Former pharma exec could represent a departure from the priorities of his predecessor and the president's campaign, say observers.
The Senate confirmed former Eli Lilly executive Alex Azar as the next Health and Human Services secretary Wednesday with a 55-43 vote, despite opposition from most Democrats.
Azar, who served HHS under President George W. Bush, has enjoyed broad-based support among Republicans who cite his experience in the pharmaceuticals industry as an asset. Democrats largely describe Azar’s work history as a liability that could exacerbate the problems caused by rising drug prices.
Even so, seven members broke from the Democratic caucus Wednesday to vote in favor of the confirmation, giving Azar the majority he needed to succeed former HHS Secretary Tom Price, who resigned last September, amid controversy, after less than eight months on the job.
Cross-aisle votes
The six Democrats and one Independent who voted with the GOP offered a variety of reasons for their support:
Sen. Chris Coons, D-Del., said he’s known and been impressed by Azar for several decades.
“I personally met with Mr. Azar last month and pressed him on a number of key issues that he will impact as Secretary, including the Affordable Care Act, drug pricing, and continued progress on health care system delivery reform,” Coons said in a statement. “There is plenty that we disagree on, but I was encouraged by his answers during our conversation and I believe he is committed to representing the interests of Delawareans and Americans everywhere. I disagree with most of the Trump Administration’s health policies, but HHS needs a competent leader. Mr. Azar is prepared to be that.”
Sen. Tom Carper, D-Del., said he continues to have concerns about Azar’s views on the Affordable Care Act and Medicaid but that he is encouraged by Azar’s goal of transforming the healthcare delivery system into one that rewards quality over quantity.
“We should reward doctors, hospitals and pharmaceutical companies for making people well, not for the number of procedures done, hospitalizations required or drugs prescribed,” Carper said in a statement.
Sen. Heidi Heitkamp, D-N.D., praised Azar as intelligent and competent, noting he will be a “solid” leader for HHS.
“We had a good conversation about health priorities for North Dakota like rural health and Native American health,” Heitkamp said in a statement. “He and I don’t agree on everything philosophically, but I believe he’s someone I could work well with and who I’ll be able to have open communication with to help improve health care for North Dakotans.”
Sens. Joe Donnelly, D-Ind.; Doug Jones, D-Ala.; Joe Manchin, D-W.Va.; and Angus King, I-Me.—who voted in favor of Azar’s confirmation—did not release statements on their websites about the vote.
Sen. Rand Paul of Kentucky was the only Republican to vote against Azar’s confirmation. Sens. John McCain of Arizona and Bob Corker of Tennessee were absent.
Outside observers
Bloomberg’s Sahil Kapur noted that Azar’s priorities could differ markedly from those President Donald Trump touted as a candidate.
“The president campaigned on allowing drug re-importation to lower costs; he largely ignored that after taking office, and his new HHS Sec. Alex Azar is a former pharma executive who's been cool to the idea,” Kapur wrote.
And Axios noted that the new direction could differ markedly from the one Price began implementing less than a year ago.
“He's not a fan of the Affordable Care Act, so don't expect HHS to enforce it more enthusiastically now that Price is gone,” Axios wrote. “Don't look for an aggressive crackdown on rising drug prices, either.”
That being said, Azar could be more willing to pursue mandatory pilot programs and other initiatives Price opposed, Axios noted.
With lawmakers unlikely to dive headlong into another hot-button healthcare agenda during an election year, wrote Politico’s Adam Cancryn, Azar is set to “become the face of administration efforts largely focused on unraveling Obamacare and remaking the health system through rulemaking and regulatory action.”
The proposed class action suit calls Medicaid ‘the cornerstone of the social safety net’ and alleges the executive branch overstepped its bounds.
Fifteen plaintiffs filed a lawsuit Wednesday challenging the Department of Health and Human Services over its approval of work requirements for those who, like the plaintiffs, are enrolled in Kentucky’s Medicaid program.
Kentucky Gov. Matt Bevin submitted a request to HHS in 2016 for a waiver from certain provisions of the Medicaid Act. His plan included a proposed work requirement, according to the complaint, which was filed in the U.S. District Court for the District of Columbia by attorneys with the National Health Law Program, the Kentucky Equal Justice Center, and the Southern Poverty Law Center.
Earlier this month, the Centers for Medicare and Medicaid Services announced it would begin approving waiver requests that would pave the way for work requirements. A memo to state Medicaid directors outlined guidelines on how states could pursue such waivers.
