Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
After more than two years of development, the Agency for Healthcare Research and Quality has released its MONAHRQ (My Own Network powered by AHRQ) software that hospitals can use without charge to compile, analyze, and post data on the quality and cost of their healthcare.
The Windows-based software is designed to permit hospitals and other users to create customized Websites with data that can be used either for internal quality improvement or public reporting of quality information. Average approximate time to set up the software is about one to two days, according to Anne Elixhauser, Ph.D., a senior research scientist with AHRQ.
The use of the software is open to other entities as well such as state governments, health insurers, health information technology vendors, and other providers. The costs to organizations creating a Website with quality data from scratch—before the introduction of MONAHRQ—have run as high as $300,000 and could take a year to set up, based on the experiences of some users, according to Elixhauser.
Hospitals that download MONAHRQ can customize it by entering in hospital administrative data, including elements such as patient characteristics, diagnoses, procedures, health insurance type, and charges. MONAHRQ processes that information and then creates a Website that can be customized, Elixhauser says.
The initial version of the MONAHRQ Website is able to display four main paths at the current time, says Elixhauser. Two of the paths are at the hospital level:
AHRQ quality indicators subset. Currently, there are 57 measures that include hospital mortality, volume of procedures, and patient safety indicators that can be displayed.
Measures of utilization. This helps examine the numbers of discharges, costs, lengths of hospitalizations, and charges for various health conditions and procedures.
And, two of the paths are at the county level:
Potentially preventable hospitalizations. This will create maps of county by county rates for where hospitalizations can be avoided, plus provide a view of potential cost savings. This could include looking at uncontrolled chronic conditions such as diabetes or asthma.
Rates of health conditions and procedures. This includes a view of the prevalence of diseases or medical procedures—looking at discharge data within a specific geographic area.
"We are currently working on [MONARHQ] Version 2," Elixhauser says. "That will allow data organizations to download their hospital-level statistics" from data sources such as the Centers for Medicare and Medicaid Services Website, including data with Hospital Compare, she says. This version probably will be completed by next year.
In response to the motion filed two weeks ago by the Obama administration to dismiss Virginia's lawsuit over the new federal healthcare reform law, State Attorney General Ken Cuccinelli countered in his motion filed this week that the state can challenge the federal government over the individual mandate to purchase healthcare insurance.
In the May 24 federal motion filed in the U.S. District Court for the Eastern District of Virginia, Health and Human Services Secretary Kathleen Sebelius said that the healthcare reform law was within the scope of the Constitution's Commerce Clause. However, in his June 7 motion, Cuccinelli disagreed: "A claim of power under the Commerce Clause to regulate the status of being uninsured is unprecedented, as Congress well knew prior to passing the law."
"Despite the Secretary's attempt to characterize this lawsuit as a policy battle, it is not," Cuccinelli added in his motion. "This is a legal contest. At issue is whether a state law survives because the federal law that would displace it is beyond the power of Congress to enact--or whether the state law must yield to a valid federal enactment."
If the government prevails in the case and "Congress uses the Commerce Clause to order Americans to buy private health insurance, then Congress will have been granted a virtually unlimited power to order you to buy anything," Cuccinelli added.
Cuccinelli also countered that it does not matter that the mandate will not take effect until 2014. Based on several previous Supreme Court decisions, if a dispute is certain to occur in the future, this will not prohibit the suit from being brought in the present, he observed in a statement.
The Virginia case is separate from a Florida suit, which includes 20 states challenging the legislation over similar grounds on the insurance mandate. It is also separate from a suit filed in Michigan on behalf of four uninsured individuals who did not plan to buy health insurance and claimed they would be harmed by the monetary penalty when insurance becomes mandatory in 2014.
If U.S. District Court judge allows the case to move forward, it could be heard Oct. 18.
Under the Senate substitute amendment to the jobs bill (HR 4213) unveiled Tuesday, physicians would get some relief from the 21% cut in Medicare and TRICARE physician reimbursements now in effect.
