Thursday, May 31, 2012
Wednesday, May 30, 2012
Tuesday, May 29, 2012
Monday, May 28, 2012
Thursday, May 24, 2012
Wednesday, May 23, 2012
Monday, May 21, 2012
Sunday, May 20, 2012
Thursday, May 17, 2012
Kids’ Advocates Worry About How State Exchanges Will Determine Medicaid Eligibility
Kids’ Advocates Worry About How State
By Jane Norman, CQ HealthBeat Associate
Editor
Advocates for children’s health warn that low-income families might slip
through the cracks in the new state health benefits exchange system, according
to a letter advocacy groups submitted in response to provisions in an exchange
rule issued earlier this year.
In the rule, “many provisions would potentially undermine the ACA’s
[Affordable Care Act] clear intent to establish a simple, unified pathway to
health coverage for consumers,” wrote the groups, including the American Academy
There have long been concerns about making sure that families eligible for
Medicaid, the Children’s Health Insurance Program or subsidized coverage in the
exchanges understand how the new system works and that they are not frustrated
by its complexities.
The idea of the exchange itself is that it is a one-stop shop. However in
its comments the group said that might not be the case for the poor, many of
whom may be gaining health insurance coverage for the first time in their
lives. Under the health care law, Medicaid will be extended to every adult
under 65 who is earning less than 133 percent of the federal poverty level.
The groups are also concerned that states will be given too much time to
ponder their final say-sos on whether people are eligible for insurance
coverage, especially pregnant women in need of prenatal care and newborn babies
who should be seen by doctors regularly.
While a final 644-page exchange regulation was issued in March, Department
of Health and Human Services officials kept several provisions as interim final
regulations, which meant they were still open to public input. Overall, the
rule sets up a framework in which HHS will assist states in setting up their
exchanges, though not every detail is available yet. Public comments were due
on Friday.
The coalition of children’s health advocates, including the Children’s
Defense Fund, Children’s Hospital Association and March of Dimes, wrote that
they were “very troubled” by a decision to allow the state exchanges to decide
if they want to give up responsibility for making eligibility decisions on
Medicaid. Instead, under the exchange rule, state Medicaid and Children’s
Health Insurance Program offices would make those determinations, the groups
said.
Proposed rules published in 2011 said that Medicaid determinations would be
made initially by the exchanges so they could ensure that people were enrolled
in the right programs, said the children’s advocates. However in the revised
rule published in March, states can opt to have the exchanges make a
preliminary “assessment” and hand off the final decision to Medicaid agencies.
In the past it has been a problem when this responsibility was split among
agencies even in states with the best of intentions, the groups said.
This could prove a problem for families in which different members may be
covered by different programs, or where household income fluctuates month to
month and eligibility changes. A February 2011 study in Health Affairs
estimated that in a typical year, 28 million people will shift between being
eligible for Medicaid and for subsidized health care through the exchanges.
These families would then have to figure out how to navigate as many as three
different systems during the course of a single benefit year: the exchange,
Medicaid and CHIP, said the groups.
“Unfortunately, we know that families in this situation are at greater risk
of falling through the cracks of coverage and that a fragmented eligibility
system will exacerbate this risk,” they wrote. “We are deeply concerned that it
is the nation’s children who will most frequently suffer if states fail to
establish simple, user-friendly eligibility and enrollment systems.”
States strapped for cash might even opt to split up the responsibility if
they think it might slow down enrollment in Medicaid and CHIP, the groups said.
They suggest that “if a state is going to be allowed to adopt a more
complicated eligibility system than is necessary, it should be required to
first establish that it could do so without harming families.” The groups said
that states should have to demonstrate that their Medicaid agencies are capable
of making eligibility determinations in full compliance with the final Medicaid
eligibility rule issued by the federal government, that their health technology
systems can work in tandem with the exchange systems and that they will comply
with requirements that they not subject families to repeated verifications or
requests for information.
