Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Medicare Recovery Audit Contracting has made great strides in recovering millions of dollars lost to waste and fraud in the past few years. However, it will face challenges as it expands to include new areas of Medicare Advantage (Part C), Medicaid, and prescription drug coverage (Part D)—as spelled out earlier this year under the new healthcare reform law—according to those testifying last week before a Senate panel.
These expansions will take the RAC Medicare program beyond Medicare fee-for-service for the first time by Dec. 31, said Deborah Taylor, head of the Office of Financial Management at the Centers for Medicare & Medicaid Services. But while the "RACs proved effective and relevant" to Medicare fee-for-service, "it remains to be seen how this effort will translate into other programs."
"Each of these programs are administered and reimbursed differently and present their own unique challenges," she testified before the Senate Homeland Security and Governmental Affairs' Subcommittee on Federal Financial Management, Government Information, Federal Services and International Security. Medicaid in particular will create new demands since there are more than 50 programs found in the states and territories.
An audit by the Department of Health and Human Services Office of Inspector General (OIG) discovered that "Medicare does not have a strong process" to ensure valid identification numbers on reimbursed prescriptions under the drug program, said subcomittee head Sen. Tom Carper (D-DE).
However, the Office of the HHS Inspector General (OIG) recently found that safeguards for indentifying claims with invalid prescriber numbers were not functioning correctly for Part D claims, Vito said. These problems with Part D actually paralleled problems encountered over the past decade with Medicare Part B for medical devices.
In its report released last month, for instance, the OIG found that more than 18 million prescription drug records in 2007 had invalid prescriber identifiers, he told the Senate Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security. With these identifiers, which represented 2% of all Medicare Part D claims, pharmacists were paid more than $1.2 billion in one year.
One invalid prescriber identifier that did not meet format specifications was a string of nine zeroes: However, this single invalid identifier accounted for nearly 40,000 prescription records worth $3.7 million in 2007, Vito said.
CMS's implementation of National Provider Identifiers—the standard method now being used to identify prescribing physicians on Part D claims—and its agreement to take steps to address recommendations in the latest OIG report indicates "the agency plans to address these vulnerabilities," Vito said.
The length of the average Medicare certified hospice stay in a nursing home has doubled—from 46 days to 93 days—during the last 10 years, according to researchers at Brown University in Providence, RI.
Part of the reason for the increase is related to a standard daily payment rate for most Medicare hospice enrollment days is an incentive for some of the longer stays, according to the study, which evaluated hospice use in U.S. nursing homes between 1999 and 2006. It will appear in the August issue of The Journal of the American Geriatrics Society.
The study also found that the doubling of Medicare services in nursing homes is related to a 50% growth rate in the number of hospices—primarily for profit hospices. At the current time, a third of Medicare beneficiaries who die in nursing homes are accessing hospice services, and the study predicts that this number is expected to increase.
While the increased availability and use of Medicare sponsored hospice services was cited as a positive development by the researchers, concern was raised that stays were longest in states with the greatest provider growth. The researchers raised the possibility that reimbursement policies could be contributing to the volume of these very long stays.
"Although a direct link was found between increases in hospice enrollments and a rise in the number of providers, it is the increasingly long lengths of stay we believe that raise policy concerns." says Susan Miller, associate research professor of community health at Brown and lead author of the report.
However, she says caution should be placed against making sweeping changes to the program, which could deny nursing home residents hospice care. "What is needed is a tiered Medicare hospice payment system, which gives higher rates for the beginning and end of the patient's treatment," she says.
In addition to changing the rates of payment to reflect the timing of the more intense care needs, the researchers agree with a Medicare Payment Advisory Commission's recommendation that procedures for determining hospice eligibility recertification should be strengthened.
