House Republicans Seek to Replace Medicare SGR

Republicans on the House of Representatives’ Energy and Commerce committee continued work on their plan to replace Medicare’s physician payment system. On Tuesday, they released the latest update to a bill that they hope to get passed by the end of the year.

The draft legislation would repeal Medicare’s current payment formula, the sustainable growth rate or SGR, and replace it with an enhanced fee-for-service system. Many experts say the fee-for-service system rewards the volume of services over value, but the lawmakers contend that the system in the legislation would “improved”.

The new system would allow doctors and medical specialty organizations to work with the Department of Health and Human Services (HHS) in developing quality measures for specific provider groups. Physicians would then be judged against those measures and receive incentive payments for good performance.  Providers could also choose to participate in approved alternative payment models, such as accountable care organizations, medical homes, or bundled payments.

The whole process would be guided by input from stakeholders, beginning with a hearing next week. The Health Subcommittee of the House Energy and Commerce Committee will be inviting stakeholders to testify at the hearing; the specific panel members have yet to be published. Should the law go into effect, HHS would be required to take stakeholder input into account when reviewing the incentive payment system each year.

The Senate Finance Committee has also held hearings on the topic, according to CQ, but they have no legislation introduced. You can view the House’s draft legislation here. 

New Methods in Hospitals to Encourage Hand Washing

Hospitals are employing new methods to encourage hand washing among staff, according to a New York Times article. The renewed effort to encourage hand washing can be explained by recent events such as the rise in “superbugs” and the rise in hospital acquired infections which, according to the Centers for Disease Control, cost hospitals $30 billion and lead to nearly 100,000 patient deaths per year. New Medicare laws also penalize hospitals that have high preventable infection rates by lowering the hospital’s Medicare reimbursement rate.

Some hospitals, like North Shore University Hospital on Long Island, NY, are placing motion activated cameras in the Intensive Care Unit to monitor hand washing. In another method, General Sensing inserts technology similar to Wi-Fi or Bluetooth into badges worn by hospital workers.  “The badge communicates with a sensor on every sanitizer and soap dispenser, and with a beacon behind the patient’s bed. If the wearer’s hands are not cleaned, the badge vibrates, like a cellphone, so that the health care worker is reminded, but not humiliated in front of the patient.”

Studies have suggested that reasons like dry skin, emergency situations, and resistance to authority factor into explaining why hospital staffs don’t wash their hands as often as they should.  Some hospitals also use reward and punishment systems for hand washing, including free pizza as a reward, or a “red card” as a penalty.

The measures seem to be working. At North Shore, hand washing rates were less than 10 percent during a 16-week preliminary period when workers knew that they were being filmed but were not informed of the results. When the hospital started reporting the rates through emails and on an electronic board, the hand washing rates jumped to 88 percent. 

Healthcare Assisters Verses Navigators

Open enrollment for coverage under the new healthcare marketplaces is set to open in 5 months, and opponents of the law are raising new concerns with the plans. Recently, CQ reports that Republicans in the House of Representatives have questioned the authority of the administration to provide “in-person assisters” in the program. The assistants, separate than the navigators provided for in the law, are also meant to help participants in the exchanges apply for insurance.

Gary Cohen, the Director of the Center for Consumer Information and Insurance Oversight acknowledged that an assister was “essentially the same” as a navigator. Navigators are paid with federal funds, however, and states that are running their own exchanges are barred from federal money. Still, a mandate of all exchanges is to provide outreach, education, and enrollment assistance. This poses an issue for states whose exchanges have not yet become independently viable.

The House Oversight and Government Reform Committee held a joint hearing earlier this month with and the subcommittees on Energy Policy, Health Care and Entitlements and on Economic Growth, Job Creation and Regulatory Affairs. After, the chairmen sent a letter to HHS Secretary Sebelius expressing concern over the role of the in-person assisters. They stated that they didn’t see any statutory authority for the assister program, and that there is no functional difference between the assisters and the navigators.

