HHS: Value-Based Payments Future Of Healthcare In America

Earlier this week, the U.S. Department of Health and Human Services (HHS) announced that it was planning on fundamentally changing the way it pays providers for treating Medicare patients. The primary intent is to cut down on the volume of duplicative procedures while improving care coordination and patient outcomes. For the first time, HHS is “setting clear goals–and establishing a clear timeline–for moving from volume to value in Medicare payments” and “will use benchmarks and metrics” to measure progress.

Following this announcement, Patrick Conway, M.D., deputy administrator for innovation and quality and the chief medical officer at CMS, said the agency will tie 30 percent of all fee-for-service provider payments to quality initiatives through alternative payment models, particularly ACOs and bundled payments by 2016. This number will increase to 50 percent by 2018. Currently, about 20 percent of Medicare FFS payments are through new payment models. CMS intends to accelerate the program through expansion of current payment models, such as Pioneer and ACO programs, as well as emerging models, including bundled payments for oncology care.

Click here to see the HHS announcement.

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CBO Report: Federal Deficit Decreasing, But Will Rise With Baby Boomer Retirement

According to the Congressional Budget Office’s report focused on the decrease in the federal deficit, Medicare reimbursements grew modestly in 2014. In the report, titled “The Budget and Economic Outlook: 2015 to 2025,” researchers said there is a deficit of $468 billion expected for the budget year. This figure is down from last year’s $483 billion deficit. Additionally, the report found that the number of Americans without health insurance is expected to drop from 42 million to 36 million this year, approximately 19 million fewer people than would have been uninsured in the absence of the ACA. By 2019, the law insurance’s provisions will cost an estimated $571 billion, which is down $139 billion from initial estimates. The CBO also found that Medicare spending grew at a “modest rate” in 2014. In 2015, gross Medicare spending will total $622 billion, or 3.5 percent of GDP, the same share as in 2014. By 2025, Medicare spending will reach nearly $1.2 trillion. After 2018, federal deficits are expected to increase as more baby boomers retire and enroll in Social Security and Medicare.

Click here to see the report.

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NAHC Provides Recommendations For Complying With New F2F Rules

In the final rule for the 2015 home health prospective payment rate update, CMS revised the face-to-face (F2F) encounter requirements for physician certification for home health services. CMS has eliminated the narrative requirement but will still require that the F2F encounter occurred no more than 90 days prior to the start of home health care or within 30 days of the start of the home health care, and be performed by a physician or allowed non-physician practitioner (NPP).

CMS has also altered its medical review process for determining patient eligibility for home health services. CMS will now request the agency’s medical record when additional documentation is requested, and will also look for evidence that supports eligibility for home health services from the physician’s medical record.

CMS says it has eliminated the narrative requirement to simplify the F2F encounter regulations and reduce burdens for agencies and physicians. However, NAHC believes CMS’ revisions have only made the F2F requirements even more burdensome. NAHC is still in communication with CMS regarding F2F and how agencies are expected to operationalize the new aspects of the requirement. Based on information NAHC has gathered so far, NAHC offers a number of recommendations.

Click here to see the recommendations from NAHC.


NAHC Submits Comments On Five Star Rating System

CMS held a Special Open Door Forum on December 17 to solicit stakeholder feedback on the proposed five star rating system for home health agencies scheduled to start in 2015. CMS announced the quality measures it will use along with the proposed methodology for obtaining the five star rating. Comments regarding the five star rating system were due on January 16. NAHC submitted comments which addressed three main areas of concern with the CMS proposed star rating system, including the selected measures, the calculation methodology, and the next steps.

NAHC is especially concerned with CMS’ decision to include five measures that show improvement in functional status or clinical condition. For many patients admitted to home health care, the expected outcome is to stabilize or prevent decline of a condition or functional limitation. The recent settlement in the Jimmo v. Sebelius case further confirms that the improvement standard does not apply to all Medicare home health patients. Additionally, an agency’s ability to affect a patient’s improvement in any measure depends on the services provided and the length of time the patient spends on service with the agency. The quality measures in home health agencies include data from four unique payment sources. However, each patient population and the applicable payers have varying utilization patterns.

NAHC recommends CMS include outcome measures reflecting care to patients who cannot and will not improve in any ADL or IADL function and add measures from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey. NAHC also expresses concerns with the star rating model and believes it is misleading and could have significant consequences for patients and home health agencies.

Click here to view all of NAHC’s comments.