These changes would help the Medicare system avoid the possible scrutiny of nursing home residents who live beyond the physician certified six month prognosis—a Medicare requirement for hospice eligibility—and would permit patients to access the hospice care when they need it, Miller says. In 2006, 30% of nursing home hospice stays were found to be seven days or less. Currently, 500,000 U.S. adults die in nursing homes each year.
The Medicare hospice benefit is designed to provide visits by an interdisciplinary care team to better manage pain and other end of life issues and to provide psychosocial and spiritual support in the nursing home setting for residents and their families.
Medicare Recovery Audit Contracting has made great strides in recovering millions of dollars lost to waste and fraud in the past few years. Its success with the new areas of Medicare Advantage (Part C), Medicaid, and prescription drug coverage (Part D) as spelled out earlier this year under the new healthcare reform law, is uncertain according to those testifying last week before a Senate panel.
These expansions will take the RAC Medicare program beyond Medicare fee-for-service for the first time by Dec. 31, said Deborah Taylor, head of the Office of Financial Management at the Centers for Medicare & Medicaid Services. But while the "RACs proved effective and relevant" to Medicare fee-for-service, "it remains to be seen how this effort will translate into other programs."
"Each of these programs are administered and reimbursed differently and present their own unique challenges," she testified before the Senate Homeland Security and Governmental Affairs' Subcommittee on Federal Financial Management, Government Information, Federal Services and International Security. Medicaid in particular will create new demands since there are more than 50 programs found in the states and territories.
An audit by the Department of Health and Human Services Office of Inspector General (OIG) discovered that "Medicare does not have a strong process" to ensure valid identification numbers on reimbursed prescriptions under the drug program, said subcomittee head Sen. Tom Carper (D-DE).
However, the Office of the HHS Inspector General (OIG) recently found that safeguards for indentifying claims with invalid prescriber numbers were not functioning correctly for Part D claims, Vito said. These problems with Part D actually paralleled problems encountered over the past decade with Medicare Part B for medical devices.
In its report released last month, for instance, the OIG found that more than 18 million prescription drug records in 2007 had invalid prescriber identifiers, he told the Senate Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security. With these identifiers, which represented 2% of all Medicare Part D claims, pharmacists were paid more than $1.2 billion in one year.
One invalid prescriber identifier that did not meet format specifications was a string of nine zeroes: However, this single invalid identifier accounted for nearly 40,000 prescription records worth $3.7 million in 2007, Vito said.
The Centers for Medicare and Medicaid Services' (CMS) implementation of National Provider Identifiers—the standard method now being used to identify prescribing physicians on Part D claims—and its agreement to take steps to address recommendations in the latest OIG report indicates "the agency plans to address these vulnerabilities," Vito said.
"Our findings cast serious doubt on the ability of medicine to self regulate with regard to impaired or incompetent physicians," said study co-author Catherine DesRoches, DrPh, of the Mongan Institute at the Massachusetts General Hospital, Boston. "Since physicians themselves are the primary mechanism for detecting such colleagues, understanding their beliefs and experiences surrounding this issue is essential. This is clearly an area where the profession of medicine needs to be concerned."
The 1999 Institute of Medicine report, To Err Is Human, and various media accounts have heightened public awareness of egregious physician behaviors, such as surgeons leaving midway through an operation or performing wrong-site surgery. But the rate of reporting by physicians appeared to be far lower than it should be—given the estimated numbers of physicians who become impaired or who are otherwise incompetent to practice at some point in their careers.
For the survey, a sample of nearly 3,500 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry were contacted. Overall, nearly 1,900 responded. Only 64% of the respondents agreed that physicians should always report impaired or incompetent colleagues. About 70% of respondents indicated feeling prepared to deal with an impaired colleague, and 64% felt prepared to deal with an incompetent colleague in their practice.
Pediatricians appeared to be the least likely to report feeling prepared to deal with impaired or incompetent colleagues, while psychiatrists and anesthesiologists said they felt most prepared. Direct, personal knowledge of an impaired or incompetent physician during the past three years was indicated by 17% of respondents, but only 67% of those with such knowledge actually had gone ahead to report those colleagues.