“The very next day—January 12, 2018—without seeking or permitting comments on the radical expansion of the Medicaid waiver authority, the Defendants granted the Kentucky HEALTH application, asserting that this grant and Kentucky’s imposition of work requirements are consistent with CMS’s newly-minted approach set out in its letter to State Medicaid Directors,” the suit states.
It argues the executive branch overstepped its bounds by effectively rewriting legislation passed by Congress.
The plaintiffs, who range in age from 20 to 62 years old, seek to have their complaint certified as a class action lawsuit so other similarly situated beneficiaries of Kentucky’s Medicaid program can join in challenging the work requirement and other waivers. They accuse the defendants of violating the Administrative Procedure Act eight times and the Take Care Clause once, and they asked the court to block HHS from implementing the policies outlined in the memo to state Medicaid directors.
The six defendants are HHS, CMS, HHS Acting Secretary Eric Hargan, CMS Administrator Seema Verma, CMS Principal Deputy Administrator Demetrios L. Kouzoukas, and Center for Medicaid and CHIP Services Director Brian Neale.
Verma said during an American Hospital Association webinar last week that CMS has received proposals from 11 states seeking waivers for work requirements.
"The purpose behind this is not about reducing the Medicaid rolls, but it's really centered around helping individuals gain self-sufficiency, helping them to rise out of poverty,” Verma said.
“This is about dignity for individuals," she added.
A spokesperson for CMS said the agency does not comment on pending litigation.
Press representatives from HHS did not immediately respond Wednesday to requests for comment.
This story has been updated to note that CMS declined to comment.
Director of CMS signals ‘an inter-agency group’ to be formed with HHS OIG, DOJ, others.
For years, providers have complained that federal statutes known as the Stark laws have impeded their ability to improve the quality and efficiency of their healthcare delivery.
Now those complaints will receive the detailed review they deserve, according to Centers for Medicare and Medicaid Services Administrator Seema Verma.
“We’re going to put together sort of an inter-agency group to start looking at this,” Verma said during an American Hospital Association webinar last week.
AHA President and CEO Rick Pollock said the anti-kickback statutes and Stark laws—which prohibit a physician from referring Medicare and Medicaid patients to entities with whom the physician has financial ties—have made it difficult for hospitals to take advantage of the value-based payment opportunities in which CMS has been investing.
“They both present significant barriers to the implementation of some of these new, innovative models that reward coordination and reward value,” Pollock said during the webinar.
Verma agreed that the Stark laws—which were first introduced 30 years ago by U.S. Rep. Fortney Hillman “Pete” Stark, D-Calif.—have had a tough time keeping up with the times.
“This was developed a long time ago, and the payment systems and sort of how we are operating is different, and we need to sort of bring along some of those regulations and figure out what we can do,” she said.
Certain changes could require an act of Congress, Verma noted.
For the time being, CMS officials will work with representatives with other offices and agencies that have jurisdiction over relevant provisions of the laws, including the Health and Human Services Office of Inspector General, the General Counsel’s Office, and the Department of Justice, Verma said.
“Right now, we’re committed to looking at the issue, responding to the very specific challenges that have been cited by the providers, and we’re committed to working through it.”
A previous version of this story misstated CMS Administrator Seema Verma's title. It has been corrected.
Officials said states need flexibility to establish qualifications for Medicaid providers. Others see an attack on Planned Parenthood.
In a letter to state Medicaid directors across the country, the Centers for Medicare and Medicaid Services rescinded a memo Friday that had barred state programs from taking action against abortion providers without evidence of wrongdoing.
The short letter, which was signed by Center for Medicaid and CHIP Services (CMCS) Director Brian Neale and Center for Program Integrity Director Alex Alexander, cited concerns that the Obama-era guidance could run afoul of the Administrative Procedure Act. It also suggested states should have more flexibility in setting standards for Medicaid providers.
“We may provide further guidance in the future,” the letter concluded.
The rescinded memo, which was sent to state Medicaid directors exactly 21 months ago, had argued that states cannot take action against a provider without evidence of fraud, criminal conduct, substantive noncompliance with state requirements, or some other “material issues” affecting the provider’s fitness to perform covered services.
