behaviors aimed at creating a seamless experience for the patient across multiple healthcare settings,” Healthcare Dive reported.
The AHA has again asked the Centers for Medicare & Medicaid Services to delay implementing the site-neutral provisions of the Bipartisan Budget Act next Jan. 1, citing potential risk for hospitals to violate the Stark law and Anti-Kickback statute.
Under the site-neutral rule, CMS would pay for services rendered in hospital outpatient departments at the same, lower rate it pays for treatment in physicians’ offices. The proposal has engendered controversy since its announcement, with physicians and hospitals taking opposing views.
The AHA now has further ammunition in its push to delay the rule’s implementation. Parts of the rule would apparently make hospitals vulnerable to punishment under laws restricting hospitals’ provisions of free goods or services to referring physicians.
The AHA analysis concludes that hospitals could unfairly suffer by bearing the extra cost of operating their outpatient departments at ”no cost to physicians.”
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.)
Ron Shinkman, the editor of FierceHealthcare, argues that despite the complaints of many hospital executives, the Centers for Medicare & Medicaid Services should be commended for coming out with its star system for rating hospital quality.
He writes, among other things that:
“One of the hospital sector’s arguments for suppressing the data: Safety-net hospitals tend to fare more poorly in the CMS ratings. Given that the poor usually wind up with inferior services in just about every walk of life, that the healthcare they receive is more spotty shouldn’t be a surprise.
“The solution is simple: Assume that patients are going to read your {online} ratings on safety. That means up your game, involve your staff in more training, and isolate and address potential flaws in care delivery.
“It may be tough going for a while, but the end result will be fewer errors, unnecessary deaths and injuries. And those healthier patients will spell healthier margins.”
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.”