Overall, the study underscores the need for the medical profession to better educate its members on their reporting duties to ensure safe and competent patient care, said John Fromson, MD, associate director of Postgraduate Medical Education, MGH Psychiatry, and also report co author.
"Those obligations include referring colleagues to physician health programs that can guide and monitor their recovery from substance use and mental disorders, Fromson said.
Among those who would not report a colleague, the most frequently cited reason was the anticipation that someone else would report or take care of the problem, as indicated by 19% of those surveyed. This was followed by the belief that nothing would ever happen even if a report was made—cited by 15%—and a fear of retribution, noted by 12%.
Other reasons associated with not reporting the impaired or incompetent physician were having that physician belong to one or two person practices or being a member of an underrepresented minority or a graduate of a foreign medical school. Respondents who came from a state with high, medium, or low rates of malpractice claims were not linked with a failure to report.
The American Medical Association's Code of Ethics requires colleagues to report those of whom they suspect are unable to practice medicine safely because of impairment or incompetence. Additional efforts on the part of medical societies, specialty and accrediting organizations, and hospitals are needed to reinforce the responsibilities of the medical community and to prepare physicians to deal with these difficult situations, the researchers said.
The Centers for Medicare and Medicaid Services last week expanded its popular Hospital Compare website to include outpatient data related to areas such as hospital 30 day mortality rates and 30-day readmission rates for patients with heart failure, heart attacks, and pneumonia. But one critical health issue is still missing from the national database: the rate of healthcare-associated infections (HAIs) occurring in hospitals.
That's certainly not to say CMS is ignoring the issue. Since 2008, CMS said it would no longer make additional Medicare payments related to certain HAIs obtained in the hospital such as catheter associated urinary tract infections or vascular catheter associated infections.
And, under the healthcare reform legislation approved earlier this year, Hospital Compare—beginning in October 2014—will finally report hospitals' records for several infections covered by Medicare's policy of nonpayment for hospital acquired conditions.
The Department of Health and Human Services also has moved forward with a five-year action plan to tackle HAIs. But it just may not be enough, some consumer groups are saying. These organizations are urging HHS and CMS to go further and adopt proposed regulations that will require all hospitals to disclose how many patients develop certain infections during treatment.
"The goals in this action plan are extremely conservative. When we commented on the action plan, we said that [they] needed to have higher goals," says Lisa McGiffert, director of Consumers Union's Safe Patient Project in Austin, TX. McGiffert helped author a letter on behalf of consumer groups to CMS responding to the plan and pending legislation on reimbursement issues.
"Our feeling was that if this was where we were going to be five years from now, we're in trouble. We need to be much further along," McGiffert says. And it can be done. "We're seeing great progress in hospitals that have implemented the bundles of prevention activities. Some of them are getting their infections down to zero and keeping that over a long period of time."
If efforts "fall short to stop this epidemic," McGiffert says, "10 million hospital patients will get an infection over the next five years and a half a million of them will die," she adds. "We definitely need accountability."
An ongoing effort can be seen in the states that have passed legislation requiring specific HAI reporting plans to be in place. Only one state, though—Pennsylvania—has been publicly releasing hospital-specific data related to HAIs to the public.
To assess whether the HHS's action plan's metrics and targets are being met, it will be necessary to reveal these results to the public in "a meaningful way"—or at the hospital level, McGiffert says.
A proposed federal regulation to report central line bloodstream infections in ICU patients and surgical infection, for instance, is a start toward this accountability—but it does not go far enough, says McGiffert.
All of the HAI targets should be included in the public reporting proposal—especially measures relating to MRSA, c.difficile, urinary tract infections, and ventilator associated pneumonia.