The Department of Health and Human Services acknowledged that they received the letter on Tuesday, and that they were gathering the information to respond.  

San Francisco Hosts Health Innovation Conference

San Francisco this week hosted the HealthBeat 2013 conference, a new event exploring “smart hospitals” and “smart practices” in an effort to determine where old technology is disrupting healthcare. According to the event website, the event was aimed to help decision makers, including hospital and other physicians, chief information officers, and insurers understand what technologies are transforming healthcare.

Themes of the conference included The ROI of Health Information Technology: Going Digital in a Reformed Health Care System, The Next Generation of EHRs/EMRs, The Health Care Cloud: Data Warehousing, Big Data Analytics: Business Intelligence for Smart Health Care, Patient Engagement & Activation/mHealth for Smart Patients, and Intelligent Technology, Tools, & Teams for Smart Hospitals and Practices.

Despite emerging technologies, a Washington Post article about the event points out the unique challenges that come with Health IT and HIPAA laws. The law is meant to protect confidential patient information, which means that some standard and relatively inexpensive technologies are out. File transfer and storage company Box however, has proved that new technologies can work within the law by receiving HIPAA certification.

The conference also featured an “innovation showdown” where healthcare industry startups competed to pitch their ideas in front of more than 400 health care executives, leaders, IT decision makers, venture capitalists, and press. Some of the ideas included an online community for cancer patients with a built in clinical trial search engine, a technology that makes any compiled application HIPAA compliant with proximity-based security, and several different ideas of how to improve communication and maximize efficiency in hospitals. 

Federal Officials Arrest 89 People in Medicare Fraud Schemes

Federal officials credited the new healthcare law for providing the authority that led to arrest of 89 people in separate Medicare fraud cases last week. The arrests were made in eight cities by the Health Care Fraud Prevention & Enforcement Action Team (HEAT), and CQ reports that they are expected to recover about $223 million to Medicare.

The HEAT Team is a cooperative effort between the Department of Justice and the Department of Health and Human Services.

The Medicare fee for service program processes more than a billion claims per year, and detecting false claims can be a dubious task. The Obama administration estimates that $60 billion per year is lost to fraudulent claims. Since 2007, however, Attorney General Holder and HHS Secretary Sebelius say that federal official have brought 1,500 Medicare fraud cases against individuals who falsely billed Medicare for more than $5 billion.

Included in the arrests last week were 25 people in Miami who falsely billed a total of $44 million in home health care, mental health, occupational and physical therapy, medical equipment, and HIV infusion charges. Four of the 25 were two nurses, a paramedic, and a radiographer. Another case included three defendants who bribed Medicare recipients in order to use their information for the purpose of billing $20 million in false charges. Arrests also took place in Detroit, Houston, Baton Rouge, Los Angeles Brooklyn, Tampa Bay, and Chicago.

Read the full Department of Justice press release here. 

Senate Confirms CMS Administrator

Although later than expected due to a hold placed by Senator Tom Harkin (D-IA), the Senate voted yesterday to confirm Marilyn Tavenner as Administrator for the Centers for Medicare and Medicaid Services. The roll call vote, which passed 91-7, places Tavenner as the first confirmed administrator since 2005, when Mark McClellan left the agency. She has been Acting Administrator since December of 2011.

HHS Releases Enhanced Culturally and Linguistically Appropriate Service Guidelines

Last month, the Department of Health and Human Services released enhanced National Care Standards for Culturally and Linguistically Appropriate Services (CLAS) in health care.  The enhanced standards, developed by the HHS Office of Minority Health, are a comprehensive update of the 2000 National CLAS Standards, and include the expertise of federal and non-federal partners nationwide.

These standards, according to the Office of Minority Health, are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health care organizations to implement culturally and linguistically appropriate services.

