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183 posts categorized "Medicare"

January 29, 2015

Better, Smarter, Healthier: Medicare and Value Based Purchasing

EvolutionThe big announcement this week from Medicare -- setting forth specific targets for a historic shift away from fee-for-service reimbursement in order to reduce costs and improve quality -- is less than it seems.

Medicare has been talking about value based purchasing for decades now, and thus far has taken baby steps towards implementation. Even the strides taken in recent years, and the targets laid out this week for the future, don't really leave FFS medicine in the dust. ACOs and other MSSP innovations don't entirely move away from FFS reimbursement; they just add cost and quality kickers as part of a retrospective reconciliation.

CMS identified four categories of payment and targets related to each of these categories.

  • category 1—fee-for-service with no link of payment to quality
  • category 2—fee-for-service with a link of payment to quality
  • category 3—alternative payment models built on fee-for-service architecture
  • category 4—population-based payment

Continue reading "Better, Smarter, Healthier: Medicare and Value Based Purchasing" »

December 15, 2014

Farzad Mostashari on the Proposed ACO Regulation: The future of the Medicare Shared Savings Program examined in an interview with David Harlow

Mostashari_Farzad_ORIGINALThe Accountable Care Organization regulations were first promulgated under authority of the ACA's Medicare Shared Savings Program in 2011. Three years later, the regs are in the shop for a tune-up. Farzad Mostashari MD was one of the authors of the Brookings Institution ACO issue brief released in the spring, suggesting some changes to the program that would keep current ACOs engaged past the end of their three-year contract term, and improving the program overall. Dr. Mostashari, former National Coordinator for Health IT, is now the founder and CEO of Aledade, a startup focused on helping physician organizations develop ACOs. With a level of excitement shared only by a small coterie of health wonks -- and usually reserved for video recordings of unboxing the latest hi-tech toy -- Farzad livetweeted his reading of the 429-page typewritten version of the proposed ACO rule when it was released late last Monday. (See the CMS Fact Sheet on Proposed Changes to the MSSP and the Aledade post on the proposed reg.

The rule was published officially on December 8, with a 60-day comment period. I had the opportunity to interview Dr. Mostashari about the new rule. As he noted in our conversation, CMS is calling for input on a variety of issues, so don't be shy, especially if you have some data to back up your suggestions on the choices that remain to be made in this rulemaking process.

(Read or listen to the full interview after the jump.)

Continue reading "Farzad Mostashari on the Proposed ACO Regulation: The future of the Medicare Shared Savings Program examined in an interview with David Harlow" »

November 13, 2014

Telemedicine: CY 2015 MPFS reportage and dangers of the echo chamber

Station-grungeMany of us are waiting with bated breath for CMS to broaden its coverage of telemedicine services. Upon the release of the CY 2015 MPFS, the American Telemedicine Association got a little ahead of itself in the excitement over some changes in the physician fee schedule, and announced that CMS had added payment for remote patient monitoring of chronic conditions (99091). In fact, CMS's response to the proposal that this and other E&M codes should be payable if provided via telemedicine was: "These services are not separately payable by Medicare. It would be inappropriate to include services as telehealth services when Medicare does not otherwise make a separate payment for them." (79 FR at 67600.)

Continue reading "Telemedicine: CY 2015 MPFS reportage and dangers of the echo chamber" »

April 24, 2014

Hospital Readmission Data for All Payors

HCUPEfforts to reduce hospital readmissions have been focused on a handful of diagnoses and on government payors (primarily Medicare). In order to get a handle on the roughly 15% of the U.S. health care spend that goes to readmissions, it is vital to have a better understanding of what these readmissions are for, who is experiencing them, and why. Not every readmission is a preventable readmission -- though health reform wonks are pretty highly focused on preventable readmissions for specific diagnoses (starting with acute myocardial infarction, heart failure and pneumonia).

