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Mo. hospital to close units after CMS decides it’s too small

July 19, 2016by Robert Whitcomb in Uncategorized tagged , ,

spingfield

Lightning over downtown Springfield.

Ozarks Community Hospital, in Springfield, Mo., will lay off 200 employees as the system closes its surgery and emergency departments, according to a Springfield  (Mo.)  News-Leader report.

Hospital officials blamed the layoffs on a CMS decision  ”that it is terminating our Medicare agreement because we do not satisfy the federal definition of a hospital.” CMS  has questioned whether OCH has enough inpatient volume to be deemed an acute-care hospital. The hospital is appealing  the CMS’s decision.

And so the hospital will no longer admit  people to its inpatient unit, effective immediately, and will close its surgery and emergency departments July 29.

An OCH spokeswoman told the paper that its Springfield clinics —including the OCH Medical Offices Clinic, OCH Primary Care Clinic, OCH Northside Behavioral Medicine Clinic  and OCH Evergreen Clinic — will continue to operate as normally.

To read the full news story, please hit this link.

CMS wants to expand diabetes-prevention program

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

diabetes2

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.

Things to know about CMS’s Oncology Care Model

July 1, 2016by Robert Whitcomb in Uncategorized tagged , , ,

 

Here is a stripped-down version of Becker’s Hospital Review’s “9 things to know” about CMS’s five-year Oncology Care Model, one of  CMS’s first physician-led specialty-care models, meant to improve quality and cut  costs.

1. “HHS selected 17 payers and 196 physician practices to participate — almost twice the number it expected.”

2. “The program takes  episodic approach to cancer treatment to help contain costs and enhance patient care.”

3. “Under the OCM, physicians are paid in two ways.”

4. “Episodes last six months each and cover almost all cancer types.”

5. “Performance payments are awarded to practices based on how well they perform in relation to benchmarks calculated by CMS.”

6. “There are two risk options under the OCM.”

7. “The two-sided risk track is considered an Advanced Alternative Payment Model under the newly proposed Medicare Access and CHIP Reauthorization Act.”

8. “CMS will provide a learning system for participants to share and diffuse resources, tools, ideas and data-driven approaches to care.”

9. “Dual participation in OCM and other programs is allowed in some cases.”

To read the whole Becker’s article, please hit this link.

 

Unique Device Identifier data should be integrated with Medicare claims

June 30, 2016by Robert Whitcomb in Uncategorized tagged , , ,

blackhole

This HealthAffairs article discusses the need to close “black hole in Medicare data.”

The authors write:

“Every year, the Medicare program pays for nearly 500,000 hip- and knee-replacement surgeries for America’s seniors. At the same time, approximately 25,000 patients undergo procedures to remove and replace a previous artificial joint, sometimes because it failed before the end of its expected useful life. Remarkably, and largely due to inadequacies in the systems that collect data through routine billing, the Medicare program is unable to identify product failures and patient safety problems, or to measure and promote high-value care with medical devices. This problem is serious, but can, and should, be fixed.”

They note:

“Regulations finalized in 2013 establish a Unique Device Identifier (UDI) to provide each product with a code corresponding to its make and model. FDA required all implanted devices to have one of these identifiers by September 2015.”

“With Medicare spending billions of dollars annually on joint replacement procedures alone, the program’s administrators and taxpayers should, at the very least, know which brands of products are being purchased and implanted. Making this information available will help improve the quality of implanted devices, reduce costs to the taxpayer, and improve patient outcomes. Until UDI is integrated into claims, CMS—and Congress—will be unable to effectively administer and oversee healthcare for American seniors who rely on medical devices.”

To read the HealthAffairs article, please hit this link.

HHS picks 196 physician groups, 17 health insurers in coordinated cancer-care project

June 30, 2016by Robert Whitcomb in Uncategorized tagged , ,

 

The U.S. Department of Health and Human Services has selected 196 physician group practices and 17 health-insurance companies to take part in a value-based delivery model that seeks to provide more coordinated cancer care at a lower cost to Medicare.

Under what has been named the Oncology Care Model, CMS will use certain quality measures to track the care that each physician practice provides to Medicare beneficiaries undergoing chemotherapy.

Becker’s Hospital Review reports that practices “will receive performance-based payments for each six-month episode of care based on quality scores and whether they saved money over the episode, compared to historical fee-for-service payments.”

The news service added: “Practices will also receive a $160 monthly care management payment for each beneficiary. Participants will be enrolled in a one-sided risk model for the first two years of the Oncology Care Model and dive into two-sided contracts beginning in 2018.”

To read the Becker’s article on this, please hit this link

ACO benchmarking issues may be fixed; next problem?

June 13, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

 

Bob Herman, writing in Modern Healthcare, reports that while CMS may have fixed its benchmarking issues with Accountable Care Organizations, that might be inadequate.

He writes: “{M}any have raised concerns that the CMS still is not doing enough to ease providers into riskier ACO models, which is paramount for Medicare’s new physician-payment system.

