The Government Accountability Office says that federal rules governing Section 1332 waiver approvals under the Affordable Care Act might discourage states from applying for the program.
The U.S. GAO said stakeholder groups have predicted fewer Section 1332 waiver requests this year because of application review controls and other complication.,
Modern Healthcare noted that starting Jan. 1, 2017, “states can request waivers for virtually every coverage component of the Affordable Care Act as long as the state’s healthcare coverage is consistent with ACA terms and doesn’t increase the federal deficit.
“But HHS and the Treasury Department issued rules and guidance preventing states from using savings from other federal waivers—like Medicaid waivers—to justify their 1332 applications, and groups have told the GAO that could ‘considerably limit’ the number of requests.”
The GAO said: “Representatives told us that states may be concerned that such proposals may not be able to meet the deficit neutrality criteria for the 1332 waiver independently of the Medicaid waiver.”
The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released this week show.
The government will punish more than half of the nation’s hospitals — a total of 2,597 — having more patients than expected return within a month. While that is about the same number penalized last year, the average penalty will increase by a fifth, according to a Kaiser Health News analysis.
The new penalties, which take effect in October, are based on the rehospitalization rate for patients with six common conditions. Since the Hospital Readmissions Reduction Program began in October 2012, national readmission rates have dropped as many hospitals pay more attention to how patients fare after their release.
The penalties are the subject of a prolonged debate about whether the government should consider the special challenges faced by hospitals that treat large numbers of low-income people. Those patients can have more trouble recuperating, sometimes because they can’t afford their medications or lack social support to follow physician instructions, such as reducing the amount of salt that heart failure patients consume. The Centers for Medicare & Medicaid Services says those hospitals should not be held to a different standard.
Medicare said the penalties are expected to total $528 million, about $108 million more than last year, because of changes in how readmissions are measured.
Medicare examined these conditions: heart attacks, heart failure, pneumonia, chronic lung disease, hip and knee replacements and — for the first time this year — coronary artery bypass graft surgery.
The fines are based on Medicare patients who left the hospital from July 2012 through June 2015. For each hospital, the government calculated how many readmissions it expected, given national rates and the health of each hospital’s patients. Hospitals with more unplanned readmissions than expected will receive a reduction in each Medicare case reimbursement for the upcoming fiscal year that runs from Oct. 1 through September 2017.
The payment cuts apply to all Medicare patients, not just those with one of the six conditions Medicare measured. The maximum reduction for any hospital is 3 percent, and it does not affect special Medicare payments for hospitals that treat large numbers of low-income patients or train residents. Forty-nine hospitals received the maximum fine. The average penalty was 0.73 percent of each Medicare payment, up from 0.61 percent last year and higher than in any other year, according to the KHN analysis.
Under the Affordable Care Act, which created the penalties, a variety of hospitals are excluded, including those serving veterans, children and psychiatric patients. Maryland hospitals are exempted as well because Congress has given that state extra leeway in how it distributes Medicare money. Critical-access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, are also exempt.
As a result, more than 1,400 hospitals were automatically exempt from the penalties. Other hospitals did not have enough cases for Medicare to evaluate accurately and were not penalized. Of the hospitals that Medicare did evaluate, four out of five were penalized.
The KHN analysis found that 1,621 hospitals have been penalized in each of the five years of the program.
Kaiser Health News staff writer Sydney Lupkin contributed to this report.
Here’s one of Becker’s Hospital Review’s “Things to Know” features — this one has seven things to know about Democratic vice-presidential nominee Tim Kaine’s stand on healthcare issues.
1. Sen. Kaine supports the Affordable Care Act.
2. However, Sen. Kaine says more fixes to the ACA are needed.
3. Addressing the opioid crisis is a top priority for Senator Kaine. .
4. He is also positioning himself as a champion of preventive care.
5. Senator Kaine supports a woman’s right to choose.
6. He has a substantial background in health IT.
7. Senator Kaine supports allowing Medicare to negotiate drug prices with pharmaceutical companies.
Researchers report that the Medicare annual wellness visit, mandated under the Affordable Care Act and including an assessment of mental impairment, is underused.
MedCity News reported that an analysis of electronic health records (EHR) from Allina Health System, based in Minneapolis, found that only about 30 percent of its eligible Medicare population had an annual wellness visit in 2015.
And, not surprisingly, the researchers determined that the patient groups who would benefit most from cognitive screening were less likely than other elderly people to go for an annual check-up.
Sounds as if a lot more public-information outreach is needed.
After a raucous debate lasting nearly a year, the Democrats are united on health care. But that unity does not include a call for a single-payer “Medicare for all” health system.
