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Big mental-health-reform bill is filed

Senators Bill Cassidy (R.-La.) and Chris Murphy (D.-Conn.) have proposed a bipartisan mental-health reform bill with an eight-point agenda intended to shore up the U.S.  mental-health system ( Among other measures, the bill proposes to designate an Assistant Secretary for Mental Health and Substance Use in the U.S. Department of Health and Human Services, require audits on mental- and physical-health-parity law implementation, and establish new grants for early mental-health intervention.

Of course, given the close connections among behavioral health, mental heath and “physical health” (as if the brain isn’t an organ!) such a bill, if it becomes law, could have a huge impact across the healthcare system.

Senator Murphy’s office sent us this summary of the bill:

The Cassidy-Murphy Mental Health Reform Act will do the following:

Integrate Physical and Mental Health

  • Encourages states to break down walls between physical and mental health care systems by requiring states to identify barriers to integration. States would be eligible for grants of up to $2 million for five years, prioritizing those states that have already taken action. States taking part are eligible with additional federal funds to treat low-income individuals who have chronic conditions or serious and persistent mental illness. 

Designate an Assistant Secretary for Mental Health and Substance Use

  • Elevates the issue of mental health by establishing an Assistant Secretary for Mental Health and Substance Use Disorder within the U.S. Department of Health and Human Services who will be responsible for overseeing grants and promoting best practices in early diagnosis, treatment, and rehabilitation. The Assistant Secretary will work with other federal agencies and key stakeholders to coordinate mental health services across the federal system and help them to identify and implement effective and promising models of care.

Establish New Grant Programs for Early Intervention

  • Establishes a grant program focused on intensive early intervention for children as young as 3 years of age who demonstrate significant risk factors recognized as related to mental illness in adolescence and adulthood. A second grant program supports pediatrician consultation with mental health teams, which has seen great success in states like Massachusetts and Connecticut.

Establish Interagency Serious Mental Illness Coordinating Committee

  • Establishes a Serious Mental Illness (SMI) Coordination Committee under the Assistant Secretary to ensure documentation and promotion of research and treatment related to SMI and evaluate efficiency of government programs for individuals.

Establish New National Mental Health Policy Laboratory

  • New entity will fund innovation grants that identify new and effective models of care and demonstration grants to bring effective models to scale for adults and children.

Reauthorize Successful Research & Grant Programs

  • Reauthorizes key programs like the Community Mental Health Block Grants and state-based data collection. The bill also increases funding for critical biomedical research on mental health.

Strengthen Transparency and Enforcement of Mental Health Parity

  • Requires the U.S. Department of Labor, the U.S. Department of Health and Human Services, and the U.S. Department of the Treasury to conduct audits on Mental Health Parity implementation and issue guidance on how determinations are made regarding comparability mental health services and physical health services.

Improve Mental Health Services within Medicare/Medicaid

  • Makes critical reforms to allow for patients to use mental health services and primary care services at the same location, on the same day. Repeals the current Medicaid exclusion on inpatient care for individuals between the ages of 22 and 64 if the CMS actuary certifies that it would not lead to a net increase of federal spending.


CMS ratings said to lack key socio-economic data


The groups says that Medicare’s five-star scale that rates the quality of care doesn’t offer a complete picture because it fails to reflect these distinct  factors.

One way to address the problem, the groups say, is for CMS to add  income-related information into its ranking calculations. The star-rating system currently uses patient-satisfaction data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to determine the scores.

Beth Feldpush, senior vice president for policy and advocacy for America’s Essential Hospitals, told CMS that research warns  that larger hospitals, teaching hospitals and hospitals serving many low-income patients could well receive lower star ratings even though they provide quality care to the most vulnerable populations. She also complains  the system  oversimplifies complex and individualized choices that patients must make about their health.

She urged the agency to use  measures endorsed by the National Quality Forum that clearly  account for these socio-economic and demographic factors.


Hospitals play the ‘observation’ vs. readmission game


David Himmelstein and Steffie Woolhandler write in HealthAffairs:

The Centers for Medicare and Medicaid Services (CMS) has trumpeted the recent drop in hospital readmissions among Medicare patients as a major advance for patient safety. But lost amidst the celebration is the fact that hospitals are increasingly ‘observing’ patients (or treating returning patients in the emergency department) rather than ‘readmitting’ them. But while re-labeling helps hospitals meet CMS’s quality standards (and avoid costly fines), it probably signals little real quality gain and often leaves patients worse off financially.”

Safety-net hospital execs complain about new rating system


The Centers for Medicare and Medicaid Services is developing a hospital-quality star-rating system for the Hospital Compare Web site to provide currently available data on quality measurement to help inform healthcare decisions.The new  system will pull data from several sources, “which is different than the current system that’s based on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, according to the CMS,” reports the publication.

“America’s Essential Hospitals, which represents 250 safety net hospitals around the country, said it’s concerned about the proposed methodology for the new system released by the agency earlier this year.

“We are not confident that the measures currently available on Hospital Compare enable CMS to create a single, methodologically sound rating of all aspects of hospital quality.”

“Although the intent of CMS, in developing an overall star-ratings system, is to provide patients with a simplified assessment of how hospitals perform overall on quality, each patient’s circumstances are different and the quality measures most relevant to their care will differ.”

“Also of concern is whether the system will take into account if a hospital serves more of a high-risk population. The trade group believes the CMS methodology should incorporate risk adjustment for socio-economic factors so results reflect differences in treatment across hospitals. ”


Seeming success in a CMS bundled-care pilot


Although the jury remains out on many bundled-payment programs, the success of a Centers for Medicare & Medicaid Services pilot program at Baptist Health on San Antonio in saving $1 million in its first year while improving outcomes has led 360 more providers to  try the program. Further,  a total of 1,755 other providers will partner with them and assume the same financial risk for care episodes.