“Providing the full range of women’s health services neither disqualifies a provider from participating in the Medicaid program, nor is the provision of such services inconsistent with the best interests of the beneficiary, and shall not be grounds for a state’s action against a provider in the Medicaid program,” the 2016 memo, signed by CMCS’s then-Director Vikki Wachino, stated.
The guidance had noted that federal law prohibits federal Medicaid dollars from funding abortion services, except in extraordinary cases, such as rape, incest, or when the woman’s life is in danger. It was issued as at least two dozen states cut funding to Planned Parenthood facilities following the 2015 release of under-cover videos by anti-abortion activists that purported to show clinic officials negotiating the sale of tissue from aborted fetuses, as Reuters reported.
Republicans in the House spent more than a year looking into the matter with a select investigative panel that released a 471-page report in late 2016, with no charges. Nearly a year after that, the fiery investigation appeared to be finding new oxygen, as evidenced by a letter to the Senate Judiciary Committee last month from Assistant Attorney General for Legislative Affairs Stephen E. Boyd, as The New York Times reported.
"Reinstating the pre-2016 standards frees up states to once again decide for themselves what reasonable standards they use to protect Medicaid programs and their beneficiaries," said Charmaine Yoest, Health and Human Services assistant secretary for public affairs and former president of Americans United for Life, during a call Friday with reporters, as The Hill reported.
In a statement to HealthLeaders Media, Planned Parenthood denounced the Trump administration's move.
"They are laser-focused on using their power to control women’s bodies and lives," said Dawn Laguens, executive vice president for Planned Parenthood Action Fund. "Their latest action encourages states to try to block access to care at Planned Parenthood and control where women can go for health care."
Disputed legal interpretation
Wachino’s 2016 letter had cited a section of the Social Security Act that says eligible individuals may obtain medical assistance “from any institution, agency, community pharmacy, or person, qualified to perform the service or services required.”
If a state lacks evidence to support its finding that a provider fell short of the state’s standards, then the provider remains qualified, Wachino wrote.
In announcing Friday that the Obama-era guidance had been rescinded, HHS said CMS is “concerned that the 2016 letter may have gone beyond merely interpreting what the statute and current regulations require.”
The announcement coincided with President Donald Trump’s appearance at the annual anti-abortion March for Life rally in Washington, D.C., where he listed rescinding the 2016 memo as among his administration’s accomplishments, as Reuters reported.
Spokespeople for HHS and CMS did not immediately respond Friday to requests for comment.
This story has been updated to include a comment from Planned Parenthood.
The case highlights challenges healthcare orgs face when patients become targets of law enforcement.
A former police officer was indicted and arrested this week on federal civil rights and obstruction of justice charges over his handling of a patient’s arrest outside the Veterans Affairs Medical Center in Indianapolis last year.
Michael Kaim, 27, repeatedly struck the patient in the face and head last April without a legal justification to do so, causing injury, according to the indictment, which was unsealed Thursday.
Kaim then allegedly filed a false report asserting that the patient had shown aggression and refused to comply with his orders to leave the medical facility.
“In truth and in fact, as the defendant then well knew, [the patient] was following the defendant’s orders and exiting the Veterans Affairs Medical Facility when the defendant used illegal and unjustifiable force against him,” the two-count indictment states.
This case once again highlights the challenges healthcare organizations face when their patients become the targets of aggressive law enforcement tactics.
A nurse in Utah reached a $500,000 settlement after a Salt Lake City police officer forcibly removed her last summer from the hospital and placed her in handcuffs for refusing to permit the officer to draw blood from an unconscious patient under her care. The incident prompted a policy change to shield nurses from interactions with the police, and prosecutors asked the FBI to join in on the investigation.
The FBI investigated Kaim’s case, which is being prosecuted by the U.S. Department of Justice Civil Rights Division with help from the U.S. Attorney’s Office in Indianapolis.
Kaim faces a maximum sentence of 10 years for the civil rights charge and 20 years for obstruction of justice, according to court records from the U.S. District Court for the Southern District of Indiana.
Kaim was arrested Thursday and released on bond. He is prohibited from possessing weapons and is required to actively seek employment and to surrender his passport.
Though the program and its savings have steadily climbed, CMS released participant data without fanfare.
There are more accountable care organizations (ACOs) participating in the Medicare Shared Savings Program this year than ever before.
The Centers for Medicare and Medicaid Services released data online this month, listing 561 ACOs and 10.5 million assigned beneficiaries for performance year 2018—up from 480 ACOs and 9 million beneficiaries in 2017.
