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Trinity Health chief: CMS should stop micromanaging

May 18, 2015by Robert Whitcomb in Uncategorized tagged , , , , ,

 

Richard Gilfillan, M.D., president and CEO of Trinity Health, a Livonia, Mich.-based healthcare network serving patients in 21 states, said Medicare would work better if the Centers for Medicare and Medicaid Services (CMS) stopped micromanaging quality measurement.

“I would love for the {Obama} administration to recognize that they need to stay ‘high-level,'” Dr. Gilfillan told a briefing on the future of Medicare sponsored by the Alliance for Health Reform.

“Thirty-two [quality] metrics for Accountable Care Organizations (ACO’s) to meet is too much — we should have five to seven patient-reported functional status outcomes,” MedPage Today reported he said.

“Hold us accountable, sure but don’t go describing 30 to 50 different ways that allow us to teach and perform to the test. Don’t go deep — let the marketplace be innovative in responding.”

When asked what examples of those five to seven measures would be, Gilfillan said, “I would think there’s a way for us to ask people, ‘How is your functional status? How are you doing now compared to when you went into the hospital?’ Or for all the hip [replacement] folks, ‘How are you doing at 30 days or 60 days?’ Look for those kinds of measures that are straightforward, that are based in the patient.”

Dr. Gilfillan also suggested that CMS give money to  about 20 specialty societies for each to develop an outcomes registry to which providers would voluntarily contribute.

AAFP pushes to defend hospital-employed physicians

May 15, 2015by Robert Whitcomb in Uncategorized tagged , , , , , ,

 

 

The American Academy of Family Physicians has written  a letter to  the the Centers for Medicare and Medicaid Services seeking to defend the rights of family physicians employed by hospitals.

Becker’s Hospital Review reports that in a letter to Andy Slavitt, CMS acting administrator,  AAFP’s board chairman, Reid Blackwelder, M.D.,  argued that hospital-employed physicians have the right to “due process” before being fired from hospitals’ medical staff.

“We believe physicians deserve fair hearings when threatened by termination from a hospital and that fear of retribution may limit or prevent physicians from fully advocating for their patients’ best interests,” Dr. Blackwelder wrote. He added that “physicians with due process rights are more likely to protest fraudulent practices that threaten the integrity of the Medicare and Medicaid programs.”

Becker’s reported that the AAFP is asking CMS to revise the “conditions of participation” form that Medicare-participating hospitals sign, saying that AAFP believes that  hospitals and physician-staffing companies should be prohibited “from including language that facilitates physician dismissal without a fair hearing in physician employment contracts.”

 

Another bid to kill a Medicare-cost curb

May 12, 2015by Robert Whitcomb in Uncategorized tagged , ,

 

Here’s a perfect example of  how, despite Americans’ complaints about their having the world’s highest healthcare costs, special healthcare  economic interests do everything they can to keep those costs high.

Congressional Republicans are pushing to repeal the Independent Payment Advisory Board (IPAB), whose job is to give Congress recommendations on how to slow the growth of Medicare spending if it tops certain thresholds.

Medscape reports that the Affordable Care Act’s language “makes it hard for Congress not to enact IPAB proposals, and if lawmakers fail to do so, the U.S. Department of Health and Human Services is required to implement them.”

Some conservatives even call the IPAB a “death panel,” although, as Medscape notes, the law prohibits the board from proposing anything that “would ration healthcare or restrict benefits.”

IPAB backers say the board is a way to offset the power of industry lobbyists in Congress (actually, legislators and lobbyists are often effectively the same creatures) to stop efforts to control Medicare spending.

Organized medicine strenuously opposes the IPAB because they fear that it will tend to reduce physicians’ incomes, which are  by far the highest  in the world.

