Healthcare groups seeking IPAB repeal

Originally designed as a board of impartial experts to oversee the health care system and develop recommendations regarding the procedures, medications and spending priorities for Medicare and Medicaid, criticism against the Independent Payment Advisory Board (IPAB) reached a new level last week, when  a robust cross-section of health care stakeholders signed a letter to members of Congress urging them to repeal the controversial cost-cutting IPAB panel established under health care reform

The IPAB, which will not make it's first recommendation until 2014, is under intense scrutiny by stakeholders  concerned with it's ability to make rational recommendations to payment methods and the belief that the IPAB might lead the way to rate setting for all payers.    As currently defined, any IPAB recommendations would take effect without Congressional approval,  and as such, removes elected officials from the decision making process when changes occur in the Medicare and Medicaid programs.

Proponents point out that Market forces alone cannot control health care costs and by implementing best practices and devising methods by which Medicare and Medicaid may provide better services at lower costs, the IPAB is an impartial process that will control skyrocketing costs and allow the Medicare and Medicaid programs to continue.  A three-fifths Senate vote could override any recommended payment cuts, and Congress could always increase Medicare funding through independent legislation.



The House Energy and Commerce Committee is planning a hearing on the panel in July. 

Medicare Data Will Become Publicly Available

On June 3rd, the Centers for Medicare and Medicaid Services (CMS) announced proposed rules that will give certain organizations access to Medicare data.  The proposed rule supports efforts of the health reform law to improve health care quality and lower costs. 

Currently, private insurance companies sometimes make quality assessments on physicians based on their own claims data.  While the goal of the reports was and is to identify hospitals and physicians with the highest quality and cost-effective care, providers can receive multiple and sometimes contradictory reports from a variety of insurers and are often unable to appeal or correct inaccuracies in those reports.

Because Medicare is the largest payer in the US health care system, it's claims data can make quality measures more accurate.  The proposed rule will allow certain organizations access to Medicare claims data and would offer a more accurate snapshot of the performance of physicians and hospitals by ensuring the organizations that crunch the data combine both private sector claims data with Medicare data.  These organization would be required to share the reports confidentially with the providers prior to their public release.  In this way, physicians will have an opportunity to review and work with the company to prevent mistakes in the reports.    Public reports will contain aggregated information only, and no individual patient data will be shared.

CMS will formally publish the rule in the June 8th Federal Register and accept public comment for 60 days.

AMA names James L. Madara MD, as top executive

The American Medical Association has announced it's new executive vice president and CEO.  Effective July 1, 2011, James L. Madara, MD will become the top executive of the AMA. He will replace Michael Maves, who announced last November that he would be stepping down.

Madara, a pathologist and gastroenterologist, has most recently served as senior adviser at Leavitt Partners, a health care consulting firm founded and chaired by former Health and Human Services Secretary Michael O. Leavitt.  He has also served as the CEO of the University of Chicago Medical Center and Chair of the Department of Pathology and Laboratory Medicine at Emory University School of Medicine in Atlanta.  Dr Madara has published more than 200 research papers. 

In a Thursday conference call with reporters, Madara, an 11-year AMA member, said he was "enthusiastic" about his new job and vowed to "refocus" the nation's largest, oldest physicians' organization on its "core mission" of promoting medicine and the public health.

Medicare E-Prescribing Exemptions Are Expanding

On May 26th, CMS released a proposed rule that would give physicians another way to avoid a 1% cut in Medicare payments in 2012 if they have failed to complete at least 10 paperless drug orders using an e-prescribing system in the first half of 2011.

While the original E-prescribing rule made exemptions for rural physicians with limited Internet access or doctors in areas with few pharmacies accepting electronic prescriptions (and only if the exemption was claimed before June 30, 2011), the proposed rule includes recognizing the following hardships:

• Physicians who have limited prescribing activity
• Physicians who have delayed purchasing an e-prescribing system because they intend to participate in the Medicare electronic medical record incentive program in 2011
• Physicians who live in an area where regulations prevent e-prescribing, including prohibition of paperless orders for narcotics
• Physicians who e-prescribe, but only for types of visits that do not count towards the 10-order minimum necessary to avoid the mandated reduction in Medicare payments

The CMS proposal  includes the plan to develop a website where physicians would report such hardships.  In addition to having multiple ways to register their hardship, the proposal would allow more time for physicians to indicate the reason(s) they were unable to e-prescribe, by setting a new deadline of October 1, 2011. Additionally, the proposed rule will make it easier for practices that already utilize certified EMRs to use those systems to satisfy the e-prescribing requirements.  