Using the same language found in the jobs bill passed by the House 10 days ago, physicians would see an increase in payment rates of 2.2% for the remainder of 2010 and a 1% increase in 2011. Rates would return to present law after 2011.
At a "tele-town" meeting with seniors on Tuesday, President Obama did provide some recognition of the physicians' current plight by noting that "temporarily, we've got to make sure that your doctor is getting reimbursed so that they can stay in business and keep their doors open."
"We've got to fix this permanently," Obama said. "What we shouldn't do is have this guillotine hanging over their heads every year where they're having to figure out: 'Am I am going to get reimbursed or is suddenly my income going to drop by [21%]?'"
Making a reappearance in the jobs bill amendment was an extension of the Medicaid assistance plan—the Federal Medical Assistance Percentage (FMAP)—that was designed to help financially strapped states under the economic stimulus package pay for additional Medicaid coverage.
FMAP runs through Dec. 31 of this year, but many states had been calling for an extension through June 2011 to coincide with their state budget planning. The House had dropped the FMAP provision in its jobs bill approved last month over the price tag of the provision ($24.2 billion over 10 years) after pressure from fiscally conservative congressmen.
The Senate bill also keeps the provision, included in the bill approved by the House, to change Medicare's "72 Hour Rule" to prevent hospitals from submitting separate Medicare reimbursement claims for inpatient and outpatient therapeutic care that are provided within three days of a hospital admission. Hospital groups have expressed concern over the bill's payment reduction to hospitals.
Not included in the amendment—and excluded from the House jobs bill—were subsidies to assist unemployed workers in paying for their healthcare through COBRA through November of this year. The current subsidy expired this month.
An evaluation of 200 of the nation's largest hospitals found that 42% currently do not have policies in place to fully protect gay and lesbian patients from restrictions based on sexual orientation, according to a report released Monday by the Human Rights Campaign (HRC) Foundation.
These policies, though, may soon by changing. In April, President Obama requested that Health and Human Services Secretary Kathleen Sebelius initiate rulemaking to lift restrictions on unrelated visitors to act as surrogate decision makers and to visit hospitalized patients. The ruling would affect hospitals that participate in Medicare or Medicare, is expected in several months.
While the "good news is the healthcare landscape is about to change dramatically . . . the sad reality it the status quo is very poor," said Joe Solmonese, HRC's president, in a teleconference on Monday. He called for hospitals to move ahead of the proposed legislation to draft more inclusive policies on their own.
Kaiser Permanente, which recently updated its Patients' Bill of Rights to protect lesbian and gay patients and their families, from discrimination, on Monday became the first large health network to have a fully inclusive non discrimination policy for gay individuals. Kaiser Permanente's network of 36 hospitals also achieved Top Performer status in the HRC Foundation’s Healthcare Equality Index.
The survey also included data from 178 facilities across the country that voluntarily provided information on patient non discrimination, visitation, cultural competency training, and employment non discrimination issues. Of the 178 facilities nationwide, 11 individual facilities and one network of 36 hospitals received "perfect" ratings.
Forty two facilities (one network representing 31 hospitals, 8 individual hospitals and 3 clinics) received top performer status (aside from Kaiser Permanente):
Advocate Illinois Masonic, Chicago;
Baystate Medical Center, Springfield, MA;
Beth Israel Medical Center, New York;
Callen-Lorde Community Health Center, NY;
Dana Farber Cancer Institute, Boston;
Group Health Central Hospital, Seattle;
LA Gay and Lesbian Center, Los Angeles;
Penobscot Community Health Center, Bangor, ME;
Rush University Medical Center, Chicago;
University of California, San Francisco Medical Center, San Franscisco;
University of Texax MD The University of Texas MD Anderson Cancer Center Houston.
When Congress returns from its Memorial Day recess this week, it will be looking at a jobs bill (HR 4213)—passed by the House and still pending in the Senate—that no longer extends subsidies to assist unemployed workers in paying for their healthcare through COBRA.