 

Medicaid expansion marvelous for Molina

May 8, 2015by Robert Whitcomb in Uncategorized tagged , ,

 

Long Beach, Calif.-based managed-care insurer Molina Health is booming, both in revenue and net income, and the main reason is the Affordable Care Act’s expansion of Medicaid.
“We believe that government-sponsored initiatives, including the Affordable Care Act, will continue to provide us with significant opportunities for membership growth in our existing markets and in new programs in the future,” Molina said Thursday in a filing with the Securities and Exchange Commission.

Molina almost exclusively focuses on Medicaid. It sells health plans in 11 states. Six —California, Illinois, Michigan, New Mexico, Ohio and Washington—have expanded Medicaid under the ACA to low-income people making below 138 percent of the federal poverty line.

Molina’s managed-care skills are  particularly important with its large Medicaid population since states want that population to be in rigorous managed-care systems. It’s tougher to do that with the Medicare population because the elderly have much more political clout than do the poor.

Banned from Medicare but billing Medicaid

May 4, 2015by Robert Whitcomb in Uncategorized tagged , ,

cardsharpers

“Card-sharpers by Candlelight,” by Feliks Peczarski.

Reuters notes that  the Affordable Care Act “explicitly requires that states suspend the billing privileges of most providers who have been ‘terminated’ or ‘revoked’ by another state or Medicare.”

“But in an exclusive analysis of state and federal data, Reuters found that more than one in five of the thousands of doctors and other healthcare providers in the U.S. prohibited  {for various infractions] from billing Medicare are still able to bill state Medicaid programs.”

With millions of patients newly covered by Medicaid under the ACA, and wild differences in the program’s oversight between states, it’s hard to see how this problem won’t get worse.

No more low-hanging fruit?

May 4, 2015by Robert Whitcomb in Uncategorized tagged , ,

low-hanginhg fruit

A JAMA study has found that a federal test program that stems from the Affordable Care Act involving physicians and hospitals slowed healthcare spending in Medicare coverage by hundreds of millions of dollars in 2012 and 2013 but savings were less in the second year.

Reuters reported that the study looked at beneficiaries in 32 Pioneer Accountable Care Organizations (ACOs), in which hospitals and physicians follow 33 quality and care standards for Medicare fee-for-service patients. In return they can receive part of any healthcare savings back from the government.

The savings were 4 percent in the first year but less than 1.5 percent in the second, compared with spending on beneficiaries in traditional Medicare fee-for-service.

The big question is, of course, whether it will much tougher to get hefty new savings over the next few years or whether new systems  and processes (including new technology) will make further efficiencies when those systems are fully integrated. Were the first-year savings simply low-hanging fruit?

New ACO incentive systems are in the pipeline.

One would suspect that some folks at JAMA might not like ACO’s at all because they would tend to reduce the revenues of physicians who have prospered greatly in the fee-for-service system now  under attack by private- and public-sector payers.

An ACA payment reform success story

April 30, 2015by Robert Whitcomb in Uncategorized tagged , , , ,

By JAY HANCOCK for Kaiser Health News

 

To understand how the health law is supposed to fix the mediocre, overpriced, absurd medical system, you could read wonky research papers on bundled payments and accountable care organizations.

Or you could look at what’s going on at Baptist Health System in San Antonio.

Under the potent lure of profit, doctors, nurses and managers at Baptist’s five hospitals have joined forces to cut costs for hip and knee replacements, getting patients on their feet sooner and saving taxpayers money.

“Everybody was aligned on this,” said Michael Zucker, Baptist’s chief development officer. “What we’ve seen is just incredible from a cost savings standpoint.”

Baptist made money doing what used to be industry heresy: reducing patients’ use of the medical system.

The hospital group made a deal with Medicare as part of an ambitious array of experiments authorized by the Affordable Care Act.

Medicare let Baptist take responsibility for the whole process of replacing knees and hips, from admission to surgery to rehab and anything else that happened within a month. (Traditionally the system, essentially tied with Methodist Health System as the region’s biggest, managed only what happens within its doors.)