The burden of insufficient and inequitable care related to racial and ethnic health disparities has been estimated to top $1 trillion, according to a study cited by HHS. These losses are due to the provision of care to a sicker and more disadvantaged population, as well as the indirect costs of health inequities such as lost productivity, lost wages, absenteeism, family leave, and premature death.  Specifically, the study found that More than 30 percent of direct medical costs faced by African Americans, Hispanics, and Asian Americans were excess costs due to health inequities – more than $230 billion over a four year period.

The new standards, released at a joint press event with the Kaiser Family Foundation, are part of an effort to emphasize the importance of integrating standards into practice in order to improve quality of care and services for everyone.

HHS officials were joined in the announcement by representatives from the American Hospital Association, Texas Health Institute, and National Center for Cultural Competence at Georgetown University. 

Outdated Technology Costs Hospital Money

A new study conducted by the Ponemon Institute and reported by USA Today’s “CyberTruth”, finds that hospitals are absorbing an estimated $8.3 billion annually due to outdated technology. The losses are due to lost productivity and increased patient discharge times caused by the old technology.

According to the study, clinicians waste an average of 46 minutes per day waiting for patient information. Specifically, 37 minutes of the average discharge time of 102 minutes is due to waiting for hospital staff to respond with information necessary for the patient's release. Other lost time is due to inefficient pager systems, no Wi-Fi access, and bans on the use of personally owned devices.

As NAHAM News has previously reported, the Obama administration authorized $19 billion in 2009 to promote the use of electronic medical records. The program reimburses doctors and medical facilities for expenses that can provide “meaningful use” in advancing medical technology at their facility.

Some facilities are adopting technologies like secure text messaging systems that staff can download to their personal phones. One program in particular encrypts text messages that it sends, and stores the messages so that they can be audited. Other technologies include the implementation of a virtual desktop system so staff only has to remember one password to log onto terminals anywhere in the hospital.

Unique challenges within the healthcare industry may prevent rapid implementation of new technology and cause the lag in technology. Security and privacy policies mandated by law, for example, must be taken into account for any upgrades. Competing electronic health record vendors and the lack of a national EHR infrastructure further complicate matters.

The GAO Says the Medicaid Matching Rate is Unfair

The Government Accountability Office (GAO), a nonpartisan congressional watchdog group, released a report this month arguing for a new Medicaid matching rate. The GAO says this rate, currently calculated using the Federal Medical Assistance Percentage (FMAP), is unfair because it doesn’t take into account factors other than per capita income.

According to a CQ article, the FAMP is based on each state’s per capita income in comparison to the national per capita income. Currently, states on average get a federal matching rate of 57 percent, but the share varies widely among states. The report says that a funding allocation mechanism should take into account the demand for services in each state, geographic cost differences among states, and individual state resources,  in order to be equitable from the perspective of beneficiaries and allow states to provide a comparable level of services to each person in need.

Specifically, the GAO suggests creating new measures based on those three criteria. To assess the demand for Medicaid services, the government could use federal surveys such as the American Community Survey and the Current Population Survey to target the population in need of services. The program could account for geographic health care cost differences by looking at the provider costs from the Occupational Employment Statistics survey. Finally, state resources can be taken into account by using data in the Total Taxable Resources measure.

The report is non-binding, and any changes to the program would have to come via congressional legislation. That could pose issues with lawmakers from states that would lose matching funds with the new criteria.

Insurance Marketplace “Navigators” Spark Debate

As specifics about the health insurance exchanges continue to come out, opponents continue to scrutinize and criticize regulations. The most recent concerns, according to CQ, come from Republicans who are worried about the role that “navigators” will play in the marketplace.

NAHAM has previously written about the idea of navigators; people that will help customers choose which insurance plan to pick, and will help determine whether they are eligible for Medicaid or tax credits. The navigators are needed because “many people who would buy insurance through the marketplace have never had insurance before, and will need help in choosing the right plan” says Gary Cohen, director of the HHS Center for Consumer Information and Insurance Oversight.

