Participation in Alternate Payment Models Rises

In 2017 nearly 360,000 clinicians will participate in Medicare and Medicaid Alternative Payment Model programs sponsored by the Centers for Medicare & Medicaid Services.

CMS also reports that this year 570 accountable care organizations, including 131 that bear risk, will serve more than 12.3 million Medicare and Medicaid beneficiaries.

In addition, nearly 3000 primary care practices will participate in advanced primary care medical home models.

Find more about the growth of participation in CMS’s alternative payment models, including descriptions of the different models and breakdowns in the numbers of participants, in this CMS news release.

CMS Unveils New Medicaid Managed Care Regulation

For the first time in more than 20 years, the federal government is introducing major changes in how it regulates Medicaid managed care.

cmsThe Centers for Medicare & Medicaid Services describes the 1425-page rule as aligning Medicaid managed care with other health insurance programs, updating how states purchase managed care services, and improving beneficiaries’ experience with Medicaid managed care.

To learn more about what CMS has proposed, go here to see the rule itself.

Go here to see CMS’s news release accompanying the new regulation.

Go here to (under the link “final rule”) to find nine fact sheets summarizing key aspects of the new regulation.

And go here for a commentary on the new rule and the context in which it was released by CMS acting administrator Andy Slavitt.

NAUH has prepared a detailed memo describing the new rule and some of its implications for private safety-net hospitals. Representatives of such hospitals may request a copy of this memo by using the “contact us” link in the upper right-hand portion of this screen.

MedPAC Recommends Socio-Economic Risk Adjustment of Medicare Advantage Star Ratings

The agency that advises Congress on Medicare payment issues has suggested to the Centers for Medicare & Medicaid Services (CMS) that it revise its star ratings systems for Medicare Advantage plans.

In a letter to CMS in response to its request for comment on star ratings, the Medicare Payment Advisory Commission (MedPAC) agreed with CMS that there is evidence of a difference in Medicare Advantage plan performance based on the low-income status or disability of plan members that reflect social determinants of health. While CMS continues to consider how to adjust for such a challenge, MedPAC recommended an interim approach called a “Categorical Adjustment Index” that would

… group MA contracts together, by deciles (for example), based on their share of the relevant populations (low-income, disabled). For each of these initial contract groupings, there would be a comparison between the overall or summary star rating determined under the current methodology, and an overall or summary star rating determined if there are adjustments made to measure results. The adjustment to the measure results would be based on a beneficiary-level regression model that determines the average within-contract difference in measure results for the relevant populations. The initial grouping of contracts would then be combined (if appropriate) into final groups for adjustment purposes so as to group together contracts that had similar mean differences between adjusted and unadjusted summary or overall results. Once that final grouping is determined, each contract within the group would receive the same adjustment to its summary or overall star rating, and the adjusted star rating determines the contract’s status for purposes of determining bonus payments.

For a closer look at the issue and the MedPAC recommendation, see this article in McKnight’s Long-Term Care News. See the MedPAC letter to CMS here, on MedPAC’s web site.

CMS Requires States to Monitor Medicaid Access

A new federal regulation requires states to monitor access to Medicaid services.

According to a new regulation issued by the Centers for Medicare & Medicaid Services (CMS), states must submit to CMS plans for monitoring Medicaid beneficiary access to care in five service areas: primary care, physician specialists, behavioral care; pre- and post-natal care; and home health services.

federal registerState monitoring plans must address the extent to which Medicaid is meeting beneficiaries’ needs; the availability of care; changes in service utilization; and comparisons between Medicaid rates and rates paid by other public and private payers.

Interested parties have 60 days to submit comments to CMS about the new regulation.

For a closer look at the regulation, see this CMS fact sheet and the regulation itself here, in the Federal Register.

CMS Proposal Would Mandate Hospital Discharge Planning

Hospitals that participate in Medicare and Medicaid would be required to develop discharge plans for all inpatients and many outpatients under a new regulation proposed by the Centers for Medicare & Medicaid Services (CMS).