“This campaign is about moving the United States toward universal health care and reducing the number of people who are uninsured or under-insured,” Sen. Bernie Sanders (I-Vt.) said Tuesday in endorsing his rival Hillary Clinton, the presumptive Democratic presidential nominee.
Sanders did win a few health care concessions in the negotiations leading to the endorsement. Clinton vowed to support more funding for community health centers and access to a “public option” government insurance plan, which she has supported in the past.
But on Sanders’s top health priority — his “Medicare for All” plan — there was not a word. At the Democratic Platform Committee meeting over the weekend, an amendment to add a single-payer plan to the document was defeated.
It wasn’t much of a surprise.
Most health-policy analysts — including those who are sympathetic to the idea — say moving from the current U.S. public-private hybrid health system to one fully funded by the government in one step is basically impossible. And that’s making a huge assumption that it could get through Congress.
“To try to do it in one fell swoop would be massively disruptive,” said Paul Starr, a professor at Princeton who was a health policy adviser to President Bill Clinton.
The U.S. healthcare system, said Jeff Goldsmith, a healthcare consultant and health futurist, is “the size of a country — it’s bigger than France — and it employs 16 million people.”
In moving to a single-payer system, he said, “you’re talking about reallocating $3 trillion, reducing people’s incomes and creating” in effect a single entity that would set prices for all medical services. Single-payer supporters dispute the idea that getting from here to there could not be done.
“We’re so used to such a complicated system in the U.S. that we envisage any change would be incredibly complicated as well,” said Steffie Woolhandler, a physician and one of the founders of the single-payer advocacy organization Physicians for a National Health Program. “But what you’re doing with single-payer is actually simplifying the system.”
For example, said Woolhandler, “the latest data are that U.S. hospitals are spending 25 percent of their total budget on billing and administration, and hospitals in single-payer nations like Canada and Scotland are spending 12 percent.”
But while a single-payer system would undoubtedly produce efficiencies, it would also bring huge disruptions. Said Starr, single-payer supporters “haven’t worked through the consequences.”
One of the biggest is exactly how to redistribute literally trillions of dollars. The problem, said Harold Pollack, a professor at the University of Chicago, is that the change will create losers as well as winners.
“Precisely the thing that is a feature for single-payer proponents is a bug for everyone who provides goods and services for the medical economy,” he said, since their profits — and possibly their incomes — could be cut.
And it’s not just the private insurance industry (which would effectively be put out of business) that could feel the impact to the bottom line. Parts of the health care industry that lawmakers want to help, like rural hospitals, could inadvertently get hurt, too. Many rural hospitals get paid so little by Medicare that they only survive on higher private insurance payments. Yet under single-payer, those payments would go away and some could not make it financially. “You would not want to wipe out a third of the hospitals in Minnesota by accident,” Pollack said. “And you could,” if payments to hospitals end up too low.
There are also questions about how feasible it would be to have the federal government run the entire health care system. “It’s hard to be nimble” when a system gets that big, said Ezekiel Emanuel, a former health-sector adviser in the Obama administration now at the University of Pennsylvania. “No organization in the world does anything for 300 million people and does it efficiently.”
The politics of Medicare — which serves roughly 50 million Americans — already make some things difficult or impossible, he said, pointing to a current fight in which doctors and patient advocacy groups blasted a proposal to move to a more cost-effective way to pay for cancer drugs. “You already can’t do certain things in Medicare because of the politicization,” he said. ”When you cover the whole country, it would be a lot of gridlock.”
Pollack agreed, and pointed out it’s not just the health care industry that could revolt. When the full Affordable Care Act was rolled out in 2013, he said, “the people who couldn’t keep their old plans — a very tiny number as a percent of Americans” were furious. “We saw how difficult that was and how angry the public was when that promise wasn’t kept. Now imagine the major shift we’d have to do to move to a single payer system.”
There’s also the question of whether it’s simply too late to go back to the health care drawing board.
Single-payer supporter Woolhandler insists it is not. “Other nations have gone to single-payer systems,” she said. “It usually can be done in about a year.”
The last industrialized country that did the switch was Taiwan, in the mid-1990s. Taiwan, however, with its 23 million residents, has a population larger than New York and smaller than Texas, and had no existing private health insurance system at the time.
“What I’ve often said is we could have done this in the 1940s when Harry Truman proposed it,” said Starr, who has written at length on the history of American health politics. “Health care at that point was probably about 4 percent of [gross domestic product] and there existed at that time a relatively small private insurance industry.” Today health care spending in the U.S. is approaching 18 percent of the nation’s GDP and the private health insurance industry accounts for half a trillion dollars per year.