Initially, the jobs bill included an extension through November of this year in which unemployed workers (laid off between September 2008 and May 31 of this year) would be responsible for 35% of their COBRA payments, while the federal government would pick up the remaining 65% of the tab. As the House sought to keep costs down in the jobs bill, that provision was dropped.
As of June 1, this subsidy—initially granted under the economic stimulus legislation in 2009—is now expired, meaning unemployed workers would have to pay 100% of their COBRA costs.
Without this subsidy, many families will not be able to afford COBRA coverage, according to a new study from Families USA. With assistance from the federal government, the average family premiums for COBRA coverage had averaged $387 per month nationally. However, without this subsidy, those costs will jump to an average of $1,107 a month for unemployed families.
Without the subsidy, unemployed workers nationwide will have to spend, on average, 84.3% of their monthly unemployment insurance checks on COBRA premiums to maintain coverage, the report estimated. The average monthly cost of family COBRA coverage without a subsidy exceeds the average monthly unemployment income in 11 states: Alabama, Alaska, Arizona, Delaware, Florida, Louisiana, Mississippi, New Hampshire, South Carolina, Tennessee, and West Virginia, the report noted.
The elimination of COBRA subsidies means unemployed people will lose their healthcare coverage, said Ron Pollack, executive director of Families USA, in a statement. "Such a loss of health coverage flies in the face of the recently enacted health reform legislation that is intended to expand health coverage to tens of millions of people."
In addition, the current jobs bill approved by the House also dropped an extension of the Medicaid assistance plan—the Federal Medical Assistance Percentage (FMAP)—that was designed to help financially strapped states under the economic stimulus package pay for additional Medicaid coverage.
FMAP runs through Dec. 31 of this year, but the states had requested an extension through June 2011 to coincide with their state budget planning. Failure of Congress to approve both COBRA and FMAP extensions "will fly in the face of the recently adopted health reform law, which is intended to expand health coverage substantially, starting in 2014," the report said. This failure could create the opposite effect—"causing more and more people to join the ranks of the uninsured and underinsured."
The challenge was issued just a mere three months ago by the Department of Health and Human Service (HHS) and the Institute of Medicine: Find innovative ways to distribute public health data that is local, regional, and national to help providers, patients, and local leaders across the country improve healthcare.
On Wednesday in Washington, DC, that call was met with the introduction of the Community Health Data Initiative (CDHI)—which will use free Web applications, mobile phone applications, social media, video games, and other cutting edge technologies, as HHS Secretary Kathleen Sebelius said, to "put our public health data to work."
"It's a participatory venture," Sebelius said at a briefing introducing the initiative. "This project was launched by a pretty simple belief that people in communities can actually improve the quality of their healthcare and their public health systems if they just have the information to do it—to make it happen."
"Our national health data constitute a precious resource that we are paying billions to assemble, but then too often wasting," Sebelius said. "When information sits on the shelves of government offices, it is underperforming. We need to bring these data alive."
The initiative highlighted data currently available: HHS already has posted 117 data sets and tools on the Data.Gov site since its debut in May 2009. These data sets and tools include:
Hospital by hospital quality performance statistics compiled by CMS to help inform consumer choices regarding where to get care (with additional statistics on nursing homes, dialysis facilities and home health agencies).
A regularly updated data set representing technologies available for licensing from the National Institutes of Health and the Food and Drug Administration, helpful to entrepreneurs and companies looking to drive innovation.
A household cleaning products data set that links over 4,000 consumer brands to health effects that the manufacturers are submitting and which allows scientists and consumers to research products based on chemical ingredients
Detailed summaries of Medicare expenditures on physician services, which allow the public to understand patterns of Medicare spending and analyze the types of services being delivered to address the health needs of the Medicare population.
But new efforts are being pursued as well. To promote community health data, HHS Deputy Secretary Bill Corr said that a new web-based health indicators warehouse would be launched online at the end of this year—providing data on national, state, regional, and county health performances on rates of smoking, diabetes, obesity, and other health indicators.