“The elephant in the room is not the benchmarking rule,” Clif Gaus, CEO of the National Association of ACOs, a trade group run by hospitals and physician groups, told Mr. Herman. “It is: What is CMS going to do to improve the business model for the one-sided ACOs and provide a lower-risk track for the two-sided programs?”

Hit this link to read Mr. Herman’s article.

CMS releases stronger incentives to join ACOs

June 7, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

CMS has released final regulatory revisions  to strengthen incentives for Accountable Care Organizations in the Medicare Shared Savings Program.

CMS Acting Administrator Andy Slavitt said the changes  will “encourage more physicians to improve patient care by joining ACOs, while also refining how the program measures success, so that current participants are better rewarded for quality.”

Mr. Slavitt said the changes will also help physicians prepare for the new Quality Payment Program That program will hold providers to unprecedented accountability not just for reporting, but also, among large physician groups, for performance on a broad range of behaviors.

Here, according to Becker’s Hospital Review, are five takeaways from the MSSP ACO final rule.

1. “CMS modified the process for resetting benchmarks used to determine ACO performance.”

2. “CMS removed the adjustment that explicitly accounts for savings generated under an ACO’s prior agreement period.”

3. “The rule includes a phased-in approach to implementation.”

4. “CMS finalized an additional option for ACOs participating under Track 1 to apply to renew for a second agreement period under a two-sided model.”

5. “The rule establishes timeframes and criteria for ACOs to appeal CMS’ calculation of bonuses and penalties.”

 

Outpatient joint replacements pose big threat to hospitals

June 6, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

hipreplace

In the past, people getting total hop or knee replacements have usually been operated on in a hospital inpatient surgical unit, then they remain a few days in the hospital and finally they are are moved to a skilled-nursing or rehab facility or get home health care.

“{T}hat’s starting to change, and tensions are rising between hospitals and orthopedic surgeons as a result. Building on advances in surgical technique, anesthesia and pain control, a small but growing number of surgeons around the country are moving more of their total joint replacement procedures out of the hospital, performing these lucrative operations in outpatient facilities. Some are sending their patients home within a few hours, while others have their patients recover overnight in the surgery center or hospital during 23-hour stays. These surgeons say very few of their patients require skilled nursing, rehab or home healthcare. ”

The publication then  states what might be obvious:

“Moving these procedures to outpatient settings poses a major threat to hospital finances, since total joint replacements are one of the largest and most profitable service lines at many hospitals….The financial threat will be even greater if the CMS changes its rules and allows Medicare and Medicaid payment for these outpatient procedures, which observers expect will happen in the next few years.”
“The migration of total joint replacements to outpatient settings also raises questions about the future of Medicare’s mandatory bundled-payment initiative for inpatient procedures in 67 markets around the country, called the Comprehensive Care for Joint Replacement program, which began in April. If the CMS decides to pay for ambulatory procedures, that could undercut the hospital bundling initiative.”

 

MH TAKEAWAYSThe migration of lucrative joint-replacement surgeries to outpatient settings will cause friction between surgeons and hospitals and raises questions about the premise of Medicare’s new bundled-payment initiative for hospital-based procedures.

Critics ask, so what? “Why would we not encourage the migration to outpatient if the outcome is the same and the cost is lower?” said Jeff Goldsmith, a national adviser to Navigant Healthcare. Goldsmith, a Medicare beneficiary, recently underwent a hip replacement and recovered so quickly he thinks it could have been done on an outpatient basis. “Why preserve the (inpatient bundling) program if the whole point is to save money for Medicare?” he said.

Until recently, outpatient total joint replacements were rare. Most providers and patients thought a several-day hospital stay was needed because of the pain, mobility and infection risks associated with these major surgeries. Now, when patients’ health plans allow it, leading surgeons in this field say they are doing many or most of their joint replacements on an outpatient basis—except for patients who are extremely obese or have unstable chronic conditions. They say even healthy patients in their 70s or 80s can be candidates for outpatient surgery, but careful patient selection is essential.

Many more surgeons are eager to learn these improved clinical processes and start doing joint replacements outside the hospital. “Dr. Hoffman has surgeons and administrators from all over the country come tour and watch our processes two or three times a month,” said Michael Patterson, CEO of the Mississippi Valley Surgery Center, who recommends slow, careful adoption of outpatient procedures. “We advise surgeons that first they need to be able to get patients in and out of the hospital within 24 hours. They can’t go straight from three- to five-day stays to 23 hours.”

The emerging outpatient delivery model is driven by both patients’ and payers’ desire to reduce their costs, increase convenience and satisfaction and diminish the risk of hospital-acquired infections. Orthopedic surgeons say doing joint replacements on an outpatient basis cuts costs nearly in half, although reimbursement is also lower. “People want quality at a reduced cost,” said Dr. Patrick Toy, who has done nearly 250 hip and knee replacements at the outpatient Campbell Clinic in Memphis, Tenn., which he partially owns. “This hits the nail on the head.”

Despite the looming financial threat, many hospitals have not settled on a strategy to address the outpatient migration, particularly where local surgeons have not yet adopted this new practice pattern. In some markets, hospitals and surgeons are starting to collaborate, while in others there may be conflict over who will capture the big dollars from joint replacements, which are surging as the baby boomers move into their creakier years.

