Tag: CMS

A Call For a New Primary Care Society

Jun 30, 2012• 23

By Brian Klepper

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.Continue reading…

How The Affordable Care Act Will Affect Doctors

Jun 15, 2012• 25

By Tevi Troy

Just over two years ago, President Barack Obama signed the Affordable Care Act (ACA), a law purported to increase access to health care and to “bend down” the health care cost curve. A great debate over the implications of that law, especially in the areas of coverage, affordability, and quality of care, has arisen. Furthermore, a series of political and legal challenges have generated uncertainty about the law’s prospects within the health industry and at the state level. Despite this, the Department of Health and Human Services (HHS) has already issued over 12,000 pages of regulations elaborating on the original 2,700-page law, leading to more uncertainty regarding how appointed and career federal officials will determine the exact shape of the law’s final requirements. All of this uncertainty raises real concerns about how the new law will impact the most crucial actors in any health care reform effort: doctors.

Doctors are demonstrably nervous about the new law and how it will affect their incomes, their access to technologies, and their professional autonomy. According to a survey by the Doctors Company, 60 percent of physicians are concerned that the new law will negatively impact patient care. Only 22 percent are optimistic about the law’s impact on patient care. Fifty-one percent feel that the law will negatively impact their relationships with patients. These statistics raise questions about how and whether doctors will participate in the new system.

Medicare Advantage Star Ratings: Detaching Pay from Performance

May 23, 2012• 5

By Douglas Holtz-Eakin

Rewarding quality health plans is an admirable goal for the Medicare Advantage program. Unfortunately, the current system of linking star ratings to bonus payments and rebate adjustments instituted by the Patient Protection and Affordable Care Act (and expanded by the CMS Quality Bonus Payment Demonstration) fails to achieve that goal, and depending on its specific implementation, may even be counterproductive.

Because criteria for evaluation are not published until after the period for which performance will be evaluated, there is no possibility that MA plans will be able to improve their performance to achieve the goals CMS intends to incentivize. Any adjustment plans will be able to make to their bids or plan offerings would have to be aimed at increasing enrollment in counties with the highest bonuses and rebates based on data from performance in previous years, possibly at the expense of improving their performance in the future.

The system rewards beneficiaries for choosing those plans favored by the selected CMS criteria, rather than the plans that best meet their needs. In effect patients whose preferences, health status, and even counties of residence, don’t match the CMS model of a highly rated plan will be at a disadvantage. Simultaneously, the system will likely reduce the scope of choice available to MA-eligible beneficiaries, and reduce competition among MA plans.

Finally, the system rewards beneficiaries for living in counties with low poverty rates (since relatively wealthier counties tend to have more plans with higher ratings), thus adversely impacting poor beneficiaries even more than non-poor beneficiaries.

These impacts are inconsistent with the overall policy purpose. The goal of incentivizing quality health plans is legitimate and admirable; that goal will not be achieved by the rating structure currently being put into place.

Enabling Patients to Be Part of Their Care

May 4, 2012• 7

By David Lansky, PhD

In May 2008, when the Roper poll asked a random sample of Americans “If your medical records and personal health information, such as test results and doctor’s instructions, were available to you online, how likely do you think you would be to access those records and information?” Sixty-five percent said they were somewhat, very, or extremely likely to access their records. In the February 2009 stimulus bill, Congress asked the Health IT Policy Committee “to facilitate secure access by an individual to such individual’s protected health information” and “… to facilitate secure access to patient information by a family member, caregiver, or guardian acting on behalf of a patient…”

CMS now proposes that in 2014, hospitals receiving the billions of dollars of Stage 2 federal EHR incentive payments must provide patients with electronic access to their hospital discharge information within 36 hours of leaving the hospital. CMS is not only asking hospitals to give patients reasonable access to their own current and actionable health information, but it’s also trying to help patients and families address the wasteful and dangerous rates of hospital readmission and failures in continuity of care that haunt American healthcare. But the American Hospital Association is arguing that “Establishing a web portal or other mechanism to provide patients online access to this magnitude of data is unrealistic and premature.”

