GAO Finds Smart Cards Won't Stop Most Healthcare Fraud

Regardless of one’s political affiliation, the elimination of fraud from government healthcare programs is an issue universally supported. In 2014, the Department of Justice spent $571 million to find and prosecute fraud and recover $3.3 billion in settlements.

A proposed solution to cutting fraud is incorporating technology. Recently, the Government Accountability Office conducted study examining whether electronically readable card technology, or “smart cards,” could weed out fraud by properly identifying beneficiaries or providers at the point of care.

In the report, the GAO found that smart cards could spot some types of fraud, but not most. This is because the vast majority of cases involve schemes in which the beneficiaries or the providers—or both—were complicit in the action.

GAO ran tests of 739 fraud cases from 2010 to determine whether the use smart cards would have made a difference. The results were not promising: in only 165 cases (22%) would smart cards have been able to prevent fraud.

The investigators gave several reasons why smart cards are not a cure-all for Medicare and Medicaid fraud. The most common fraud schemes involve billing for services that were not provided (43%) or for medically unnecessary services (25%), and in the case of Medicare especially, the patient may not even be aware that the service is not needed. Other schemes involve falsifying records to support fraud (25%) and fraudulently obtaining controlled substances or mis-branding prescription drugs (21%).

In sum, GAO finds that when it comes to fraud, providers are complicit 62% of the time, while beneficiaries are at fault 14% of the time.  

The original article by Mary Caffrey can be found at the following address: http://www.ajmc.com/focus-of-the-week/0216/smart-cards-wouldnt-stop-most-healthcare-fraud-gao-finds?utm_source=Informz&utm_medium=AJMC&utm_campaign=MC%5FMinute%5F2%2D24%2D16

CMS Boosts Coverage for Telehealth

The Centers for Medicare & Medicaid Services released new rules that significantly broaden coverage for chronic care telehealth services.The rulemaking changes are inside the 1,185-page document detailing Medicare payments to physicians and other providers. The new rules also include seven new covered procedure codes for telehealth, including annual wellness visits, psychotherapy services, and prolonged services at physicians' offices.

Health Leaders Media reports, "The American Telemedicine Association, which had sought the expanded coverage for five years, notes that among the rules are provisions that will pay for remote chronic care management using the new current procedural terminology (CPT) code 99490, with a monthly unadjusted, non-facility fee of $42.60.

"For us, it was more important to begin to specifically address chronic care," says Gary Capistrant, senior director of public policy at ATA. "The combination of the chronic care management code and being able to use it in conjunction with monitoring of those chronic conditions is a big step forward and a very substantial change for Medicare." Capistrant says the new rules also represent an acknowledgement by CMS that reimbursing for chronic care could prove to be cost effective.

"It's an important policy move. Whether it is sufficient, time will tell, but it is certainly a step in the right direction and an important initiative," he says. "There has been a lot of focus on primary care, even with the Medicare population. That may be the 80% of the people but it is only 20% of the problem. There's an increasing emphasis on looking at the 80% of the problem that is 20% of the people, and that is chronic and specialty care. They understand that the government is spending a huge amount for chronic care conditions and that there is a value managing those to reduce the overall expenditures."

CMS Names Niall Brennan First Chief Data Officer

The Centers for Medicare & Medicaid Services (CMS) today announced the formation of the Office of Enterprise Data and Analytics (OEDA) which will be led by Niall Brennan, the agency’s first Chief Data Officer (CDO), and tasked with overseeing improvements in data collection and dissemination as the agency strives to be more transparent. OEDA will help CMS better harness its vast data resources to guide decision-making and develop frameworks promoting appropriate external access to and use of data to drive higher quality, patient-centered care at a lower cost.

CMS collects a wealth of data that is critical to decision making for the agency and other stakeholders in the nation’s health care system. CMS generates data administering the Medicare, Medicaid and CHIP programs. In addition, new responsibilities, including stewardship of the EHR Incentive Programs, more expansive quality measurement programs, and the establishment of the Health Insurance Marketplaces, have expanded the scope of data that CMS collects. As CMS works to shift the focus from volume of services to better health outcomes for patients, coordinating care, and spending dollars more wisely, the need for CMS to analyze data across its multiple programs and provide greater access to this data, whether in granular or aggregate form, will only intensify.

“It’s clear how much data transparency will help the country improve outcomes, control costs and aid consumer decision making,” said CMS Principal Deputy Administrator Andy Slavitt. “This appointment signals to the industry that there is no turning back from the health care data agenda. Niall Brennan will help make sure CMS leads the way.”