CMS is accepting public comments on this proposal until July 25th.  The entire proposed rule can be found here:   (www.ofr.gov/ofrupload/ofrdata/2011-13463_pi.pdf).

Administration Offers New Path for ACOs

The Centers for Medicare & Medicaid Services on Tuesday announced three new ideas to drive interest among healthcare providers for forming an accountable care organization.  The initiatives will be run by the newly created Center for Medicare and Medicaid Innovation, which is a byproduct of the Affordable Care Act.  

The new "Pioneer" ACO would allow existing integrated-care organizations that have already begun coordinating care for patients to pocket more of the expected savings an ACO offers.  The plan allows providers to move more rapidly from a shared savings payment model to a population-based payment model consistent with, but separate from the Medicare Shared Savings Program.  CMS estimates the Pioneer model could save Medicare up to $430 million over three years by better managing care and eliminating duplication. Organizations interested in applying to the Pioneer ACO Model must submit a letter of intent on or before June 10, 2011.  To apply, go to: http://innovations.cms.gov/wp-content/uploads/2011/05/Pioneer-ACO-Letter-of-Intent.pdf.  Applications must be received on or before July 18, 2011. 

For less mature health systems, CMS is considering an "Advance Payment" initiative that would provide additional up-front funding to providers to support the formation of new ACOs.  The program would test whether and how pre-paying providers could increase participation in the Medicare Shared Savings Progarm.  Providers would be expected to use the funds (an advance on the shared savings they are expecting) to make the infrastructure and staff investments crucial to successfully coordinating and improving care for patients.  The agency is requesting comments on this idea by June 17th. To comment, go to http://www.regulations.gov./

CMS has also announced free learning sessions on ACOs for providers interested in learning more about how to coordinate patient care through ACOs.  Four on-site learning sessions will be held in 2011.  The plenary session will be made available to all interested organizations through a web-cast and all materials from the sessions will be publicly available.  Individuals wishing to attend the June Accelerated Development Learning Session in person may register at https://acoregister.rti.org. Registration is on a first come, first served basis.


For additional information, go to: 
http://www.cms.gov/apps/media/press/release.asp?Counter=3957&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

A Proposed Five Year Overhaul for Medicare

Three of the nation's largest physician groups told Congress on Thursday that Medicare needs to overhaul the way it pays for care.  The American Medical Association, along with the American Academy of Family Physicians and the American College of Surgeons testified before the House Energy and Commerce Health subpanel about proposals to replace the Sustainable Growth Rate (SGR) formula, which if left intact, will require a 29.5% cut to Medicare payment rates beginning on January 1, 2012.

Pointing out that the current formula "cannot pay for thought, analysis, deduction, discussion and persuasion and the value that comes from managing the care of the whole person, as well as the care that comes from avoiding unnecessary care" all three presenters advocated for repeal the SGR formula this year.

Each agreed that Congress should put in place a five-year transition period during which different payment models can be tested.  A new system that transitions to a new generation of payment models designed to reward physicians and hospitals for keeping patients healthy, managing chronic conditions in a way that avoids hospitalizations and delivering high quality care with efficient use of resources was one suggestion made to Congress.

Another was to create a system of separate service category growth rates that recognizes the unique nature of the various types of services that physicians provide to their patients, while allowing for increased payments for areas experience workforce shortages.  A third suggestion was to offer primary-care physicians a 2 percent higher payment update than others during the transition period.

Committee Chairman Fred Upton has previously indicated that the committee is committed to working together with physician organizations to implement a permanent, sustainable solution this year that lessens taxpayers’ burden and ensures providers have the resources they need to provide quality care to patients.

Minimum Payment Act of 2011 - Rhode Island attempts to guarantee payment

Last month, legislators in Rhode Island introduced bills in the House and Senate that set a minimum reimbursement rate for commercial payers. 

The bills are in response to a study that shows most Rhode Island physicians are paid substantially less by commercial insurers than their counterparts in Connecticut and Massachusetts.  This is particularly problematic for medical specialists.

Payment inequities have made it difficult to recruit and retain physicians in the "Ocean State."  As older physicians retire, there are few physicians to take their place. Medical speciality providers are already in short supply in the state and according to the bill's authors, without a network of qualified physicians, citizens could soon face long waits for appointments or be required to travel out of state to see a specialist. 

