Revisions to Medicare's most popular accountable care model include new benchmarking methodologies and incentive to adopt two-sided risk.
The Centers for Medicare & Medicaid Service released on Monday the final rule that sets 2017 regulations for the Medicare Shared Savings Program.
The agency aims to encourage more physicians join accountable care while also refining how the program measures success.
Andy Slavitt, acting administrator of CMS, said in a statement that "These new flexibilities are based on significant input from participants and will help physicians prepare for the new quality payment program, part of bipartisan legislation Congress passed last year repealing the failed Sustainable Growth Rate [formula]."
CMS provided highlights of the 2017 final rule for MSSP in a fact sheet:
The benchmarking methodology for national fee-for-service calculations has been revised for the first agreement period of MSSP ACOs. The new methodology will use assignable Medicare FFS beneficiaries instead of all FFS beneficiaries.
CMS also is revising the approach for resetting an ACO's benchmark for a second or subsequent agreement period beginning on or after January 1, 2017. This change replaces the national trend factor with regional trend factors.
An ACO's regional service area will include any county where one or more assigned beneficiaries live. CMS will use county-level data to determine regional FFS expenditures for the assignable beneficiary population in the ACO's regional service area.
In a significant step away from past MSSP benchmarking methodologies, the 2017 final rule will determine an ACO's rebased historical benchmark to reflect the ACO's performance relative to other providers in the same regional market, rather than evaluating an ACO against its own past performance.
To help ACOs and other stakeholders calculate risk and forecast expenditures, CMS plans to release annual data files with county-level expenditure and risk score data.
The 2017 final rule seeks to ease an ACO's transition from upside-only risk to two-sided risk. The 2017 final rule will allow Track 1 ACOs to take on two-sided risk but defer exposure to downside risk for one year, essentially granting a Track 1 ACO a fourth year of upside-only risk before it has exposure to two-sided risk.
For the first time since MSSP was launched in 2012, the 2017 final rule sets timeframes for the reopening of shared savings gains or loss payments determinations when an audit finds there has been an error in the calculation.
There are more than 430 MSSP ACOs in 49 states and the District of Columbia serving more than 7.7 million Medicare beneficiaries, according to CMS.
Guidelines from the American Society of Clinical Oncology strongly advise "against cancer-directed therapy… in patients with advanced solid tumors who are unlikely to benefit from them."
Despite evidence-based Choosing Wisely recommendations, cancer patients under the age of 65 continue to receive aggressive care in the last 30 days of life, according to analysis presented on Monday at the American Society of Clinical Oncology (ASCO) meeting in Chicago.
Aggressive end-of-life care includes "cancer-directed procedures and therapies; emergency room and ICU admissions and in-hospital deaths," according to researchers from the University of North Carolina at Chapel Hill.
The researchers looked at data from 2007 to 2014 and found no reduction in the use of aggressive end of life care after ASCO issued the guidelines in 2012. They also saw an increase in end of life care for lung, pancreatic, and prostate cancer patients after 2012.
The ASCO guidelines strongly advise "against cancer-directed therapy (treatments that slow, stop or eliminate cancer) in patients with advanced solid tumors who are unlikely to benefit from them," according to a statement released with the study.
The researchers analyzed claims data for 29,000 patients enrolled in either Blue Cross and Blue Shield, or both, in 14 states.
The data covered the years 2007 to 2014 for those diagnosed with metastatic lung, colon, breast, pancreatic, and prostate cancers.
They found that 71% to 76% received aggressive care within the last 30 days of life. Between 30% and 35% died in the hospital. The rate of hospitalization during the study ranged from 61% for lung cancer and 65% for colon cancer.
The authors concluded: "There is substantial overuse of aggressive end-of-life care among younger patients with incurable cancers. Aggressive care did not decrease following the 2012 ASCO Choosing Wisely recommendations."
They noted, however, that the study is limited because the exact cause of death could not be determined.
Researchers did not review medical records, so they could not determine the medical reasons for aggressive care.
ACLU-backed lawsuit claims San Francisco-based health system's denial of medically necessary care violates Civil Rights Act, Affordable Care Act.
A transgender nurse at Dignity Health is suing the San Francisco-based healthcare system for allegedly denying insurance coverage for medically necessary transition-related healthcare.