According to a CMS news release,

…hospitals, including inpatient rehabilitation facilities and long-term care hospitals, critical access hospitals, and home health agencies would be required to develop a discharge plan based on the goals, preferences, and needs of each applicable patient . Under the proposed rule, hospitals and critical access hospitals would be required to develop a discharge plan within 24 hours of admission or registration and complete a discharge plan before the patient is discharged home or transferred to another facility. This would apply to all inpatients and certain types of outpatients, including patients receiving observation services, patients who are undergoing surgery or other same-day procedures where anesthesia or moderate sedation is used, and emergency department patients who have been identified by a practitioner as needing a discharge plan. In addition, hospitals, critical access hospitals, and home health agencies would have to —

  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only);
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only);
  • For patients who are transferred to another facility, send specific medical information to the receiving facility; and
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

cmsThe proposed regulation stresses the preferences and goals of patients in the development of their discharge plans, including the selection of post-acute-care providers to which they may be discharged or the home health providers that may serve them when they return home.

Significantly, from the perspective of private safety-net hospitals, the proposed regulation calls for hospitals to consider the socio-economic status of the patients for whom they are planning – although no requirements are associated with that status and the social determinants of patients’ health.

Interested parties have until January 3 to submit comments to CMS on the proposed regulation.

To learn more about what CMS is proposing and what it hopes to accomplish, see this CMS news release. Find the proposed regulation itself here.


Patient Satisfaction, Quality Not Necessarily Related

Patients who express satisfaction with the quality of the hospital care they received are not necessarily receiving high-quality care.

Or so says a new study in the journal JAMA Internal Medicine.

The study found that many patients who expressed satisfaction with the hospital care they received did not necessarily understand the care they had undergone and the care they would require in the future, casting doubt on the assumption that satisfaction equates with quality.

iStock_000008112453XSmallPatient satisfaction is a major component of Medicare’s value-based purchasing program, and hospitals can be rewarded or penalized based on their patients’ satisfaction as measured in surveys.

The National Association of Urban Hospitals (NAUH) has expressed the same concern over the years, beginning with a 2012 letter to the Centers for Medicare & Medicaid Services (CMS) about its proposed use of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey as a means of measuring patient satisfaction as part of determining whether hospitals were to be rewarded or punished financially as part of Medicare’s value-based purchasing program.  In that letter, NAUH wrote that it

…has serious reservations with the direction in which CMS is taking the HCAHPS survey as a tool for evaluating the effectiveness of hospitals and adjusting Medicare payments to those hospitals.  We believe the survey is biased against large urban hospitals in several respects.  In some instances, we believe the survey’s questions are biased against large urban hospitals; in others, we believe the manner in which the survey’s findings are weighted is biased against large urban hospitals.

First, we believe some of the survey’s questions are biased against large urban hospitals.  We think it is inappropriate, for example, to compare the degree of quietness of a seventy-five-year-old hospital with semi-private rooms located in a congested urban area with that of a new facility with private rooms located on a sylvan, multi-acre campus set well off any major thoroughfares.

Second, we believe the manner in which the responses to some questions will be weighted is biased against large urban hospitals.  We think it is unfair, for example, to downgrade the survey results from the kinds of patients urban safety-net hospitals serve in especially high numbers and proportions, such as maternity patients and those for whom English is not their native language.  Similarly, the American Hospital Association has found that more seriously ill patients are more likely to respond with negative observations when completing the HCAHPS survey.  Urban safety-net hospitals care for such patients in disproportionate numbers and believe this situation calls for appropriate adjustment.  In addition, CMS’s own data shows significantly lower scores in more urbanized states – the very places in which most urban safety-net hospitals can be found.  Consequently, NAUH believes more should be done to adjust HCAHPS scores appropriately before they are used to influence Medicare payments to hospitals.