“This is coming whether we like it or not, and we have to figure out how to better partner with physician practices to deliver the best care for patients and hopefully protect patient volume for the hospital,” said Kyle Armstrong, CEO of Baptist Memorial Hospital-Collierville, a suburb of Memphis served by Toy’s free-standing surgery center. “I can imagine there will be some areas where it is contentious.” His system has considered buying or partnering in a Memphis outpatient surgery center.

In 2014, 23% of 354 hospitals surveyed by the Advisory Board Co. performed at least some outpatient knee replacements, while 7% performed at least some outpatient hip replacements. Experts say those numbers likely have increased in the past two years as more surgeons and their teams gain confidence with new and improved clinical protocols, making it possible to release patients more quickly.

“More hospitals are starting to move joint replacement into outpatient settings to compete with (free-standing) ambulatory surgery centers,” said Shruti Tiwari, a senior consultant at the Advisory Board. “Patients are warming up to the idea, particularly younger and healthier patients who don’t have time for a three-day hospital stay and a protracted recovery process.”

“The smart, strategic hospital management teams understand they need to get ahead of this, so that when volume shifts out of their buildings they won’t lose patients,” said Brian Tanquilut, a senior healthcare analyst at Jefferies & Co. “That’s why the investor-owned hospital companies are making a big push on surgery centers.”

Even at hospitals that are already collaborating with their surgeons on outpatient joint replacements, executives caution that there are problems making outpatient joint replacements financially viable.

“The current ambulatory reimbursement system isn’t really sufficient to cover the overall cost of care,” said Michael Dandorph, chief operating officer at Rush University Medical Center in Chicago. He projects that up to 25% of joint replacements may be done on an outpatient basis within five years if Medicare starts paying for them. “On a single-case basis, we’re taking a revenue hit. But if it produces better outcomes and lowers the cost, that should attract more patients,” he said.

Orthopedic surgeons say that while they would like to collaborate with hospitals on outpatient joint replacements, institutional inertia makes it hard to implement innovative practices that better serve patients.

Dr. Richard Berger performs nearly 800 outpatient total joint replacement procedures a year, split between Rush University Medical Center’s ambulatory surgery unit and the Munster (Ind.) Specialty Surgery Center, a free-standing facility he partially owns. “Even at Rush, which is a great hospital, it’s hard to make changes and try new things,” he said. “At the surgery center, I make one phone call and anything I want to do, I can do.”

“You can control costs so much better in the ambulatory surgery center setting,” said Dr. Alexandra Page, who chairs the American Academy of Orthopaedic Surgeons’ Health Care Systems Committee and whose practice partner has started doing joint replacements in a free-standing outpatient center in San Diego. “That works for everyone but the hospital.”

Some hospitals, such as Rush and CentraCare Health’s St. Cloud (Minn.) Hospital, are responding by working with surgeons to do same-day or

23-hour joint replacement procedures either in hospital-run surgical units or outpatient centers, depending on each patient’s needs. Dr. Joseph Nessler and his colleagues at St. Cloud Orthopedics, a 21-physician independent practice group, are doing more than 300 total joint replacements a year on an outpatient basis, divided between the physician-owned St. Cloud Surgical Center and the hospital. The chosen surgical setting is based on each patient’s medical condition and whether an overnight stay is needed

Partners urgently trying to fix Medicare snafu

June 6, 2016by Robert Whitcomb in Uncategorized tagged , , ,

 

Partners HealthCare, trying to prevent steep declines in Medicare payments to its Massachusetts hospitals, is  urgently urging CMS to use corrected data that the Boston-based system submitted for 19-bed Nantucket (Mass.) Cottage Hospital.

As Becker’s Hospital Review notes: “Under hospital payment rules, Medicare is required to reimburse employee wages at urban hospitals at the baseline set at rural hospitals in the state. Nantucket Cottage Hospital typically sets the floor for wages at hospitals across Massachusetts because it is the only rural hospital in the state. However, that isn’t the case this year.”

“Consultants hired by Partners made several errors in the data Nantucket Cottage Hospital submitted to Medicare. The errors reduced the hourly wage rate by overestimating hours and failing to include enough overtime pay and high-paid physician hours. Due to the mistakes, Massachusetts hospitals could lose a total of $160 million in Medicare funding next year. ”

 

 

 

Feds fine insurance startup for misleading marketing

June 1, 2016by Robert Whitcomb in Uncategorized tagged , ,

barker

Barker at Vermont State Fair, 1941.

Federal regulators have fined Clover Health $106,095 for misleading consumers about their out-of-network benefits.

Clover Health sells Medicare Advantage products in New Jersey. The health- insurance startup provides enrollees with out-of-network benefits and lets them pay nothing for monthly premiums, co-payments and generic prescriptions.

Becker’s Hospital Review reported that CMS says that Clover’s  marketing misled potential enrollees about their ability “to always receive covered services from any out-of-network provider. The regulators said that the materials incorrectly stated that out-of-network providers participating in the Medicare program had  to accept Clover enrollees.”

For the full story from Becker’s Hospital Review, read this link.

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