Both Starr and Pollack, however, said it would be possible to make a switch, although it would have to be carried out over a very long period of time.
“You could imagine some kind of long transition, where you gradually expanded Medicare,” said Starr, “for example moving it down to age 55” and then in later years continue to lower the age threshold.
But even if the U.S. did manage to execute a single-payer system, said Pollack, it would likely prove problematic, particularly in how it would be financed.
“The major value of a single-payer system would be to help the bottom third of the income distribution, and that means the top 20 percent of the population will have to pay more,” he said. “I’m actually in favor of that, but let’s not kid ourselves. That’s a knife fight that’s going to be had.”
U.S. Atty. Gen. Loretta Lynch has discussed in detail why the Feds are rejecting the huge insurance company mergers sought by Anthem and Aetna. Anthem wants to buy Cigna; Aetna wants to buy Humana.
“If allowed to proceed, these mergers would fundamentally reshape the health insurance industry They would leave much of the multitrillion-dollar health industry in the hands of three mammoth insurance companies, restricting competition in key markets,” she said.
The government says the transactions would “substantially lessen competition in numerous markets around the country,” leading to “higher prices and reduced benefits” for consumers.
Justice Department officials also worry that the deals would kill most competition in the Affordable Care Act’s insurance marketplaces.
Indiana Gov. Mike Pence is in the spotlight this week as the man Donald Trump has picked to be his running mate. Pence’s decisions about health and healthcare in Indiana have drawn attention from within and outside the state. His record could be important in November, because Trump doesn’t have a legislative record at all.
Here’s a quick look at the governor’s history in health policy in Indiana.
Medicaid Expansion
Pence has always been a vocal opponent of the Affordable Care Act, even after the federal law passed in 2010 and was upheld by the Supreme Court.
But when faced with the choice of whether to expand Medicaid to cover Indiana residents who earn incomes that are 138 percent or below the federal poverty level — a key part of the ACA — Pence made a compromise. He debuted a conservative-friendly version of the expansion, one that requires Medicaid recipients to pay a monthly contribution, based on income, into a health savings account. Recipients who miss a payment can be bumped to a lower level of coverage, or lose it entirely, for six months.
Now, after a year and a half, the Healthy Indiana Plan, or HIP 2.0, has enrolled about 190,000 more people into health coverage.
Caitlin Priest, director of public policy at Covering Kids & Families of Indiana, said the plan has helped many people get health insurance for the first time in their lives.
“It’s really been a wonderful way to move the needle both on health care access and ultimately on long-term health outcomes,” Priest said.
Pence took criticism from the right for accepting a component of Obamacare, but his conservative tweaks to Medicaid have other Republican-led states looking at that model.
HIV Outbreak
Pence drew criticism from local and national infectious disease experts for his response to an urgent health crisis in Indiana. In February 2015, the state reported an outbreak of HIV in Scott County, blamed on opioid addiction and needle sharing.
It got so bad — growing to more than 80 cases in the month after the announcement, and more than 190 to date — that the CDC came to Indiana to investigate, and public health experts began calling for a needle exchange. At the time, syringe exchanges were illegal in the state and Pence was opposed to changing that, at first.
He later signed an emergency declaration allowing Scott County to start a needle exchange program. Rather than legalize such exchanges statewide, Pence signed a bill that forces counties to ask permission to start a needle exchange.
Only a few counties have done it, so far, because the process takes a lot of planning, local support and money, which the state doesn’t provide, said Carrie Lawrence, a researcher with the Rural Center for AIDS/STD Prevention.
“If you’re the health department with only two part-time staff, and a full-time health director, who’s going to do this, and when is it going to happen?” Lawrence said.
Public Health Budgets
The HIV crisis also brought some attention to Indiana’s lack of public-health funding in general, Lawrence said.
“I think we are dealing with the consequences of the fact that that we don’t have a strong infrastructure for public health in the state,” she said.
As governor, Pence signed legislation that slashed Indiana’s budget for public- health programs, despite the state’s many pressing public-health problems. Indiana has a high smoking rate, high obesity rate and high infant mortality rate. The state is ranked nearly last for both federal and state public health funding. According to Trust for America’s Health, Indiana spends just $12.40 per resident on public health. West Virginia, in contrast, spends more than $220.
As a member of Congress from 2001 to 2013, Pence voted against funding for health programs such as the State Children’s Health Insurance Program and the Prevention and Public Health Fund.
Abortion Access
As a congressman, Pence was an early advocate for defunding Planned Parenthood, and this year, women’s health advocates have clashed with him again.