The creation of this new post and the data and analytics office  builds on the steps CMS has taken in recent years to better harness its data resources both internally and externally. CMS is now routinely analyzing claims data in real time and applying predictive analytics to proactively identify fraud and abuse and track key metrics such as hospital readmissions. Accountable Care Organizations and State Medicaid agencies receive monthly near real-time feeds of Medicare data to support care coordination. CMS has launched the Virtual Research Data Center to facilitate lower cost access to CMS data for researchers and federal grantees. CMS has also released numerous public use datasets; the most notable releases to date include the release of data on hospital charges and physician utilization in 2013 and 2014.

“Our commitment to transparency is matched by our commitment to keeping personal information safeguarded. We can't expect to advance health outcomes unless we also ensure that our policies and practices around data privacy are leading the way,” said Slavitt. “We look forward to building on the success of recent releases, providing a clearer picture of the health care delivery system.”

ICD-10 Transition Date Finalized for October 2015

The Centers for Medicare and Medicaid Services announced last week that the final deadline to comply with the ICD-10 implementation requirement is October 1, 2015. The tenth edition of the International Classification of Diseases is widely viewed as a significant change in the way claims that are submitted to Medicare and private insurance payers are classified. 

These changes enable providers to coordinate patients care over distance and time, improve the accuracy of patient records with more detailed patient history coding, and reduce fraudulent claims. CMS also believes that the ICD-10's granular classifications will improve the data and analytics related to public health research, surveillance, and reporting. The more specific classifications found in ICD-10 represent, in part, the evolution of diagnosis and the modern developments in medicine and medical technology used to treat patients. 

CMS released an online resource designed to help providers in small practices make a timely transition to ICD-10. The "Road to 10" is an online resource available here. The  Road to 10 breaks allows providers to select a profile based on their expertise that is specifically tailored to each speciality's common codes, clinical documentation procedures, and clinical scenarios. Additionally, the Road to 10 gives users the opportunity to create an ICD implementation action plan specifically suited to the needs of their small practices. 

CMS Looks to Limit Estate Recovery Actions for New Medicaid Recipients

Commentators on both sides of the Affordable Care Act (ACA) debate have pointed out that lower-income Americans may be deterred from enrolling in the expanded Medicaid program because of the currently estate recovery actions are allowed. An estate recovery action is a legal collection method that allow states to recover the amount of payments for long-term Medicaid services from patients after their death to repay the state for the cost of their medical care. 

This practice stems from a 1993 federal law that requires states to recoup the costs spent on long-term Medicaid services from the estates of deceased recipients. The 1993 law also gives states the option of recovering all Medicaid costs incurred from the age of 55 until death, even if they are not related to long-term care. In practice this often results in states placing a lien on the deceased's home after being notified of the death. However, states generally try not to collect the debt immediately in instances where a surviving spouse or dependent is living in the home. 

Last week the Centers for Medicare and Medicaid Services (CMS) issued a letter to state medicaid directors providing guidance that seek to limit estate recovery actions for Medicaid recipients that qualify under the ACA's Medicaid expansion program. While the letter does not compel states to follow the conditions set forth in the letter, experts say it will likely serve as a deterrent for states considering estate recovery actions against expanded Medicaid recipients. 


More discussion on Medicaid Estate Recovery and the CMS letter can be found at the following sources:

•  Asbury Park Press, Feds: Don't try to bill new Medicaid recipients after their death.
• National Senior Citizens Law Center, MAGI Medicaid and Estate Recovery: CMS Issues State Medicaid Director Letter.
• Modern Healthcare, Reform Update: Medicaid estate-recovery law may hamper enrollment efforts.

CMS Extends Medicare EHR Meaningful Use Attestation Deadline to March 31, 2014

The Centers for Medicare and Medicaid Services announced an extension for some participants in the Medicare Electronic Health Records meaningful use attestation deadline. The extension did not retroactively change any requirement for the date the criteria must have been met, it merely extended the deadlines for data submission for some physicians, eligible professionals and hospitals. The deadline extensions do not apply to the Medicaid portion of the Electronic Health Records incentive payment program. The Medicaid incentive payment program does not incorporate penalties.

Both the Medicare and Medicaid Electronic Health Records incentive payment programs were created in the American Recovery and Reinvestment Act of 2009. The programs have a significant impact with payments thus far in the amount of over $19 billion to more than 320,000 physicians and other professionals and 4,400 hospitals.  


Physician and Eligible Professional Extension

The Centers for Medicare and Medicaid Services (CMS) extended the deadline for eligible professionals to attest to Electronic Health Records (EHR) meaningful use in 2013. Physicians and eligible professionals will now have until 11:59p.m. on March 31, 2014 to submit their performance data. The new deadline, extended from February 28, 2014, does not change the requirement that the criteria for meaningful use must have been met by the end of the reporting period for the incentive payments, December 31, 2013. 