Because of these challenges, NAUH urges CMS to reduce the weight given to HCAHPS results in the value-based purchasing program.

NAUH recognizes the importance of hospitals providing care that meets patients’ expectations but believes that before undertaking the major step of adjusting Medicare payments to hospitals based on the perception of those patients, a better and more realistic approach needs to be taken to using and adjusting the results of HCAHPS surveys.

Learn more about the study in this Fierce Healthcare article.  Find a link to the study itself here, on the JAMA Internal Medicine site, and read an interview with the study’s principal investigator here.

Medicare to Add Services to Telehealth Program

Medicare would add new telehealth services to those for which it already pays providers under a newly proposed regulation.

iStock_000005787159XSmallThe new telehealth services that would be eligible for Medicare payment to physicians are annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services.

The additions are part of Medicare’s annual regulation updating how it pays providers for various outpatient services.

To learn more about the Medicare telehealth additions and the proposed regulation in general, see this fact sheet or find the regulation itself here.

Medicare Proposes Updating Physician Quality Program

Medicare is proposing changes in its quality program for outpatient care provided by physicians.

law booksIn a newly proposed regulation, the Centers for Medicare & Medicaid Services (CMS) proposes adding 28 new measures to Medicare’s Physician Quality Reporting System and removing 73 current measures.  In all, the program would still encompass 240 measures designed to quantify the quality of care doctors provide to their Medicare patients.

The proposal comes as part of Medicare’s annual update on how it pays physicians for outpatient services.

To learn more about the Medicare outpatient quality changes or the proposed regulation in general, see this CMS fact sheet or find the regulation itself here.

CMS Provides Details on Medicare Chronic Care Payments

Following up on last year’s announced introduction of special payments to physicians who care for seniors with chronic medical conditions, the Centers for Medicare & Medicaid Services (CMS) has published a draft regulation that provides further information about how those payments would work.

cmsUnder the proposed rule, Medicare will pay physicians $41.92 for non-face-to-face management of chronic care services for selected Medicare patients.  Physicians could receive no more than one such payment per patient per month for activities that include the development and revision of care plans, communication with the involved patient’s other providers, and prescription drug management.

The proposed policy, part of Medicare’s annual regulation updating physician payment policies and rates, addresses other aspects of Medicare’s proposed changes in its approach to chronic care management as well.  To learn about these changes, see a CMS fact sheet on the new regulation here or find the entire regulation here.

Observation Status, the “Two-Midnight Rule,” and Continuing Controversy

Amid continuing complaints from hospitals, the Centers for Medicare & Medicaid Services (CMS) has delayed implementation of its so-called Medicare two-midnight rule for another six months.  Implementation of the rule, originally scheduled for October 1, 2013 and delayed for six months, is now slated for October 1, 2014.

With hospitals calling for greater guidance on how to determine whether to classify patients as inpatient admissions or on observation status, CMS proposed using a two-midnight standard:  hospitals could safely classify patients who spent two midnights in the hospital as inpatient admissions.

iStock_000015640638XSmallBut when hospitals objected to the standard, sued to prevent its implementation, and enlisted support from Congress, CMS relented, delaying implementation of the rule for six months and then extending that delay another six months.

The challenges posed by the inpatient admission/observation status issue are considerable and complex.  At stake for hospitals is accurate accounting, Medicare inpatient revenue, and concern about readmissions affecting future Medicare payments.  The issue can be especially difficult for private safety-net hospitals because they serve so many patients with limited access to primary care and follow-up services after being discharged from the hospital.

Patients, too, have a considerable stake in the issue.  Many who believed they had been admitted to the hospital find themselves with unexpected hospital bills and, in some cases, they also are ineligible for Medicare-covered, post-discharge skilled nursing care.

The publication Georgia Health News has taken a broad look at the many questions this issue raises.  Read its report here.