Despite MSSP’s sustained growth in both size and performance payments earned, this year’s participant numbers were released quietly, and a spokesperson for CMS declined to arrange an interview to discuss the program’s apparent success.
But representatives from many of the ACOs taking advantage of the program this year were eager to tell HealthLeaders Media about their efforts to improve quality and cut costs.
“From our perspective, we are looking to help hospitals and clinicians improve the quality of care they provide and do it in a sustainable way that supports their business needs,” says Tim Gronniger, MHSA, MPP, a former CMS official in the Obama administration and current senior vice president of development and strategy for Caravan Health, based in Kansas City, Mo.
Caravan Health, which has worked with hospitals to build MSSP ACOs across the country, added 15 ACOs this year to the 23 it already had. The expansion reflects Gronniger’s confidence in MSSP’s utility and durability moving forward.
That confidence endures despite uncertainty last year over how the Trump administration might seek to change the Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-based Incentive Payment System (MIPS).
“You know, Tom Price has come and left, and MACRA is still standing, and the Innovation Center is still churning out models, and we still see a pretty strong push for value from the government but also an organic desire from the health industry to continue finding ways to improve,” Gronniger says.
“So I think that some of the uncertainty that was there in 2017 with the new administration, I think a lot of that has disappeared, and there’s a clear direction that MACRA is staying and that there’s still really strong financial reasons to be in an ACO, even apart from all of the clinical and patient experience sides of things.”
Assisting, protecting physicians
One of the financial reasons to consider joining an ACO is that CMS gives them preferential treatment under MIPS, Gronniger says.
“We see a lot of hospitals that are using this program to protect their physicians in their clinical networks from penalties under the MIPS program, using it as an opportunity to embrace their physician networks,” Gronniger says. “There’s certainly also revenue-generating opportunities and shared savings, but that’s usually like a secondary issue for a lot of the providers we work with.”
Gronniger served as CMS deputy chief of staff until the end of the Obama administration, but that hasn’t stopped him from criticizing some of his own team’s work product.
“I am no fan of the MIPS program, even though I helped to write the rules for it,” he says. “I think there are a lot of problems with the MIPS program. One of the benefits of an ACO is that it takes you out of the worst elements of the MIPS program, honestly. I think that the MIPS program, as it’s currently constituted, is burdensome for clinicians and that it can’t really be easily repaired.”
Gregory M. Whisman, MD, serves as chief medical officer for OhioHealth Venture LLC, a new MSSP ACO that serves OhioHealth’s employed physicians group and independent practices that are part of the system’s clinically integrated network.
Before OhioHealth Venture was formed, many of OhioHealth’s employed practices were part of Comprehensive Primary Care Plus (CPC+), meaning they were already part of an advanced alternative payment model (Advanced APM) that kept them prepared, Whisman says. Small practices, however, were feeling the strain.
“On behalf of the independents,” Whisman says, “there was a lot of angst because there was a lot of reporting that had to go into MIPS if they were doing it on their own: how they were going to get their data out of their systems or out of their patient charts, certainly the risk of losing money and losing payments if they weren’t on an electronic record already, and then also being compared across practices to large groups, such as employed groups that had the economies of scale that smaller practices didn’t have.”
With the MSSP ACO model, physician offices are empowered to learn from each other, says Shannon L. Ginther, JD, OhioHealth Venture’s chief operating officer.
“These doctors are every day seeing patients, seeing patients, trying to keep the doors open. So the idea of participating with another group they can learn from and access some resources, I think, is part of it as well,” Ginther says.
Incentivizing risk with bonus payments
Avalere Health, based in Washington, D.C., released updated research on the financial benefits of a new hybrid risk model made available to MSSP ACOs this year: Track 1+.
By analyzing data from performance year 2016, Avalere reached the conclusion that participants would benefit from taking on a limited amount of financial risk under the model, which would make them eligible to qualify for 5% bonus payments currently offered under the Quality Payment Program (QPP) to Advanced APMs.
“As they take on more risk, Medicare beneficiaries should see their providers doing more to keep their patients healthy,” said Avalere Senior Vice President Josh Seidman, in a statement.
Regardless of its potential benefits, only 10% of MSSP ACOs are taking part in the Track 1+ model this year. The non-risk based Track 1 model remains the most popular, with 82% of ACOs participating.
