Washington is the fourth state to announce that it will not pay for “never events,” joining Massachusetts, Minnesota, and Vermont. Gov. Chris Gregoire announced on Jan. 29 the adoption of the resolution by the Washington State Hospital Association, the Washington State Medical Association, and the Washington Ambulatory Surgery Center Association, which adopted the voluntary agreement to not ask patients to pay for care related to serious medical errors.
The agreement applies to 28 specific adverse events such as wrong-site surgery, death or serious disability from malfunction of a device or from a fall, or a serious ulcer of the skin. Read the news release.
By means of a Jan. 24 Federal Register notice, the Office of Inspector General (OIG) is requesting the input and recommendations of interested parties as it revises the compliance program guidance (CPG) for nursing facilities, especially those serving Medicare, Medicaid, and other federal healthcare program beneficiaries. The nursing home industry has experienced a number of changes since OIG first published a CPG in this area on March 16, 2000. Also, the subsequent years of enforcement and compliance activity in the industry have allowed the OIG to address more fully the various risk areas in nursing home compliance.
The OIG is soliciting comments, recommendations, and other suggestions from concerned parties and organizations on how best to revise the nursing facility CPG to address relevant compliance issues. Specifically, OIG seeks comments addressing any changes to existing risk areas and introducing any new risk areas. Comments are due by Feb. 25, 2008. Read the notice.
The Centers for Medicare and Medicaid Services (CMS) will host a National Provider Identifier (NPI) roundtable on Feb. 6 from 2:30 p.m. to 4:00 p.m. EST. This call will focus on the status of the Medicare implementation and a related question-and-answer session.
Also, the Workgroup for Electronic Data Interchange (WEDI) will host an audiocast on Feb. 21 to discuss NPI implementation from an industrywide standpoint. Please note there is a charge to participate in WEDI events.
Be aware that two key dates remain for 2008 in Medicare’s NPI implementation plan. There is also some confusion as to the difference between the implementation steps for March 1 and May 23. The CMS web site includes information about the implementation steps for each date and further clarifying the difference between the two dates.
In guidance provided on April 2, 2007, the Centers for Medicare and Medicaid Services (CMS) announced that, through May 23, 2008, it would not impose penalties on covered entities that deploy contingency plans to facilitate National Provider Identifier (NPI) compliance. However, as of May 24, 2008, CMS will lift that leniency policy. Complaints will be investigated as they are today, but CMS will impose penalties if the entity does not demonstrate compliance or corrective action.
CMS will continue to employ a complaint-driven approach to enforcement. For example, if a complaint is received alleging a failure to comply with the NPI requirements, CMS will contact the entity for evidence of compliance and the contingency plan that had been in place. If violations are identified, enforcement actions will take place.
In conversations and correspondence with health care providers, health plans, and others within the healthcare industry, it is clear that there are misconceptions concerning the National Plan and Provider Enumeration System (NPPES) and the NPI enumerator. Following are some common misconceptions and the facts correcting them.
Misconception: NPPES sends data directly to the Medicare provider enrollment system.
Fact: NPPES does not send data to the Medicare provider enrollment system or to the provider enrollment system of any health plan. As explained in the NPI final rule, applying for enrollment in a health plan is a completely separate process from that of applying for an NPI.
Misconception: NPPES sends data directly to the Medicare claims system.
Fact: NPPES does not send data to the Medicare claims system or to the claims system of any health plan. Medicare extracts certain NPPES data and uses those data in its Medicare NPI crosswalk. That crosswalk is used in processing Medicare Part A and Part B claims. Other health plans are also free to use NPPES data to help process their claims.
Misconception: NPPES is part of the Medicare provider enrollment system.
Fact: Obtaining an NPI is required in order for a healthcare provider to enroll in Medicare; however, the NPPES does not function as a part of the Medicare provider enrollment system. Medicare requires a healthcare provider to have an NPI and to furnish it on the Medicare provider enrollment application form (CMS-855). In addition, once a provider submits a CMS-855 to Medicare, Medicare compares the NPI and certain other information on the CMS-855 with certain information in that provider’s record in NPPES. If the information being compared does not match, the provider must correct whichever information (NPPES or CMS-855) is incorrect in order for the enrollment process to continue.
Misconception: Obtaining an NPI guarantees payment to the healthcare provider by a health plan.
Fact: As explained in the NPI final rule, obtaining an NPI does not guarantee payment to the healthcare provider by Medicare or by any other health plan. NPI assignment simply establishes the uniqueness of an enumerated healthcare provider among all other enumerated healthcare providers. Most health plans will not pay a healthcare provider that is not enrolled in that health plan.
Misconception: NPPES verifies licenses and credentials that are reported by healthcare providers when applying for NPIs.
Fact: NPPES does not verify licenses or credentials. NPPES verifies only two things: (1) a healthcare provider’s Social Security number if the provider is an individual who furnished his/her SSN when applying for the NPI; and (2) whether the provider’s business mailing and practice location addresses are legitimate postal service addresses, but not that the provider is actually associated with or located at either of those addresses. Licensure and credentials must be verified by health plans as part of their enrollment processes. It is possible, under certain circumstances, that the NPI enumerator may contact providers who have submitted applications, updates, or deactivations to verify information that was furnished in order to properly process those actions. Healthcare providers are reminded that the information they send to NPPES must be true, correct, and complete, in accordance with the certification statement of the NPI application/update form (paper form and web-based form).