In a lawsuit filed in U.S. District Court in San Francisco, Josef Robinson, an operating room nurse at Chandler Regional Medical Center in Chandler, AZ, claims Dignity Health's insurance policy is discriminatory, contradicts medical standards and violates federal law.
The health system's refusal to provide insurance coverage for medically necessary transition-related care discriminates on the basis of sex, Robinson alleges, and is a violation of Title VII the Civil Rights Act and the Affordable Care Act.
"I was shocked when Dignity, which is supposed to be in the business of healing and holds itself out to the public as a bastion of 'human kindness,' told me they would not authorize insurance coverage for my doctor-prescribed treatment," Robinson said in prepared remarks.
"All I want is the same health benefits other, non-transgender Dignity employees receive, which is coverage for medically necessary treatments."
In response to the allegations, the health system said late Monday, "We have not received the lawsuit in question, and it is not our policy to comment on pending litigation."
Robinson said he was saddled with thousands of dollars in out-of-pocket expenses after Dignity denied his insurance coverage for gender dysphoria treatment.
He filed a discrimination charge with the Equal Employment Opportunity Commission, which said there was reasonable cause to believe that the Dignity Health insurance plan discriminates against Robinson on the basis of sex and authorized him to sue the health system, the ACLU said in a media release.
"Every major medical association has affirmed that transition-related health care for transgender people is medically necessary," Josh Block, an attorney with the ACLU LGBT & HIV Project, said in prepared remarks. "Under Title VII and the Affordable Care Act, these sorts of discriminatory insurance provisions are illegal in all 50 states."
Dignity Health, one of the largest health systems in the nation, operates 39 hospitals and more than 400 care centers in California, Nevada, and Arizona, has its corporate headquarters in San Francisco.
Primary care and psychiatry specialties are among the most-requested recruiting searches, but pay continues to lag behind other specialties, data from Merritt Hawkins shows.
As the nation grapples with a widespread and persistent provider shortage, salaries for the 20 most-sought physician specialists and advance practice nurses spiked over the past year, according to a report from physician recruiters Merritt Hawkins.
"You could say universally every single salary segment went up, and most of them did it in double-digit style, which is abnormal," says Travis Singleton, senior vice president at Merritt Hawkins.
The Irving, TX-based recruiter's 23rd annual review is based on in-house findings for 3,342 physician and advanced practice nurse recruiting requests between April 1, 2015 and March 31, 2016.
Annual starting salaries and year-over-year increases for select specialties include:
Family medicine, $225,000, up 13% year-over year;
Psychiatry, $250,000, up 11%;
Obstetrics-gynecology, $321,000, up 16%;
Dermatology, $444,000, up 13%;
Urology, $471,000, up 14%;
Otolaryngology, $380,000, up 15%;
Non-invasive cardiology, $403,000, up 21%;
General surgery, $378,000 up 12%
"This paints a picture of a healthcare system that is at capacity. It's busting at the seams no matter where you look," Singleton says.
"It's created this feeding frenzy for all physicians, and that includes advanced practitioners. It doesn't matter how you segment it out."
"If you want to look at major disease groupings that drive our healthcare system, chronic disease management, mental health, geriatrics, you can almost pick from that what our most requested specialties should be, and they are."
Primary care specialties, nurse practitioners and physician assistants represented seven of the 10 most-requested recruiting searches, and for the first time family medicine starting average salaries breached the $200,000 threshold.
However, primary care specialties continue to lag significantly behind other specialists, and Singleton says that's not going to change.
"Unless we completely overhaul how we pay physicians, unless we flip on its head a system that favors procedures and puts diagnostics at a monetary disadvantage this is what you are going to get," he says.
"You are going to see some tweaks when you get into value-based care and certain snippets of the market that are going to pay a little better, but we are not going to wake up one day and find that family practitioners are making $300,000. That's not possible."
Psychiatrists were the second-highest search request behind family physicians. The federal government has designated 3,968 whole or partial counties as Health Professional Shortage Areas for mental health, and close to half the counties in the U.S. have no mental health provider.
Singleton says the demand for psychiatrists comes with the growing realization that mental health is a key component of population health and has the potential to greatly influence care regimens, outcomes, readmissions and reimbursements.
"When you look at the absolute demand, psychiatry is in more demand" because there aren't that many psychiatrists, Singleton says.
"I knew the demand was prevalent but I didn't expect it would be our second-most-requested specialty. And so far this year we are already ahead of last year's pace."