Her program serves federally qualified health centers that treat populations with a high rate of uninsured patients—all of whom receive care, regardless of their ability to pay. The real benefit of MSSP is in its reliable data, informational websites, and personnel who walk participants through their expectations, she says.
“There’s a lot of infrastructure that you have to have in place to go into these arrangements, and the payment doesn’t come until a year-and-a-half after you do the lift. So you do the work with the potential that a payment will come a year-and-a-half from now,” Ketchum-Ward says. “If the motivation is purely financial, you’re not going to be successful.”
Participant data for the much-smaller Next Generation ACO Model, which builds upon MSSP, were released Thursday. It, too, showed an increase in participants, moving from 45 ACOs in 2017 to 58 this year.
Proponents say laws protecting freedom of conscience in healthcare have gone under-enforced, while critics worry this shift could open door to more discrimination against LGBTQ patients.
Lawmakers and faith leaders joined Health and Human Services officials Thursday morning to launch a new HHS division that aims to protect healthcare organizations and their employees from discrimination on the basis of religion.
The Conscience and Religious Freedom Division, within the HHS Office of Civil Rights (OCR), will ramp up enforcement of legal protections that went neglected under the Obama administration, proponents said. They cited cases in which healthcare workers were penalized for their objection to abortion.
“No nurse or doctor should lose her job, her livelihood, or her profession because of her faith,” Rep. Vicky Hartzler (R-Mo.), chair of the House Values Action Team, said during a series of speeches at HHS headquarters with fellow backers of the initiative.
Hartzler recalled the case of Cathy Cenzon-DeCarlo, a nurse at Mount Sinai Hospital in New York who sued after being forced to help perform a second-term abortion in 2009, as The Washington Post reported. Cenzon-DeCarlo filed an OCR complaint that was not addressed until 2013.
“Despite clearly communicating her moral objection to assisting with abortions as a nurse, Cathy’s employer coerced her to participate in an abortion procedure that took the life of a vulnerable unborn child,” Hartzler said Thursday, citing similar cases in Illinois and New Jersey.
The division’s work will be authorized by several existing statutes that make it illegal to discriminate against healthcare workers who refuse to participate in abortions, sterilization, or assisted suicide. These are included in the Church Amendments, the Public Health Service Act, the Weldon Amendment, and the Affordable Care Act.
“Enforcing these statutes, some of which have been on the books for decades and some of which have lain largely dormant, will expand and complement the already-excellent work that OCR does protecting all Americans’ civil rights,” said Acting HHS Secretary Eric D. Hargan, JD, who was sworn in as deputy secretary last October, shortly after the resignation of former HHS Secretary Tom Price, MD, amid controversy over travel spending.
The American Civil Liberties Union and other critics worry, however, that this shift could open the door to more discrimination against women and LGBTQ people in need of medical care.
American College of Physicians President Jack Ende, MD, MACP, said his organization will evaluate the new HHS division as it begins operating, measuring its actions against ACP's ethics manual and public policy positions.
"Those state that physicians have a professional obligation to not discriminate against any class of patients, but also that a physician may have a conscience objection to providing a specific medical service to a patient," Ende said in a statement.
Harper Jean Tobin, director of policy for the National Center for Transgender Equality, released a statement saying HHS “appears ready to create sweeping, dangerous exemptions to patient protections that would encourage doctors, hospitals, paramedics and other medical providers to pick and choose which patients they will and won’t treat, and who does and doesn’t get life-saving medical care.”
As evidence, Tobin pointed to a recent controversy over an HHS request for information. The department received 10,729 comments on its proposal to reduce regulations for religious and faith-based groups, but it published only 80, as Politico reported. Those 80 comments largely supported the Trump administration’s anti-abortion policies and opposed Obama-era rules, such as the one that requires healthcare providers that accept federal money to serve transgender patients.
Roger Severino, director of the HHS OCR, was a staff member with The Heritage Foundation, where he coauthored a report that described the Obama administration’s proposal to prohibit differential treatment on the basis of gender identity as a threat to religious liberty and freedom of conscience for doctors and healthcare organizations.
A proposed rule pertaining to the HHS OCR, titled “Ensuring Compliance with Certain Statutory Provisions in Health Care; Delegations of Authority,” was still listed Thursday as pending review at the White House Office of Management and Budget.
This story has been updated to include a statement from the American College of Physicians.
Workers shut down the entire computer network Monday night to thwart what the organization described as attempted extortion.