The groups also said they are worried that
the government would give states as many as 45 days to determine Medicaid
eligibility for people without disabilities and as many as 90 days for people
with disabilities. The groups pointed out that prompt prenatal care is
important and newborns are supposed to see a health care provider three times
in their first month. Given that the government is making massive investments
in new health technology, eligibility decisions should be made within a few
days when data is available and “under no circumstances” longer than 30 days,
they said.
Wednesday, May 16, 2012
Primary Care Doctors Who Treat Medicaid Patients Get a Two-Year Boost
Primary Care Doctors
Who Treat Medicaid Patients Get a Two-Year Boost
By Jane Norman, CQ HealthBeat Associate
Editor
Primary care physicians will receive
reimbursements for Medicaid equal to what Medicare pays in a two-year “fix”
mandated by the health care law, Health and Human Services officials said
Wednesday.
The increase will apply to Medicaid
services provided in calendar years 2013 and 2014, and will go to family
practice physicians, pediatricians and other practitioners of family medicine,
as well as some primary care sub-specialties such as neonatologists.
This could be a significant increase for
many doctors. States set Medicaid provider reimbursement rates, and primary
care practitioners currently are paid 66 percent of the Medicare rate on
average, though the percentages vary from state to state, Centers for Medicare
and Medicaid Services (CMS) officials told reporters in a conference call.
Cindy Mann, deputy administrator at CMS,
said that the $11 billion, two-year boost in reimbursements will be entirely
paid for by the federal government rather than the state-federal sharing that
generally is the practice for Medicaid. One of the key goals of the health care
law is to emphasize primary care, and the increased payments are an example of
that, even if they will only last two years, Mann said.
The reimbursement increase was included in
a proposed rule published by CMS on Wednesday.
Roland Goertz, board chairman of the
American Academy of Family Physicians, who was on the call with Mann, said that
family doctors know that people who don’t have access to care put off health
needs, and then a simple problem can become complicated. Two-thirds of the
members of his academy continue to accept Medicaid patients even though the
payment rates are low, he said. “We can’t continue to depend on the good will
of physicians who continue to provide care for less than the cost of that
care,” Goertz said.
Asked if doctors will seek to extend the
temporary pay increase just as they have tried to avert scheduled reimbursement
cutbacks under the Sustainable Growth Rate, Mann said that officials will be
reviewing the results of the two-year change and whether the pay boost has
provided a clear improvement in health care.
Said Goertz: “We’re ready to lobby for
what’s right for improving the system.”
Overall, the pay increase is projected to
cost the government $5.7 billion in calendar year 2013 and $5.9 billion in
2014, CMS says. Unless Congress provides additional money, the higher rates for
primary care providers would end after 2014. Individual states could, however,
choose to maintain the higher reimbursements.
Sen. Orrin G.
Hatch of Utah ,
ranking Republican on the Senate Finance Committee, criticized the rule in a
statement late Wednesday.
“It’s
nonsensical to think a temporary, two-year bump in pay will actually attract
and retain doctors to the Medicaid program unless the White House thinks Congress
will keep extending these higher payment rates in perpetuitym,’’ Hatch said.
“Every year, Congress has to stop Medicare physician payment rate cuts and this
proposed regulation will now create the same dilemma under the Medicaid
program. When that rate drops back down after 2014, what will happen to the
health care Medicaid beneficiaries receive? Or is this just another budget
gimmick to hide the true cost of the President’s $2.6 trillion health law?”
As the nation moves toward full
implementation of the health care law in 2014 and the expansion of eligibility
for Medicaid to all adults under 133 percent of the federal poverty level, “it
is critical that a sufficient number of primary care physicians participate in
the program,” the rule says.
Tuesday, May 15, 2012
Monday, May 14, 2012
Public Health Experts Make Recommendations For Obesity Prevention
Public Health
Experts Make Recommendations For Obesity Prevention
By John Reichard, CQ HealthBeat Editor
An intense round of meetings and briefings on obesity in recent days and new reports appeared to heighten that awareness. The experts involved said that nothing less than a culture change is required to counter the health threat. And every level of society must be involved.