Here's the data from 2011, thanks to HCUP (the Healthcare Utilization and Cost Project) at AHRQ:

Continue reading "Hospital Readmission Data for All Payors" »

February 07, 2014

SGR Fix - Can This Really Be Happening?

MagicianThe Sustainable Growth Rate mechanism creating a zero-sum game for Medicare Part B reimbursement rates (dropping rates as volume picks up) has long been unsustainable, and so Congress has been messing around with short-term SGR fix legislation for years now. Every six to twelve months we've been hearing about the impending 20% or 30% Medicare pay cut about to hit physicians' pocketbooks, and the likely exit of physicians from the rolls of participating providers. However, the stars are now aligned in such a way that real progress seems likely: multiple powerful Congressional committees have signed off on a deal to replace the SGR rule with something more workable: A unified approach to financial incentives to physicians and other medical professionals who are Medicare participating providers intended to promote quality and enrollment in alternative payment arrangements.

The full text of the bill will be available here: It's H.R. 4015. Check out the SGR fix section-by-section-summary and the websites of the House Energy & Commerce Committee and the Senate Finance Committee too. The substance of the proposal is discussed below.

How has this happened?

Continue reading "SGR Fix - Can This Really Be Happening?" »

December 02, 2013

Narrow Networks and Medicare Advantage: The True Meaning of Managed Care?

Narrow road signUnited HealthCare and other Medicare Advantage plans are dropping numerous providers from their networks, to the consternation of members given short notice of the changes. Predictably, the story is presented as big bad insurance co. vs. grandma, but the real story is less clear-cut.

For years, Medicare Advantage plans have benefited from a regulatory structure that pays them more than the average Medicare fee for service cost for parallel populations and asks the plans to provide some addtional services to beneficiaries in return for the bonus payments. The reimbursement has been attractive enough to keep numerous insurance companies involved in Medicare Advantage.

Continue reading "Narrow Networks and Medicare Advantage: The True Meaning of Managed Care?" »

September 20, 2013

Upcoming Speaking Engagements and Conferences

Friendship Pins No 89 David HarlowYour faithful HealthBlawger will be out and about at a number of conferences and events over the next month or so, mostly in Boston, speaking, moderating and just hanging out ("on air" and in real life).

I hope to see you at one or more of these. See descriptions below for links to registration and in some cases, discount codes.

Keep an eye out for "Friendship Pins" -- my jacket from The Walking Gallery, pictured over there to the left -- and I will be in or near it.

If you are organizing a conference a little further down the road, please consider including me as a keynote speaker or otherwise. We should talk.

StrataRx: Where Big Data Meets Healthcare

September 25-27, 2013, Boston, MA

Discount code: HARLOW will get you 20% off registration.

I'll be speaking in the data liquidity track on patient consent to use of data and holding office hours.

Continue reading "Upcoming Speaking Engagements and Conferences" »

June 18, 2013

Alternative Quality Contract with Blue Cross Blue Shield of Massachusetts: A model for ACOs?

Managed Care Magazine recently ran a story on the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which serves as a model for the ACO program under the Affordable Care Act. Check it out: Bay State Blues Combine Global Payment With Quality Metrics. The author of the piece, Joe Burns, contacted me as well as others in Massachusetts for comment.

My take, drawn from the story:

David Harlow, a health care lawyer in Newton who writes the HealthBlawg, agrees [that the early findings are encouraging], calling the AQC a significant development for two reasons. First, it is an alternative to fee for service.
“That’s appropriate because there is a need to change the incentives of health care providers in the system,” he adds. Second, the AQC is important because it has served as a model for the federal Centers for Medicare & Medicaid Services’ accountable care organizations.
“The problem with past attempts to control health care spending is that adequate quality standards were not in place,” Harlow says. “It was all about keeping costs down. While this model represents an improvement over other models, the amounts at risk are relatively trivial and, standing alone, will not bend the cost curve.
“Nevertheless, the AQC is different because no provider group can earn a quality bonus unless the physicians and hospitals achieve or exceed the quality standards.”