A CMS press release explained that this extension would allow more time for providers to submit their meaningful-use data, receive an incentive payment for the 2013 year and avoid the 1% penalty 2015 payment adjustment. 

EPs attesting for the Medicaid program or Physicians Quality Reporting Systems incentive pilot program did not receive an extension and must complete the attestation requirements by the original deadline. 


Hospital Extension

CMS is also offering what the agency is calling a "one-time" extension to hospitals "that may have experienced difficulty attesting" by the November 31, 2013 Medicare meaningful use attestation deadline. To be eligible to participate in the deadline extension hospitals must contact CMS by 11:59p.m March 15, 2014 for assistance. 

This extension will allow eligible hospitals to receive incentive payments under the program and avoid the price adjustments effective in 2015. 

Like the extension for physicians, the extension for hospitals does not change the deadline for the date the meaningful use criteria must have been met. The implementation deadline for the hospitals program, which operates on the fiscal year, was September 30, 2013. 


Resources
A Modern Healthcare article discussing the extension is available here.

A Medscape article discussing the extension and incentive payments is available here. 

A FierceHealthIT article discussing industry representative opinions on the extension is available here. 

A user guide for eligible professionals on meaningful use attestation is available here. 

A user guide for eligible hospitals on meaningful use attestation is available here.

The EHR Information Center is Open Monday-Friday from 8:30a.m.-5:30p.m. EST. The toll-free number to reach the center for assistance with meaningful use attestation is 1-888-734-6433. 

Affordable Care Act and Emergency Rooms: Enrollment Opportunity and Visits

NPR and Kaiser Health News reported Tuesday that California hospitals are beginning to provide emergency room patients with information on signing up for health insurance plans, expanded Medicaid programs, and possible subsidies to lower the cost of health insurance for those who qualify. Hospitals such as O’Connor Hospital are hiring more staff dedicated to health benefits and insurance coverage to reach out to the 5,000 uninsured patients their emergency department treats each year.

Benefits coordinators Araceli Martinez reports more uninsured patients view health insurance as an affordable possibility after Martinez provides them with information on coverage options. However, most uninsured that pass through her door find the process of purchasing insurance on their own for the first time daunting and confusing. About half of poor uninsured adults are unaware that they would qualify for Medicaid.

There is an economic motivation for hospitals to sign patients up. Increasing the number of patients with private insurance increases reimbursement rates. This is especially appealing at a time when hospitals are facing Medicare cuts. The expansion of Medicaid allows hospitals to receive payment retroactively for medical treatments if the patient enrolls in Medicaid. The retroactive payments may be applied to treatment received up to three months prior to the patient’s enrollment.

Jim Dover, president and CEO of O’Connor Hospital, explains that dedicating resources to enrolling patients in healthcare insurance plans is also a worthy goal because the newly insured patients “don’t have to come to the ER for common problems.” This is a common argument for increasing Medicaid enrollment.

The argument came under fire recently when Science published a study that concluded emergency room visits increased with the expansion of Medicaid. The study found that people recently enrolled in Medicaid went to the emergency room 40-percent more frequently than others, even when the conditions could be treated less expensively in a doctor’s office.

"Increasing coverage and seeing people use more medical care isn't necessarily a bad thing," said Dr. Renee Hsia, an associate professor of emergency medicine at University of California San Francisco and a health policy researcher who wasn't involved in the study but reviewed it for Science. "The outcome that we desire is not that we don't have people going to see their doctors anymore. The outcome is that we have people who feel protected from (financial problems and) seeking care when they feel they need it."

Sources for this Blog:

Kaiser Health News, “Emergency Rooms Are Front Line for Enrolling New Obamacare Customers” 

NPR, “California Hospital Workers Pitch Obamacare to ER Patients” 

Kaiser Health News, “Medicaid Expansion Boosted Emergency Room Visits in Oregon, Study Finds”

Associated Press story in Seattle Times, “Study finds Medicaid expansion drove up ERvisits”

Many Hospitals Concerned about Final CMS Payment Rules

The Centers for Medicare and Medicaid Services (CMS) announced a final rule for hospital outpatient services, or the Outpatient Prospective Payment System (OPPS), this November. The CMS estimates that the rule will increase payments for hospital outpatient departments by 1.7 percent. The new rule will be effective January 1, 2014; however, CMS will delay implementation and final configuration of the new 29 comprehensive APCs until 2015.

The rule will create 29 comprehensive Ambulatory Payment Classifications (APCs) to handle payment for device-dependent services and will require direct supervision for a range of outpatient services in critical access hospitals (CAHs). 

This rule combines five payment codes into a single payment code that covers all outpatient clinic visits. The outpatient clinic visits code will include drugs, biologicals, and radiopharmaceuticals used in a diagnostic test or surgical procedure, lab services and device removal procedures. The American Hospital Association believes that the payments will be well below the cost of treatment for complex patients.