If the bill becomes law, physicians who participate in medical assistance and devote at least 5% of their practice to free care could receive insurance payments at 125% of the Medicare rates.   Increased payments are viewed as a way to attract practitioners to the State and to increase access to high quality medical care.

The Rhode Island Medical Society opposes the bill, saying it doesn't like the idea of setting rates by law.  A similar measure failed last year.

ONC Names Mostashari National Coordinator for HIT

Last week, the U.S. Department of Health & Human Services named Farzad Mostashari, MD, as the new National Coordinator for Health Information Technology, effective immediately. He replaces Dr. David Blumenthal, who is returning to Harvard University after leading Office for the past two years, the Department of Health and Human Services announced.

Trained at the Harvard School of Public Health and Yale Medical School, internal medicine residency at Massachusetts General Hospital, Mostashari completed the Centers for Disease Control and Prevention's Epidemic Intelligence Service.  Motashari joined the Office of the National Coordinator in July 2009, serving as deputy national coordinator for the office.  Before that he worked as an assistant commissioner for the Primary Care Information project at the New York City Department of Health & Mental Hygiene.  In that role, he helped adopt prevention-oriented HIT used by more than 1,500 providers in under served communities.

Motashari was among the first developers of real-time electronic disease surveillance systems and acted as lead investigator in the outbreaks of West Nile Virus and anthrax in New York City.  He is expected to continue Blumenthal's push for providers to adopt electronic health records in order to optimize care quality and enhance communication between multiple medical professionals.

Health Information Exchange Pilot Projects Paving the Way for Nationwide Exchange

By 2012, you may have access to an easy-to-use Internet-based tool that can replace mail and fax transmissions of patient data with secure, efficient electronic health information exchange (HIE), thanks in part to physicians and other health care providers now testing HIE using specifications developed by the Direct Project.

The Direct Project is a streamlined version of the Nationwide Health Information Network and is designed to help health care providers with limited resources meet criteria for the meaningful use program.

The Office of the National Coordinator for Health IT has launched the first pilot demonstrations of the Direct Project for simple electronic health information exchanges in Minnesota and Rhode Island.  Other pilot programs will be launched soon in New York, Connecticut, Tennessee, Texas, Oklahoma, and California to demonstrate the effectiveness of the streamlined Direct Project approach, which supports information exchange for core elements of patient care and public health reporting.

Both large and small health care organizations will have an option for electronic exchange of information, including the ability for a specialist to send a care summary report back to the referring provider.  For more information, see:  http://wiki.directproject.org/Specialist+sends+summary+care+information+back+to+referring+provider

Physician Payments Could be Revealed Under Bipartisan Bill

Senators Ron Wyden (D-Ore) and Chuck Grassley (R-Iowa) plan to cosponsor legislation requiring the Department of Health & Human Services to publicize information on Medicare payments made to  physicians. 

This information has been off limits to the public since the 1970's, when the Florida Medical Association and the American Medical Association sued to keep it secret.  The issue has resurfaced in recent months after the Wall Street Journal and the Center for Public Integrity sued the Department of Health & Human Services to obtain information on payments made to doctors and other individual providers in the Medicare claims database.  After their lawsuit, the Wall Street Journal and the Center for Public Integrity agreed to receive a pared-down version of the database, and were forbidden from identifying the 5% of providers on whom they received data. 

Even with those restrictions, both organizations were quickly able to identify patterns of likely fraud and the idea of opening the database has been gaining traction across party lines as Medicare and Medicaid fraud - estimated at $70 billion to $120 billion a year - becomes an even bigger worry. 

The AMA argues that opening up the database would be a violation of doctors' privacy and could lead to some of them leaving the program.  While pointing out they have zero tolerance for fraud, the AMA believes Medicare claims are already subject to scrutiny by organizations specifically designed to aggressively ferret out improper claims. 

CMS Final Rule on Fraud Prevention Becomes Effective March 25, 2011

The Patient Protection and Affordable Care Act made a number of change to the Medicare, Medicaid and CHIP programs designed to combat fraud, waste and abuse. Effective March 25, 2011, various screening tools, including unannounced site visits and criminal background checks may become standard procedure when a provider or supplier enrolls or re-validates their participation in these programs. 

