Minnesota state regulators want more information from the Mayo Clinic about its apparent plan to favor patients with commercial insurance over those with Medicare and Medicaid.
“I remain concerned that Mayo has yet to offer the community a strong, clear position on the equal treatment of patients on Medicaid,” Nathan Moracco, assistant commissioner of the state’s Department of Health Services, wrote.
Mayo Clinic was strongly criticized last month after John Noseworthy, M.D., urged his staff to prioritize patients with private insurance. Backing and filling, the system later issued a murky statement clarifying that Dr. Noseworthy meant that Mayo people should consider the type of insurance if patients can receive comparable care elsewhere and he asserted that medical need was still the main factor in its decision-making process.
Providers struggle to balance payer mix. The fact is that money from well-insured (and thus generally more affluent) patients helps pay for those with public insurance. The private insurance also helps hospitals and other providers offset bad debts and pay for charity care.
Because Cambridge Management Group has done considerable work in community/population health, including in addressing the social determinants of health, especially in the Pacific Northwest, this article in The New England Journal of Medicine caught our eyes.
The authors of the article, headlined “Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid,” write:
“As health systems are increasingly being held accountable for health outcomes and reducing the cost of care, they need tools and interventions that address patient and community factors contributing to excess utilization. Effective partnerships among medical care, social services, public health, and community-based organizations could improve population health outcomes, but developing sustainable payment models to support such partnerships has proved challenging.
“Some encouraging innovations have emerged. Catalyzed in part by statewide all-payer delivery-system reform and the growth of value-based or shared-risk payment models, some purchasers and providers of medical care have found innovative ways to support high-value community-focused interventions. For example, Hennepin Health, a county-based Medicaid managed-care organization in Minnesota, has reduced emergency department visits by 9% by using housing and community service specialists who are part of a tightly integrated medical and social service system.”
“To accelerate the development of a scalable delivery model for addressing upstream determinants of health for Medicare and Medicaid beneficiaries, CMS recently announced a 5-year, $157 million program to test a model called Accountable Health Communities (AHC). …{T}he test will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”
“The AHC model reflects a growing emphasis on population health in CMS payment policy, which aims to support a transition from a health care delivery system to a true health system. The AHC test will improve our understanding of whether savings can materialize when upstream factors are addressed through collaboration among stakeholders who are accountable for the health and health care of their community.”
Responding to complaints from health plans questioning the accuracy of the CMS template for predicting costs, the agency has disclosed that it has been underpaying health plans that enroll many people dually eligible for Medicare and Medicaid. CMS says it will modify its risk-adjustment model to make up for the underpayment.
The CMS has been using a model (called the CMS-HCC) to calculate risk scores, using health status in a base year to predict costs in the next one. Modern Healthcare reports that “scores drive adjustments to capitated payments made for elderly and disabled beneficiaries enrolled in Medicare Advantage (MA) plans and certain demonstration programs. ”
After nearly 30 years, the Obama administration wants to modernize the rules nursing homes must follow to qualify for Medicare and Medicaid payments.
The hundreds of pages of proposed changes cover everything from meal times to use of antipsychotic drugs to staffing. Some are required by the Affordable Care Act and other recent federal laws, as well as the president’s executive order directing agencies to simplify regulations and minimize the costs of compliance.
“Today’s measures set high standards for quality and safety in nursing homes and long-term care facilities,” said Health and Human Services Secretary Sylvia M. Burwell. “When a family makes the decision for a loved one to be placed in a nursing home or long-term care facility, they need to know that their loved one’s health and safety are priorities.”
Officials announced the update as the White House Conference on Aging convened Monday. The once-a-decade conclave sets the agenda for meeting the diverse needs of older Americans, including long-term care options. This month also marks the 50th anniversary of the Medicare and Medicaid programs, which cover almost 125 million older, disabled or low-income Americans. Medicare and Medicaid beneficiaries make up the majority of residents in the country’s more than 15,000 long-term care facilities.