Then Medicare lowered the average amount of what it pays for all that care by 3 percent, giving Baptist a lump sum for each patient getting the procedures. If the system and its orthopedic surgeons reduced costs below that price, they could keep the difference and divvy it up so long as quality didn’t suffer. If costs went up, Baptist was on the hook.

This is a purified form of the health law’s recipe to save healthcare: Get hospitals, doctors and other providers to work together. Cap their costs. Offer incentives to save and penalties for breaking the budget. Repeat.

A preliminary study of the tests at Baptist and elsewhere, overseen by the health law’s Center for Medicare & Medicaid Innovation, found substantial savings along with shorter patient stays in the hospital and lower use of expensive nursing facilities afterward.

Experts caution that even the focused program at Baptist may be hard to reproduce elsewhere. Successfully applying the model to other diseases and the entire healthcare system is an even longer shot.

Even so, policymakers have bet heavily on such arrangements as the solution to the medical-cost spiral. Medicare aims to make half its reimbursements through such “alternative payment” methods by 2018, officials said this year.

At Baptist, which is owned by Tenet Healthcare, the first step was basic financial education. Doctors are famously clueless about what taxpayers, employers and consumers have to pay for the care they prescribe.

“The public is like, ‘Wow, you guys have no idea what that costs.’ We never really did,” admitted Dr. Sergio Viroslav, a participating orthopedic surgeon.

Baptist surgeons, who select which artificial joint to use, were shocked to find out how much more some devices cost than others. Once they had a stake in the total bill, they became more discriminating shoppers.

Metal hip and knee prices started plummeting “the second the flashlight got lit on the implant makers,” Viroslav said. No manufacturer wanted to be the most expensive.

Surgeons were also surprised to learn that almost half the expense of joint replacement can come from physical therapy, home nurse visits and temporary nursing home stays after the surgery.

Dr. David Fox never paid much notice to the birthday cards that rehab nursing homes sent him. Now that the knee-and-hip surgeon knows what they were making on his referrals, “it’s no damn wonder” they were so nice, he said.

These days, Baptist doctors are likely to order home therapy rather than a nursing home stay unless it’s clearly needed. For the nursing homes they do use, they’re more likely to stay in touch, coordinate care and reduce expensive readmissions, they say.

Simply getting independent surgeons to work with their own hospital system and give it financial control took some doing.

“Hospitals and doctors don’t trust each other,” said Fox. “There’s not an orthopedic surgeon out there that trusts his hospital. You can’t find one. If you do, he’s lying.”

But at Baptist the parties met, sometimes reluctantly, to discuss how to cut costs, help patients recover quickly and apply science-based rules to recuperation.

Is Warfarin the best blood thinner for a particular patient? How much? What kind of compression stockings should be ordered to stop swelling and clots? Is a cane needed? One rubber tip? Or four?

Doctors and nurses had always asked those questions but never in such a disciplined way.

Compensating diverse caregivers to work together on an episode of treatment such as knee replacement is called bundled payment. Baptist has been through two bundled-payment experiments with Medicare.

One began before the health law was passed and focused only on costs inside the hospital, not on what happened later. That saved $284 per patient.

Zucker declined to give detailed figures on the new test. But adding savings incentives for joint-replacement and post-hospital care saved more than $1 million the first year, he said. At the same time, patients recovered more quickly, with fewer complications and resulting readmissions to the hospital, he added.

Such results mean hospitals and doctors “are thinking much more holistically” about care, not just focusing on their own roles, said Rob Lazerow, a practice manager at the Advisory Board Company who consults with hospitals on payment reform.

Baptist keeps part of the savings and shares part with the orthopedic surgeons — a bonus of up to half their surgery fee if they maintain the highest quality measures and their patients do well. The loss to the nursing homes and other post-discharge providers was their gain.

A typical surgery fee is $1,200 per knee, so hitting all the goals could generate as much as $600 more for a doctor.