The project was centered on joint replacements. Under the pilot with CMS, Baptist received a lump sum for each procedure priced at 3 percent below what it normally received from Medicare to perform the procedures.  “If it kept costs below that threshold and maintained high-quality outcomes, Baptist got to keep the difference,” FierceHealthFinance reported.

CMS reported that changes to in-hospital processes saved nearly $300 per patient, saving about $1.1 million based on the number of patients that received treatment through the  bundle.

“Baptist Health also took hard looks at nearly automatic referrals for physical therapy, home nurse visits and nursing homes. Such referrals account for nearly half the cost of a joint replacement procedure. Instead, under the pilot program the patient was more likely to receive therapy at home. The health system also re-examined the use of particular blood thinners, compression stockings and canes for each patient, ” Fierce reported.



Medicare official eyes cutting subsidies for some rural hospitals


Thus he reopened the debate about which  rural hospitals should receive  special federal funds to stay open—and whether  some would be better served by finding another lifeline, such as merging with other, larger hospital in their regions.
Modern Healthcare reports that “The CMS in recent years has made a number of Medicare payment adjustments to help rural hospitals improve their operating margins. Those changes have worked. The 860 rural hospitals that are paid on the inpatient prospective payment system have higher Medicare margins than their urban counterparts, Miller said, according to documents posted on the committee’s Web site.
“But not all of these facilities should qualify for the same assistance; special adjustments should be reserved for isolated hospitals, he added. Nine percent of hospitals designated as sole community providers, as well as 16 percent of designated critical-access hospitals, are actually located within 15 miles of another hospital, he said.”’“These providers are not necessary for access, and it may be inappropriate to give a low-volume adjustment to two competing low-volume hospitals that are five or 10 miles from each other,’ Miller said. ‘Such a policy may also encourage two nearby hospitals to merge, increasing patient volumes.”’




Cardiovascular value-based prevention payment


A look at the Million Hearts Cardiovascular Risk Reduction Model, which will represent the largest test of value-based prevention payment ever conducted by  the Centers for Medicare & Medicaid Services.

This article in JAMA says that if successful, it could point to an innovative path forward for other kinds of preventive care.  CMS has begun  recruiting physician practices to prepare for enrolling the first Medicare beneficiaries in the new program in early 2016.

Medicaid managed-care plans face more red tape


The National Association of Medicaid Directors says that new CMS guidelines meant to ensure the adequate reimbursement of Medicaid managed-care plans will confuse and frustrate state Medicaid agencies while creating too much paperwork for the CMS.


Modern Healthcare reports that “the new rate guidance outlines lengthy data requirements that states must cite so that the CMS is able to determine whether rates are sound. This includes citations to studies, research papers, other states’ analyses, or similar secondary data sources.

“Medicaid directors were taken aback by the {amount and complexity} of the documentation that the agency was requesting.”

“If the agency truly wants to ensure adequate rates, it should work with states and their actuaries to strike a reasonable balance in the level of documentation required and ensure CMS oversight of a feasible rate review process, the association said, ” Modern Healthcare reported.


Making Medicare Advantage work for hospital-insurers


The biggest problem is that they underestimate how tough it is to compete with established insurance carriers.


Planning carefully for this competition  “can help determine whether it’s best to enter as an independent plan, partner with an established entity that brings the right capabilities, or to take delegated risk from a health plan for an attributed population.”

Further, “to maximize the benefits, providers need to know exactly what patients are attributed to the plan—and fiercely manage each and every individual accordingly. For the sickest and riskiest patients, that means delivering care differently—more targeted and coordinated across points of care—to drive savings in a major way.”

“Most provider-turned-health plans are at least somewhat well-positioned to improve the quality and reduce the cost of patient care across a network if incentives are appropriately aligned; this of course is fundamental to running a profitable plan.”

“The best plans go to great lengths to learn and document every last issue about their patients to get this right, and then receive higher payments from CMS for those riskier patients.”





Experts applaud ‘Next Generation’ ACO’s



Experts applauded the Centers for Medicare & Medicaid Services’ “Next Generation” Accountable Care Organization (ACO) plan, which asks participants to take on more financial risk in return for more  potential reward. The aim is to move away from fee for service to capitation as payers push healthcare industry toward a value-based reimbursement system.

“It’s a real effort to move away from shared savings or limited risk models. On both counts it’s an important step,” said Mark McClellan, M.D., a former CMS administrator,  told FierceHealthcare.

Larry Kocot,  a visiting fellow in the economic-studies program at the Brookings Institution, agreed. “I do think CMS should be credited for thinking creatively to extend the model to meet the needs of providers no matter what stage they are at within the ACO program,” he told the news service.

Farzad Mostashari, M.D., former national coordinator for health- information technology, told Clinical Psychiatry News Digital Network that the new model will likely suggest how CMS will structure other ACO’s.  “This is directionally, absolutely where the Medicare Shared Savings Program (MSSP) is headed.”

“We are hopeful the changes they proposed and the comments received that they will make the MSSP program more accessible and more friendly to a number of providers,” said Kocot, who also served as a senior administrator of CMS.

FierceHealthcare reported that Kocot said he’d like the CMS to establish a ”fourth track that would lead to full capitation. He recommends tracks that reflect a continuum of ACOs that may begin with little risk and end with the full capitation model.”

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