How TEDMED ‘Groupinspire’ Could Change the World

Apr 25, 2012

By Dr. Layla McCay

Last week I found my usually-diverse Twitter feed had coalesced into a single hashtag, the trolley buses chugging through the streets of Washington, D.C. were sporting bold logos on their sides, and all around the city people were wearing giant nametags bearing their name, face, and three things they liked to talk about. There was no mistaking it: TEDMED was in town.

For the world of health care, TEDMED was the only party at which to see and be seen. The thousand or so delegates had been specifically “curated” to encapsulate the epitome of health care innovation. For 3.5 days they basked in cutting-edge, quirky talks by people “shaping and creating the future of health and medicine,” punctuated by lavish dinners and parties, TEDMED-themed M&Ms, and morning runs, as sanctioned by the Cookie Monster (one of the celebrity speakers at this extravaganza). Meanwhile, the rest of the medical world followed the #TEDMED hashtag on Twitter or soaked up the inspiration in real time at one of TEDMED’s mostly academic simulcast venues around the U.S.

And as for me? I threw myself into getting invited to the cool kids’ party. Or to be more accurate, the cool, privileged kids’ party. Because as well as being accepted on merit, attending TEDMED in person costs an eye-watering $4,950. A wealth of sponsors paid for 200 people to attend on scholarships (and for the Simulcasts), but by the time I’d realized this and persuaded them of my innovative brilliance, they’d already allocated their funds and I was consigned to their priority waiting list. But at the last minute, delightfully, my persistence and anticipation were rewarded with a pass for the Thursday night party and the final Friday morning session.

Decentralizing the Analysis of Health Data

Mar 26, 2012

By Harley Geiger

The transition from paper to digital health care records promises a significantly enhanced ability to leverage claims and clinical data for secondary uses – uses beyond that for which the health data was originally collected, such as research, public health surveillance, or fraud prevention. Done properly, these secondary uses of data that were originally collected for treatment or payment can aid the creation of a more effective, information-driven health care system. For example, researchers are using digital claims data to provide the public with comparisons of the quality and cost effectiveness of treatment for particular conditions among plans or health care facilities in a given market.

Patient privacy and data security are among the first considerations of agencies establishing such programs, and many agencies have instituted strong technical controls (such as de-identifying the data) and policy frameworks to protect the confidentiality and integrity of the data. Although a strong policy framework is essential, the technical architecture of information exchange is another important factor. This week, the Center for Democracy & Technology (CDT) released a report challenging the prevailing centralized model of health data analysis and urging Dept. of Health and Human Services (HHS) to explore distributed systems for secondary use programs. The paper comes at the same time that the Centers for Medicare and Medicaid (CMS) issued a final rule for its risk adjustment program – mandated by the Affordable Care Act of 2010 – that would use a distributed system as a default, changing course from the proposed rule, which would have required a centralized model.

Oops! ICD-10 To Be Delayed Indefinitely. Never Mind!

Feb 15, 2012• 13

By ROBERT LASZEWSKI

After years of telling us they are serious this time and everyone in the health care system had better be ready on time to implement the new disease coding system, CMS said today the whole project is going to be delayed indefinitely.

The new ICD-10 system requires payers and providers to convert from the old system of 13,000 codes to the new system of 68,000 codes.

All payers and providers were supposed to be ready by October 1, 2013. The acting CMS Administrator said, “There is a concern that folks cannot get their work done around meaningful use [of information technology], ICD-10 implementation, and be ready for [insurance] exchanges. So we decided to listen and be responsive.”

Apparently, a new timeline will be developed through a “rule making process.”

Fine, but that has not been the message for months now and lots of people have spent lots of money for apparently no good reason.