'Severe Mal-distribution'
Singleton says the "simple explanation" is that there aren't enough psychiatrists in the pipeline to replace their retiring older colleagues.
"Even when you look at those who are coming out of training, it's not even close to the numbers who are going to retire in the next four to five years," he says.
"There is also a severe mal-distribution. Most psychiatrists are in urban and we need them in rural. Most are in outpatient and we need them inpatient. This is all happening as we're going through a re-emphasis on the importance of mental health."
Nearly all (96%) of U.S. hospitals use electronic health records, and 85% share clinical data with other hospitals, AHA data shows.
Data released this week shows nearly all of the nation's hospitals have adopted certified electronic health record systems (EHRs).
The new figures represent a nine-fold increase since 2008, according to survey data from the American Hospital Association Information Technology Supplement.
The data also shows that there have been increases in sharing health data among hospitals, with more than 85% of hospitals sending key clinical information electronically.
The report comes at the start of the annual meeting of the Office of the National Coordinator for Health Information Technology in Washington, D.C.
Additionally, ONC data briefs show the adoption rate of certified EHRs has increased from almost 72% in 2011 (when this information began to be collected) to 96% in 2015.
While the overall rate for the use of certified EHR has held stable, the data shows that adoption rates for small, rural, and critical access hospitals has increased.
The AHA data also shows that the percentage of hospitals sending, receiving, and finding key clinical information grew between 2014 and 2015.
In 2015, about half of hospitals had health information electronically available from providers outside their systems, a 5% increase from 2014. About half of hospitals report they often or sometimes use patient information they receive electronically from providers outside their systems.
The two data briefs, Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008 – 2015, and Interoperability among U.S. Non-Federal Acute Care Hospitals in 2015, can be viewed at HealthIT.gov.
Chief nursing officers and other nurse leaders report high levels of job satisfaction, but are less satisfied with their salaries and benefits, AONE survey data shows.
Based on results published in the second edition of the American Organization of Nurse Executives' Salary and Compensation Survey for Nurse Leaders executive summary, the answer varies depending on job title, experience, and geography.
Data from calendar year 2015 was collected from 2,541 AONE members and non-members who responded to an online survey in the winter of 2016. The three most represented titles among the survey respondents were:
Director (35%)
Manager (22%)
CNO/CNE (21%)
The executive summary was released in May 2016. Below is a snapshot of some of the survey's findings:
Job vs. Compensation Satisfaction
On a five-point scale, survey respondents said they were either "5, very satisfied" (40%) or "4, somewhat satisfied" (41%) with their current positions.
Yet only 35% of nurse leaders report being "highly satisfied" with their benefits and only one-quarter are satisfied with compensation.
Salaries Vary Widely
Half of respondents report annual salaries between $90,000 and $149,999. On the low-end of the salary scale, 12% report earning less than $90,000 annually. The remaining 38% of respondents earn $150,000 or more. The $150,000 or more group breaks down into the following categories:
15% earn between $150,000 and $179,999
13% earn between $180,000 and $229,999
10% earn $230,000 or more
Salary Aligns with Experience
As in most other industries, those with leadership experience earn higher wages.
Two-thirds of respondents with 10 years of leadership experience or less report an annual salary lower than $130,000.
60% of those with 11 to 20 years of leadership experience earn $130,000 or more, as do 74% of those with 20 or more years of experience
Bigger Title; Bigger Paycheck
Nurse leaders with senior-level titles earn more than other nurse leaders:
Directors and managers are most likely to earn between $100,000 and $159,999 annually.
More than half (58%) of non-system CNOs earn between $100,000 and $199,999; 23% of them earn between $200,000 and $249,999, and 17 % earn $250,000 or more.
More than half (52%) of system CNOs earn $250,000 or more.
More than half (61%) of those surveyed received bonuses in 2015. Factors that influenced bonuses included:
Financial performance of the organization (71%)
Clinical performance measures (64%);
Patient satisfaction (51%)
Geography Matters
Salaries vary among AONE's nine geographic regions:
Region 9 (Alaska, California, Hawaii, Nevada, Oregon and Washington) has the greatest percentage of respondents (62%) earning $150,000 or more.
In Region 1 (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont) nearly half (45%) of all the nurse leaders earn $150,000 or more.