The Access to Medical Imaging Coalition is concerned that the rule will dramatically reduce the outpatient payments to hospitals for CT scans and MRI services. The group is concerned because the rule will establish similar reimbursement rates for a CT scan and x-ray image of the same body part even though a CT scan requires more expensive equipment and is more expensive to adminster. 

Many hospitals are concerned about being able to implement the changes required by the rule by January 1, 2014, the date the rule becomes effective. 

HHS: Progress With HIT

The U.S. Department of Health and Human Services’ (HHS) Secretary Kathleen Sebelius announced the number of hospitals using health information technology (IT) has more than doubled in the last two years. She also announced new data showing nearly 2,000 hospitals and more than 41,000 doctors have received $3.1 billion in incentive payments for ensuring meaningful use of health IT, particularly certified Electronic Health Records (EHR).

Secretary Sebelius is in Kansas City, Missouri visiting Metropolitan Community College-Penn Valley Health Science Institute to make this announcement and discuss the growth of professional jobs in the health information technology field.

“Health IT is the foundation for a truly 21st century health system where we pay for the right care, not just more care,” said Secretary Sebelius. “Health care professionals and hospitals are taking advantage of this unprecedented opportunity to begin using smarter, new technology that improves care and creates the jobs we need for an economy built to last.”

The announcement details information from a new survey conducted by the American Hospital Association and reported by the HHS Office of the National Coordinator for Health IT which found that the percentage of U.S. hospitals that had adopted EHRs has more than doubled from 16 to 35 percent between 2009 and 2011. And, 85 percent of hospitals now report that by 2015 they intend to take advantage of the incentive payments made available through the Medicare and Medicaid EHR Incentive Programs.

The announcement also highlights new data from the Centers for Medicare & Medicaid Services (CMS) detailing $3.12 billion in incentive payments the agency has made to physicians, hospitals, and other health care providers who have started to meaningfully use EHRs to improve the quality of patient care. In January alone, CMS provided $519 million to eligible providers. EHR incentive payments can total as much as $44,000 under the Medicare EHR Incentive Program and $63,750 under the Medicaid EHR Incentive Program.

According to the Bureau of Labor Statistics, the number of health IT jobs across the country is expected to increase by 20 percent from 2008 to 2018, a pace much faster than the average for all occupations through 2018. In conjunction with her announcement, Secretary Sebelius will tour the Penn Valley Community College Health Science Institute, which trains students for careers in this growing industry. She will also participate in a roundtable discussion with Community College leaders, students training in the health IT field, health care providers, patients and area employers about the importance of health information technology training in both improving patient outcomes and creating jobs.

The Obama administration provides financial support to eligible health care professionals and hospitals to make the switch to health IT and certified EHRs through the Medicare and Medicaid EHR Incentive Programs. These programs are funded by the HITECH Act provisions of the 2009 Recovery Act. The administration has also created a nationwide network of 62 Regional Extension Centers to provide technical guidance and resources to help eligible health care providers participate in the EHR Incentive Programs and meaningfully use certified EHRs.

To meet the demand for workers with health IT experience and training, the Obama Administration has also launched four workforce training programs. Training is provided through 82 community colleges and nine universities nationwide. As of January 2012, over 9,000 community college students have been trained for health IT careers and another 8,706 students have enrolled. And as of February 2012, participating universities have enrolled over 1,200 students and graduated nearly 600 post-graduate and masters-level health IT professionals, with over 1,700 expected to graduate by the summer of 2013.

Two other workforce training programs have resulted in the development of a health IT workforce curriculum and a health IT worker competency examination. The health IT workforce curriculum offers colleges and universities in all 50 states innovative health IT teaching materials at no cost to instructors. And, since its release in May, 2011, over 2,000 individuals have taken the HIT Pro Exam, a competency examination designed to show employers that job-seekers have attained a proficient level of knowledge and skills in health IT.

Health IT can help keep information private and secure. In addition, federal laws require key persons and organizations that handle health information to have policies and security safeguards in place to protect health information—whether it is stored on paper or electronically.

For more information on how health IT can lead to safer, better, and more efficient care, visit http://www.healthit.gov/

For more information about the Medicare and Medicaid EHR Incentive Programs, see http://www.cms.gov/EHRIncentivePrograms

For more information about the HHS Recovery Act health IT programs see http://www.hhs.gov/recovery/announcements/by_topic.html#hit

Source: HHS News Release

Innovation Center Report Released

A national center set up a year ago to test and implement new ways to improve patient care while cutting costs has delivered its first report. The Center for Medicare and Medicaid Innovation was created by the health care reform act.