Providers will also be assessed an application fee (that will be used to fund the screening and integrity efforts) and undergo verification of licensure requirements as well as pre and post application examination of all enrollment criteria.

The new rule also authorizes CMS to impose moratoria on new provider enrollment to protect against fraud and authorizes the suspension of payments pending any investigation of a credible allegation of fraud.  Additionally, a State may rely on the results of the screening conducted by Medicare or other State Medicaid programs to fulfill the provider screening requirements under Medicaid and CHIP or may may also establish additional screening methods if they so desire.

More information on the specifics of the Final Rule can be found here:
http://edocket.access.gpo.gov/2011/pdf/2011-1686.pdf

Fixing the Medicare physician payments system

The White House budget released on Monday includes a two-year fix to the Sustainable Growth Rate (SGR) formula, which determines Medicare reimbursements.  The two-year proposal includes a number of politically tough provisions, such as getting generic versions of biologic drugs to market faster and restricting generic manufacturer's ability to drop patent challenges in exchange for cash payments from brand-name drug makers. 

A two-year fix is seen by some as vital for building physician support for the healthcare reform law and would give Congress thru 2013 to find a permanent solution. 

Congress voted five times last year to delay cuts in Medicare physician payments.  The mos recent $19 billion fix expires at the end of 2011.  Physicians face a 28 percent cut in their reimbursements at the end of this year if the proposed fix, or some variation of it is not enacted this session.

Medicare proposes expansion to patient complaint process

Medicare took steps this week to make it easier for patients to file complaints about unsatisfactory medical care.

Already, hospitals must give patients a written notice telling them how to file a complaint with an independent review agency. Under the new proposal, the rule would be expanded to clinics, home health agencies, surgery centers, rehabilitation centers, nursing homes, hospices and other providers — all of which would have to give patients the notices. Doctors would not be included.

 Examples of issues that could be raised include medication errors, unnecessary tests, wrong diagnoses or incorrect medical instructions.

Medicare's policy on therapy is challenged

Five national health care advocacy groups are suing the federal government, saying Medicare benefits are being cut for people with Parkinson's disease, Multiple Sclerosis and stroke.  The class action lawsuit is the first to mount a broad challenge to a controversial Medicare policy requiring patients achieve demonstrable improvements in functioning to qualify for physical, speech or occupational therapy. 

The Center for Medicare Advocacy filed the lawsuit with Vermont Legal Aid, on behalf of the National Multiple Sclerosis Society, Parkinson's Action Network, Paralyzed Veterans of America, National Committee to Preserve Social Security and Medicare and the American Academy of Physical Medicine and Rehabilitation.

Under current law, Medicare is obligated to provide therapy that is "reasonable and necessary for the diagnosis and treatment of illness and injury."  The complaint states that if a patent's condition is stable, benefits can be reduced or the person found ineligible for the care.  The suit further contends the standard has never gone through an official federal rule-making process and is denying therapy to thousands of chronically ill Americans.

According to a spokesperson, the Department of Health and Human Services has not yet reviewed the complaint and will not comment until they've had an opportunity to do so.

Healthcare buzzwords for 2011

With rapid changes in healthcare comes a new vocabulary with terms and phrases every provider should know. According to the Healthleadersmedia.com website, these phrases will be heard many times in 2011:

• EHR-EMR-HIT - these acronyms are among the most important to know and understand.  Using technology to connect providers and patient data will be the number one issue in 2011.
• Creative destruction - this oxymoronic phrase is derived from the economic theory that in order to create a new system, the old one will have to be torn down.  The next few years will see our current health care delivery system transformed into a system where strong incentives for efficient, coordinated care become commonplace.
• Teachback - Many patients do not understand much about what they've been told during their healthcare experience.  To ensure they comprehend what they need to know to continue their recovery and care, patients given any instructions should be encouraged to "teach it back"  to the provider. 
• SAT scores - Increasingly heard in physician offices is whether the patient will give a positive answer when asked if the healthcare experience was satisfying. Soon, federal payments will be based on satisfaction (SAT) scores.
• Alignment - standardizing equipment, procedures, programs, policies
• Checklists - step by step protocols to prevent adverse events and infections.
• Medical Loss Ratio - the amount that can be spent by insurance carriers on executive salaries, overhead & marketing as compared to the amount that must be spent on patient care and/or quality improvement.

For the complete list of hot buzzwords for 2011, go to:  www.healthleadersmedia.com