Misconception: NPPES is a Medicare system.
Fact: NPPES is not a Medicare system; it belongs to no health plan. It is maintained by CMS for the healthcare industry in general, in accordance with the NPI final rule and as part of CMS’ delegated HIPAA authority. Healthcare providers who apply for NPIs are not required to furnish any information about their enrollment in any health plan. In an optional field, providers may report legacy identifiers that health plans have assigned to them in the past. This field, “Other Provider Identification Numbers,” can capture the legacy identifiers and the issuers of those identifiers (i.e., the names of the health plans that assigned them). The information in this field is used by health plans to help them locate their enrolled providers in NPPES in order to know of their NPI assignments. For this reason, Medicare providers are urged to report their Medicare legacy identifiers in this field.
Misconception: The NPI enumerator can update the Medicare claims and enrollment systems.
Fact: The NPI enumerator cannot view, update, or interact with Medicare claims or the Medicare enrollment systems, nor can it do so with any health plan’s claims or enrollment systems.
Misconception: The NPI enumerator can view and update/change the Medicare NPI crosswalk.
Fact: The NPI enumerator cannot view or update/change the Medicare NPI crosswalk. The NPI enumerator can assist providers with certain aspects of updating their NPPES records, and some of that information in those NPPES records could be used by Medicare in the Medicare NPI crosswalk.
Misconception: The NPI enumerator serves Medicare providers and supports Medicare operations, not other providers or health plans.
Fact: The NPI enumerator operates under contract to CMS in accordance with the NPI final rule and as part of CMS’s delegated HIPAA authority. The NPI enumerator serves the entire healthcare provider community for NPI purposes, not just Medicare providers. The functions of the NPI enumerator are not specific to any health plan.
CMS has posted information that lists the specific duties and responsibilities of the NPI enumerator in a recent MLN Matters article. An article that further clarifies the functions of NPPES and the NPI enumerator is in development; this article will be announced once available.
The enactment of ambitious health access reforms in Massachusetts and Vermont has ushered in a new wave of state coverage expansions, according to a Health Affairs web exclusive study published Jan. 29. The study identifies 39 states that have passed laws expanding access in at least one area since Massachusetts and Vermont enacted their reforms in 2006.
The researchers provide a comprehensive catalog of state coverage enactments in 2006 and 2007, the most common form of which was adding coverage for children: 26 states expanded children’s coverage, principally through reforms involving the State Children’s Health Insurance Program (SCHIP). Eighteen states passed laws increasing the number of adults eligible for Medicaid and other public programs.
As of the end of 2007, no state had joined Massachusetts and Vermont in passing comprehensive reforms. All told, governors and key legislative leaders in at least 13 states other than Massachusetts and Vermont have proposed comprehensive reforms. The authors emphasize that, given the advantages enjoyed by Massachusetts and Vermont and the length of time it takes to develop and pass wide-ranging coverage expansions, “the lack of success to date for other states’ comprehensive reform efforts should not be surprising.” Read the abstract.
New reports released Jan. 28 by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) describe aggressive efforts by states in the past year and a half to expand coverage to low-income children and their families, but the actions may be curtailed as a deteriorating economic climate and new limits on federal assistance take effect.
A downturn in the economy, the federal failure to reauthorize the State Children’s Health Insurance Program (SCHIP), and new federal rules affecting Medicaid and SCHIP eligibility all suggest that the recent period of aggressive expansion of coverage by states may be over. This is the conclusion based on a series of new studies by the KCMU, including a 50-state survey of eligibility and enrollment rules in Medicaid and SCHIP for children and families, interviews with Medicaid directors in 10 states representing all regions of the country, and recent studies of enrollment in Medicaid and SCHIP.
“State momentum to address the growing problem of the uninsured has run into a double whammy of a declining economy that is putting additional pressure on state budgets and funds for Medicaid and SCHIP and federal barriers to state expansions,” said Diane Rowland, executive director of the KCMU. “Without additional federal assistance for Medicaid and SCHIP in this economic downturn, we are likely to see added growth in the uninsured,” she added. Access the reports.
When asked to consider the health reform proposals of the 2008 presidential candidates, most leaders in health care and health policy favor plans that build on the nation’s current mixed system of public and private group insurance, a new survey finds. Proposals relying on tax incentives that help individuals purchase coverage themselves, however, are viewed by these same experts as ineffective strategies for either achieving universal healthcare coverage or containing spiraling healthcare costs.
Key elements of the mixed private-public proposals--which have been put forward by Sens. Hillary Clinton and Barack Obama as well as former Sen. John Edwards--received widespread support in the latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey. For instance, 83 percent of the opinion leaders surveyed said they favor requiring that all individuals obtain health insurance, with premium assistance available for low- and moderate-income Americans. Most (71 percent) respondents also support requiring employers to either offer coverage to employees or pay a percentage of their payroll to help finance expanded coverage. Support for a “pay-or-play” requirement is strong even among opinion leaders in the business community, with 66 percent approving such a feature.
New Jersey needs an “early warning system” to monitor acute care hospitals, identify those in financial distress, and intervene in advance to protect communities’ access to care, according to the final report of the Governor’s Commission on Rationalizing Healthcare Resources. Citing the fact that five New Jersey hospitals have filed for bankruptcy since July 2006 and that 15 hospitals have closed in the past decade, the report states that a large number of hospitals are in poor financial health at a time when hospitals nationally are doing well.