A health system in southern Mississippi was still recovering Wednesday afternoon, nearly two days after its computers were targeted by hackers.
The information systems team at Pascagoula-based Singing River Health System shut down the organization’s entire computer network to protect its data once an attempted intrusion was detected late Monday.
The team was still working Wednesday to restore some systems, a spokesperson told HealthLeaders Media.
“It is deplorable that hackers would attempt to extort hospitals and interrupt patient care at places in the business of saving lives,” Chief Operating Officer Lee Bond said in a statement. “We will be working with our data contractors and law enforcement to help identify whoever is responsible for this attempt.”
The statement described the incident as an attempted malware attack. But the health system’s information technology director was unavailable Wednesday afternoon to specify whether the incident involved ransomware, a type of malware that locks computers and demands payment in exchange for a promise to release data back to its rightful owner.
Cybersecurity breaches in general have seen a dramatic surge among healthcare organizations in recent years. And ransomware, in particular, made the scope of its threat clear last year when the so-called WannaCry virus spread around the globe, affecting not only healthcare-sector organizations but a number of other public and private organizations as well.
These incidents can prove expensive, too. A hospital in New York that lost access to its computers last year due to a ransomware attack has paid nearly $10 million to recover after choosing to replace its hardware and software rather than comply with the ransom demand.
That case could be quite different, however, from the recovery process underway at Singing River. Bond’s statement said the attack had been successfully thwarted. An evaluation is ongoing, he said, but there has so far been no sign that any protected health information or patient data was compromised.
Two of the system’s hospitals, Ocean Springs and Singing River, were impacted by the incident, the SunHerald reported Tuesday.
Despite the interruption, clinical care teams continue to deliver care as they are trained to do with downtime procedures, Bond noted.
“Our processes are high tech but our care is still delivered personally by highly skilled professionals, so we are good to go,” he said. “Our IT Team along with all of our doctors, nurses and technicians have done a great job caring for our patients despite the inevitable delays that computer system downtime creates.”
Officials with CMS agreed with some, but not all, of the OIG’s recommendations.
The Health and Human Services Office of Inspector General issued a report on Medicare Advantage this month, suggesting seven changes to the way officials ensure the accuracy and completeness of the program’s encounter data.
The report sampled more than 100 million Medicare Advantage cases from the first quarter of 2014 and found one or more potential errors in 28% of the encounter records. After correcting a problem with the data, however, officials with the Centers for Medicare and Medicaid Services say only 5% of the relevant records have potential errors.
“Some of these errors may raise concerns about the legitimacy of services documented in the data, such as records that lacked a beneficiary last name or a valid identifier for the billing provider,” the OIG report states.
Although CMS officials seem receptive to most of the OIG’s ideas, they take issue with a few suggestions deemed too burdensome.
“When undertaking a complex data collection effort such as this one, CMS is mindful of balancing immediate needs with long-term goals for use of the data, as well as provider and plan burden,” the CMS response says. “Therefore, while there are additional data fields that may be helpful for study, CMS must focus on development of fields necessary for payment purposes before broadening the scope of collection and validation.”
Officials with CMS say they concur with four of the OIG’s seven recommendations, which are outlined below.
1. Address errors in the encounter data
The OIG report recommends that CMS consider a variety of ways to reduce the number of errors in its Medicare Advantage encounter data, such as introducing more reject edits, pinpointing the reasons why data went missing, restoring data if appropriate, and determining why some code values fail to follow the program’s format specifications.
CMS concurs: The agency says it will continue working to address possible errors by assessing the validity of high-priority data points and by reviewing instructions for consistency.
2. Provide targeted oversight
Officials with CMS should also consider keeping a closer eye on Medicare Advantage Organizations (MAOs) that exhibit high percentages of possible data errors. The OIG provided CMS with a list of those MAOs that could benefit from technical assistance and guidance.
CMS concurs: The agency says it will review the OIG’s list and “consider how to incorporate this information into our already extensive oversight activities.”
3. Verify all billing provider identifiers
Each and every Medicare Advantage billing provider’s identifier should be verified as both valid and active on all records in the data, the OIG report says. While CMS already rejects submissions that are formatted incorrectly or coming from providers under sanction, the OIG recommends extending these efforts with reject edits that ensure the validity and active status of each provider identifier on a record.
CMS concurs: The agency says it will add an edit that checks the validity of a provider’s identifier.