With the site, data will be easily downloadable and made available to other sites. The Centers for Medicare and Medicaid Services will be supplying new data to this site on disease prevalence, cost, quality, and utilization of services.
But at the introduction of the CDHI, a number of new innovations were unveiled as new examples at the briefing to show the power of public health data in providing better healthcare. The briefing can be viewed at HHS' Open Government website.
One company introduced a new way to track and manage anonymously the occurrence of asthma—via a GPS device in an inhaler. This method would look at how often asthma inhalers were being used and where they were being used on a map. This information could be viewed on a computer or a mobile device to show if asthma symptoms were being controlled and where asthma symptoms were most likely to arise
And another provided different ways to use dashboards and data sets to support research. As one example, a map was used to mark the areas where child poverty was high in counties around the country, to note the availability of HHS federal assistance grants in those areas, and to show locations of nearby hospitals providing acute care.
And who said data can’t be fun? A new social networking online game, called Community Clash, was launched at the meeting to help learn about available health data, according to its creators. It permits two players representing two communities to duel with their cards over such topics as rates of obesity, death by motor vehicle, exercise, or smoking. Conversation is encouraged afterwards through channels such as Twitter or Facebook.
This is only the beginning, Corr said. "HHS is not controlling, choreographing, or paying for the development of these applications.”
“Our role simply is to supply high quality, free community health data, and then let you—the innovators—take it from there," he said.
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The National Association of Insurance Commissioners (NAIC), in a letter to Health and Human Services Secretary Kathleen Sebelius, said it was unable to meet the revised deadline of June 1 set by HHS to translate what qualifies for health insurers for "medical loss ratio" in the new healthcare reform law.
"We certainly appreciate the need to complete this project as soon as possible—waiting until the [original] deadline of December 31, 2010, in the law is not an option—but we also appreciate, as you do, how critically important it is to do this right," said NAIC President Jane Cline, who is also the West Virginia insurance commissioner.
With the medical loss ratio, health insurers are to spend at least 80 cents out of every premium dollar on actual medical care in the individual and small group markets and at least 85 cents on that care in the large group market starting Jan. 1, 2011. Rebates would be owed to consumers if insurers failed to meet the ratios.
However, what exactly is considered medical care could have multiple definitions—as NAIC found out last month when it requested suggestions from healthcare providers, insurers, consumers, and others. Questions have come up whether it can mean areas such as nurse hotlines or disease management programs.
The NAIC noted further in its letter that the medical loss ratio and rebate program in the reform law have the potential to "destabilize the marketplace and significantly limit consumer choices if the definitions and calculations are too restrictive."
In addition, a medical loss ratio and rebate program could be "rendered useless if the definitions and calculations are too broad," it said. "Only through an open, deliberative process can we hope to reach a reasonable consensus that meets the dual objectives of protecting consumers and preserving competitive markets."
NAIC told HHS it will continue "to work diligently and transparently to complete its report on medical loss ratio, and will keep [HHS] updated on our progress." However, no new deadline was given.
A number of Medicare Advantage plans that attracted beneficiaries in "good health" with lower cost plans in 2008 had far higher levels of cost sharing and unexpected expenses than those plans attracting beneficiaries in "poor health," according to a Government Accountability Office (GAO) report.
Acting CMS Administrator Charlene Frizzera, in response to the report's findings, said they were consistent with CMS' general experience that "beneficiaries select health plans based on their individual health status"—that beneficiaries with "poorer health status tend to choose plans with higher premiums and lower cost sharing."
However, others in Congress saw the report, requested by Democrats on the House Ways and Means and House Energy and Commerce committees, somewhat differently.
"This report shows that left to their own devices, insurance companies will design plans that benefit their profit margins above all else, House Ways and Means Health Subcommittee Chairman Pete Stark (D CA) said in a statement.
"Unfortunately, these discriminatory plans leave many seniors with unexpected out of pocket costs, much higher than they would have had if they had been in traditional Medicare," Stark said. "As CMS implements Medicare Advantage reforms, they need to hold insurance companies accountable so they can't stick seniors with the bill for their profit maximizing schemes."