It has funded 16 initiatives since it began operations, primarily focused on incentives for delivering care to Medicare, Medicaid, and the Chilren's Health Insurance Program (CHIP).

Source: The Washington Post Article

Report on Identifying Health Care Quality Measures in Medicaid-Eligible Adults Released

The Agency for Healthcare Research and Quality (AHRQ) released a background report documenting the process, deliberations, and results of AHRQ's National Advisory Council Subcommittee for Identifying Health Care Quality Measures for Medicaid-Eligible Adults.
The Affordable Care Act requires the Secretary of the Department of Health and Human Services to identify and publish a core set of health quality measures for Medicaid-eligible adults.

Source: AHRQ Release

CMS Announces New Demonstrations to Help Curb Improper Medicare, Medicaid Payments

The Office of Management and Budget (OMB) announced that the Administration cut wasteful improper payments by $17.6 billion dollars in 2011 as part of the Obama Administration’s Campaign to Cut Waste, fueled by decreases in payment errors in Medicare, Medicaid, Pell Grants, and Food Stamps. Combined with the avoided improper payments in 2010, agencies have avoided making over $20 billion in improper payments in the two years since President Obama issued an Executive Order initiating an aggressive campaign against the wasteful payment errors.

To help cut improper payments, the Centers for Medicare & Medicaid Services (CMS) has announced it will launch demonstration programs beginning in January 2012 targeting some of the most common factors that lead to improper payments. The demonstration programs will help strengthen Medicare by aiming at eliminating fraud, waste, and abuse.

To see the OMB press release, please visit: http://www.whitehouse.gov/the-press-office/2011/11/15/we-can-t-wait-agencies-cut-nearly-18-billion-improper-payments-announce-

To learn more about CMS efforts to cut improper payments, please visit: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4176

Source: HHS News Release

CMS Proposes Regulatory Reduction Rules

On October 18, the Centers for Medicare & Medicaid Services (CMS) took steps to reduce unnecessary, obsolete, or burdensome regulations on American hospitals and healthcare providers. These steps would help achieve the key goal of President Obama’s regulatory reform initiative to reduce unnecessary burdens on business and would save nearly $1.1 billion across the health care system in the first year for a total of over $5 billion over 5 years.

CMS proposed two sets of regulatory reforms and finalized a third. All are designed to improve transparency and help providers operate more efficiently by reducing their regulatory burden. One set proposes updates to the Medicare Conditions of Participation (CoPs) for hospitals and critical access hospitals (CAHs). The second set addresses regulatory requirements for a broader range of health care providers and suppliers who are regulated under Medicare and Medicaid. CMS also finalized a third rule reducing regulatory burden for ambulatory surgical centers (ASCs).

CMS estimates that annual savings to hospitals from the proposed revisions to the Conditions of Participation could exceed $900 million in its first year as hospitals increasingly use this new flexibility. The Medicare Regulatory Reform rule could save up to $200 million in the first year. The final rule for ASCs could generate an extra $50 million in savings per year.

Taken together, these three rules would reduce hospital and other healthcare provider costs by nearly $1.1 billion the first year. These cost savings would come directly from reduced regulatory burdens, and are not accompanied by reimbursement reductions. As such, all of these savings would be available to help providers improve the quality of care they provide to Medicare beneficiaries and all Americans.

Click here to view the news release.

Source: CMS News Release

CMS Launches Innovation Advisors Program

The Centers for Medicare & Medicaid Services (CMS) announced that it was accepting applications for a new Innovation Advisors program to help health professionals deepen skills that will drive improvements to patient care and reduce costs. These health care improvements will benefit people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Made possible by the Affordable Care Act, this initiative will be managed by the Center for Medicare and Medicaid Innovation (Innovation Center).

“We seek to support and expand the number of health care leaders with the knowledge and the vision to find innovative ways to improve care for patients and use our healthcare dollars more wisely,” said CMS Administrator Don Berwick, M.D. “The CMS Innovation Center is an ideal host for this network of experts. It will support their work on efforts that can strengthen public-private partnerships and ensure patients can spend more time with their doctor and get higher-quality care and lower costs.”

Under the new program, there will be up to 200 Innovation Advisors, including clinicians, allied health professionals, health administrators and others. They will attend in-person meetings as well as remote sessions to expand their skills and knowledge, and apply what they learn in their organizations and areas.

After an initial, intensive orientation phase, Innovation Advisors will work with the Innovation Center to test new models of care delivery in their own organizations and communities. They will also create partnerships to find new ideas that work and share them regionally and across the United States.

Innovation Advisors will be expected to commit up to 10 hours per week to the Innovation Advisor Program during the initial six months of the program, with part of that time devoted to seminars and instruction. The rest of that time will be devoted to implementing the improvement project they propose in their initial application. The Innovation Advisors who are selected will meet regularly to exchange insights, report on successes and discuss common challenges.