Congressman Tim Murphy (R-PA), a member of the House committee on Energy and Commerce, agrees that there needs to be a helper, but disagrees with HHS’s idea. Currently, HHS plans to fund the navigators with $54 million in grants that will be spread across the 33 states that have a federally run exchanges or a state-federal partnership. Murphy announced a hearing that the role can be filled by insurance brokers, paid by private sector companies instead of the federal government.  

HHS disagrees with Murphy, stressing the need for the navigators to be independent. Otherwise, they fear, brokers will be more focused on selling their company’s plan to the customer, even when it may not be the right plan for them. Regulations set down by HHS bar licensed brokers and insurance agents from acting as navigators, but allows them to assist people in signing up for coverage. This approach worries some Republicans who fear that those experienced in the insurance industry will not be able to help, leaving the navigator roles to be filled by inexperience newcomers.

These navigators will finish their training in August before the public starts seeing eligible plans in September. The open enrollment period begins in October, and all marketplace plans will cover individuals beginning January 2014. 

HHS Offers Unprecedented Look at Hospital Charges

For the first time, the Centers for Medicare and Medicaid Services released standardized data about healthcare costs at different hospitals around the country. According to a CMS press release Wednesday, the data that they collected included hospital-specific charges for the “more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments,” and compared the “top 100 most frequently billed discharges”. The data showed “significant variation across the country, and within communities, in what hospitals charge for common inpatient services.”

Some variation across the country is expected, due to different costs of living and different state insurance structures.  Due to insurance structure in Maryland, for example, the highest rate charge for a lower joint replacement was $36,000. This is compared to $160,832 for the same procedure at a medical center just outside Dallas.

The variation is not only across the county; an article by the Washington Post highlights the massive variation that can occur within the same city. In Washington, DC, for example, the Post found that “George Washington University’s average bill for a patient on a ventilator was $115,000, while Providence Hospital’s average charge for the same service was just under $53,000. For a lower joint replacement, George Washington University charged almost $69,000 compared with Sibley Memorial Hospital’s average of just under $30,000.”

Of course, these charges are an average of all billing amounts per procedure. Further, it is common for hospitals and insurers, including Medicare, to negotiate rates below the full charge.

The release of this data was part of a transparency push from CMS and the Obama administration. According to CMS, the Robert Wood Johnson Foundation (RWJF) is planning a data visualization challenge which will further the dissemination of these data. You can download the raw data here. 

CMS Administrator Confirmation Back On Track

Following a rocky start, the confirmation of Acting CMS Administrator Marilyn Tavenner seems to be back on track this week. As NAHAM reported last month, Tavenner’s confirmation was stalled when Senator Tom Harkin (D-IA) placed a hold on it. A hold is a parliamentary procedure in the Senate that can prevent a measure from coming to the floor for a vote.

Harkin did this over a directive that Tavenner signed in March, channeling funds away from the healthcare reform’s Prevention and Public Health Trust fund, and instead spending it on Outreach efforts.

ModernHealthcare.com reports that Harkin is still upset, but that he has no objections to Tavenner leading the CMS. Senate Majority Leader Harry Reid (D-NV) announced that he will bring the nomination up for a vote when the “Republicans back off.” Sen. John Thune (R-SD) responded by saying that he wasn’t aware of any massive opposition.

CMS has not had a Senate confirmed administrator in seven years.

The Case for Universal Health Records

Electronic Health Records have gotten increased support from both Federal policy and private enterprise over the past few years. New models of health information technology have given doctors and patients alike a clearer vision of what health care could and should look like, according to recent article in Forbes. The article cites several ideals that have come out of the models, including complete medical records that will be sent to all of the patient’s doctors and fostering communication between a patient’s primary care physician and hospitals or specialists. EHRs can also serve as a consistent and lifetime health record that can assist in illness prevention as well as treatment.

Patient access professionals have been advocating for EHRs, citing the enhanced patient identity integrity. NAHAM’s Public Policy and Government Relations Committee has also been talking about this, and is currently developing a public policy statement regarding the need for enhances patient identity integrity.