The 200-page report, released Jan. 24, proposes dozens of steps that should be taken to stabilize New Jersey’s troubled hospital system. They deal with state oversight, hospital funding, hospital efficiency, transparency in hospital operations, and accountability for $3.7 billion in state money used to pay for health care in New Jersey. Read the report.
The Department of Health and Human Services (HHS) has published in the Jan. 23 Federal Register its annual update to the federal poverty guidelines.
The update is accomplished by increasing the latest published Census Bureau poverty thresholds by the relevant percentage change in the Consumer Price Index for All Urban Consumers. The 2008 guidelines reflect the 2.8 percent price increase between CY06 and CY07. After the inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family sizes. The 2008 guidelines are roughly equal to the poverty thresholds for CY07, which the Census Bureau expects to publish in final form in August 2008. Read the Federal Register notice.
A new report from the Institute of Medicine (IOM) offers a blueprint for a national program to assess the effectiveness of clinical services and to provide credible, unbiased information about what really works in health care. The report, Knowing What Works in Health Care: A Roadmap for the Nation, recommends that Congress direct HHS to establish a program with the authority, expertise, and resources necessary to set priorities for evaluating clinical services and to conduct systematic reviews of the evidence. This program would also be responsible for developing and promoting rigorous standards for clinical practice guidelines, which could help minimize the use of questionable services and target services to the patients most likely to benefit, said the committee that wrote the report.
Although several organizations conduct evidence reviews and develop clinical practice guidelines, a single entity with the authority and resources is needed to determine what works and end confusion, the report says. Lack of coordination has led to duplication of effort, dozens and even hundreds of competing practice guidelines, and uncertainty about which study results and guidelines are the most reliable and objective. This situation complicates the push to empower individuals to become more engaged in choosing and managing their care, the committee said.
The House voted 260-152 on Jan. 23 to override President Bush’s veto of State Children’s Health Insurance Program expansion legislation (HR 3963), falling 15 votes short of the two-third majority required.
As reported in The New York Times, the legislation would have expanded the program to cover 10 million children and increased spending on the program by $35 billion over five years, funded with an increase of the federal cigarette tax by 61 cents per pack. It also would have limited coverage to children in families with annual incomes below 300 percent of the federal poverty level. Bush vetoed another version of the bill in October 2007.
The vote marks the second failure in three months by House Democrats to override a Bush veto of legislation to expand the program.
A copayment of $12.50 to $35 reduces by 8.3 percentage points the likelihood that women will receive regular mammograms to detect breast cancer, according to a study published Jan. 24 in the New England Journal of Medicine.
Researchers examined data from more than 366,000 women ages 65 to 69 who were enrolled in 174 Medicare managed care plans in 38 states between 2001 and 2004. During that time, the number of plans requiring a copay for a mammogram increased from three in 2001 to 21 in 2004. Most copays were $20, but the amounts ranged from $12.50 to $35. The study found that mammogram rates increased by 3.4 percentage points among women in plans that paid the full amount, while the rates declined by 5.5 percentage points among women who had a copay.
Stating that “a system that is unaffordable for many today won’t work for even more people tomorrow,” Blue Cross and Blue Shield Association (BCBSA) president and CEO Scott P. Serota on Jan. 23 unveiled a five-point plan for building on the employer-based system to improve quality, rein in costs, and expand coverage to all Americans.
The plan, titled The Pathway to Covering America: Ensuring Quality, Value and Access, lays out recommendations to change the incentives in today’s delivery system to help ensure high-quality, affordable care and offers solutions to expand access to coverage. Specifically, it includes recommendations to:
School-based immunization of students ages 5-18 can be a cost-effective way of fighting influenza. That’s the conclusion of a study published Jan. 23 on the Health Affairs web site.
In one large multistate trial, school-based immunization saved an estimated $171.96 per student-household over the course of a flu season, say a team of researchers led by Jordana Schmier. Indeed, the researchers found that reductions in direct and indirect flu-related costs during the peak week of flu season alone offset the incremental costs of school-based immunization.
The difference in costs during the peak week of flu season between intervention and control households was small: only 71 cents. However, over the course of the entire flu season the difference would likely be magnified: Intervention households would be expected to incur costs of $759.92, versus $931.88 for control households--a $171.96 difference. “The major cost disadvantage for intervention schools is the costs of the vaccine themselves. But by peak week, most students who are going to be immunized have already received their vaccines, leaving intervention schools to reap the savings from their higher vaccination rate for the rest of the flu season,” Schmier explained. Read the abstract.
As U.S. stocks tumble, reflecting the growing concern of a recession, the National Conference of State Legislatures has asked Congress to consider states’ fiscal concerns in an economic stimulus package that is still being developed. In a letter to House and Senate leadership, NCSL offers options for consideration, including temporary changes in the Medicaid matching rate and increases in discretionary funds for states.
A freeze or increase in federal matching payments for Medicaid would assist people who lose healthcare coverage during the economic downturn and complement support provided in the economic stimulus package to extend and increase unemployment benefits.
And as each state will likely face different fiscal challenges in FY08 and FY09, discretionary grants provide states with the flexibility to address fiscal concerns through one-time state grant assistance. In addition, discretionary grants funds help eliminate shortfalls in state-federal partnerships.