This initiative is just one of a number of efforts made possible by the Affordable Care Act to help bring better health and better health care not just to Medicare beneficiaries, but also to all Americans, while helping use healthcare dollars more wisely. Already, more than 5,000 organizations have joined the Partnership for Patients and pledged to reduce hospital-acquired conditions and improve transitions in care. The Bundled Payments for Care Improvement initiative will give providers flexibility to work together to coordinate care for patients over the course of a single episode of an illness. The Comprehensive Primary Care Initiative will allow CMS and other payers, such as employer-based health plans, to align strategies designed to strengthen primary care services delivered to Medicare beneficiaries.

Applications for the Innovation Advisors program are due on November 15, 2011. Applications will be reviewed and Innovation Advisors will be notified of their selection by mid-December 2011.

More information, including a fact sheet, frequently asked questions, application and terms and conditions can be found at: http://innovations.cms.gov/innovation-advisors-program.

Source: CMS News Release

New CMS Proposed Rules Designed to Cut Red Tape

New proposed rules released by the Centers for Medicare & Medicaid Services (CMS) would reduce unnecessary, obsolete, or burdensome regulations and save hospitals and healthcare providers nearly $1.1 billion each year and over $5 billion over 5 years. The new proposals regarding the rules for hospitals that treat Medicare and Medicaid patients were developed in response to President Obama’s call on all Federal agencies to eliminate burdensome and unnecessary regulations.

“The President and I have challenged agencies to hunt down burdensome regulations,” said Vice President Joe Biden. “Today’s steps will remove outdated, duplicative, unnecessary burdens on hospitals - saving money and improving care.”

“President Obama has been clear: it’s time to cut the red tape,” said HHS Secretary Kathleen Sebelius. “Our new proposals eliminate unnecessary and obsolete standards and free up resources so hospitals and doctors can focus on treating patients.”

CMS proposed two sets of regulatory reforms and finalized a third. All are designed to improve transparency and help providers operate more efficiently by reducing their regulatory burden.

One set proposes to update the rules for hospitals that treat Medicare and Medicaid patients -- the Medicare Conditions of Participation. As an example, the proposed reforms would consolidate patient care plans and eliminate outdated requirements for hospital management. This could save hospitals over $900 million per year and perhaps grow to much more over time as hospitals increasingly use this new flexibility.

The second set of reforms address regulatory requirements for providers other than hospitals and could save up to $200 million in the first year. The rule would identify and begin to eliminate duplicative, overlapping, outdated, and conflicting regulatory requirements for healthcare providers and suppliers such as end-stage renal disease facilities and durable medical equipment suppliers. Examples of these reforms include updating obsolete e-prescribing technical requirements to meet current standards and eliminating other out-of-date and overly prescriptive requirements for healthcare providers.

CMS is also finalizing a third rule that reduces regulatory burden for ambulatory surgical centers (ASCs), which is expected to save ASCs $50 million per year. This rule makes common-sense changes to the requirements ASCs must follow in order to meet Medicare and Medicaid health and safety standards.

These regulatory reforms are just one part of a wide-ranging effort by the Obama Administration to improve the quality of health care and lower costs for all Americans, using important new tools provided by the Affordable Care Act. These efforts include the National Quality Strategy and the Partnership for Patients. These initiatives aim to reform the health care delivery system and bring together both private and public sector partners to keep patients from getting injured or sicker in the health care system and to improve transitions between care settings. CMS intends to invest up to $1 billion to help drive these changes through the Partnership for Patients initiative. And beginning in FY 2013, for the first time, the Hospital Value-Based Purchasing program authorized by the Affordable Care Act will pay hospitals’ inpatient acute care services based partially on care quality, not just the quantity of the services they provide.

To view the proposed and final rules, please visit: www.ofr.gov/inspection.aspx.

Both proposals invite the public, including doctors, hospitals, patient advocates, and other stakeholders, to comment. To submit a comment, visit www.regulations.gov, enter the ID number CMS-9070-P or CMS-3244-P, and click on “Submit a Comment.”

For additional information on these and other Conditions of Participation, visit http://www.cms.gov/CFCsAndCoPs/01_Overview.asp

For additional information on the Department of Health and Human Services overall Plan for Retrospective Review of Existing Rules, visit http://www.hhs.gov/open/execorders/13563/hhs_final_retrospective_review_plan_8-19-11_4.pdf.

Source: HHS News Release

Health Care Reform Presents Opportunities for Performance Improvement

A recent article Becker's Hospital Review says that providers will need to find ways to reduce costs - particularly in Medicare and Medicaid - while maintaining or improving quality.

William C. Mohlenbrock, MD, FACS, discusses "three specific initiatives to improve quality and control costs [in the healthcare reform law]: the Medicare Shared Savings Program, which establishes Medicare accountable care organizations; the Bundled Payments for Care Initiative, which expands CMS' Acute Care Episodes; and Consumer Operated and Oriented Plans."

Source: Becker's Hospital Review

HSPH Study: Lower Quality, High Cost Hospitals Treat More Poor, Minorities

Hospitals with the lowest scores on certain quality and cost measures treat more than twice as many minority and poor patients as hospitals with the highest scores, according to a Harvard School of Public Health study published in Health Affairs.

The study compared quality and cost measures at roughly 3,200 hospitals with the proportion of minority and Medicaid patients the hospitals served. "As the United States embarks on efforts to improve hospital care using value-based purchasing principles, we will need to help hospitals improve quality and efficiency simultaneously and to monitor the results of their efforts, so that we do not inadvertently worsen disparities in care," the study concludes.

Maulik Joshi, president of the Health Research & Educational Trust and senior vice president of research for the AHA, said the AHA "is committed to sharing with hospitals tools and strategies that can help eliminate disparities in care. As noted by today's study and others in Health Affairs, there are many community-based influences on health and health care. We need to address the many factors that impact community health, such as access to preventive and follow-up care, and work with all stakeholders to ensure improved care for patients and communities."

Source: AHA News Release

Blue Cross Blue Shield Association Unveils Action Plan To Improve Healthcare Quality; Rein In Costs

The Blue Cross and Blue Shield Association (BCBSA) released a comprehensive, interconnected action plan that fundamentally transforms the healthcare system, moving it away from a fee-for-service model to a patient-centered model. The action plan, Building Tomorrow's Healthcare System: The Pathway to High-Quality, Affordable Care in America, provides specific recommendations to improve healthcare quality and tackle rising costs and is based on the experience of BCBSA's 39 Plans in all 50 states and federal territories, in every market and every zip code. An independent economic analysis of the recommendations shows that, if adopted, this action plan will achieve more than $300 billion in federal savings over the next 10 years.

"We believe that the healthcare system needs to fundamentally change so that people get the best, most affordable care possible. We need to put the patient back in the center of healthcare and this is going to take a significant collaborative effort between both public and private sectors," said Scott P. Serota, president and CEO of BCBSA. "It's time to stop the finger pointing and start working together to make our system the best for patients. In Building Tomorrow's Healthcare System, we make specific recommendations for what the government should do and show how Blue companies nationwide have been working with doctors, hospitals, consumers and policymakers to transform the healthcare system."

The proposal lays out specific, actionable steps the government should take in four key areas:
1.Reward Safety: National and local leadership along with new provider incentives are needed to eliminate preventable medical errors, infections and complications that harm hundreds of thousands of people each year and cost billions of dollars.
2.Do What Works: The incentives in our system must be changed to advance the best possible care and reward quality outcomes, instead of paying for more services that are ineffective or redundant and add unnecessary costs to the system.
3.Reinforce Front-Line Care: A higher value must be placed on primary care and on ensuring there is an adequate workforce of professionals to deliver necessary, timely and coordinated care that results in better outcomes and lower costs.
4.Inspire Healthy Living: With 75 percent of today's healthcare dollar spent on the treatment of chronic illnesses — many of which are preventable — consumers must be empowered and encouraged to make better choices, live healthier lives and better manage their health.

If adopted, the recommendations would save $319 billion over the next decade according to an economic analysis by Ken Thorpe, Ph.D., Robert W. Woodruff Professor and Chair Department of Health Policy & Management Rollins School of Public Health, Emory University.

"The BCBSA proposal reflects a clear understanding of the transformational approach needed to reform our prevention and healthcare delivery system," said Thorpe. "Building evidence-based approaches to coordinate care for Medicare and Medicaid patients that will improve the quality and reduce healthcare spending is a discussion we need to have. Rather than simply shifting federal costs to seniors, the states, or elsewhere, these proposals have the potential to reduce total healthcare spending."

The proposal contains several examples of Blue Cross and Blue Shield initiatives underway across the country that can work as models for improving care and reducing costs. One example is the Michigan Health and Hospital Association's Keystone: ICU Program, which has dramatically reduced central line-associated bloodstream infection rates and ventilator-assisted pneumonia rates in ICU patients. More than 70 Michigan hospitals participate in this program and over a six-year period the initiative has saved 1,830 lives, eliminated an estimated 140,700 avoidable hospital days for patients, and saved more than $300 million.

"This action plan recommends changes that will bring about real improvement for our fragmented healthcare system," said Daniel Loepp, president and CEO, Blue Cross Blue Shield of Michigan. "In Michigan, and in local communities across the country, the Blues are seeing first hand the difference that these types of programs can make for patients. That is why we're encouraging the government to work with the private sector to expand on efforts that improve the quality and affordability of care."

To read Building Tomorrow's Healthcare System: The Pathway to High-Quality, Affordable Care in America, please visit www.bcbs.com/pathway.

Source: BCBSA Press Release

Democrats Signal Discomfort with Obama's Openness to Health Care Cuts

According to a report in the New York Times, Democrats in Washington are concerned about President Obama's willingness to cut up to $300 billion over 10 years from popular programs such as Medicare.

To view the article, please click here.

Source: NYT Article

CMS Launches New Consumer Data Tool

The Centers for Medicare & Medicaid Services (CMS) announced a new tool for patients and caregivers and other enhanced initiatives today to empower consumers to make informed choices about their health care, and to help improve the quality of care in America’s hospitals, nursing homes, physician offices, and other health care settings.

“These tools are new ways CMS is making sure consumers have information about health care quality and important information they need to make the best decisions about where to receive high-quality care,” said Dr. Don Berwick, the CMS Administrator. “These efforts are designed to also encourage providers to deliver safe, patient-centered care that consumers can rely on and will motivate improvement across our health care system.”

The steps include:

• A Quality Care Finder to provide consumers with one online destination to access all of Medicare’s Compare tools -- comparison information on hospitals, nursing homes and plans: www.Medicare.gov/QualityCareFinder.

• An updated Hospital Compare website, which now includes data about how well hospitals protect outpatients from surgical infections and whether hospitals care for outpatients who are treated for suspected heart attacks with proven therapies that reduce death: www.hospitalcompare.hhs.gov

• An enhanced Quality Improvement Organization (QIO) program under which QIOs provide technical assistance and resources to health care providers across the country to assist them in changing how care is delivered in hospitals, nursing homes, physician offices, and across care settings.

CMS has also updated data for outcomes of inpatient hospital care on Hospital Compare. Today’s update includes new 30-day mortality rates and 30-day readmissions rates for inpatients admitted with heart attack, heart failure, and pneumonia. These rates encompass three full years of claims data (from July 1, 2007 to June 30, 2010).

This year, the national 30-day mortality rates for heart attack have continued to decline, falling by 0.3 percent from the 2006 through 2009 rate of 16.2 percent to the more recent 2007 through 2010 rate of 15.9 percent. Mortality rates for heart failure and pneumonia increased slightly over the same period, showing an increase from 11.2 to 11.3 percent for heart failure and 11.6 to 11.9 percent for pneumonia, respectively.

Also this year, national 30-day readmissions rates for heart attack, heart failure, and pneumonia showed small changes in their updated rates. The new 2007 through 2010 rates for these three conditions are 19.8 percent, 24.8 percent, and 18.4 percent, respectively. These rates were slightly higher for heart attack in 2006 through 2009, at 19.9 percent, and slightly lower for pneumonia, at 18.2 percent, and heart failure, at 24.5 percent.

“Both sets of inpatient measures are risk-adjusted, taking health conditions into account to ‘level the playing field’ among hospitals and to help ensure accuracy in performance reporting,” Dr. Berwick said.

Hospital Compare also includes 10 measures that capture patient experience with hospital care. After two years of reporting these patient experience measures, hospitals have shown modest but meaningful improvement on most experience measures. The degree of this improvement has been relatively uniform across most measures and hospitals.

The website also contains 25 process-of-care measures and three children’s asthma care measures. The site also features information about the volume of certain hospital procedures performed and conditions treated for Medicare patients and what Medicare pays for those services.

Consumers have relied on Hospital Compare since 2005 to provide information about the quality of care provided in over 4,700 of America’s acute-care, critical access and children’s hospitals. So far this year, Hospital Compare has received about 1 million page views each month. More information about Hospital Compare is online at www.hospitalcompare.hhs.govse

The QIOs will integrate and coordinate care across settings within communities, improve community health by promoting preventive services, and make health care costs sustainable in the long term by supporting care that keeps patients safe from costly and dangerous complications and harm. The works supports the administration’s National Quality Strategy and its Partnership for Patients, designed to build collaborative models to improve health care quality, reduce hospital-acquired conditions and lower hospital readmissions.

“Patient-centeredness means that every decision that’s made and every program that’s established is focused on patients and their families,” said Patrick Conway, M.D., M.Sc., CMS chief medical officer and director of the agency’s Office of Clinical Standards and Quality. “QIOs will promote this concept by including beneficiaries and front line clinicians in quality improvement initiatives, learning and action networks and communications. Listening to the voices of patients and staying focused on their outcomes and experiences are essential to achieve care centered on the patient.”

More information about the QIO Program is on the CMS website at www.cms.gov/qualityimprovementorgs.

Source: CMS News Release