The concerns that particularly physicians would not be ready on time have not been minor. CMS conducted a survey between January and March of 2011 that clearly showed there were big problems ahead. But in the year since that survey, they continued to tell stakeholders to keep going ahead full speed, spending big money to be ready.

But in the last few weeks, the American Medical Association has been sounding the alarm–their people wouldn’t be ready.

Sounds like the lowest common denominator in the health care system wins out.

Here are the results from a survey CMS conducted from January to March of 2011 by type of industry participant. AHIP is the insurance industry trade association, HBMA and AAPC are associations of industry coding and billing providers, ACP is the American College of Physicians and the AMA is the American Medical Association. The survey also measured readiness for the Version 5100 standards for electronic health transactions that were effective in January 2012, but for which enforcement has been delayed until March 31, 2012.

Care Innovations Summit

Feb 2, 2012• 9

By Kent Bottles, MD

Anyone who is concerned about the future transformation of the United States clinical delivery system should pay attention to the Care Innovations Summit. The selection of presentations as well as the content that was discussed says volumes about where CMS believes payment is headed. Speaker after speaker stated that decreasing the per-capita cost of health care and increasing the quality patients receive is the dominant political, social, and economic issue for all Americans.

Marilyn Tavenner, the new Acting Administrator for the Centers for Medicare and Medicaid Services, outlined what she saw as the major accomplishments of the past few years. Her list included providing partial relief for 3.8 million seniors who hit the prescription drug “doughnut hole,” creating high risk pools for 45,000 Americans, creating a consumer website, allowing young adults to stay on their parents’ health care insurance until age 26, eliminating denial of coverage for patients with pre-existing conditions, eliminating lifetime and annual health care insurance maximums, increasing the coverage of many prevention measures, creating pilots to explore how to base payments on quality not volume, and getting the Innovation Center up and running.

Atul Gawande, MD, the Harvard surgeon and New Yorker author, presented the morning keynote. Gawande, the author of three books on health care (Complications, Better, and The Checklist Manifesto), said the “cost of health care is destroying the American dream.” In Massachusetts the state government sent nearly a billion dollars to local schools to pay for smaller class sizes and better teachers’ pay, but every dollar was diverted to covering higher health care costs. For each dollar added to school budgets, the costs of teacher health benefits consumed $1.40.

Gawande listed three causes of our current health care problem: business interests, government bureaucracy, and the sheer complexity of delivering clinical care in a broken system. He focused on the last of these causes and noted that there are at present 13,600 diagnoses, 4,000 medical procedures, and 6,000 medications. In 1970 the average patient saw two physicians for their medical conditions; today the average patient has more than 15 physicians consulting on their care. He also stated that the health care system “trained and hired physicians to be cowboys, when what we really need are pit crew team members.” He is also hopeful because the health care systems that have the best results are not the most expensive.

A Promise Made to Be Broken

Jan 23, 2012• 8

By David Dranove

In last week’s Wall Street Journal, Princeton economist Alan Blinder exposes four myths about the federal deficit. He saves the most important myth for last. After noting that the long term deficit problem does not cut across all areas of spending, he observes that the problem is almost entirely rooted in the need to fund Medicare and Medicaid. If we base future spending projections on past trends, then Blinder is absolutely correct. Spending growth on Medicare and Medicaid nearly always outstrips the growth in tax revenues. The main contributors to spending growth – demographics, labor costs, and, especially, technology – are likely to keep this trend alive indefinitely. Blinder challenges us to focus the debate about the deficit on the key facts, which essentially means that we should focus on Medicare and Medicaid spending. Let me take up his challenge.

Let’s start with the obvious debating points. There is a lot of fat in both programs. CMS just acknowledged that as much as 10 percent of spending in Medicare and Medicaid is “improper.” This does not include spending on defensive medicine, unnecessary services demanded by fully insured patients, unwarranted variations in practice, and all the other usual suspects. Nor does it reckon with all the waste due to poor health behaviors, although eventually the grim reaper will have his say and dying is usually very costly no matter how well you have pampered your body along the way.