“If I do 35 patients a month, all of a sudden it’s real money to me,” said Fox — potentially $21,000 a month, although no doctor maxes out the incentive on every patient.

Such “shared savings” with medical providers who were once oblivious to costs are key, said Dr. David Nash, dean of Thomas Jefferson University’s School of Population Health.

“If you change the economic incentives you will change physicians’ practice behavior,” he said.

Knee and hip replacements are relatively easy to manage. They can be scheduled. Doctors have a pretty good idea of what will happen. A more ambitious attempt at reform is trying capped, bundled payments with heart attacks, pneumonia and other conditions that might come with more wild cards.

Even more aspiring is the accountable care organization. Providers in ACO’s receive incentives — from Medicare, commercial insurers or perhaps employers — to keep large populations healthy and reduce the cost of care for every kind of ailment.

That’s a much taller order, and results have been mixed.

But what’s going on at Baptist shows what might be possible, experts said.

Standardizing procedures, avoiding overpriced hardware and coordinating care always did make sense for hip and knee replacements. Now, four decades after such surgery became routine, some hospitals and doctors seem to agree.

“That was really good that we did that,” said Viroslav. “It really helps doctors get better. It kind of forced them to look at their practice.”

Officials look at ways to cut Medicare hospice costs

April 24, 2015by Robert Whitcomb in Uncategorized tagged , , , , ,

By  SUSAN JAFFE, for Kaiser Health News.

Medicare officials are considering changes in the hospice benefit to stop the federal government from paying twice for care given to dying patients. But patient advocates and hospice providers fear a new policy could make the often difficult decision to move into hospice care even tougher.

Patients are eligible for hospice care when doctors determine they have no more than six months to live. They agree to forgo curative treatment for their terminal illness and instead receive palliative or comfort care. However, they are also still allowed Medicare coverage for health problems not related to their terminal illness, including chronic health conditions, or for accidental injuries.

Medicare pays a set amount to the hospice provider for all treatment and services related to the terminal illness, including doctor’s visits, nursing home stays, hospitalization, medical equipment and drugs.  If a patient needs treatment that hospice doesn’t provide because it is not related to the terminal illness — or the patient seeks care outside of hospice — Medicare pays the non-hospice providers. The problem is that sometimes Medicare pays for care outside the hospice benefit that it already paid hospice to cover.

To reduce the chances of these duplicative payments, Medicare officials have announced that they are examining whether to assume “virtually all” the care that hospice patients receive should be covered under the hospice benefit.

Medicare has been paying millions of dollars in recent years to non-hospice providers for care for terminally ill patients under hospice care, according to government reports.

The Medicare Payment Advisory Commission (MedPAC), an independent organization that advised Congress, found that in 2012, Medicare paid $1 billion to hospitals, nursing homes, therapists and other providers for services for hospice patients unrelated to their terminal illness.

The commission did not estimate how much of that was incorrectly billed and should have been covered by hospices. Prescription-drug plans received more than $33 million in 2009 for drugs that probably should have been covered by the hospice benefit, according to an investigation by the Department of Health and Human Services’ inspector general.

Hospice is growing rapidly among older Americans. Of those Medicare beneficiaries who died in 2013, nearly half used hospice, double the rate in 2000, MedPAC also found. Over the same time period, Medicare spending for hospice services grew five-fold, to $15 billion.

Medicare officials initially mentioned last year that they were exploring possible changes. Concerns about duplicative payments “strongly suggests that hospice services are being ‘unbundled,’ negating the hospice philosophy of comprehensive, holistic care and shifting the costs to other parts of Medicare, and creating additional cost-sharing burden to those vulnerable Medicare beneficiaries who are at end-of-life,” they wrote in regulations containing this year’s hospice payment rates and other program rules. Officials have not yet issued a formal proposal.

“There will always be exceptions for people who have terminal conditions and have other conditions that need to be attended to,” said Sean Cavanaugh, deputy administrator at the Centers for Medicare & Medicaid Services. “But the majority of their services would be provided through hospice.”