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Attention Hospices: CMS Conversion Of IACS To EIDM System

We have recently been notified by NAHC that CMS is transitioning the IACS system (through which providers gain access to their P S & R reports) to EIDM on February 9. Due to the new requirement that hospice providers calculate and self report their 2014 cap by March 31 (but secure their data from the P S & R no sooner than January 31), NAHC has been advising hospice providers to ensure that they are “active” in the IACS system so that they can access their P S & R beginning January 31. Click here for more information on hospice self-reporting. With the pending transition, it is important that hospice providers confirm they are in active status in the system. Click here for guidance from CMS.

Please note that CGS has advised if a providers password has not been changed (within the last 10 days) that the provider should log in and change the password by TODAY, JANUARY 26 to protect against password issues arising in EIDM. Click here to see the CGS notice.

In related news, NAHC says it is continuing to await release of the spreadsheet and guidance related to calculation of hospice providers’ aggregate caps.

Monday Morning Recap

The HMS Healthcare Management Solutions Monday Morning Recap reviews some of the top stories and healthcare highlights you may have missed last week.


Nurse Practitioner Field Is Booming

According to a statement from the American Association of Nurse Practitioners (AANP), the number of nurse practitioners (NPs) has nearly doubled over the past 10 years, increasing from 106,000 to 205,000 as of December 31, 2014. During the 2012-2013 academic year, more than 15,000 students graduated from nurse practitioner programs. According to the President of AANP, the growth of nurse practitioners is directly linked to the nation’s “skyrocketing demand for high-quality, accessible care.” The challenge now will be “rightsizing state and federal laws” so that patients will have full and direct access to nurse practitioners.

Click here to read more.

Tenet CEO: Plans To Acquire CT Hospitals Could Be Revived

The CEO of Tenet Healthcare, Trevor Fetter, has sent a letter to Connecticut Governor Dannel P. Malloy saying that he is open to coming back to the negotiating table to acquire five Connecticut hospitals if the state loosens some of its regulatory requirements. Several conditions would have to exist for Tenet to reconsider acquiring Waterbury, St. Mary’s, Bristol, Manchester Memorial, and Rockville General hospitals. Fetter emphasizes that any conditions placed on its deals must apply equally to all hospitals in the state as well as other organizations interested in buying a hospital in Connecticut – whether they are nonprofit or for-profit operators. Malloy sent a letter earlier this month urging Fetter to send a Tenet representative to meet with Mark Ojakian, the governor’s chief of staff, to negotiate a deal. In December, Tenet pulled out of its plan to acquire five Connecticut hospitals after state regulators issued 68 conditions on the purchase that would bar layoffs and price increases for at least five years.

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Many Nonprofit Hospitals Sue Poorest Patients

Recently, NPR and ProPublica have been reporting about nonprofit hospitals that seize the wages of lower-income and working-class patients. Each year, hundreds of patients get their paychecks docked by hospitals and their debt collection arms. One family interviewed by NPR should have qualified for free medical care under the hospital’s own charity care policy. Instead, the family has been getting their wages seized for nearly 10 years, and still owes $25,000. Senator Chuck Grassley, the chairman of the Senate Judiciary Committee, says hospitals could be breaking the law by suing patients and docking their pay.

Grassley, R-Iowa, says he is “astounded” by these collection practices. Grassley has been working to make nonprofit hospitals more accountable for the huge tax breaks they get. Nonprofit hospitals don’t pay federal income tax or local property tax and in order to justify their tax-exempt status, must “earn” it by “taking care of people who couldn’t provide for their own health care.” Grassley says that under the ACA, a hospital has responsibility to make a determination: Can the person pay, or can they not? The ACA requires that hospitals take the initiative to determine whether patients qualify for aid and should not shift that burden onto patients. Grassley is now focusing on sending a wider message to nonprofit hospitals that he believes are being too aggressive collecting bills from patients who can’t afford to pay. According to Grassley, if hospitals don’t get the message, the health law may need to be strengthened so the poorest patient receive financial assistance.

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Study: Medicaid Pay Bump Helps Beneficiaries Get Appointments

According to a new study published in the New England Journal of Medicine, increasing Medicaid reimbursement for primary care services to match Medicare rates have led to increases in appointments for Medicaid patients. However, care access gains may be completely “wiped out” this year because the ACA’s provision authorizing the increase in Medicaid rates has expired. Researchers noticed an increase from 58.7% to 66.4% in the availability of primary care appointments for Medicaid beneficiaries in the surveyed areas. The increases in appointment availability were similar in states that expanded Medicaid coverage and in states that did not. With this newly available data, physicians hope the Medicaid pay bump will be extended. Average national Medicaid reimbursement to primary care physicians is expected to drop between 43% and 47% as a result of the provision ending.

Click here to read more.