“States are mandated to balance their budgets,” said William T. Pound, executive director of the National Conference of State Legislatures. “If the economy continues to slow or takes a turn for the worse, state finances undoubtedly will decline.” Read the letter.
The Centers for Medicare and Medicaid Services (CMS) on Jan. 22 issued a proposed payment rule designed to ensure that long-term care hospitals (LTCHs) continue to receive appropriate payment for services provided while giving them incentives to provide more efficient care. The new policies and payment rates would apply to services provided to individuals who are discharged from these hospitals on or after July 1, 2008. The proposed rule would affect the nation’s nearly 400 LTCHs, generally defined as inpatient hospitals where the average length of stay for Medicare patients is greater than 25 days.
CMS is proposing a standard federal rate of $39,076.28 for the 2009 rate year. This is based on a proposed update of 2.6 percent compared with the standard federal rate for RY08, as revised to comply with provisions of the recently enacted Medicare Extension Act. The update represents a 3.5 percent increase in the hospital marketbasket less a 0.9 percent adjustment to offset coding changes in RY06 that do not reflect real changes in the severity of the cases treated by these hospitals. Comments on the proposed rule are due by March 24, 2008, and a final rule will be issued later in the spring. Download the proposed rule.
President Bush likely will reveal his proposal for changing the Medicare physician fee formula during his State of the Union address on Jan.28, according to CongressDaily.
Bush for the first time is required by law to send a Medicare savings plan to Congress after he releases his FY09 budget proposal because Medicare trustees last year triggered a “Medicare funding warning.” The warning is issued when trustees for two consecutive years predict that federal general fund revenue must be used to pay for 45 percent or more of total Medicare costs within seven years. Bush last month signed into law a bill that delays the fee cut through July 1 and extends the State Children’s Health Insurance Program through March 2009. The bill increased Medicare physician fees by 0.5 percent during that period and extended several programs that provide higher Medicare reimbursement rates to rural healthcare providers and hospital laboratories, according to the Kaiser Daily Health Policy Report.
The U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) last week announced a new guide to help employers, private health plans, the federal government, and state Medicaid agencies as they consider consumer financial incentives as part of a strategy to improve the quality of health care and get better value for what they spend on services. By using financial incentives, healthcare purchasers hope to encourage patients to take actions that either may improve the results of their treatment or reduce costs by eliminating unnecessary emergency room visits and decreasing preventable hospitalizations.
The decision guide consists of an evidence summary organized around a series of 21 questions that purchasers need to consider when implementing consumer financial incentives. The guide reviews the application of incentives to five types of consumer decisions, including selecting a high-value provider, choosing a high-value health plan, deciding among treatment options, and reducing health risks by seeking preventive care and by decreasing or eliminating high-risk behavior.
In addition to a summary of the evidence base, the guide includes examples of consumer financial incentives currently being offered, criteria for selecting performance measures, elements to enable patients to participate in medical decision making and in managing their chronic diseases, and characteristics that increase the likelihood that a consumer will respond to financial incentives.
In a Jan. 17 letter to the Government Accountability Office, Sen. Edward Kennedy, chairman of the Health, Education, Labor and Pensions Committee, asked that it investigate why regulations implementing the Patient Safety and Quality Improvement Act of 2005, which would establish patient safety organizations, have not been fully implemented.
“Almost three years later, these regulations are still languishing in the review and clearance process,” wrote Kennedy. “The failure to issue regulations has had a chilling effect on efforts to improve a culture of safety in American medicine, putting the health and safety of patients at risk.” Read the letter.
Three long-term care associations--the American Health Care Association (AHCA), the Alliance for Quality Nursing Home Care (AQNHC) and the National Center for Assisted Living (NCAL)--last week unveiled a comprehensive plan designed to create a consumer-oriented system bringing greater private resources into the long-term and post-acute care delivery system.
The proposal emphasizes better coordination of both care and financing, greater private sector involvement, and appropriate personal responsibility. The plan would reorganize the Medicaid long-term care and Medicare post-acute care systems by centralizing and streamlining government services and making more private resources available to pay for care. Read the executive summary.
In a Jan. 14 letter to HHS Secretary Mike Leavitt, House and Senate Democrats blasted December 2007 action by the Centers for Medicare and Medicaid Services (CMS) that denied Ohio’s request to extend health coverage to more children through Medicaid.
Sen. Max Baucus (D-Mont.), Rep. John Dingell (D-MI), Rep. Frank J. Pallone, Jr. (D-NJ), Sen. John D. Rockefeller, IV (D-WV), and Rep. Henry Waxman (D-CA) expressed concern that the Department of Health and Human Services (HHS) is endangering health coverage for low-income, uninsured American children with inappropriate changes to policies for Medicaid and the State Children’s Health Insurance Program (SCHIP).
The congressional leaders called the Dec. 20, 2007, denial of Ohio’s state plan amendment an action that exceeds the statutory authority of CMS and one that, if pursued elsewhere, will result in millions of children living without health care. “CMS can’t just make unilateral, under-the-radar changes that keep poor kids from getting the doctor’s visits and medicines they need,” said Baucus. “Congress made it clear in law that Medicaid and the Children’s Health Insurance Program should be there for lower-income kids living without insurance, and the changes made by CMS are threatening to kick children out of the doctor’s office and back into the dangerous world of the uninsured.” Read the letter.
More than $4 million has been raised to begin construction of the not-for-profit HealthInfoNet network, placing Maine among the first states in the nation to build and operate a statewide electronic health information network.
The network is intended to help reduce medical errors and lead to more informed treatment decisions by allowing caregivers to access key clinical information. An estimated $50 million per year in healthcare costs is expected to be saved as caregivers order fewer unnecessary and duplicative tests, procedures, prescriptions, and hospital admissions.
The pilot program will begin this winter, more than 2,000 healthcare providers, including 15 rural and urban hospitals across the state, joining with the Maine Center for Disease Control and Prevention in a 24-month demonstration of the network. Following the demonstration phase, plans call for HealthInfoNet to be expanded to include other providers who care for Maine’s 1.3 million residents. Read the press release.
Aetna announced in mid-December that it will reimburse physicians participating in most of Aetna’s medical plans nationwide for webVisit consultations in more than 30 specialties, including allergy and immunology, neurology, cardiology, and psychiatry. These clinically structured online interviews offer patients an efficient way to report nonurgent symptoms.
Aetna provides its online consultations and other secure messaging services through RelayHealth’s intelligent network. These services include appointment requests, referrals, lab and test results, and prescriptions and medication refills. Coverage for RelayHealth online visits will be available to most fully insured plan members; self-insured plan sponsors may choose to participate. Read the news release.
A new patient safety law that took effect this week will require New York State physician practices that perform office-based surgical procedures to achieve and maintain accreditation from a nationally recognized accrediting organization. The state has designated the Joint Commission as one of the accrediting bodies that it will recognize.
Prior to this new legislation, surgeries performed in physicians’ offices were not regulated in New York State. Many types of office practices are affected by the new law, including endoscopy suites, plastic surgery practices, and urology practices. If not already accredited by the Joint Commission or two other approved accrediting agencies, office-based surgery practices in New York must become accredited on or before July 14, 2009.
The law reflects a national trend of state health departments and boards of medicine strengthening their oversight of quality efforts. Currently, 25 states recognize Joint Commission accreditation for ambulatory care settings--in whole or in part--in fulfillment of regulatory requirements, and 14 states recognize Joint Commission accreditation for office-based surgery. Read the news release.
The Centers for Medicare and Medicaid Services (CMS) had earlier indicated that the Medicare, Medicaid and SCHIP Extension Act of 2007 replaced the scheduled 10.1 percent reduction in the Medicare physician fee schedule (MPFS) conversion factor with a 0.5 percent increase for dates of service beginning Jan. 1 through June 30, 2008.The agency issued an update on Jan. 11 stating that physicians do not need to take any additional action in order for their MPFS claims to be paid at the new rate that reflects the 0.5 percent increase in the conversion factor. Medicare contractors have been instructed to process, beginning Jan. 7, all claims that contain MPFS services with dates of service of Jan. 1, 2008, and after, with the new 2008 rates.
CMS also reiterated the fact that the new fees are expected to be posted on local contractors’ web sites no later than Jan. 11, 2008. The Medicare physician fee schedule look-up link on the CMS web site, which allows users to customize their search, will be updated with the new 2008 fees during the week of Jan. 21, 2008. However, the carrier-specific public use files are available now on the CMS web site.
An official CMS change request and an MLNMatters article will be forthcoming.
CMS has announced an additional election period for the 2008 Medicare Part B Drug Competitive Acquisition Program (CAP), a voluntary program that offers physicians the option to acquire many injectable and infused drugs from an approved CAP vendor. The election period, which began on Jan. 15, 2008, and will conclude on Feb. 15, 2008, was added because recent changes in the CAP make it more flexible for physicians.
Among other changes to the program, physicians now have up to 30 days to file CAP drug administration claims after administering CAP drugs. Also, participating CAP physicians may now request to leave the CAP under certain circumstances if program participation results in a burden to their practice.
Effective dates of participation for physicians who elect to join the CAP during this additional election period will be April 1, 2008, to Dec. 31, 2008.
As patient volumes in hospital emergency departments (EDs) are going up, waiting times to see an ED physician are getting longer, particularly for heart attack patients and those in need of the most immediate attention, according to a study by Harvard Medical School researchers at the Cambridge Health Alliance published today as a Health Affairs web exclusive.
The researchers found that the median ED wait time went up from 22 minutes in 1997 to 30 minutes in 2004, a 36 percent increase. For patients diagnosed in the ED with acute myocardial infarction, the median wait time increased a steep 150 percent, from 8 minutes in 1997 to 20 minutes in 2004. And for those identified in ED triage as needing attention “emergently,” wait times increased from 10 minutes in 1997 to 14 minutes in 2004, an increase of 40 percent.
The researchers say that the most important factor in increasing ED wait times is likely the greater crowding that has resulted from ED closures combined with an increase in ED visits: Between 1994 and 2004, the number of annual ED visits increased from 93.4 million to 110.2 million, while the number of EDs fell 12.4 percent. Read the abstract.
A proposed rule that would allow more Medicaid beneficiaries to be in charge of their own personal assistance services, including personal care services, instead of having those services delivered by an agency, was announced Jan. 14 by the Centers for Medicare and Medicaid Services (CMS). Under the proposed rule, if a state adopts a self-directed personal assistance services state plan option, beneficiaries could receive a cash allowance to hire their own workers to help with such activities as bathing, preparing meals, household chores, and other related services that help a person to live independently. Allotments could also be used to purchase items that help foster independence, such as a wheelchair ramp or microwave oven.