The message to Congress: Do not shirk your role in addressing the many influences that foster obesity. Schools, employers, health care providers, insurers, families and individuals cannot afford to do so either.
Anchoring a week’s worth of events was the May 8 release of a 478-page report by the
Americans have slowly but surely modified their behavior to cope with other public health threats. They have significantly reduced their use of tobacco, for example. But the
A Bad Neighborhood
“People have a very tough time achieving healthy weights when inactive lifestyles are the norm and inexpensive high-calorie foods and drinks are readily available 24 hours a day,” said Dan Glickman, who chaired the institute panel that produced the report. Glickman, a former
Without successful anti-obesity efforts, the percentage of obese adults will reach 42 percent in 2030, up from 33 percent now, according to projections released by the Centers for Disease Control and Prevention at a “Weight of the Nation” conference the agency sponsored in
Experts worry especially about the young. Type 2 “adult-onset” diabetes brought on by obesity and inactivity now accounts for half of new diabetes cases in adolescents, compared with 3 percent a few decades ago.
“We are learning that type 2 diabetes is a more aggressive disease in youth than in adults and progresses more rapidly,” said Philip Zeitler, a researcher at Children’s Hospital in
Widespread media coverage of these and other alarming findings adds to the drumbeat of press reports in recent years on obesity. The institute suggests that awareness eventually will reach a point where the “bold, widespread and sustained action” called for by the study begins to occur. “Funding for implementation is likely to become available as the seriousness of the obesity threat is understood,” the report says.
To help coordinate action the report offers dozens of recommendations to reach five goals: make schools the heart of anti-obesity efforts; make physical activity a daily part of everyone’s lives; offer healthy foods and beverages in all settings; change food marketing; and involve employers, doctors and hospitals in the effort. Congress, it says, should consider taxing soft drinks. And within two years it should legislate marketing standards if industry does not act voluntarily before then to promote healthier nutrition.
But the going will be slow before any tipping point is reached. A major finding calls for 60 minutes a day of physical education through grade 12 — tough to achieve given tight budgets and school testing demands. Industry blocked a soda tax during the health law debate and has resisted federal marketing guidelines. Lawmakers are raiding the multibillion dollar health law fund created to prevent obesity and other costly conditions.
That’s “not a very good priority choice when health care is the fastest growing part of our national budget and the whole focus is on debt reduction,” Glickman said.
Friday, May 11, 2012
Wednesday, May 9, 2012
Tuesday, May 8, 2012
Monday, May 7, 2012
Preventive care stepped up
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Preventive
care stepped up
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Misty
Williams; Staff
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'Medical
home' model may expand, aiming to boost care, cut costs.
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Imagine
this: Doctors getting paid more if they help improve your overall health
rather than simply treat ailments as they arise.
It
could become a reality for some
Both
companies' initiatives focus on the "medical home" model in which
primary care doctors become a hub for a patients' care, whether creating
plans to manage chronic diseases, connecting them with specialists or
extending office hours to accommodate work schedules.
The
goal is to improve care and cut costs by preventing unnecessary hospital
visits and catching illnesses early.
"The
health care system that we have in this country is incredibly
fragmented," said Jill Hummel, WellPoint's vice president of payment
innovations. "We can't just sit around twiddling our thumbs, waiting for
the ... industry to transform."
Introduced
by pediatricians in the 1960s, the medical home concept has built momentum in
recent years as a possible solution to escalating health care costs, in part
because advanced technology allows doctors to keep tabs on more patients, communicate
with each other and better measure outcomes.
Medical
homes have historically treated small groups of chronically ill people, said
William Custer, a health care expert at
"Connecting
them all in a meaningful way was impossible even 20 years ago," he said.
Still,
the medical home movement will likely take years to spread, reaching just a
fraction of patients at first.