In March, the governor signed a bill that’s been cited as one of the most restrictive in the U.S., barring abortion on the basis of disability, gender or race of the fetus. It also requires women to get an ultrasound at least 18 hours before the procedure and requires that the fetal remains be buried or cremated.
Some Indiana women responded by updating the governor’s office with (sometimes graphic) news on their menstrual cycles by phone and on social media with hashtag #periodsforpence. The social media backlash mirrors #periodsarenotaninsult, which took aim at Donald Trump last year.
The Indiana ACLU brought a lawsuit against the state’s abortion restrictions — and a judge has since blocked portions of that law. “What the state of Indiana has attempted to do here … grossly flies in the face of existing law,” said ACLU lawyer Ken Falk.
Republican and Democratic platforms usually don’t mean much as political reality bites, however this Modern Healthcare report on the new GOP platform in worth reading. The article says, among other things:
“The {House Speaker} Paul Ryan wing of the party mostly carried the day, getting its conservative health policy proposals into the platform. The platform statement, which will be voted on by delegates at the convention, left no trace of presumptive presidential nominee Donald Trump’s repeated campaign statements about not touching Medicare, Medicaid and Social Security and making sure all Americans have healthcare when they need it. And despite Trump’s statements about letting Medicare negotiate prices with pharmaceutical companies, there is no discussion about how to control soaring prescription drug costs.
“The platform promises that on the first day in office, a Republican president will use ‘legitimate waiver authority’ to ‘halt’ the ‘advance’ of the Affordable Care Act, and then, with the unanimous support of congressional Republicans, sign its repeal. But the platform makes no mention of what Republicans would replace it with to help consumers afford health insurance. In addition, legal experts say there is no waiver authority in the law that would allow a president to block enforcement of the ACA.”
In a wide-ranging interview with Anthony Tersigni, CEO of Ascension Health, the largest Catholic healthcare system, conducted by Modern Healthcare editor Merrill Goozner, Mr. Tersigni talks about reducing the financial burden for low-income people. Among his remarks:
“We believe that we need a healthcare policy in this country. We don’t have one. We have a healthcare financing policy. What we’ve cobbled together over the last 70 years is a financing mechanism. The Affordable Care Act, quite honestly, was really meant to be a reformation of insurance companies. So, we still don’t have a healthcare policy in this country. ”
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“We’d like to ask whoever ends up {next year} in the White House to create a position that has the ability to do pilot projects that connect healthcare with other governmental agencies. Oftentimes in healthcare, we providers are the recipient of somebody who presents with their health deteriorated, not because of healthcare, but because they lack housing, lack food, employment, and so on. We believe there’s an opportunity for us to move upstream in terms of caring for people’s health if we can collaborate and have a panel of folks from different governmental agencies (to sit down) with the private providers and begin looking at what are the causes of ill health. We know what the determinants are, and they’re not always part of the healthcare industry.
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“We are moving in that direction {more toward outpatient, ambulatory care} because we’re looking at the life cycle of the people we’re privileged to serve. Fifty percent of our revenue at Ascension comes from other than inpatient care. And so we continue to look at those ambulatory sites and those different sites of care because we believe that there are better sites, lower-cost sites, where people should be able to have care. That means we need to have partnerships. And some of the laws prevent us from having partnerships, either with the physicians or with other competitors in the marketplace. Those are the kinds of things that we want to look at to see how we can, in fact, raise quality and lower cost.”
Hillary Clinton, under pressure from the left wing of the Democratic Party, is now pushing for “public option” coverage in the state and federal health insurance exchanges.
This would be a compromise between Sen. Bernie Sanders, who backs a “Medicare-for-all” approach, and the current very complex system of private insurance partially paid for by employers, private insurance bought in insurance exchanges, and expanded Medicaid under the Affordable Care Act.
Polls have suggested that a majority of the public favors extending Medicare t0 all or at least a public option, in which people could chose government-financed insurance instead of coverage from a private insurer.
It appears that hospital executives oppose a public option because they fear that it would cut the payments that hospitals receive to provide care. So the American Hospital Association and the Federation of American Hospitals has sent this message to the Democratic Platform Drafting Committee.
“Our members have serious concerns that creating a public option with Medicare-like payments would subvert those goals by depressing insurer payments to healthcare providers and disrupting the fragile finance system that sustains hospitals today.”
The letter asserted that two-thirds of the two groups’ member hospitals received Medicare reimbursements that are below cost of providing care, while the average operating margin on Medicare reimbursements for hospitals was negative 5.8 percent in 2014.
“Adding millions more enrollees whose healthcare would be reimbursed at Medicare rates would likely threaten access to needed healthcare services, particularly for those in vulnerable communities,” the letter said.
