A few weeks ago as my 12-year-old son was heading to tech camp at a local high school, I heard the jingle of coins in his pocket. When I asked about it, he said it was for the soda machine. Maybe he'd get a root beer, cola, or sports drink that day. And no, it wouldn't be a diet beverage because other kids would make fun of him because "only fat kids drink diet."
Fortunately for him, he is not overweight. But some of his friends are, including one who was recently diagnosed with Type II diabetes. Unfortunately, his generation is one that is facing what is being called the epidemic of obesity. They're caught in an environment where eating right is not valued—and where their quality of health is threatened at earlier ages.
"Obesity [among children] has tripled in just a generation," said Thomas Frieden, MD, director of the Centers for Disease Control and Prevention (CDC) earlier this week in Washington, DC, at the first annual CDC conference on the "Weight of the Nation."
"We know that our genes haven't changed this fast. We know that our preferences have not changed this fast. We are hardwired to like sweet and salty food," he said. "What has changed is our environment, and if we are to make a change in the obesity epidemic, we're going to have to change the environment in order to gain control."
While no easy answers exist on how to tackle this epidemic, Frieden said that the public health community may want to take pages from the playbook on eliminating smoking, the leading preventable cause death in the country. He suggested a three-pronged approach used to reduce tobacco use that could be used to rewire the way children—and even adults—approach food.
Price is the first prong. What has happened during the past several decades—and in his view is "the single most likely explanation for the obesity epidemic"—is that carbonated drinks, sugar, and sweets have gotten relatively less expensive. Meanwhile, fresh fruits and vegetables have become relatively more expensive.
This means that the cheaper junk food becomes the food of choice. One solution, which was done with tobacco products, is to make these junk foods more expensive through taxes. "A substantial soda tax would probably be the single most effective way we could reduce obesity," he said, citing one example where a 10% increase in the price of soda resulted in an 8% decrease in consumption. Meanwhile, focus should be placed on lowering healthy food costs.
"As we think about sources of revenue for health reform or other societal needs, at one cent an ounce, the revenue from a soda tax could be on the order of $100 billion to $200 billion over the next 10 years," he said.
Exposure is the next key intervention. This means increasing exposure to healthy foods through placement in supermarkets or small grocery stores, and making these foods more readily available.
And it means turning healthy foods into "picker" foods: "If you think about the difference between unhealthy foods and healthy foods, one of the [distinctions] is that you can pick up unhealthy foods a lot more easily than you can pick up healthy foods—with the possible exception of carrot sticks, and you can't only have carrot sticks," he said.
Decreasing exposure to unhealthy foods—like decreasing exposure to tobacco—is another avenue, albeit a tricky one. At schools, for instance, many kids are exposed to these foods through vending machines, which help in part to finance school activities. "Principals face a devil's dilemma of whether they get revenues for very important programs in incredibly strained fiscal times or whether they try to have a commercial-free environment for children to learn in through graduation."
Image is the third key area. "Food ads for children are extensive," Frieden said. "I think when we look back 20 to 30 years from now, we'll say 'what in the world were they thinking'?—allowing the kind of advertising that occurs today still to exist in the midst of an epidemic of childhood obesity."
In the future, the ads on TV and Internet today "will look as anachronistic to us then as the tobacco ads from a generation or two ago looked to us now," he said. But the reality is that today, children continue to be exposed to extensive marketing and promotion.
One way to approach this is counter advertising—much like was done with tobacco ads. "Counter advertising works to change the image. What works unfortunately are not positive ads about smoke-free living. Those have limited or no impact." he said.
Instead, the ads should show that "human impact of a product but should never attract the victim. It should show only the reality of what the product causes in terms of illness, disability, and death," he said. "Counter advertising is essentially untested in obesity prevention and control. It is, in my personal opinion, very likely to be effective. It is certain to be very controversial."
Overall, as a society, "I do not think that we can wait for perfect evidence" to tackle obesity now, he said. "The question, I think before us—and what we have to weigh as a group as we consider the 'Weight of the Nation'—is whether we as a society are willing to take the actions necessary to reverse the epidemic of obesity."
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Some say President Obama shouldn't have commented during his press conference last week on a situation he didn't fully understand. They say he insulted the integrity of an entire profession whose members are frequently forced to make stressful decisions with the best information available. At the very least, it was a distraction from his broader message on healthcare reform.
I'm speaking, of course, about the tonsillectomy the President used to explain the healthcare system's perverse financial incentives.
"[If] your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, 'you know what, I make a lot more money if I take this kid's tonsils out,'" Obama said in response to a question about changes to the delivery system. "Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out."
A few physicians were offended by the insinuation that they would so crudely put their own financial interests ahead of the well-being of their patients. The American Academy of Otolaryngology immediately issued a press release to clarify the benefits of tonsillectomies and express disappointment at Obama's "portrayal of the decision-making processes by the physicians who perform these surgeries."
I can certainly sympathize with the difficulty of trying to discuss clinical issues without having a clinical background, but it was a bad example and oversimplified the way individual physicians interact with patients and make clinical decisions.
But that doesn't mean he was wrong about the larger point.
The President prefaced his example by noting the influence of the fee schedule on medical practice, and he certainly isn't the first or only person to delve into how financial incentives affect physician behavior.
Policy wonks and healthcare experts (including CMS) constantly talk about paying physicians for performance and other financial carrots and sticks that will change how physicians practice. Most hospital leaders understand the difference a financial relationship can make when it comes to physician alignment. Even most physicians are aware of the effects of financial incentives; private practices typically divide up revenue based on elaborate compensation formulas that encourage productivity.
Yet for all the talk about the end of fee-for-service, we are waiting to see an alternative. The two bills introduced so far keep the current reimbursement system for the most part, and the public option would be based on the same Medicare payment model, only paid at a higher rate.
The Senate Finance Committee has yet to release a bill, so I may be judging the sausage before it has been made. Or perhaps the reimbursement overhaul is intended to come from the Independent Medicare Advisory Council I wrote about last week.
But where are the bundled payments that piqued the industry's interest earlier this year? Where is the reimbursement system that the Mayo Clinic asked for last week that rewards quality and evidence-based care? Where is the real change?
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As physicians strive every day to provide the best healthcare to their patients, they may be overlooking a strong ally in this process: the pharmacy benefit management (PBM) company that manages their patients' prescription drug benefit.
As a practicing physician, I know that busy doctors often see PBMs as one more layer in the bureaucracy of patient care. Yet if that's our perspective, we're overlooking a resource that can be a significant help to us in our common goal: getting the right medication to the right patient at the right time, and at an affordable price.
My own experience is unique in that I see both sides of the picture. I now work for a PBM, and I still practice medicine. In many ways, it's never been more challenging to be in private practice. We can all benefit from assistance that helps us deliver the best care we can.
For decades, we've relied on pharmaceutical companies and their representatives to be an important conduit for information on effective use of prescription drugs. PBMs are another major resource to practicing physicians, not only for information on prescription drugs, but on how our patients are taking them, on potential adverse drug interactions that can be avoided, and on how to obtain the most affordable medications. This latter point is especially important in today's economy, when we know that many patients are compromising their care by skimping on or not taking their prescription medications because they can't afford them.
With these common goals in mind, let's take a look at how your patients' PBMs can be a resource to you and your practice, for the benefit of your patients.
The Role of the PBM: Adversary or Ally?
Pharmacy benefit management companies exist to manage the pharmacy benefit program that is funded by plan sponsors. While their original value was primarily in purchasing drugs in bulk and in processing claims, the role of PBMs today encompasses numerous programs and initiatives to help patients use drugs safely, to stay compliant with their prescription drug regimen, and to obtain drugs conveniently and as affordably as possible.
A significant asset that PBMs bring to these initiatives is the knowledge within their claims data base. They see the overall picture of a patient's prescription drug use across multiple physicians, facilities, and geographic areas—knowledge that the individual physician does not have in today's medical world. This information provides practical value to physicians to help provide their patients with the best healthcare.
Still, in the day-to-day practice of medicine, it's easy to view the interactions with the PBM as another administrative chore and even as interference in the physician-patient relationship. Another perspective is to see beyond the interruption of routine and to recognize the value of the information that the PBM brings to the physician that is otherwise unavailable.
Getting Value from PBM Interactions Value from Basic PBM Practices
PBM “best practices” with which physicians are most familiar—such as prior authorization, step therapy, and programs that look at drug interactions and polypharmacy—are designed to work to the benefit of everyone: physician, patient, and plan sponsor. They are a checkpoint that brings together a wide range of information that the physician does not have available at the point of prescribing, to help make the best choice for a particular patient.
Here are some examples:
Prior authorization—the practice of requiring approval for a specific drug—is used to ensure that the right medication gets to the right patient for the right length of time. It is a good strategy to ensure that patients who need high-cost drugs receive them, while helping plan sponsors manage costs. Often, the physician is not familiar with the plan design and does not know all the drugs that may be covered in the formulary that may be options. Similarly, prior authorization is often required for new drugs on the market, to ensure that there is a full understanding of the drug's appropriate usage.
The goal of step therapy—prescribing the least expensive, equivalent drug first before proceeding to more costly medications—ensures that high-cost medications are the last, not the first, choice for treatment. It is a tried and true practice that works to ensure that patients are treated with the best medication at the best price for their disease or illness. If a generic drug is available and appropriate, it should almost always be the first-line therapy. If the outcome achieved is not as desired, then the next step would be to move up to another medication until the desired outcome is reached.
Avoiding drug-drug interactions and managing the dangers of polypharmacy is a critical health challenge as baby boomers age and chronic illness across all age groups increases. PBMs can help because they are in a position to identify at-risk patients, providing physicians with feedback on whether or not the patient is filling their medications and taking them correctly, and if there is the potential for a dangerous drug interaction, which can often happen when patients see multiple physicians. By contacting physicians and providing them with educational materials to use as a discussion point with their patients, a PBM's intervention can be very effective in preventing these interactions.
The communication in these touchpoints should always be two-way. Often the physician has important information on the patient's situation that impacts the decision. My PBM work includes many hours of such discussions each week, to reach the best choice for each patient.
Support with Medication Compliance
PBMs can also help patients to be more compliant with their medications, which is a huge challenge for physicians, as well. Some PBMs offer programs for physicians that identify patients who are not taking medications as prescribed and help them to directly reach out to those patients, thereby improving adherence and outcomes. Some PBMs also have clinical management expertise to improve medical outcomes. They offer disease therapy management programs, for example, to help manage the medication therapy component for patients with chronic illnesses. The goal of these programs is to improve patient compliance, which will improve outcomes over time.
Increase the Use of Generics
PBMs encourage the use of generics for two reasons: a generic drug is therapeutically equivalent to its branded counterpart, and the cost savings from using generics help everyone control their prescription drug costs. Among the efforts that some PBMs make to ensure physicians stay abreast of what is going on in the world of generics is direct contact to let them know about the availability of a new generic drug. Another method is direct mailings to physicians with information on generic drugs, along with identification of patients who are taking branded drugs for which generics are available. The mailing may be followed by contacting the doctor to suggest the generic alternative.
Information on a Broad Range of Drugs
It's estimated that the average physician is primarily familiar with the 100 or so medications prescribed most frequently. Yet there are hundreds of other potentially beneficial medications. For example, specialty pharmaceuticals represent promising, yet costly drug therapies. PBMs can offer doctors clinical insights and knowledge about the latest therapeutic advances to help them better sort through and identify the medication regimens so that their patients that can best benefit from new treatments, new pharmaceuticals, and new biologics.
PBMs offer a real value to physicians by helping them to help their patients. Most PBMs are not trying to limit medication utilization or limit the prescription choices of doctors. Instead they are promoting the appropriateness of prescription medications with a focus on the clinical efficacy and quality. Looked at from this perspective, it makes sense for physicians to use the information and services PBMs provide for the benefit of their practices and their patients.
Brian K. Solow, MD, FAAFP. is vice president and medical director for Clinical Services at Prescription Solutions, a UnitedHealth Group company and a PBM that manages the drug benefit of commercial, Medicare, and governmental health plans, as well as employers, union trusts, and third-party administrators. For information, visit www.rxsolutions.com.For information on how you can contribute to HealthLeaders Media online, please read ourEditorial Guidelines.
OIG Opinion 09-05, approving a hospital's proposal to compensate physicians for on-call services performed on behalf of the hospital's uninsured patients, may have broad implications for on-call coverage.
The 400-bed nonprofit general hospital is the sole provider of acute care inpatient hospital services in the county.
Under the proposed arrangement, the hospital would pay physicians on a per-encounter basis for the following services provided during on-call periods to indigent patients:
$100 flat fee for emergency consultations on an eligible patient presenting
$300 per admission for care of eligible patients admitted as inpatients from the ED
$350 flat fee for the primary surgeon of record for the surgical procedure or procedures performed on an eligible patient admitted from the ED
$150 flat fee for the physician performing the endoscopic procedure or procedures performed on an eligible patient admitted from the ED
The OIG noted that although there is "substantial risk that improperly structured payments for on-call coverage could be used to disguise unlawful remuneration" under the anti-kickback statute, the proposed arrangement had adequate safeguards.
Those safeguards can provide guidance to physicians, says Todd A. Rodriguez, partner and cochair of the Health Law Practice Group at Fox Rothschild, LLP, in Exton, PA. Among them:
The hospital certified that the payment amounts are within the range of fair market value for services rendered, without regard to referrals or other business generated between the parties
The hospital had a legitimate rationale for revising its on-call coverage policy—namely, that it did not have adequate call coverage
The proposed arrangement will be offered uniformly to all physicians and will impose tangible responsibilities on them
The proposed arrangement would appear to create an equitable mechanism for the hospital to compensate physicians who actually provide the care that the hospital is required to furnish
"While the advisory opinion does not contain any surprises, it provides a very useful analysis at a time when on-call compensation arrangements are proliferating. Physicians who have on-call compensation arrangements or who are considering entering into one are well-advised to review their arrangements in light of the OIG's analysis," Rodriguez writes in his Physician Law blog.
This article was adapted from one that originally appeared in the July 2009 issue of Physician Compensation & Recruitment, a HealthLeaders Media publication.
Most women surgeons would make the same career choice again if given the option even though it affected their personal lives, according to researchers at the University of California-Davis. Women were somewhat more likely than men to say they would choose the surgical profession again (82.5% versus 77.5%), the report found. But female surgeons were also five times more likely than men to forego having children and nearly twice as likely to have a first child later in life.
Bob Coli, MD, discusses the benefits of application service providers, a remote-hosting option for electronic health records that can save physicians thousands when implementing an EHR system. [Sponsored by Emdeon]
Nurses helped design a new $92 million patient tower that opened last year at Monongalia General Hospital in Morgantown, WV.
At Carondelet Health Network in Tucson, AZ, nurses have access to on-site bachelor's of science in nursing and master's of science in nursing education, through collaboration with a local university.
And at Scripps Health in San Diego, CA, experienced and mature nurses are encouraged to stay on the job through a multitude of flexible work arrangements and phased retirement options.
While seven case studies describe projects that work, the report also details the outcomes of 13 selected research projects designed to test positive and negative outcomes of strategies to retain experienced nurses who otherwise might quit for less demanding jobs.
Healthcare executives are well aware of the problem. According to a January report by the Lewin Group, the average replacement cost for a full-time equivalent RN is about $36,567. About two-thirds comes from the added termination expenses, such as paying the departing nurse for unused vacation time, as well as finding temporary replacement and conducting new RN training and orientation.
By next year, more than half of the nation's registered nurses will be over age 50 and many will be considering retirement.
Surveys reveal that 116,000 registered nurse positions are now unfilled in U.S hospitals; another 100,000 job vacancies exist in nursing homes. Although the recession has caused some nurses to delay retirement, the aging demographic means an increasing demand for nurses looms, and may outpace the supply of nursing school graduates.
"We know that there is no quick fix to the crisis in healthcare," said Susan B. Hassmiller, the Robert Wood Johnson Foundation's senior advisor for nursing. "But initiatives explored in our Wisdom at Work are pieces of a larger puzzle that will help healthcare organizations keep experienced nurses from walking out the door–and taking their expertise with them–just when we need them most."
The recent report focused on efforts in three key areas to retain nurses:
Ergonomic initiatives to help nurses better manage the demand for strength
Human resource-related strategies and employee wellness
Technology and leadership development
For example, Cedars Sinai Medical Center in Los Angeles, a 952-bed facility, launched a lift-team initiative to decrease the number of back injuries, lost work days and costs related to injuries while handling patients. Since the program started, the number of days of work lost due to patient handling injuries and disability costs declined. Challenges, however, included uneven use of the teams by some inpatient units and the lengthened time to respond to some parts of the large hospital.
At Florida Health Science Center in Tampa, FL, an 877-bed facility, a similar initiative was not as successful. The system saw a large drop in the number of days lost by experienced RNs because of patient handling injuries. Also, "experienced RN turnover trended upward," in part because of competition from non-bedside nursing opportunities as well as the hospital's staffing policy that required 12-hour shifts in some units.
The report found that overall, such ergonomic initiatives did not contribute to an overall drop in turnover, although they did improve morale and cut expenses associated with injuries.
On general staffing issues, Centra Health's Lynchburg General Hospital and Virginia Baptist Hospital, a 526-bed system, realized that nurses were often calling in sick when scheduled to work outside their home units because many did not feel "comfortable or confident being pulled from one medical center to another." The resulting launch of a "closed staffing" policy, in which nurses who volunteer for the program can work outside their home unit, was credited with reducing turnover of experienced staff.
At Froedtert Memorial Lutheran Hospital in Milwaukee, a 434-bed facility, experienced nurses were employed to staff a virtual intensive care unit that monitors intensive care at a number of sites. Since the setting is less physically demanding, it was credited with reducing physical strains on older nursing staff.
Kay McVay, president emeritus of the California Nurses Association, which represents 85,000 of the state's 200,000 nurses, says these techniques are all well and good, and it's laudable that hospitals are using better ergonomic equipment to ease strain on older nurses.
But to some extent, she said, "that's a gimmick, something that hospitals can use to say, in effect, 'We're going to change things and you're going to like this.' "
"But what we really want is respect, and to be assured that we really will have the time we need to take care of our patients," says McVay, former critical care nurse with Kaiser Permanente Medical Center in Martinez, CA.
What helped achieve better working conditions in California was a court room victory several years ago to uphold nurse staffing ratios set by former Gov. Gray Davis in 1999, but which Gov. Arnold Schwarzenegger attempted to overturn.
In medical surgery and telemetry units before the ratio limits were upheld, hospitals could staff nurses any way they liked, says McVay. Now the ratio is set at 1 nurse to 5 patients for med-surge units and 1 to 3 in telemetry.
In a culmination of efforts to better review fire protection features in acute care facilities, Life Safety Code violations became the top cited standard in all surveyed hospitals in 2008, reports The Joint Commission.
According to the July 2009 Joint Commission Perspectives, 45% of surveyed hospitals received a citation for EC.5.20, the old 2008 standard for Life Safety Code compliance. That standard has since expanded into 10 life safety standards introduced in 2009.
Life Safety Code violations are more prominent "not only due to the high emphasis The Joint Commission places on life safety, but also due to the general lack of understanding by facility managers of the code and the interpretations made by [The Joint Commission]," said Keyes, who is a former life safety specialist with the accreditor.
Life safety specialists, who have working knowledge of the Life Safety Code and often have experience as facilities professionals at hospitals, joined survey teams back in 2005.
The specialists tour the building from roof to basement, checking how well the facility complies with the various provisions in The Joint Commission's life safety standards and related Life Safety Code requirements.
The addition of the life safety specialists was prompted by a U.S. Government Accountability Office report issued in 2004 that concluded Medicare validation surveys at hospitals uncovered serious fire safety deficiencies that Joint Commission surveyors hadn't identified in earlier visits.
Other problems make the list
In addition to Life Safety Code deficiencies, the old EC.5.40, which sets a variety of provisions for the inspection, testing, and maintenance of fire protection equipment, was the sixth most-cited standard last year, affecting 26% of hospitals. EC.5.40 has since been renumbered EC.02.03.05.
Here is the top 10 list of cited standards in 2008, along with the percentage of hospitals cited, as published by Perspectives:
EC.5.20 (45%)—Life Safety Code compliance
IM.6.50 (43%)—Qualified staff members transcribing verbal or telephone orders
MM.2.20 (37%)—Properly stored medications
National Patient Safety Goal 2C (37%)—Improving timeliness of reporting and receiving critical tests and results
IM.6.10 (31%)—Keeping complete and accurate medical records
EC.5.40 (26%)—Maintaining fire protection equipment
National Patient Safety Goal 3D (25%)—Labeling medications and medication containers
HR.1.20 (22%)—Ensuring staff member qualifications are consistent with job responsibilities
Universal Protocol 1C (21%)—Conducting time-outs immediately before starting procedures
National Patient Safety Goal 8A (19%)—Comparing a patient's current medications with those ordered for the patient
Durable medical equipment suppliers miscoded claims in 2006 resulting in the federal government, private insurance, and individuals overpaying them $42 million for items like wheelchairs and oxygen, an investigation by the Office of Inspector General said yesterday.
Of the $42 million, $23.4 million was paid by Medicare. Medicare, private insurance companies, and private payers wrongly paid an additional $7.1 million, much of it in co-payments. And another $11.9 million was "inappropriately allowed" by Medicare Part B during stays in Medicaid certified nursing facilities.
The 309,626 claims were spread across 11,702 nursing homes.
Except in very special circumstances in which the nursing home does not provide rehabilitation or skilled care, such nursing facilities did not meet the definition of a home for the purpose of durable equipment reimbursement.
The OIG report is titled "Part B Services During Non-Part A Nursing Home Stays: Durable Medical Equipment," and deals with a category of care services provided after Medicare Part A expires, which is after the first 100 days a beneficiary receives care in a skilled nursing home.
The overpayments are a result of ignorance of or non-adherence to a federal rule that disallows payment for rental or purchase of such equipment unless beneficiaries are living in their homes. The report also pointed to a nationally flawed system in which states and CMS have no way of knowing which facilities qualify for reimbursement and which don't.
In response to the OIG's investigation, acting administrator for the Center for Medicare and Medicaid Services, Charlene Frizzera, said the agency "plans to recover the overpayments identified consistent with the Agency's policies and procedures." A spokeswoman for CMS said it is unclear how the agency will seek to recover the misspent funds, and whether private consumers and insurance companies will be separately notified.
Equipment that was incorrectly paid for included hospital beds, decubitus or wound healing equipment, walkers, seats or patient lifts, neuromuscular electrical nerve stimulators, commodes and baths, and air mattresses. Payment for wheelchairs and walkers accounted for 72% ($22 million) of $30 million worth of incorrect Medicare billings. Another $11.9 million was inappropriately allowed for Medicare beneficiaries who stayed in Medicaid nursing facilities. Most of it was for renting equipment rather than purchase.
If the beneficiary requires a longer stay, Part B may kick in for certain services, but not for durable medical equipment unless the facility is the patient's home.
Durable medical equipment is defined as equipment that can withstand repeated use, serves a medical purpose primarily, is not useful to someone who is not ill, and is appropriate for use in the home.
Michael Reinemer, vice president of communications and policy for the American Association for Home Care, which represents companies that manufacture and supply such equipment, says if some people are cut out of eligibility for care they need, and no other entities will provide it, "maybe the policy needs to be adjusted."
However, he emphasizes, if suppliers are miscoding in an effort to commit fraud, "we're adamantly opposed to that."
CMS has pledged to initiate Recovery Audit Contractor investigations to check on whether beneficiaries who received the services were in fact residents of homes that did not qualify as beneficiaries' homes.
Additionally, the OIG learned, neither the CMS nor the states have a good way of detecting which nursing homes meet those special circumstances that allow their beneficiaries to qualify for durable equipment reimbursement.
"If a beneficiary resides in a nursing facility or a distinct part nursing home that does not provide primarily skilled level of care or rehabilitation, the supplier should identify ‘home' as the place of service," the OIG reported. "However, suppliers that code place of service and Medicare Administrative Contractors that adjudicate claims do not have ready access to the primary level of care status of nursing facilities and distinct part nursing homes unless this information is provided directly by these facilities.
"They lack access to this information because CMS or states did not make these determinations and maintain results in an accessible database."
The OIG report recommends that CMS:
Routinely identify non-Part A beneficiary nursing home stays
Recapture inappropriate payments
Identify patients entering skilled nursing homes with rented DME, which may allow them to qualify for partial reimbursement
Implement a process to make information about which nursing homes primarily provide skilled nursing care to claims processors.
Part of the problem is that many caregivers for the beneficiaries are renting the equipment, and suppliers are billing Medicare for it, while they are still in their homes, but then they take that equipment with them to the nursing home.
"Following the monthly rental period during which the beneficiary moved to a nursing home that may not be considered his or her home, the DME claim should show the actual place of service as a (skilled nursing facility) or a (nursing facility), which would result in a denial of payment by the DME Medicare Administrative Contractors," the report said. "CMS policies require that suppliers submit accurate clams, but do not provide guidance on how or how frequently they must ensure the accuracy of the beneficiary's place of service."
Ultimately, suppliers depend on the beneficiary—or his or her responsible parties—to tell them when a beneficiary moves into a nursing home. But there is know way for suppliers to ensure that the beneficiaries do so, the report said.
The OIG report mentions that the agency is preparing several other documents on similar topics regarding reimbursement of care provided in skilled nursing facilities, such as psychotherapy and enteral nutrition therapy.
The report said 3.2 million people in 2006 received nursing home care in 16,121 nursing homes certified for Medicare or Medicaid.
Key lawmakers moved to cut roughly $100 billion from the cost of healthcare reform proposals as they sought to break weeks of gridlock. House Democrats reached a deal with conservatives in their caucus that would reduce the overall cost of the package and ensure more funding for rural hospitals. Bipartisan negotiators on the Senate Finance Committee, meanwhile, announced that a draft of their reform package would come with a lower-than-expected price tag of less than $900 billion over 10 years.