Medical
home experiments across the country have returned mixed results on quality
and cost savings, Custer said. WellPoint has reported an 18 percent decrease
in hospital admissions in a
"The
results have been encouraging enough and the intuition strong enough that the
whole industry is moving that direction," Custer said.
Becoming
part of a medical home has brought Renate Howard a peace of mind the
Her
physician, Dr. Marti Gibbs, is part of the Longstreet Clinic near
Gibbs
coordinates care among three specialists for Howard's 89-year-old mother. She
also helps the 63-year-old manage her borderline osteoporosis.
It's
good that the way doctors are paid is changing, Howard said. "[Gibbs]
can be blessed more for the services that she gives."
Giving
doctors a financial incentive is critical to the medical home concept
working, experts say.
Electronic
health record systems can cost tens of thousands of dollars. It costs more to
hire health coaches, case managers and others to help manage care. But they
don't necessarily get paid for making follow-up calls, holding health
education classes, creating exercise plans or other nontraditional services
aimed at keeping people healthy.
"Why
should a physician's practice invest the time, money and culture change if
they're not going to be compensated?" said Wayne Hoffman, a former
Atlanta family physician turned health care consultant.
Starting
in early 2013, Blue Cross and Blue Shield of Georgia, a WellPoint subsidiary,
will begin paying some physicians for services not typically reimbursed, such
as creating care plans for patients with multiple illnesses. The company has
roughly 2.4 million members and nearly 18,000 doctors in its network in
Physicians
could also see a cut of any savings generated by reducing costs and earn as
much as 30 to 50 percent more than they currently do.
Connecticut-based
That
extra cash can help physician practices afford electronic medical records or
hire extra staff, said Elizabeth Curran, head of
Dr.
Gibbs would prefer that day come sooner rather than later.
Her
practice has spent the past year and a half becoming a medical home. Nurses
spend more time with patients, analyzing charts before visits to identify
needed screenings and making follow-up calls to ensure drugs are taken
properly.
Gibbs
is still paid, however, based on each traditional medical service and
continues to see 25 to 30 patients daily to pay overhead costs and salaries.
"That's
not providing the best care for those patients, and it's certainly not what I
went into medicine for," she said. "Every patient is an individual,
and I don't want to lose sight of that in the numbers."
It
will take years for payment models to transition from volume to value, said
Dr. Jim Sams, medical director of primary care for Piedmont Medical Care
Corp.
Current
medical home efforts are a bridge --- still paying fee-for-service while
adding shared savings opportunities for lowering costs, Sams said. Physicians
will eventually assume more risk with insurers potentially withholding
payments if they don't meet quality and cost goals, he said.
"[Health
care] is capable of bankrupting our country over the next 10 years," he
said. "Something has to change."
The
'medical home' concept
Designed
to improve overall health, a medical home serves as a central point for
coordinating a patient's medical care. That often includes services doctors'
offices haven't traditionally provided. As part of a medical home, patients
may:
*Work
with nurses and doctors to create management plans for chronic illnesses,
such as diabetes.
*Receive
follow-up calls after visits from nurses who can answer questions.
*Have
expanded access to care through evening hours, weekend hours and email.
*Receive
reminders about upcoming preventive screenings.
*Be
connected with nutritionists, social workers and other professionals who can
help them achieve wellness goals.
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Thursday, May 3, 2012
Debate Heating Up Over CMS Payments for Health IT
Debate Heating Up
Over CMS Payments for Health IT
By John Reichard, CQ HealthBeat Editor
The enforcement of federal rules written to prod doctors and hospitals to
adopt health information technology is attracting wide scrutiny, with
congressional auditors worried that Centers for Medicare and Medicaid officials
are too lax and providers and their allies saying the requirements are too
tough.
A Government Accountability Office report released this week says that the
rules create a complex system of financial rewards and penalties for using the
technology. That complexity increases the risk that CMS will make improper
Medicare and Medicaid payments relating to health IT.