Some strides are being made in pushing the rates of various HAIs down. For instance, in late May, the Centers for Disease Control and Prevention released a first-ever report showing that U.S. healthcare facilities reduced the rate of central line associated bloodstream infections—which claim the lives of 30,000 patients each year—by 18%.
The new report is based on surveillance data collected through the CDC's healthcare associated infection monitoring system, the National Healthcare Safety Network. NHSN is now used among 21 other states as well to collect data, McGiffert notes.
While not all HAIs are preventable, the Association for Professionals in Infection Control found that a number of its member facilities have seen their central line associated bloodstream infections reduced—sometimes to zero—and that in many instances "zero" can be maintained.
This is information that the public would be interested in seeing—the sooner the better. So if public reporting of infection rates can serve as a powerful tool for holding hospitals accountable for reducing infection risks and keeping patients safe, why wait for data five years from now?
Under new rules announced by the White House on Wednesday, new private health plans will be required to cover preventive services—and eliminate most cost-sharing requirements—for such procedures as blood pressure, diabetes and cholesterol tests, many cancer screenings, routine vaccinations, prenatal care, and regular wellness visits for infants and children.
The new regulations, issued by the departments of Health & Human Services, Labor, and the Treasury, will be put into place on Sept. 23, 2010. New health plans beginning on or after that date must cover evidence-based preventive services that demonstrate strong health benefits. These plans may no longer charge a patient a copayment, coinsurance, or deductible for these services when they are delivered by a network provider.
"We've got a long way to go, but already you can see a more friendly health insurance market taking place," said HHS Secretary Kathleen Sebelius, speaking at a briefing at George Washington University Medical Center. "But we knew we had to make it easier for Americans whether they had health insurance or not to get screenings, go to doctor visits, get vaccines, and keep them out of the emergency rooms and hospital beds."
"Getting access to early care and screenings will go a long way in preventing chronic illnesses like diabetes, heart disease, and high blood pressure, said First Lady Michelle Obama at the briefing. And good preventative care will also help tackle an issue that is particularly important to me as First Lady ... childhood obesity in America today. These are important tools, and now it’s up to us to use them."
Under the new regulations, "evidence based preventive services" refer to the services rated by the U.S. Preventive Services Task Force, an independent panel of scientific experts. These services are rated by the group based on the strength of the scientific evidence documenting their benefits.
Preventive services with a grade of A or B, such as breast or colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling will be covered under these rules.
Among the areas addressed in the regulation:
Health plans will cover a set of standard set of vaccines recommended by the Advisory Committee on Immunization Practices—ranging from routine childhood immunizations to periodic tetanus shots for adults.
Health plans will cover preventive care for children recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics.
The guidelines provide pediatricians and other healthcare professionals with recommendations on the services they should provide to children from birth to age 21 to keep them healthy and improve their chances of becoming healthy adults.
Among the services covered are regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight.
For women, health plans will cover preventive care provided to women under both the Task Force recommendations and new guidelines being developed by an independent group of experts, including doctors, nurses, and scientists, which are expected to be issued by August 1, 2011.
One area that will not be covered under the new provision is abortions, the HHS press office clarified Wednesday evening. As is the case with Federal Employees Health Benefit plans and the current healthcare reform law, abortions will not be covered as a pre existing condition for insurance plans except in the cases of rape or incest, or where the life of the woman would be endangered.
In its annual tracking and reporting on more than 1,200 health system measures across 30 industrialized countries, the Organization for Economic Cooperation and Development (OECD), an international study group, found that the United States may be spending its healthcare dollars less efficiently when compared with those other nations.
In particular, the U.S. has a comparatively low number of hospital beds and physicians per capita, while American patients have fewer hospital and physician visits than most other countries. But on the flip side of the coin, spending per hospital visit is higher in the U.S.—with patients more likely to receive procedures requiring complex technology during their stay.
Despite these major investments, the U.S. has failed to achieve improvements in life expectancy comparable to its peer countries. This gap between the investment—and what is delivered in return—"suggests health services in the U.S. are less effectively deployed or come at a higher price," the authors say.