“The existing regulations don’t even conceive of electronic communications the way they exist today,” said Dr. Shari Ling, Medicare’s deputy chief medical officer. “Also there have been significant advances in the science and delivery of healthcare that just weren’t imagined at the time the rules were originally written. For example, the risks of anti-psychotic medications and overuse of antibiotics are now clearly known, when previously they were thought to be harmless.“
The proposed regulations include a section on electronic health records and measures to better ensure that patients or their families are involved in care planning and in the discharge process. The rules also would strengthen infection control, minimize the use of antibiotic and antipsychotic drugs and reduce hospital readmissions.
Revised rules would also promote more individualized care and help make nursing homes feel more like home. For example, facilities would be required to provide “suitable and nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside of scheduled meal times.”
Residents should also be able to choose their roommates. “Nursing facilities not only provide medical care, but may also serve as a resident’s home,” the proposed rules say. “Our proposed provision would provide for a rooming arrangement that could include a same-sex couple, siblings, other relatives, long term friends or any other combination” as long as nursing home administrators “can reasonably accommodate the arrangement.”
Consumer advocates are likely to be disappointed that officials are not including recommendations to set a federal nurse-to-resident ratio.
However, the proposed changes would require that nurses be trained in dementia care and preventing elder abuse to better meet residents’ needs.
“We believe that the focus should be on the skill sets and specific competencies of assigned staff,” officials wrote in the proposed rules, “to provide the nursing care a resident needs rather than a static number of staff or hours of nursing care that does not consider resident characteristics.”
Nursing homes will be required to report staffing levels, which Medicare officials said they will review for adequacy.
“It’s a competency approach that goes beyond a game of numbers,” said Ling. “If residents appear agitated, figure out why, get at the cause of the problem,” she said, instead of resorting to drugs to sedate residents.
Advocates for nursing home residents argue that because of inadequate staffing, residents with dementia are often inappropriately given antipsychotic drugs, even though that can be dangerous for them. The new rules would help control the use of these drugs by requiring the facility’s pharmacist to monitor drugs that are prescribed for excessive periods of time or other irregularities and require the resident’s physician to address the problem or explain in the resident’s medical record why the medication is necessary.
“We don’t have enough nursing staff,” Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, said before the rules were released. Federal law requires only one registered nurse on the day shift for a 20-bed facility or a 500-bed facility, licensed practical nurses around the clock and sufficient staff to meet residents’ needs, she said.
“We don’t look at the specific staffing positions per se,” said Greg Crist, a spokesman for the American Healthcare Association, which represents 11,000 skilled-nursing facilities. “We look at the needs of the individuals when determining staff levels, and that is best addressed in the resident’s care plan.”
Although there are also no provisions addressing enforcement in the proposed rule, Ling said it “will permit detection of violations to enable enforcement by lessening the noise.”
“The biggest problem is that the rules we have now are not enforced,” said Edelman. “We have a very weak and timid enforcement system that does everything it can to cajole facilities into compliance instead of imposing penalties for noncompliance.”
A report by the Center for Medicare Advocacy last year found that some serious violations often were not penalized.
“Once the new rules are finalized, they will be added to the items nursing home inspectors check,” Ling said.
The hearing Tuesday, chaired by U.S. Rep. Kevin Brady (R.-Texas), was entitled “Improving Competition in Medicare: Removing Moratoria and Expanding Access,” participants. It discussed a rule under the Affordable Care Act that keeps physician-owned hospitals from expanding and keeps new physician-owned hospitals from treating Medicare and Medicaid patients.
“It is our responsibility to protect Medicare for today’s seniors and for future generations — increasing competition in the marketplace can help achieve that. We will continue to hold hearings on improving the payment system for hospitals and other healthcare providers over the course of this year and develop reforms that will help save Medicare for the long term,” Mr. Brady told the session.
He says that “study after study in recent years has cast doubt on the idea that hospitals increase prices to privately insured patients because the government lowers reimbursements from Medicare and Medicaid.”
“The evidence is clear: Today, hospital cost shifting is dead, and the spillover effect reigns. A consequence is that public policy that holds or pushes down Medicare and Medicaid prices (or their growth) could put downward pressure on the prices hospitals can charge to all its customers and, in turn, on the premiums we pay to insurers.”
What this might do to hospitals executives’ salaries is unknown.