Seniors’ advocates are worried that putting all coverage under the hospice benefit will create obstacles for patients. Instead, Medicare should go after hospice providers who are shifting costs to other providers that Medicare expects hospice to cover, said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy, who urged the government to protect hospice patients’ access to non-hospice care.

“The easiest thing for CMS to do is to say everything would be related to the terminal illness and then there would be no billing problems,” Berthelot said. But federal law, guarantees hospice patients Medicare coverage to control diabetes, blood pressure or other conditions not related to their terminal illness.

“If your blood sugar gets out of control, that could hasten your death,” she said. “But people shouldn’t be rushed off to die because they’ve elected the hospice benefit.”

Cavanaugh said the government is not trying to restrict drugs or other Medicare benefits for hospice patients.

“It’s more about getting the payment right,” he said. “The question is how to clearly circumscribe the benefit, to define what’s in the hospice benefit and what is not.”

That’s not always easy to figure out.

If a cancer patient in hospice slips on some ice and breaks her wrist, the injury could have happened because the cancer has attacked the bones, making them thin and brittle, said Dr. May Al-Abousi, medical director for hospice services at University Hospitals in Cleveland. Treatment for the injury would be covered by hospice.  But the injury would not necessarily be part of the hospice benefit for someone with a terminal illness other than cancer, she said.

“Medicine has no cookbook, where we can apply all-or-none rules,” she said.

Sometimes a hospice provider may not even know when a patient has gone to the hospital and there’s usually no way the hospital knows the patient is in hospice unless the patient makes that clear, said Judi Lund Person, at the National Hospice and Palliative Care Organization,  which represents nearly 2,000 hospice companies.

“The emergency room physician should be aware that this is a hospice patient with lung cancer as opposed to an 85-year-old male who fell at Denny’s,” she said.

Patients and their families may be afraid to volunteer that information, said Dr. Al-Abousi.  “A lot of people get scared when they hear the “H” word,” she said.  “They think once they sign that paper for Medicare, nothing else is going to be covered.”

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More ACO’s but number of patients relatively small

April 23, 2015by Robert Whitcomb in Uncategorized tagged , ,

 

An Oliver Wyman analysis says that even as many providers drop out of Medicare’s Pioneer Accountable Care Organization, the  total number of ACO’s continued to rise last year, albeit at a slower pace than in 2013.

Perhaps most significant is that nearly 70 percent of Americans now live in an area served by an ACO, up about 3 percentage points from the year before.

There were 426 Medicare ACO’s as of January 2015, up 58 from a year earlier. In the  previous year,  ACO’s increased by  a roaring 234. FierceHealthcare said that besides the Medicare ACOs, the report identified 159 others, to  come to a 585 total, up 12 percent  from 2014.

But there’s a long way to go. As Modern Healthcare reported:

“About 5.6 million Medicare patients, or 11 percent, will receive their healthcare from an ACO, but while ACO’s increased by about 16 percent, the number of patients receiving care from them only increased 6 percent, which the report attributes to smaller ACO’s joining the Medicare program.”

 

WSJ: Another way for hospitals to overcharge Medicare

April 16, 2015by Robert Whitcomb in Uncategorized tagged , ,

 

This devastating investigative piece show how Medicare grossly overpays some hospitals for treating “complicated cases known as ‘cost outliers.”’

The WSJ explains:

“Medicare allows hospitals to collect for such patients based on the actual costs of treating them. But because hospitals don’t provide cost data until many months after patients are treated, the government has to estimate costs using a formula that relies heavily on list prices.

”When prices rise faster than actual costs, the government overpays. Medicare can seek to claw back overpayments when it gets fresher information about costs, but it rarely does, hospital records show.”

”A Wall Street Journal analysis of Medicare claims data and financial filings from medical facilities shows that many hospitals increased prices faster than costs rose, affecting outlier payments.”

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