4. Require ordering and referring provider identifiers
Minimum documentation requirements should be amended to clearly require identifiers for ordering and referring providers on certain records, the OIG recommends. Such requirements would be appropriate for home health services, clinical laboratory, imaging, and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), according to the report.
CMS does not concur: The agency says MAOs often do not collect this information on ordering, operating, or facility provider identifiers, so they cannot report it. That being said, CMS says it will look into the question of whether collecting these identifiers might be needed.
5. Ensure rendering providers are noted
When there’s no rendering provider identifier listed in a Medicare Advantage encounter record, CMS considers the rendering and billing providers to be one in the same. But the OIG’s review found a number of records with only one identifier listed, even though there were likely two different providers handling billing and rendering. So the OIG recommends that CMS clearly communicate which situations require the inclusion of a rendering provider’s information and figure out a way to reject records that lack the required information.
CMS does not concur: The agency again bases its objection on the fact that MAOs often do not collect this information and that CMS has to take into account the administrative burden extensive reporting requirements can place on participants.
6. Track responses to reject edits
The main way CMS can ensure the data it collects are complete and accurate is through its edit process, which results in some data being rejected. So the OIG recommends that CMS keep track of how MAOs respond to these submission rejections. How many do the MAOs correct and resubmit? How many do they void? Tweaks to the submission requirements could be worthwhile to support this objective, the report notes.
CMS does not concur: The agency says this recommendation would require both CMS and MAOs to modify their systems, and that would be “administratively burdensome both to build and maintain,” pulling limited resources away from the work currently being done.
7. Establish and monitor performance thresholds
The OIG recommends that CMS establish performance thresholds and monitor whether MAOs meet them. When a provider falls short, CMS should issue notices of noncompliance, send warning letters, and implement corrective action plans to improve performance, the report states.
CMS concurs: The agency says it has already begun developing its thresholds and compliance plans, the framework for which was already described in the 2018 Call Letter.
The Wisconsin-based nonprofit system announced this week that it had parted ways with its CEO, who praised the team she’s leaving behind.
The interim leadership team at HSHS Sacred Heart Hospital in Eau Claire, Wis., plans to pick up the pace in implementing its growth strategy, after the sudden departure this week of CEO Julie Manas.
Mary Starmann-Harrison, president and CEO of the Hospital Sisters Health System (HSHS), which operates 15 hospitals in Illinois and Wisconsin, stepped in as Sacred Heart’s interim CEO when the communications team released a statement late Tuesday indicating Manas is “no longer with the organization.”
The statement explained the hospital is “moving in a new direction,” and Starmann-Harrison expounded on that direction in an interview Wednesday with local TV station WEAU.
“We know that we have lots of opportunity and lots of care coordination in this market, and we just didn’t see that—we wanted to see that happen faster. And so that’s an important thing to us,” she said. “We want to move as quickly as we can to develop and expand our services in this market.”
It’s relatively rare for a hospital CEO to lose his or her job in such an abrupt fashion.
Last year, for example, the Chicago-based firm Challenger, Gray & Christmas Inc. counted 107 departures of CEOs from U.S. hospitals—most of whom retired, left for another job, or completed their time in an interim position.
Only six of the CEOs were openly terminated, replaced, or embroiled in a scandal, according to the firm’s 2017 report released this week. (Another 30 were listed as having resigned, stepped down, or otherwise departed without explanation.)
The leadership change at Sacred Heart comes as the hospital faces financial pressure on multiple fronts, some unique to the local market and others affecting hospitals and health systems nationwide. Last fall, Sacred Heart’s longtime partner Marshfield Clinic Health System opened a new hospital and cancer center nearby that seems poised to adversely impact Sacred Heart’s operation, as the Leader-Telegram reported.
Although the system has not set a timeline for hiring Manas’ successor, the search process has begun, with plans to conclude it quickly, as The Chippewa Herald reported.
When asked by HealthLeaders Media about her sudden departure and future plans, Manas offered well-wishes to HSHS personnel and affirmed the organization’s charitable mission.
“I’ve been blessed to serve Hospital Sisters Health System’s ministry for the last six years and leave behind an incredible team,” she wrote in an email Thursday evening. “I’m certain of their continued success in taking excellent care of the community, especially the poor and vulnerable.”
“I’m looking forward,” Manas added, “to the next chapter of my career as I consider other executive leadership opportunities.”