The "good health" group of Medicare Advantage plans had average beneficiaries with projected healthcare costs at least 10% below those for all beneficiaries within the plan's service area.
Using 2008 data on beneficiaries' expected healthcare costs, the most recent data available, GAO sorted 2,899 plans enrolling 7.5 million beneficiaries into three groups: 43% of plans were in the good health group, 37% in the average health group, and 20% in the poor health group.
According to the GAO, the good health group of plans tended to have higher cost sharing for the services they reviewed—which included inpatient hospital acute stays, inpatient mental health stays, skilled nursing facility (SNF) stays, and renal dialysis—than the poor health group of plans:
The average plan in the good health group charged about $100 more in cost sharing for a typical inpatient hospital stay (six days) and about $150 more for a typical inpatient mental health stay (21 days) than the average plan in the poor health group.
The average plan in the good health group charged about $500 more in cost sharing for a typical SNF stay (35 days) than the average plan in the poor health group.
The average plan in the good health group charged over $300 more in cost sharing for a year of renal dialysis (156 sessions) than the average plan in the poor health group.
In 2008, a greater share of plans in the good health group had an out-of-pocket maximum that limited their beneficiaries' overall financial risk compared to plans in the poor health group—63% percent compared with 40%, respectively.
However, the out-of-pocket maximum for the good health group of plans averaged 55% percent higher than the out-of-pocket maximum for the poor health group ($3,515 compared with $2,262). Also, these of plans were most likely to exclude Part B drugs (15% of plans), renal dialysis (6% of plans), and durable medical equipment (6% of plans) from their out-of-pocket maximum.
The insurance industry responded that the GAO report demonstrated that Medicare Advantage plans overall did save seniors money compared to traditional Medicare.
"The vast majority of seniors have expressed very high satisfaction with their Medicare Advantage coverage," America's Health Insurance Plans spokesperson Robert Zirkelbach said in a statement, referring to all plans.
"Recent reports have found that seniors in Medicare Advantage spend fewer days in a hospital, are subject to fewer hospital readmissions, and are less likely to have 'potentially avoidable' admissions," he said, "for common conditions ranging from uncontrolled diabetes to dehydration, compared to fee for service Medicare."
The GAO report noted that since 2008, CMS has revised its process for reviewing Medicare Advantage plans for the likelihood of discrimination. It developed a new methodology for setting cost sharing thresholds—criteria used to identify benefit packages likely to discriminate against certain beneficiaries.
For contract year 2010, CMS had contacted all Medicare Advantage plans with benefit packages identified as likely to discriminate, and "all plans subsequently met cost sharing thresholds," the report noted.
The new methodology for setting cost sharing thresholds allowed higher cost sharing for some services relative to 2009: For example, among plans without an out-of-pocket maximum or one above $3,400 for 2010, allowed cost-sharing for a typical inpatient mental health stay doubled (from $61 per day to $130 per day) and allowed cost-sharing for a typical skilled nursing facility stay increased (from $53 to $70 per day) compared to 2009 rates.
For physicians, the third time has not been the charm this year for those looking to finally get some relief from a 21% cut in Medicare and TRICARE physician reimbursements. While the House voted on Friday 245 171 to approve of a 19-month plan to stall the 21% reduction starting June 1, the Senate will not be able to act until it returns from its Memorial Day recess June 7.
With the "doc fix" approved by the House, physicians would see an increase in payment rates of 2.2% for the remainder of 2010 and a 1% increase in 2011. Rates would return to present law after 2011. This is the third deadline missed by Congress this year; the others were March 1 and April 1. In previous years, Congress had voted to delay the cuts annually.
The delay by Congress has been accompanied by sharp words from physician organizations. Last week, the American Academy of Family Physicians had expressed support for a patch proposed earlier by the House that would have extended postponement of the sustainable growth rate (SGR) formula by three years, with an increase for primary care services included in 2012 2013. But Friday, the group changed its tone over what it sees as Congress' inability to make more permanent changes in the SGR.