Here's a snapshot of the key findings from the researchers found in the report sponsored by The Commonwealth Fund:
Healthcare spending per capita in the U.S. in 2006 was $6,714—or more than twice the median per capita expenditure of the 30 OECD industrialized countries ($2,880), and 50% greater than Norway ($4,520), the second highest spending country.
Health care expenditures made up 15.3% of GDP in the U.S., while in the other OECD countries, it was generally less than 10% and did not exceed 11.3%.
Per capita spending in the U.S. on pharmaceuticals ($843) was higher than any of the other 30 countries, although pharmaceutical spending accounted for a lower share of total health expenditures in the U.S. (12.6%) than the OECD median (16.6%).
Physicians visits in the U.S. on a per capita basis generally were lower (4) than found in the 30 other industrialized countries (6.4). The rate in the U.S. was lower than all but four of the 25 countries that reported on this measure.
On a per capita basis, fewer practicing physicians were found in the U.S. (2.4 per 1,000 population) than most other OECD countries. The median there was 3.3 physicians.
Hospital stays in the U.S. were less frequent and shorter—but more expensive. The number of hospital discharges per 1,000 population in the U.S. (119) was in the bottom quartile among OECD countries—much lower than the OECD median of 162.
The U.S. had among the fewest acute care hospital beds per capita (2.7 per 1,000 population) among OECD countries (median was 3.4).
Spending per hospital discharge in the U.S was ($17,126), which was 2.5 times higher than the average of OECD median ($6,867) and almost 50 percent higher than the Netherlands, the second most expensive OECD country ($11,522).
Average life expectancy at birth in the U.S. was 77.8 years— placing it at the bottom quartile among the 30 OECD countries in 2006 (Exhibit 5). Ten countries had life expectancies at birth of over 80 years. The U.S. had the smallest increase in life expectancy among all OECD countries from 1986 to 2006—3.1 years, compared with the median of 4.7 years.
High tech medical procedures are performed at a high rate in the U.S. Sophisticated imaging technology was comparatively prevalent in the U.S., with 33.9 computed tomography (CT) scanners and 26.5 magnetic resonance imaging (MRI) units per million population, compared with 14.8 CT scanners and 7.7 MRI units in the OECD median. Only two countries (Australia and Belgium) had more CT scanners per capita than the U.S., and only one country (Japan) had more MRI units.
Patients with head and neck cancer who reported poorer sleeping quality a year after their diagnoses had more symptoms of chronic pain and complaints of dry mouth related to radiation treatments, according to a new study from the University of Michigan Comprehensive Cancer Center in Ann Arbor.
Because these side effects can be controlled or modified, the study suggested that reducing these factors in caring for head and neck cancer patients could assist in helping to improve sleep and enhance quality of life, the researchers said.
However, earlier UM studies have shown that head and neck cancer patients who reported lower physical quality of life were more likely to die from their disease.
Sleep disturbances are common complaints among head and neck cancer patients, the researchers said. They have been shown to decrease quality of life, decrease mental health, and serve as a predictor of other complications in the treatment of the cancer.
The disturbances also could negatively affect the immune system and its ability to deal with stresses of the diagnosis, said senior study author Jeffrey Terrell, MD, a professor of otolaryngology at the UM Medical School.
Also, some cancer patients in general may have greater issues such as facial disfigurements and side effects from treatments that can alter speech. These problems could lead to breathing problems, which can impact sleep, said study author Sonia Duffy, PhD, RN, an associate professor of nursing at the UM School of Nursing and otolaryngology at the UM Medical School and research scientist at the VA's Ann Arbor Healthcare System.
For the study, the researchers surveyed 457 people at three otolaryngology clinics who had been recently diagnosed with head and neck cancer. They responded to questions about their physical and emotional quality of life—including pain, sleep health, eating, and respiratory problems. They were then surveyed again one year after diagnosis.