As I've written before, I think the focus should be on long-term planning for a wholesale shift away from fee-for-service medicine rather than trying to expose and rationalize payment levels. Global payments (a euphemism for that dirty word, capitation), a bonus structure tied to performance against quality benchmarks pegged at a level sufficient to change provider behavior, and dedicated funding within the global payment system for nurse case managers and other elements of the medical home model, are the key elements of the solution we are looking for.

The AQC is a good start. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

May 19, 2013

Hospital Chargemasters and Open Data from CMS -- The conversation continues

MH900059592When CMS recently released hospital chargemaster and payment data for the 100 hospital codes most frequently billed to Medicare, there was much written and said about the significance of the data release.

Some found this to be significant; others (including your humble HealthBlawger), not so much.

Leonard Kish summed up and addressed the critiques of the value of the CMS open data, and others whose judgment I also respect found that the release was overall a good thing. Gilles Frydman, for one, in a listserv exchange, opined that the release was a net positive because it thrust the irrationality of hospital pricing into the public eye, and that "[i]f enough people get angry, a public push for more transparency will follow."

I can accept the proposition that data will be valued differently by different parties. However, I want to throw something else into the mix: We are collectively trying to move away from fee-for-service medicine. As the saying goes: the future is already here; it just isn't evenly distributed. Some are further down the path than others. I think that our time and effort is better spent on ensuring that value-based purchasing systems are up and running, rather than on improving the pricing transparency of FFS medicine.

Eighty-two percent of health plans responding to a recent survey consider payment reform a ‘major priority.’ Nearly 60 percent forecast that more than half of their business will be supported by value-based payment models in the next five years. And, of those, 60 percent are at least mid-way through implementation, according to a study published May 9 by Availity, a health information network.

The Health Plan Readiness to Operationalize New Payment Models study delves into the progress of the country’s commercial health plans, as they migrate from fee-for-service to value-based models of compensating physicians, according to a news release by Availity. The study highlights the consensus among plans that information sharing with physicians must be automated – primarily in real-time – for these models to achieve success.

HealthcareIT News.

On the Medicare front, ACO development and other initiatives of the Center for Medicare and Medicaid Innovation are moving the system away from FFS medicine as well.

There's a system-wide bet that's been placed on value-based payment. Historical amounts charged and paid shouldn't really enter into the construction of this framework, and that's part of what underlies my negative reaction to the release of the chargemaster and payment data. We should be more focused on things like: revaluing primary and preventive care, global budgeting for episodes of care, adoption and refining of meaningful quality measures and quality-based payment systems (even though not all VBP schemes are working) -- all to the same end as the end sought by those who have been cheering the release of the charge and payment data: transparency and a clear connection between payment and delivery of value.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting  

April 18, 2013

New OIG Self-Disclosure Protocol

The OIG released an updated self-disclosure protocol this week, about ten months after putting out a call for comments on the old protocol. The new protocol imposes some new burdens on the disclosing entity, such as a shorter timeline for internal investigations and reporting, and higher minimum fines.

According to the OIG, the benefits of working through the OIG self-disclosure program include lower fines (i.e., lower multipliers of damages than would otherwise be assessed) and an almost certain exemption from entering into a corporate integrity agreement. The OIG will work with DOJ so that if a False Claims Act issue is uncovered it may be dealt with through this mechanism; ordinarily, the SDP is applicable only to matters where Fraud and Abuse CMPs may be assessed by the OIG. Since health care fraud may implicate numerous federal regulatory structures administered by different agencies, it is important to remember that Stark-only (i.e., physician self-referral) violations (unlike those that are triggered by the same facts that trigger a Fraud and Abuse (i.e., anti-kickback) violation) should be disclosed through the physician self-referral disclosure protocol.

It is of course preferable to prevent fraud and abuse rather than disclose and remediate it. Health care providers should invest in compliance programs that include educational and audit components. But if all that doesn't work, there is at least some comfort in the availability of the self-disclosure protocol.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting