Hospitals that get bundled payments for joint replacements either voluntarily or through Medicare's mandatory programs, vary by size and volume, but not in spending or quality.
Voluntary bundled payment programs engage larger non-profit hospitals, while lower volume hospitals with fewer resources might only participate under a mandatory program, a new study shows.
The results, published in the June issue of Health Affairs, suggest that both mandatory and voluntary bundled payment programs are needed to engage more hospitals.
"Our results suggest that both voluntary and mandatory approaches can play an important role in engaging hospitals across the country, so policymakers should not restrict policy options to one approach over the other," study lead author Amol S. Navathe, MD, an assistant professor in the department of Medical Ethics and Health Policy at Penn Medicine, said in prepared remarks.
Critics of mandatory bundled-payments have called for the programs to be strictly voluntary amid concerns that some hospitals won't see cost savings, and will stop performing these surgeries rather than lose money.
However, the study found no evidence that hospitals in the mandatory program were obviously disadvantaged compared to their voluntary hospitals.
The researchers used data CMS and American Hospital Association that compared organizational characteristics and measures of costs and care quality for 302 hospitals in the voluntary bundled-payment joint-replacement program and 799 in the mandatory program.
The researchers found no large differences in baseline spending, care quality, or financial risk exposure for voluntary vs. mandatory program hospitals.
"The mandatory program does not seem to have disadvantaged its participants compared to voluntary participants on average, with respect to spending and care quality," Navathe said.
Hospitals in the voluntary program were self-selected; they were generally larger, had a greater volume of joint-replacement surgeries, and likely were not representative of hospitals nationwide.
NPs account for 1 in 4 medical healthcare providers in rural areas, but their potential to provide a full spectrum of primary care services can't be realized if states maintain practice restrictions.
Nurse practitioners are expected to play a critical role in alleviating the nation's rural healthcare workforce shortages, but some states continue to place hobbling restrictions on their scope of practice, a new study shows.
Researchers found that NPs comprise one-in-four of clinicians practicing in rural areas, a number that increased 43% from 2008-2016. Currently, of the 248,000 NPs in the country, about 87% are trained in primary care and more are in training.
However, study author Hilary Barnes said the increasing reliance on NPs to deliver a full spectrum of primary care services in rural areas is being hindered in some states by outmoded restrictions.
In some states, such as Pennsylvania, "an NP has to maintain written agreements with a physician to practice and prescribe medication," said Barnes, an assistant professor in the College of Health Sciences’ School of Nursing at the University of Delaware.
"In the most extreme examples, the law states that an NP must talk about every patient with a physician. Or that the physician has to sign for prescriptions," Barnes said, in remarks accompanying the study.
Barnes also described "mid-level" states, such as New Jersey, that provided latitude for NPs, but not autonomy.
"There's an in-between where an NP needs a collaborative agreement to prescribe medication," she said. "The provider can practice independently of a physician, but, without prescriptive authority, you are limited on the services that you can provide to patients."
In contrast, full-practice authority states, such as Delaware, allow NPs to practice primary care without supervision of a physician.
States with fewer NP practice restriction also have more NPs providing primary care services to residents.
Barnes said the reason why is obvious.
"In the states with more restrictive laws, say you are a trained NP in a rural area who wants to practice primary care,” Barnes said. “Because there is no physician in town, you can't have a collaborative agreement. Therefore, you can't practice at the advanced practice level."
If the physician-collaborator moves away or retires, the NP loses the ability to practice.
Anecdotal evidence suggests that many NPs have to pay physicians to sign a collaborative agreement, Barnes said.
In addition, Barnes said, more restrictive laws don't improve care.
"All that they are really doing is putting up barriers to primary care. Removing the practice restrictions can really only be a benefit," she said.
Federal prosecutors said that, beginning in 2005, Allegiance cut deals with hospitals to provide Intensive Outpatient Psychotherapy services to patients on the hospitals' behalf.
At each of these hospitals, Allegiance established an Inspirations Outpatient Counseling Center, where Allegiance employees identify potential patients, created patient treatment plans, and performed IOP services.
The settlement resolves claims that Allegiance provided IOP services to Medicare patients that did not qualify reimbursement because:
The patients' medical conditions did not require IOP treatment;
The patients' treatments were not consistent with an individualized treatment plan designed to address specific mental health needs and achievable goals;
The patients' progress was not being tracked or documented;
The patients received inappropriate levels of treatment;
The therapy provided was primarily recreational or diversional, not therapeutic.
"The Department of Justice recognizes the value of accessible mental healthcare, but will not tolerate companies that seek to exploit our most vulnerable populations by delivering inappropriate or worthless services," Acting Assistant Attorney General Chad D. Readler for the Civil Division, said in a media release.
Allegiance did not respond to inquiries from HealthLeaders Media on Wednesday.
Medicare Trustees in their annual report project that total program costs will grow from approximately 3.7% of GDP in 2017 to 5.8% of GDP by 2038.
Funding for Medicare will be depleted in 2026, three years earlier than what was projected in last year's report by the federal trustees for the program.
By 2026, Medicare's Hospital Insurance Trust Fund will pay 91% of costs, and drop to 78% by 2039, according to a report released Tuesday by trustees for Medicare and Social Security.
"The HI fund again fails the test of short-range financial adequacy, as its trust fund ratio is already below 100% of annual costs, and is expected to decline continuously until reserve depletion in 2026," the report said.
Among the projections:
Medicare Part B, and D will remain adequately funded "into the indefinite future," the trustees reported, because law provides financing from general revenues and beneficiary premiums each year to meet the next year’s expected costs.
The aging population and rising health care costs cause Parts B and D projected costs to grow steadily from 2.1% of GDP in 2017 to approximately 3.6% of GDP in 2037. General revenues will finance roughly three-quarters of SMI costs, and premiums paid by beneficiaries almost all of the remaining quarter.
Total Medicare costs will grow from approximately 3.7% of GDP in 2017 to 5.8% of GDP by 2038.
Social Security and Medicare will experience cost growth substantially in excess of GDP growth through the mid-2030s due to rapid aging of the Baby Boomer generation, and lower-birth-rate generations entering employment.
Social Security's Old-Age and Survivors Insurance Trust Fund, and Disability Insurance Trust Fund will be depleted in 2034, the same year projected in last year's report.
The trustees urged Congress to consider options to reduce or eliminate the long-term financing shortfalls in Social Security and Medicare "as soon as possible."
"Taking action sooner rather than later will permit consideration of a broader range of solutions and provide more time to phase in changes so that the public has adequate time to prepare," the trustees concluded.
For the second time in a month, the Manhattan-based urgent care chain will pay a fine to settle false claims allegations related to government-sponsored health insurance plans.
CityMD will pay New York State $883,000 to settle false claims allegations involving inappropriate facilities fees charged to the state's Empire Plan health insurance program for government workers and their families.
It's the second false claims payout in a month for the Manhattan-based urgent care franchise, which last month agreed to pay the federal government $6.6 million to settle allegations brought forward in a whistleblower lawsuit.
"My office will not tolerate healthcare providers who overbill government healthcare plans," New York Attorney General Barbara D. Underwood said of the latest settlement, in a media release issued Tuesday.
"Today's settlement makes clear that we will hold accountable any entity responsible for false payment claims to the Empire Plan or other government health plans," she said.
In a statement released Tuesday, CityMD said it was "pleased to have reached a satisfactory resolution to this matter, which involved past insurance billing and coding. This matter was unrelated to CityMD's patient care, which has consistently been of the highest quality."
New York State prosecutors found that:
From December 2010 to September 2013, CityMD knowingly overbilled the Empire Plan for facility fees to which they were not entitled.
Because CityMD had entered into Empire Plan contracts with United HealthCare, the urgent care chain's affiliates were prohibited from billing for facility fees – a detail that was explicitly made clear in the contracts.
CityMD ignored United HealthCare repeated warnings that facility fees were not permitted under the Empire Plan. Instead, CityMD claimed that facility fees that were separate from, and in addition to, the fees claimed for professional services.
CityMD admitted that despite the explicit prohibition written into the contract and UnitedHealthCare's warnings, it continued to bill for facility fees.
CityMD also admitted that it violated the New York False Claims Act and paid $706,400 to the state—including the $37,300 that was overbilled and not yet repaid, and over $669,000 in additional damages, fees, and costs.
The settlements come amid CityMD's aggressive expansion in the New York City area. Earlier this year, CityMD acquired STAT Health, an urgent care provider with 12 clinics on Long Island, and FirstMed Immediate Medical Care, an urgent care center in Queens.
CityMD Responds
CityMD issued the following statement: "CityMD is pleased to have reached a satisfactory resolution to this matter, which involved past insurance billing and coding. This matter was unrelated to CityMD's patient care, which has consistently been of the highest quality."
"Throughout CityMD's history, and especially over the past year, we have made substantial investments in strengthening our compliance program, which has included the enhancement and implementation of detailed compliance policies and procedures and the appointment of a new, full-time chief compliance officer."
"We earn the trust of the communities we serve by providing an exceptional experience through high-quality medical care and convenient access, and that includes ensuring everyone at CityMD understands that they are an integral part of our business and adheres to best-in-class compliance practices."
Using the old axiom, 'If you've seen one Medicaid program, you've seen one Medicaid program,' stakeholders say Scorecard data does not account for state-by-state program variations.
A key Medicaid stakeholder has raised concerns about what it calls the "beta version" of a new Scorecard for the program that was released this week by the Centers for Medicare & Medicaid Services.
The National Association of Medicaid Directors is questioning the comparability, accuracy and timeliness of the data that is reported on the scorecard, and the conclusions that may be drawn when comparing states with different structures and care delivery approaches.
While the Scorecard has been annotated to reflect some constraints, the measures remain problematic, NAMD said, adding that meaningful context for using the data is needed.
Problems include:
Most of the data are sourced to 2015;
In some cases, data reflect a state's beneficiaries in fee-for-service or managed care, but not necessarily beneficiaries in both delivery models. This can result in relatively healthy populations being compared to those with disabilities or complex conditions;
Some states reported using a claims-based only methodology while others used a hybrid methodology of claims and medical record review;
Variability in completeness of reporting as Medicaid Adult and Child Core set measures have been voluntary to date.
"Until these fundamental variances are addressed in the Scorecard, it will not be possible to make apples-to-apples comparisons between states," NAMD said.
Federal policymakers say the scorecard will usher in a new era of accountability by publishing state and federal Medicaid and CHIP outcomes.
The Centers for Medicare & Medicaid Services on Monday released its first ever Medicaid and Children's Health Insurance Program Scorecard.
CMS Administrator Seema Verma, in a media release, called the scorecarda central component in the modernization of Medicaid and CHIP through greater transparency and accountability for program outcomes.
"Despite providing health coverage to more than 75 million Americans at a taxpayer cost of more than $558 billion a year, we have lacked transparency in the performance and outcomes of this critical program," Verma said.
"The scorecard will be used to track and display progress being made throughout and across the Medicaid and CHIP programs, so others can learn from the successes of high performing states. By using meaningful data and fostering transparency, we will see the development of best practices that lead to positive health outcomes for our most vulnerable populations," Verma said.
The first version of the Scorecard includes measures voluntarily reported by states, and federally reported measures in three areas: state health system performance; state administrative accountability; and federal administrative accountability.
The metrics in the first Scorecard include well child visits, mental health conditions, children's preventive dental services, and other chronic health conditions.
The Scorecard is the first time that CMS is publishing state and federal administrative performance metrics, such as state/federal timeliness of managed care capitation rate reviews, time from submission to approval for Section 1115 demonstrations, and state/federal state plan amendment processing times.
At hospitals seeing fewer than 225 immunosuppressed patients with sepsis each year, these patients were 38% more likely to die while hospitalized, compared to 21% more likely to die at hospitals that saw 225 or more of these patients yearly.
Mortality rates for immunosuppressed patients with sepsis are higher when they're treated in hospitals with small numbers of these patients, a new study shows.
"While there is a lot of focus on improving sepsis outcomes through early interventions, some patients have poor outcomes from sepsis because their chronic medical conditions may worsen after the initial infectious insult," said study author Jared A. Greenberg, MD an assistant professor and critical care physician at Rush University Medical Center in Chicago.
"We hypothesized that septic patients who are immunocompromised may have improved outcomes if they are managed at hospitals that have the most experience managing immunocompromising conditions," Greenberg said in comments accompanying the study.
The researchers analyzed medical records of 350,183 patients with sepsis at 60 hospitals. One of five of those patients was classified as being immunocompromised based on being HIV-positive or having an intrinsic immune disorder, having a blood cancer or being prescribed an immunosuppressive drug for certain medical conditions while hospitalized.
The study found:
15% of immunosuppressed patients with sepsis died during hospitalization compared to 12% of non-immunosuppressed patients with sepsis at all hospitals.
At hospitals seeing fewer than 225 immunosuppressed patients with sepsiseach year, these patients were 38% more likely to die while hospitalized, compared to 21% more likely to die at hospitals that saw 225 or more of these patients yearly.
Above 225, caring for greater numbers of immunosuppressed patients with sepsis(one hospital treated 1,056 such patients) did not appear to reduce mortality.
Immunosuppressed patients withsepsis were more likely than non- immunosuppressed patients to return to their homes after discharge, rather than another health facility, 60% vs. 50%, respectively.
Greenberg said the last finding was a surprise. He said non-immunosuppressed patients may have been in declining health before sepsis than immunosuppressed patients, as they were more likely to be older and to be admitted directly from other healthcare facilities.
The study does not explain why survival rates are higher in hospitals that treat more immunosuppressed sepsis patients, but the authors speculate that "immunosuppressed patients with sepsis had improved survival at hospitals where clinicians had greater familiarity caring for immunosuppressed patients."
Sepsis kills 258,000 people each year in the United States and costs more than $24 billion. It represents 6.2% of all hospital costs across the nation, which makes it the most expensive condition in the nation's healthcare system, according to the federal government's Healthcare Cost and Utilization Project.
The Franklin, TN-based for-profit hospital chain continues to unload hospitals in its ongoing effort to reduce debt.
Community Health Systems, Inc. this week finalized the previously announced sale of three hospitals in its Tennova Healthcare subsidiary to West Tennessee Healthcare, a Jackson-based public, not-for-profit health system.
The three hospitals are: 225-bed Tennova Healthcare Dyersburg Regional; 150-bed Tennova Healthcare Regional Jackson; and 100-bed Tennova Healthcare Volunteer Martin.
Financial terms were not disclosed, but local media estimated the value of the deal at $67 million.
The three hospitals are among the planned divestitures discussed on the company's fourth quarter 2017 earnings call. CHS has been working to reduce the debt burden it accrued with the 2014 acquisition of Naples, FL-based Health Management Associates.
The WTH deal includes all physician clinics and outpatient services associated with the three hospitals, which will also become part of WTH’s 18-county network of medical centers and outpatient services.
When the deal was announced in March, WTH CEO James E. Ross called the acquisition "consistent with our stated mission to improve the health and well-being of the communities we serve while providing exceptional and compassionate care."
The Tennova hospitals were acquired and rebranded by CHS in 2014 when it bought out HMA. With the WTH sell-off, Tennova will operate 12 hospitals across Tennessee.
Infection rates were thought to be in the neighborhood of one in a million, but new research shows the rate of infection is more than 1 in 1,000 for screening colonoscopies and 1.6 per 1,000 for non-screening colonoscopies.
The rates of infection following colonoscopies and upper-GI endoscopies at some outpatient specialty centers is more than 100 times higher than previously believed, Johns Hopkins researchers say.
Using an all-payer claims database, the researchers examined 2014 data from six states — California, Florida, Georgia, Nebraska, New York and Vermont — to track infection-related emergency room visits and unplanned inpatient admissions within seven and 30 days after a colonoscopy or EGD.
They found that:
Patients who underwent one of the common procedures at ambulatory surgery centers were at greater-than-expected risk of bacterial infections, including E. coli and Klebsiella.
The rate of infection seven or fewer days after the procedure was slightly higher than 1 in 1,000 for screening colonoscopies and about 1.6 per 1,000 for non-screening colonoscopies. Rates for EGDs within that time were more than 3 per 1,000.
Almost 45 in 1,000 patients who'd been hospitalized within 30 days prior to a screening colonoscopy visited a hospital with an infection within a month.
Within those parameters, the rate of infection-related hospitalization for EGDs was more than 59 patients per 1,000.
Among the ASC post-procedure infections, the rates were slightly higher for diagnostic procedures, as opposed to screening procedures.
ASCs with the highest volume of procedures had the lowest rates of post-endoscopic infections.
The Ambulatory Surgery Center Association reports that 64% of ASCs were owned by physicians, while 28% were affiliated with hospitals or health systems.
Study lead author Susan Hutfless, an assistant professor of medicine at the Johns Hopkins University School of Medicine, said that many ASCs lack electronic medical records connected to hospital emergency departments, so they're unlikely to learn about patients' infections.
"If they don't know their patients are developing these serious infections, they're not motivated to improve their infection control," Hutfless said in remarks accompanying the study.
Hutfless said patients should be aware of infection risk associated with all endoscopic procedures.