The Forbes article cites a survey reporting that 70 percent of doctors now use EHRs, past what most believe is the “tipping point.” These systems may be able to save patients and doctors money in the long run, despite the cost upfront. The savings is somewhat mitigated, however, when the systems cannot communicate with one another. When this happens, patients still have to rely on paper forms to request records from one doctor to give to another. This process, besides being inefficient, puts the burden on the patient to figure out which records to go which doctors.

To combat this, Forbes suggests that all clinics, practices, hospitals and testing sites provide patients a standard, printed statement at each visit, detailing how (and whether) its staff will transmit records to other physicians and specifying what procedures, if any, patients need to take on their own to facilitate transfers.

While old fashioned, these steps are still needed until a universal health records system can replace it. 

HHS Revises Insurance Marketplace Application

Back in March, NAHAM News reported that the draft Health Insurance Marketplace application ran 15 pages for a family of three, with some versions going as many as 21 pages. (See the original article here ) Responding to feedback, the Department of Health and Human Services (HHS) released a shortened form on Tuesday, running just five pages for a single applicant and beginning at 12 for families.

According to an article in the Washington Post, the new form “essentially scaled back [the] draft application that could cover all applicants to one that covers the most common, basic cases of those who apply for insurance assistance. Different forms will be available for the more complex cases.” The form also includes a page of instructions and another page if the applicant wants to designate someone to help them.

The revised form has won over groups who criticized the first version, such as Families USA, but there are some expectations that it will not be used much. A lot of the applicants will probably apply online, where information will be collected in a different manner. Others may utilize customer navigators who are tasked with helping applicants figure out which insurance option suits them the best, according to the Post.

This comes in the wake of a poll also released Tuesday by the Kaiser Family Foundation that found that 42 percent of Americans thought that the Affordable Care Act was no longer law. Included in the 42 percent are 12 percent that believe the law was repealed by Congress, 7 percent that believe it was struck down by the Supreme Court, and 23 percent that didn’t know the current status of the law.

Open enrollment for all uninsured citizens is set to begin in October, with coverage to begin in January of 2014. 

Approaches to Coordinated Care

Coordinated care has been touted as a key approach to medicine over the past few years. This approach has been encouraged by rewards and penalties included in the 2010 Affordable Care Act, as well as by private insurers looking to lower costs. Despite this push, the Washington Post reports that communication failures remain disturbingly common due to lack of coordination.

Advocates for hospital patients and their families told the Post that confusion about who is managing a patient’s care contributes to 44,000 to 98,000 deaths from medical errors each year, and a 2010 federal report projected that 10,000 Medicate patients died every month due, at least in part, to hospital error. A 1999 report by the Institute of Medicine cited the fragmented health-care system and patients’ reliance on multiple providers as a leading cause of medical mistakes.

Enter the Hospitalist, doctors that some hospitals have on staff whose duties are to manage a patient’s care, coordinate the various specialists, manage medications, and then oversee the patient transition back home. This position is supposed to take ownership of coordinating care where previously there was a void. The intent is good, but nearly four in ten hospitalists say that they struggle with unsafe workloads at least once per week, according to a survey from Johns Hopkins School of Medicine.

Last summer, the Joint Commission developed a tool for hospitals to help guide communication when a patient is transferred from one hospital setting to another. Some medical centers have taken steps to improve communication, such as assigning color-coded ID tags or scrubs to staff members so patients know who’s a nurse and who’s a doctor, or installing white boards in patient rooms to post information.

This problem speaks to the larger need for a more efficient and reliable way to treat hospital patients. There is a need for identity integrity to ensure that the right procedures, medications, and treatments go to the correct person. It is also needed to ensure that the patient has their full medical history in one place, as opposed to records duplication or mix up. NAHAM is currently working on addressing that need by developing a policy statement on patient identity integrity.