Among those surveyed, sleep quality was found not to change very much from the time of diagnosis to one year after treatment. However, quality of sleep at both time points was worse than typical sleep scores for the average person.
The researchers said that the relatively minor change in sleep quality one year after diagnosis may be due to symptoms and side effects from treatments such as surgery, radiation therapy, and chemotherapy. Results of the study currently appear in the online version of the journal The Laryngoscope.
In a letter sent Monday to new Centers for Medicare and Medicaid Services Administrator Donald Berwick, 242 House members are calling for the agency to review and change its current proposal to decrease Medicare payments to hospitals by 2.9% in fiscal 2011. The reduction initially was sought to offset earlier overpayments that resulted from changes in the use of new codes.
However, this coding offset assumes that hospital payments have "increased solely due to changes in coding or classification of patients," as opposed to "hospitals' treatment of more complex and more severely ill patients," said the letter, which received bipartisan support. This assertion "fails to take into consideration that hospital patients are indeed sicker."
Increasingly, as more patients are successfully treated in the outpatient hospital departments, many hospitals are reporting that those who are admitted are now "often times more severely ill," it said. If the proposed rule is enacted, the projected inflationary index for the next year (2.4%) would be eliminated, it added.
Overall, hospitals across the country could face $3.7 billion less in Medicare reimbursements in fiscal 2011—compared to what they would have received without this proposal, they said.
The letter also noted that the Medicare Payment Advisory Commission has projected a negative 5.9% overall Medicare margin for hospitals in fiscal 2010—and recommended a full inflation or marketbasket update for hospital payments in fiscal 2011. These costs include wages and benefits (about 70% of hospital costs), medical supplies, pharmaceuticals, medical devices, food, and utilities.
The cut proposed by CMS for fiscal 2011 would weaken hospitals' ability to provide high quality services to patients and their communities, the letter concluded.
The Department of Health and Human Services and the Office of the National Coordinator for Health Information Technology released two long–awaited "meaningful use" final regulations this morning that will specify what physicians and hospitals will have to do to receive up to $27 billion in bonus Medicare payments for adoption of electronic health records.
One of the regulations issued today by the Centers for Medicare & Medicaid Services (CMS) defines the minimum requirements that providers must meet through their use of certified EHR technology in order to qualify for the payments. More than 2,000 comments were received on the proposed rule, said HHS Secretary Kathleen Sebelius, at a briefing this morning.
The CMS rule announced today makes final a proposed rule issued on Jan, 13, 2010. While the proposed rule initially called on eligible professionals to meet 25 requirements (23 for hospitals) in their use of EHRs, the requirements for meaningful use incentives now are divided into core requirements that are mandatory and a menu of 10 additional requirements—of which five need to be met, according to David Blumenthal, MD, National Coordinator for Health Information Technology.
Only 15 core requirements are now mandatory for eligible providers and 14 are mandatory for hospitals. The percentage of patients that are required to qualify as meaningful users has been lowered for many of the criteria.
This two track approach was designed to make sure that the basic elements of meaningful EHR would be met by all providers qualifying for incentive payments—while giving latitude in other areas to reflect providers’ needs, Blumenthal added.
The other rule was issued by the Office of the National Coordinator for Health Information Technology (ONC) that will assist in identifying standards and certification criteria for the certification of EHR technology.
CMS’s and ONC’s final rules complement two other recently issued HHS rules. On June 24, 2010, ONC published a final rule to establish a temporary certification program for health information technology. And on July 8, 2010, the Office for Civil Rights announced the proposed rule that would strengthen and expand privacy, security, and enforcement protections under the Health Insurance Portability and Accountability Act of 1996.
In addition, as part of this process, HHS is establishing a nationwide network of Regional Extension Centers to assist providers in adopting and using in a meaningful way certified EHR technology.