Region 5 (Ohio, Indiana, Illinois, Michigan and Wisconsin) has the lowest percentage (27%) of nurse leaders earning $150,000
Employment Settings are Shifting
Since 2013, the percentage of survey respondents working in acute care hospitals has dropped 37%.
While 42% of respondents said they work at acute care hospitals, the results of AONE's 2013 survey showed that 67% of respondents worked in acute care hospitals.
Another 34% of the 2016 survey respondents work in academic institutions (of this group 26% work in an academic medical center/hospital and 7% work at an academic institution/university/ college) while 8% work in a health care system/corporate office.
The remaining 17% of respondents work in "other" settings.
According to a complaint, a skilled nursing facility near San Diego required lawful permanent residents applying for jobs to show their green cards, while allowing U.S. citizens to show any valid work authorization document.
The Department of Justice has settled a discrimination claim against a San Diego, CA-based skilled nursing facility that federal prosecutors allege demonstrated hiring bias against work-authorized non-U.S. citizens.
According to a complaint, Villa Rancho Bernardo Care Center required lawful permanent residents applying for jobs to show their green cards, while allowing U.S. citizens to show any valid work authorization document.
Under the Immigration and Nationality Act, lawful permanent residents are not required to show their green cards to employers. They may present valid documentation from the Department of Homeland Security's lists of acceptable documents to establish their identity and work authorization, such as a state or federal identification document and an unrestricted Social Security card.
Villa Rancho Bernardo will pay $24,000 in civil penalties and undergo department-provided training on the anti-discrimination provision of the INA and be subject to monitoring requirements, DOJ said.
Villa Rancho Bernardo did not return calls Tuesday.
"The Civil Rights Division is committed to ensuring that individuals who are authorized to work in the United States do not face unlawful, discriminatory barriers," Assistant Attorney General Vanita Gupta, head of the Justice Department's Civil Rights Division, said in a media release.
"It is essential that employers review their employment eligibility verification practices to make sure they are in compliance with the law."
The screening program was offered to those with an elevated risk of colon cancer after a 2011 University of Kentucky study that found the advanced colon cancer rate for the uninsured in Kentucky was twice as high as the rate for those with insurance.
Free screening programs for uninsured Kentucky residents increased early colon cancer diagnoses at no additional cost to hospitals in the state, according to a new study.
Published online by the Journal of the American College of Surgeons, the study compared results of the free screening program, which was launched in 2013, with data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) results.
The screening program was offered to those with an elevated risk of colon cancer. Risk factors include family history of the disease, a history of inflammatory bowel disease, and blood in the stool.
The Kentucky patients were more likely to be diagnosed with stage 1 cancers—33% versus 22%—than patients in the SEER-Medicare database.
Based on these finding, researchers calculated a slightly lower cost of care for uninsured patients ($43,126) versus insured patients ($43,736). This "suggests the program is cost-neutral from a system perspective."
The researchers calculated the costs using SEER-Medicare data on health expenditures during the initial phase of care, including Medicare payments and private insurer payments, as well as patient copayments and deductibles.
They then compared overall costs between patients in the study and the SEER database based on the one-year costs for patients based on the stage of the cancer.
The screening program was a joint project of private groups and the hospital systems of Louisville. It was triggered by a 2011 University of Kentucky study that found the advanced colon cancer rate for the uninsured in Kentucky was twice as high as the rate for those with insurance.
In 2013, colon and rectal cancer incidence was 14% for whites and 20% for African-Americans, who were also more likely than whites to die from the disease, according to NCI.
"This is a promising end point for our program and is entirely consistent with the known effectiveness of cancer screening programs," the authors write.
"Hopefully, these findings can begin a more wide-reaching national conversation about improving access to health care in areas of ongoing disparity."
Cleveland Clinic researchers have developed a working definition of spirituality to help establish a framework of spiritual care training and resources for clinicians providing bedside care.
A recent study on nurses' definitions of spirituality and their comfort-levels with providing patients spiritual care has led a Cleveland Clinic research team to create a working definition for spirituality in healthcare.
The article "Critical Care Nurses' Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients," was published in the May 2 edition of the American Journal of Critical Care.
"Without a clear definition, each nurse must reconcile his or her own beliefs within a framework mutually suitable for both nurse and patient," said lead author Christina M. Canfield, RN, MSN, ACNS-BC, CCRN-E, in a media release.
"Nurses who seek to give whole-person care to their patients' sense that something beyond the technical aspects of their job is needed."