Before a state can request this change to its state plan, it must have an existing personal care services benefit or be operating a home or community-based services waiver program. Furthermore, enrollment in this new state plan option is voluntary and the state must also provide traditional agency-delivered services if the beneficiary wishes to discontinue self-directed care.
States choosing this option need to have necessary quality assurances and other safeguards in place to ensure the health and welfare of participants. States also need to train potential participants in ways to manage their budgets and assess their personal care needs. Download the proposed rule.
Tight capital market conditions promise to play a pivotal role in U.S. corporate healthcare creditworthiness in 2008, but possibly in an unexpected way, according to Capital Constriction Might Help Stem the Bleeding of U.S. Corporate Healthcare Quality in 2008, a report published Jan. 10 by Standard & Poor’s Ratings Services.
Specifically, corporate healthcare rating actions may actually be more balanced in the period ahead, in contrast to the past two years, which saw nearly triple the number of rating downgrades relative to upgrades, said S&P credit analyst Michael Kaplan. Accordingly, S&P healthcare ratings universe now bears an increased proportion of stable outlooks compared with one year ago. In fact, stable outlooks are now the large preponderance of all outlooks in the sector, with more positive outlooks now than at the end of 2006.
The report is available to subscribers of RatingsDirect. For more information, call 212-438-9823.
The Medicare Payment Advisory Commission (MedPAC) on Jan. 10 recommended that Congress reduce the indirect medical education (IME) adjustment by 1 percentage point to 4.5 percent in FY09. MedPAC’s data indicated cost increases to teaching programs in 2006 grew at 2.2 percent for each 10 percent increment in teaching intensity, and with the IME adjustment at 5.5 percent for each 10 percent increment, there is significant overcompensation. The recommended cut is to reduce that 2.2 percent versus 5.5 percent gap. The cut was estimated to produce approximately $1 billion, which, as the recommendation proposed, would be used to fund the quality incentive program.
For physicians, in addition to the update to cover the change in input prices, less an adjustment for productivity improvement, MedPAC recommended Congress require the Centers for Medicare and Medicaid Services (CMS) to measure and report physician resource use over a two-year period.
MedPAC also recommended that dialysis services receive an update equal to the projected rate of increase in the end stage renal dialysis (ESRD) market basket, less an adjustment for productivity growth, and that Congress should implement a quality incentive program for physicians and facilities that provide these services.
In addition to no update for skilled nursing facilities for FY09, the commission’s recommendation called for Congress to establish quality incentive payments (to be budget neutral), add risk adjustment, track avoidable rehospitalizations, and conduct patient assessments at admission and discharge. In contrast to most actions of the commission, this vote had its dissenters and an abstention.
The Robert Wood Johnson Foundation (RWJF) announced on Jan. 10 a new scholars program to develop the next generation of nurse leaders in academia and boost the stature of junior faculty in nursing schools. The RWJF Nurse Faculty Scholars program will provide $28 million over the next five years to outstanding junior nursing faculty to help them advance in their fields and seek faculty positions earlier in their careers by providing mentorship, leadership training, salary, and research support.
The program will be run out of the Johns Hopkins University School of Nursing, and will award up to $350,000 for three years to each RWJF Nurse Faculty Scholar; up to 15 scholars will be selected each year. Scholars will be given opportunities to develop a research program and other scholarly activities; work closely with institutional and national mentors; participate in leadership training; and network with scholars, experts, and colleagues in their field and other related fields. Scholars also will be able to gain much-needed protected time to get the critical skills needed for a successful career in academic nursing.
“Universities are turning away thousands of qualified applicants to nursing schools each year because they lack the faculty to teach them,” said RWJF president and CEO Risa Lavizzo-Mourey, MD. “We have a pipeline problem. We need to fill that pipeline or we all will suffer the consequences.” More information.
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A new study finds that, despite efforts in the past decade to mitigate cancer treatment disparities, black patients are significantly less likely than white patients to receive therapy for various types of cancer. The authors of the study conclude that efforts to close treatment gaps initiated in the 1990s appear to have had little impact. The report will appear in the Feb. 15, 2008 issue of CANCER, a journal published on behalf of the American Cancer Society.
The researchers evaluated cancer care received by Medicare beneficiaries diagnosed with breast, colorectal, lung, or prostate cancer from 1992 through 2002. They found that for both black and white patients, there was little or no improvement in the proportion of patients receiving therapy for most cancers. In addition, there was no decrease in the magnitude of racial disparities between 1992 and 2002; black patients were significantly less likely than white patients to receive therapy for cancers of the lung, breast, colon, and prostate.
The Vermont Association of Hospitals and Health Systems announced Jan. 4 that all Vermont hospitals will adopt a uniform policy to not seek payment from patients or insurers for hospital care resulting in certain rare but serious adverse events as defined by the National Quality Forum, such as wrong-site surgeries. The state joins Massachusetts and Minnesota, which have already taken this voluntary step.
The state’s hospitals have each followed their own nonpayment practices for years, but have never had a formalized process. The policy will cover eight events: surgery on wrong body part, air embolism-associated injury, surgery on wrong patient, medication error injury, wrong surgical procedure, artificial insemination/wrong donor, retention of foreign object, and incompatible blood-associated injury.
Hospitals are working to implement the policy and expect that it will be in place by fall 2008. Read the press release.
Among the 94 million women ages 18-64 in the United States, nearly one in five is uninsured. This number has grown by 1.2 million over the past three years, with half of the growth among low-income women. And the uninsured rates vary considerably from one state to the next, ranging from a high of 28 percent of women ages 18-64 (Texas) to a low of 9 percent (Minnesota). Among low-income women, the uninsured rate spans from 51 percent (Texas) to 20 percent (Maine and Vermont).
Those facts are cited in two new fact sheets released Jan. 9 by the Kaiser Family Foundation. Women’s Health Insurance Coverage provides new statistics on health coverage and insurance for nonelderly adult women, and provides data on the more than 17 million women who are uninsured. Health Insurance Coverage of Women by State provides state-by-state data on the uninsured rate.
Full implementation of the new Medicare prescription drug benefit contributed to an 18.7 percent increase in Medicare spending in 2006, the fastest rate of growth since 1981 and double the rise in 2005. In fact, in 2006, Medicare spending rose to $401.3 billion, up from $338.0 billion a year earlier, according to the Centers for Medicare and Medicaid Services’ (CMS) annual health spending report appearing in the January-February 2008 issue of Health Affairs.
Meanwhile, Medicaid spending fell slightly for the first time since its inception in 1965, to $310.6 billion in 2006 from $313.5 billion in 2005. The 0.9 percent drop was largely attributable to the transfer of drug coverage for people who are dually eligible for Medicare and Medicaid coverage, say CMS analysts.
Most other major health services and public payers experienced slower spending growth in 2006. Personal healthcare spending grew 6.6 percent in 2006, compared with 6.8 percent in 2005. Healthcare price growth accounted for more than half of the growth in 2006. Read the abstract.
CMS announced on Jan. 8 the 70 new areas across the nation that will be part of the second phase of a competitive bidding program designed to help lower Medicare beneficiaries’ out-of-pocket costs and improve their access to certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), including standard and complex power wheelchairs, walkers, oxygen supplies and equipment, hospital beds, and certain devices. Ten areas currently participate in the program.
Under the competitive bidding program, suppliers that wish to offer certain items and services to people with Medicare will have to submit bids to CMS, indicating the prices at which they are willing to supply these items to beneficiaries--prices that CMS believes will be closer to the prices charged in the current market. Once the competitive bidding program is fully implemented nationally, it is expected to save beneficiaries and Medicare $1 billion annually.
CMS expects to begin the second round of pre-bidding activities, such as announcing the specific zip codes that constitute the competitive bidding areas, in spring 2008, with the bidding period planned to begin in summer 2008 and pricing expected to go into effect in July 2009. Access the web page.
Rising out-of-pocket expenses and stagnant incomes increased the financial burden of health care for more Americans between 2001 and 2004, especially for the privately insured, according to a national study supported in part by the Commonwealth Fund and published in the January/February issue of Health Affairs. The study was conducted by researchers at the Center for Studying Health System Change and the Agency for Healthcare Research and Quality.
The researchers found that after accounting for general inflation, total average out-of-pocket spending on health care increased by $373 to $2,656 a person in 2004--about a 16 percent increase from 2001. In contrast, average family incomes during the same period were largely unchanged after accounting for inflation.
The increase in financial burden was driven entirely by people with private insurance, most of whom had employer-sponsored coverage: 17 percent, or 29 million people, with employer-sponsored insurance faced high burdens in 2004, up from 14.7 percent in 2001, the study found. For people with employer coverage, out-of-pocket spending for premiums and services rose $553 to $3,211, a 21 percent increase between 2001 and 2004 after accounting for inflation. Read the article.
The Centers for Medicare and Medicaid Services (CMS) announced on Jan. 7 a proposed regulation that aims to allow more Medicare beneficiaries with limited income and resources to remain in the Medicare prescription drug plan in which they are enrolled without having to pay a premium.
Specifically, CMS is proposing, under certain conditions, to allow prescription drug plan sponsors to offer a reduced premium amount for certain individuals eligible for a low-income subsidy. The proposal, which would apply in regions where there otherwise would be fewer than five prescription drug plan sponsors with a “zero-premium” plan option for limited-income beneficiaries, would help to ensure there are a sufficient number of organizations offering such plans.
The proposed rule is published in today’s Federal Register and the final rule is expected to be issued on March 28, 2008.
It reportedly comes as a surprise to states that the Bush administration is imposing restrictions on the ability of states to expand eligibility for Medicaid. The restrictions are the same as those placed on the State Children’s Health Insurance Program (SCHIP) in August after states tried to broaden SCHIP eligibility. According to The New York Times, the move surfaced when state officials of Louisiana, Ohio, and Oklahoma recently attempted negotiations with the federal government to change their Medicaid programs. Up to this point, the government had not stated that it would begin applying the SCHIP restrictions to Medicaid.
Regulations require that state child health plans include procedures to ensure that SCHIP coverage does not substitute for coverage under group health plans (known as “crowd-out” procedures).
The Times points to the yearlong battle between the President and Congress over SCHIP. Bush has repeatedly emphasized that he wants to return the program to its “original objective” of covering children with family incomes less than twice the poverty level.
The Massachusetts Department of Revenue issued draft guidelines Dec. 31, 2007, on tax penalties for not having health insurance in 2008.
Penalties would apply only to adults who can afford health insurance, based on separate standards established by the state Health Connector on an annual basis and subject to hardship appeals. The 2007 penalty is the loss of the personal exemption worth $219 on an individual’s state tax return; however, the 2008 penalties will be based on one-half the lowest cost of plans available through the Connector as of Jan. 1, 2008. Under the draft guidelines, the penalties will range from zero to $912 for an entire year without coverage; they will accrue each month an individual does not have health insurance in 2008 and will be due as part of the tax filing process for the year. Read the press release. Read the draft guidelines.
Most free drug samples go to wealthy and insured patients and are not used to ease the burden of the poorest nor the uninsured, according to a study by physicians from Cambridge Health Alliance and Harvard Medical School. The study, which is the first to look at free drug samples nationally, will appear in the February 2008 issue of the American Journal of Public Health. The study used data on 32,681 U.S. residents from the annual federal Medical Expenditure Panel Survey.
The study found that more than one out of every 10 Americans received one or more free drug samples in 2003. Among Americans who take at least one prescription drug, nearly one out of five got free samples.
However, few free samples went to the needy. Insured Americans and those with higher incomes were more likely to report receiving at least one free sample. More than four-fifths of sample recipients were insured all year. Conversely, less than one-fifth were uninsured for all or part of 2003, and less than one-third had low family incomes (under $37,000 for a family of four). Receiving medical care in an office and taking more medications also increased an individual’s chances of receiving free drug samples. Read the abstract.
Blacks and Hispanics who go to hospital emergency departments in pain are significantly less likely than whites to get pain-relieving opioid drugs, according to a new study funded by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) and the National Institute on Drug Abuse. The report, “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in U.S. Emergency Departments,” appears in the Jan. 2, 2008, issue of JAMA.
The study, which analyzed treatments for more than 150,000 pain-related visits to U.S. hospitals between 1993 and 2005, found 23 percent of blacks and 24 percent of Hispanics received opioids compared with 31 percent of whites. Twenty-eight percent of Asians and other groups received opioids.
Among the study findings, blacks were prescribed opioids at lower rates than other groups for almost every type of pain-related ED visit, including back pain (33 percent for blacks versus 48 percent for whites) and abdominal pain (20 percent versus 32 percent). The report does not conclude why non-whites were less likely to receive opioids, but suggests racial and/or ethnic bias as a significant factor. The authors said that new strategies are needed to address pain management in EDs, perhaps including changes to pain treatment regimens or educating patients to specifically ask for pain relief. Read the abstract.
Trust for America’s Health (TFAH) has released its fifth annual Ready or Not? Protecting the Public’s Health from Disease, Disasters, and Bioterrorism report, which found that although important progress has been made, critical areas of the nation’s emergency health preparedness effort still require attention. The report includes state-by-state health preparedness scores based on 10 key indicators to assess health emergency preparedness capabilities. All 50 states and the District of Columbia were evaluated. Thirty-five states and D.C. scored eight or higher on the scale of 10 indicators.
Illinois, Kentucky, Nebraska, New Jersey, Pennsylvania, Tennessee, and Virginia scored the highest with 10 out of 10. Arkansas, Iowa, Mississippi, Nevada, Wisconsin, and Wyoming scored the lowest with six out of 10.
Among the key findings, 13 states do not have adequate plans to distribute emergency vaccines, antidotes, and medical supplies from the Strategic National Stockpile, and 12 states do not have a disease surveillance system compatible with the Centers for Disease Control and Prevention’s National Electronic Disease Surveillance System. Also, seven states have not purchased any portion of their federally subsidized or unsubsidized antivirals to use during a pandemic flu. Download the report.
The Medicare, Medicaid and SCHIP Extension Act of 2007 made several changes affecting payments to physicians. One such change provides for a 0.5 percent increase to the physician fee schedule conversion factor for dates of service beginning Jan. 1 through June 30, 2008, instead of the -10.1 percent that was scheduled to take place. Effective for dates of service on and after July 1, 2008, the -10.1 percent update to the physician fee schedule will go into effect. The new fees will be posted on local contractors’ web sites as soon as possible.
Because there is a change to the 2008 Medicare physician fee schedule rates, CMS is extending the participation decision period an additional 45 days; the participation decision period now runs through Feb. 15, 2008, rather than ending on Dec. 31, 2007. All participating status changes are effective as of Jan. 1, 2008.
The Equal Employment Opportunity Commission (EEOC) has announced the publication of a final rule allowing employers that provide retiree health benefits to continue coordinating those benefits with Medicare (or comparable state health benefits) without violating the Age Discrimination in Employment Act (ADEA). The regulation, which safeguards retiree health benefits, was published in the Dec. 26 Federal Register and became effective immediately.
The EEOC proposed the rule in response to a controversial decision in 2000 by the U.S. Court of Appeals for the Third Circuit in Erie County Retirees Association v. County of Erie. The court held that the ADEA requires that the health insurance benefits received by Medicare-eligible retirees be the same, or cost the employer the same, as the health insurance benefits received by younger retirees. After the Erie County decision, labor unions and employers alike informed the EEOC that complying with the decision would force companies to reduce or eliminate the retiree health benefits they currently provided, leaving millions of retirees aged 55 and over with less health insurance--or none at all.
The new regulation provides an exemption for ADEA coverage for this common and longstanding employer practice. Read the final rule.
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