"Family physicians are outraged that Congress has jeopardized the healthcare security of millions of elderly and disabled Americans who depend on Medicare and TRICARE," said AAFP President Lori Heim, MD, of Vass, NC, in a prepared statement.
Congress needed to "retroactively rescind this pay cut and replace the deeply flawed SGR formula with one that reflects actual practice costs that physicians experience," she said. "The political gamesmanship must end. A comprehensive and stable Medicare payment system must be put in place."
"The American College of Physicians is deeply disappointed by Congress' recurring failure to pass legislation to stop a devastating 21% cut in Medicare and TRICARE payments to physicians," said ACP President J. Fred Ralston, Jr., MD.
Ralston, an internist in Fayetteville, TN, said that "too many members of Congress from both political parties" have declined to "support legislation to move toward a better and more stable payment system, which could have served as the basis for permanent repeal of the unworkable SGR formula."
"[Congressional members have] withheld their support even though they knew that the result will be to further undermine physicians' and patients' faith in Medicare and TRICARE," he added. "They withheld their support, even though they knew it would introduce chaos into physician practices."
ACP said that during the Memorial Day recess, it was encouraging its members to call on their congressional representatives to tell them that failure to move to "a more stable system to replace the unworkable SGR simply is unacceptable."
"Physicians and patients must let their representatives and senators know that enough is enough. Congress is wreaking havoc on the Medicare program and physician practices across the country," said American Medical Association President J. James Rohack, MD, in his blog. He called for physicians to "Make your voice heard during the Memorial Day recess."
As when Congress missed the other two deadline this year, the Centers for Medicare and Medicaid Services told its contractors to hold claims for Medicare reimbursement for 10 business days "to avoid disruption in the delivery of healthcare services" to beneficiaries and payment of claims for physicians.
The House, which had appeared close to voting Thursday on the "American Jobs and Closing Tax Loopholes Act of 2010" (HR 4213) that contains a provision to delay a 21% cut in physician Medicare reimbursements after a June 1 deadline, faltered over concerns about the bill's costs voiced by Republicans and some Democrats.
The House will continue deliberations today. However, the delay means that the bill would not make it in time to be voted on by the Senate. Late Thursday, Democratic leaders in the Senate acknowledged they would not be able to approve a bill before adjourning for the Memorial Day weekend.
This means that, like earlier this year, the deadline to postpone the Medicare Sustainable Growth Rate (SGR) formula from going into effect will be missed—meaning providers could theoretically face cuts.
However, the Centers for Medicare and Medicaid Services (CMS), as it did earlier this year, has instructed its contractors to hold claims containing services paid under the Medicare physician fee schedule for the first 10 business days of June—while Congress deliberates on postponing the SGR.
CMS said the 10 day hold—which will apply to claims with dates of service June 1 and later—should have little overall impact on provider cash flow since electronic claims are not paid until at least 14 days following claims receipt.
The missed deadline, however, has not sat well with the American Medical Association. "The Senate has turned its back on seniors, and America’s physicians are outraged that Congress has deserted patients by failing to address this year's Medicare cut before the June 1 deadline," said AMA President J. James Rohack, MD, in a statement.
"Senators are more interested in heading home for the holiday than in preventing a Medicare meltdown for seniors. The 21% Medicare physician payment cut has been looming all year, and yet all Congress has managed to do is repeated short term delays," Rohack said. "This is complete mismanagement of a healthcare program that America’s seniors and the disabled rely on."
"Enough is enough. Nine times in eight years Congress has delayed the cut and not fixed the problem. Congress needs to buckle down, stop growing the problem, and fix it once and for all," he added.
Under the latest proposed "doc fix" being considered by the House, physicians would see an increase in payment rates of 2.2% for the remainder of 2010 and a 1% increase in 2011. Rates would return to present law after 2011.
One group in the House that opposes the bill in the current form is the conservative Democratic Blue Dog Coalition, which said it wanted unemployment insurance and health subsidies for laid off workers cut even more before they would vote for the package.