“CMS could take steps, beyond those already taken, to assess and mitigate
the risk of improper payments and to improve program efficiency,” said the
report. GAO said, for example, it is “encouraging” that CMS has awarded
contracts to evaluate how well states are adopting electronic health records in
Medicaid. But the report complains about the lack of a CMS timeline to review
the agency’s audit strategy for the Medicare electronic health records program.
Temperature Rising
Meanwhile, hospitals and doctors are objecting to a CMS proposal that aims
to increase the use of health IT to make care more efficient. But IT vendors
and consumer groups are pushing back against provider objections. IT’s promise
won’t be realized if CMS caves, they assert.
At issue is the CMS “stage two” proposal for “meaningful use” requirements,
whose comment period ends May 7 (See related
story, CQ HealthBeat, March 2, 2012).
Stage one got many providers to buy IT systems and begin using them to
record patient information and some data on clinical performance measures. But
CMS wants providers to report data on more measures in stage two. It also wants
to spur the ability of hospitals to exchange medical information with
unaffiliated doctors’s offices that use different IT systems. The idea is to
create an “interoperable” system where different computer systems talk to one
another and providers throughout a wide area can easily share medical data.
But stage two goals “may be too ambitious for some small or solo practice
physicians to meet,” said Rep. Renee
Ellmers, R-N.C., chairwoman of the Small Business Subcommittee on
Healthcare and Technology. She said that doctors are worried about Medicare
payments reductions scheduled for 2015 for physicians who don’t demonstrate
meaningful use of health IT. “I urge you to allow hardship exemptions for very
small practices,” Ellmers said in a May l letter to CMS Acting Administrator
Marilyn Tavenner.
Hospitals argue that the stage two rules imperil widespread adoption of
health IT. “Taken as a whole, the proposed requirements for meeting stage two
raise the bar too high and are not feasible for the majority of hospitals to
achieve,” the American Hospital Association said in an April 30 letter to CMS.
The 68-page comment letter says when it comes to complying with meaningful
use requirements, “the rushed timelines and complex regulatory requirements
make the process difficult.” Costs are large, it adds, estimating that
“hospitals spent $57,000 a year per bed on IT in 2010.”
However, patient advocacy groups are worried about AHA’s power to pressure
CMS to water down the regulations. “With the deadline looming, one of the
powerhouses in the health care provider community has made public its
displeasure with a number of the most robust and important patient-engagement
criteria,” said Christine Bechtel of the National Partnership for Women and
Families, referring to the AHA letter. “In fact, leaders of this organization
made their views known with such vehemence that their views should be
characterized as hostility,” Bechtel added.
She chided AHA for urging that hospitals be given more time to give
patients web access to medical information relating to a hospital stay.
The stage two proposal says patients should have access to that information
within 36 hours of being discharged. But Bechtel says AHA wants hospitals to
have up to 30 days “for access to such basic, crucial and highly time-sensitive
information as discharge instructions, medication lists, lab test results and
care transition summaries.”
She adds that “this is the very information that can help keep patients
from being readmitted unnecessarily. No patient in this day and age should have
to wait a full month for access to their own health information, which is vital
to their ability to get and stay well.”
Another concern relates to a proposed requirement that hospitals to be able
to transmit electronically a summary-of-care record when a patient is
transferred or referred to another provider that has an electronic health
record system from a different vendor. At least 10 percent of summary-of-care
record transmissions in these cases should be performed electronically with
outside organizations that use different electronic health record systems, CMS
is proposing.
AHA says this requirement would create an unreasonable burden because
providers “would need to count transitions, track the organizational
affiliations of the recipients, and track the vendors used by the recipients.”
The Health IT Now coalition says this is one of the few provisions in the
stage two proposal that would begin laying the groundwork for the widespread
sharing of medical information, which is critical to achieving IT’s potential
for making care safer and more efficient, it adds.
“We believe these standards are achievable and that more must be done to
promote the exchange of information to better coordinate patient care,” said
Joel White, executive director of the coalition. “We will encourage HHS to take
steps in that direction.”
Wednesday, May 2, 2012
Tuesday, May 1, 2012
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