She is a program manager, Cleveland Clinic eHospital and clinical nurse specialist at Cleveland Clinic's main campus.
Through interviews with 30 nurses, researchers found that even though nurses report they are ready to offer direct spiritual support if they sensed it was needed, they had trepidation about initiating spiritual support for fear of potentially offending the patient or the patient's family.
Nurses also said they were eager for resources and guidance on how to address their patients' spiritual care needs.
The authors developed the definition of spirituality as "that part of a person that gives meaning and purpose to the person's life. Belief in a higher power that may inspire hope, seek resolution, and transcend physical, and conscious constraints," based on the study participants' answers to the following questions:
Could you tell me about a time when you interacted with a patient who really needed some spiritual support or attention?
Please describe your personal definition of spirituality.
How do you see the connection between religion and spirituality?
Do you feel like you have to be religious to be spiritual?
Could you talk to me about your own comfort providing spiritual care to critically ill patients?
'Whole-person Care'
The goal of developing the definition was to "to empower nurses who seek to give whole-person care to their patients," and to create a framework to help guide in development of resources for nurses providing bedside care to critically ill patients.
"Nurses are ready to offer direct spiritual support if they sense it is needed, but hesitate to initiate such support out of concern that doing so could be offensive to the patient or interpreted as proselytizing," Canfield said.
"Resources, such as classes or reference guides, may be helpful to those wishing to improve their comfort with providing spiritual care to patients."
CMS is expanding eligibility for participation in Medicare's new primary care payment model to physician practices that are in Medicare's most popular accountable care organization model.
In an update fact sheet released May 27, federal officials announced that
As many as 1,500 primary care practices will have the opportunity for dual participation in the new Comprehensive Primary Care Plus (CPC+) payment model and the Medicare Shared Savings Program (MSSP).
CPC+ was introduced in April and the multi-payer payment model is set to launch Jan. 1, 2017.
The Centers for Medicare & Medicaid Services on Friday, May 27 released an updated fact sheet after receiving "feedback from a variety of stakeholders expressing interest in the dual participation of primary care practices in both an ACO and in CPC+."
CMS officials believe dual participation in CPC+ and an MSSP ACO "may enhance the coordination of care for Medicare beneficiaries and help to achieve our aims of better care, smarter spending, and healthier people," according to a statement accompanying the fact sheet.
One of the top goals of CPC+, which is a two-track payment model, is to encourage commercial payers to align their reimbursements for Medicare beneficiaries' primary care services with Medicare's payment structures, quality measures and data sharing.
MSSP, which has three tracks with varying levels of financial risk for healthcare providers, is CMS's most popular accountable care organization model. As of January, the MSSP roster stood at 434 ACOs, compared to 404 MSSP ACOs enrolled in the program in January 2015.
The fact sheet released May 27 includes details about payment changes to CPC+ to accommodate MSSP ACOs:
Care management fees for primary care practices in MSSP ACOs will be the same as all other CPC+ primary care practices. Care management fees will be included in the ACO's calculations for shared savings.
Primary care practices in MSSP ACOs will not receive the prospectively paid/retrospectively reconciled CPC+ performance-based payment incentive.
For practices in Track 2 of CPC+, there will be a payment impact in the Medicare Physician Fee Schedule. These practices will shift a portion of Medicare fee-for-service (FFS) payments for "evaluation and management" into Comprehensive Primary Care Payments (CPCPs), an accounting move designed to reduce FFS payments while boosting comprehensiveness of care.
According to the revised fact sheet, "The CPCP and reduced FFS payments together will be calculated based on an amount 10% larger than historical billings to support increased comprehensiveness of care."
Other features of dual participation for primary care practices in CPC+ and MSSP ACOs include:
Financial benchmark calculations for MSSP ACOs will not be changed.
Primary care practices in MSSP ACOs will have to adopt the CPC+ care delivery model.
Participation is limited. A total of 5,000 primary care practices will be allowed to participate in CPC+, with 2,500 in Track 1 and 2,500 in Track 2. Only 1,500 of the 5,000 total CPC+ primary care practices can also be participating in MSSP ACOs.
Payers have until June 8 to submit proposals to CMS to participate in CPC+. CMS will then designate as many as 20 geographic regions where primary care practices will be able to participate in the program. Practices are expected to be able to apply for CPC+ participation between July 15 and Sept. 1.